Dosage and administration of anti-C5 antibody for treatment of Atypical Hemolytic Uremic Syndrome (AHUS)

文档序号：1803579 发布日期：2021-11-05 浏览：18次中文

阅读说明：本技术 用于治疗非典型溶血性尿毒综合征(ahus)的抗c5抗体的剂量和施用 (Dosage and administration of anti-C5 antibody for treatment of Atypical Hemolytic Uremic Syndrome (AHUS) ) 是由 L·佩顿 C·米克斯 R·普拉丹 A·达莫科什 E·S·斯文森 X·高于 2020-01-24 设计创作，主要内容包括：提供了使用抗C5抗体或其抗原结合片段临床治疗非典型溶血性尿毒综合征(aHUS)的方法。(Methods of clinically treating atypical hemolytic uremic syndrome (aHUS) using an anti-C5 antibody or antigen-binding fragment thereof are provided.)

1. A method of treating a human patient having atypical hemolytic uremic syndrome (aHUS), the method comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising a CDR1, CDR2, and CDR3 heavy chain sequence as set forth in SEQ ID NOs 19, 18, and 3, respectively, and a CDR1, CDR2, and CDR3 light chain sequence as set forth in SEQ ID NOs 4, 5, and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof:

(a) once on day 1 in a patient weighing ≥ 40 to <60kg at a dose of 2400mg, in a patient weighing ≥ 60 to <100kg at a dose of 2700mg or in a patient weighing ≥ 100kg at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

3000mg is administered to a patient weighing ≥ 40 to <60kg, 3300mg to a patient weighing ≥ 60 to <100kg, or 3600mg to a patient weighing ≥ 100 kg.

2. A method of treating a human patient having atypical hemolytic uremic syndrome (aHUS), the method comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising CDR1, CDR2, and CDR3 heavy chain sequences as set forth in SEQ ID NOs 19, 18, and 3, respectively, a CDR1, CDR2, and CDR3 light chain sequence as set forth in SEQ ID NOs 4, 5, and 6, respectively, and a variant human Fc constant region that binds to a human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each using EU numbering, wherein the therapeutic effect:

(a) once on day 1 in a patient weighing ≥ 40 to <60kg at a dose of 2400mg, in a patient weighing ≥ 60 to <100kg at a dose of 2700mg or in a patient weighing ≥ 100kg at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

3000mg is administered to a patient weighing ≥ 40 to <60kg, 3300mg to a patient weighing ≥ 60 to <100kg, or 3600mg to a patient weighing ≥ 100 kg.

3. The method of claim 1 or 2, wherein the patient has previously been treated

Treated with eculizumab.

4. The method of any one of the preceding claims, wherein the treatment begins at least two weeks after the patient's last dose of eculizumab.

5. The method of any one of the preceding claims, wherein the patient has been treated with eculizumab for at least 6 months prior to day 1 of the treatment.

6. The method of any one of the preceding claims, wherein the patient has been previously treated with a 900mg dose of eculizumab every 2 weeks.

7. The method of any one of the preceding claims, wherein the anti-C5 antibody comprises the heavy chain variable region depicted in SEQ ID NO 12 and the light chain variable region depicted in SEQ ID NO 8.

8. The method of any one of the preceding claims, wherein the anti-C5 antibody further comprises a heavy chain constant region depicted in SEQ ID NO 13.

9. The method of any one of the preceding claims, wherein the antibody comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID No. 14 and a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID No. 11.

10. The method of any one of the preceding claims, wherein the anti-C5 antibody has an affinity dissociation constant (K) in the range of 0.1nM to 1nM at pH 7.4 and 25 ℃_D) Binding to human C5.

11. The method of any one of the preceding claims, wherein the anti-C5 antibody is expressed in K at pH 6.0 and 25 ℃_DBinding was > 10nM to human C5.

12. The method of any one of the preceding claims, wherein the anti-C5 antibody is administered to a patient weighing ≧ 40 to <60 kg:

(a) once on day 1 at a dose of 2400 mg; and

(b) on day 15 and every eight weeks thereafter

A dose of 3000 mg.

13. The method of any one of claims 1-11, wherein the anti-C5 antibody is administered to a patient weighing ≥ 60 to <100 kg:

(a) once on day 1 at a dose of 2700 mg; and

(b) on day 15 and every eight weeks thereafter

3300 mg.

14. The method of any one of claims 1-11, wherein the anti-C5 antibody is administered to a patient weighing ≧ 100 kg:

(a) once on day 1 at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

A dose of 3600 mg.

15. The method of any one of the preceding claims, wherein the treatment maintains a serum trough concentration of the anti-C5 antibody of 100 μ g/ml or greater during the treatment.

16. The method of any one of the preceding claims, wherein the treatment maintains a serum trough concentration of the anti-C5 antibody of 200 μ g/ml or greater during the treatment.

17. The method of any one of the preceding claims, wherein the treatment is maintained

A free C5 concentration of 0.309 to 0.5 μ g/mL or less.

18. The method of any one of the preceding claims, wherein the treatment reduces the concentration of free C5 by greater than 99% throughout the treatment period.

19. The method of any one of the preceding claims, wherein the treatment reduces the concentration of free C5 by greater than 99.5% throughout the treatment period.

20. The method of any one of the preceding claims, wherein the anti-C5 antibody is administered at a dose of 3000mg, 3300mg, or 3600mg every eight weeks following the treatment for up to two years.

21. The method of any one of the preceding claims, wherein the anti-C5 antibody is formulated for intravenous administration.

22. The method of any one of the preceding claims, wherein the treatment is a total of 26 weeks of treatment.

23. The method of any one of the preceding claims, wherein the treatment results in terminal complement inhibition.

24. The method of any one of the preceding claims, wherein the treatment results in reduced hemolysis as compared to baseline as assessed by Lactate Dehydrogenase (LDH) levels.

25. The method of any one of the preceding claims, wherein the treatment normalizes LDH levels.

26. The method of any one of the preceding claims, wherein the treatment results in elimination of breakthrough hemolysis during the treatment period.

27. The method of any one of the preceding claims, wherein the treatment results in a shift to normal levels of a hemolysis-related blood biomarker selected from the group consisting of: free hemoglobin, haptoglobin, reticulocyte count, PNH Red Blood Cell (RBC) clone, and D-dimer.

28. The method of any one of the preceding claims, wherein the treatment produces at least one therapeutic effect selected from the group consisting of: severe hypertension, proteinuria, uremia, lethargy, fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and impaired renal function are reduced or stopped compared to baseline.

29. The method of any one of the preceding claims, wherein the treatment results in a shift to normal levels of factor Ba, soluble tumor necrosis factor receptor 1[ sTNFR1]), soluble vascular adhesion molecule 1[ sVCAM1], thrombomodulin, D-dimer, and cystatin C.

30. The method of any one of the preceding claims, wherein the treatment produces an increase in hemoglobin stabilization compared to baseline.

31. The method of any one of the preceding claims, wherein the treatment results in a reduction in the need for transfusion compared to baseline.

32. The method of any one of the preceding claims, wherein the treatment results in a reduction in Major Adverse Vascular Events (MAVEs).

33. The method of any one of the preceding claims, wherein the treatment produces a change in quality of life from baseline as assessed by the functional assessment of chronic disease therapy (FACIT) -fatigue Scale version 4 and the European cancer research and treatment organization, quality of life questionnaire-core 30 Scale.

34. The method of any one of the preceding claims, wherein the treatment normalizes platelets.

35. The method of any one of the preceding claims, wherein the treatment results in an increase in serum creatinine of ≥ 25% from baseline.

36. The method of any one of the preceding claims, wherein the treatment results in a complete TMA response.

37. The method of any one of the preceding claims, wherein the treatment results in an improved complete TMA response.

38. The method of any one of the preceding claims, wherein the patient's Chronic Kidney Disease (CKD) improves one or more stages after treatment is initiated.

39. The method of any one of the preceding claims, wherein the treatment produces a shift in eGFR to normal levels.

40. The method of any one of the preceding claims, wherein the treatment results in an EQ-5D-3L time tradeoff (US TTO) >0.94 for a U.S. setting.

41. A kit for treating aHUS in a human patient, the kit comprising:

(a) a dose of an anti-C5 antibody, the anti-C5 antibody comprising the CDR1, CDR2, and CDR3 domains of the heavy chain variable region having the sequences set forth in SEQ ID No. 12, and the CDR1, CDR2, and CDR3 domains of the light chain variable region having the sequences set forth in SEQ ID No. 8: and

(b) instructions for using the anti-C5 antibody in the method of any one of the preceding claims.

42. The kit of claim 41, wherein the anti-C5 antibody is administered to a patient weighing ≥ 40 to <60 kg:

(a) once on day 1 at a dose of 2400 mg; and

(b) on day 15.

43. The kit of claim 41, wherein the anti-C5 antibody is administered to a patient weighing ≥ 60 to <100 kg:

(a) once on day 1 at a dose of 2700 mg; and

(b) on day 15 and every eight weeks thereafter

3300 mg.

44. The kit of claim 41, wherein the anti-C5 antibody is administered to a patient weighing ≧ 100 kg:

(a) once on day 1 at a dose of 3000 mg; and

(b) at a dose of 3600mg on day 15 and every eight weeks thereafter.

45. An anti-C5 antibody or antigen-binding fragment thereof for administration, the anti-C5 antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 domains of the heavy chain variable region having the sequence set forth in SEQ ID No. 12 and the CDR1, CDR2, and CDR3 domains of the light chain variable region having the sequence set forth in SEQ ID No. 8, wherein the anti-C5 antibody or antigen-binding fragment thereof:

(a) once on day 1 in a patient weighing ≥ 40 to <60kg at a dose of 2400mg, in a patient weighing ≥ 60 to <100kg at a dose of 2700mg or in a patient weighing ≥ 100kg at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

3000mg is administered to a patient weighing ≥ 40 to <60kg, 3300mg to a patient weighing ≥ 60 to <100kg, or 3600mg to a patient weighing ≥ 100 kg.

Background

The complement system acts synergistically with the body's other immune systems to protect against the invasion of cells and viral pathogens. There are at least 25 complement proteins that are found to be a complex collection of plasma proteins and membrane cofactors. Plasma proteins account for about 10% of the globulins in vertebrate serum. Complement components fulfill their immune defense functions by interacting in a complex series of yet precise enzymatic cleavage and membrane binding events. The complement cascade thus generated results in the production of products with opsonizing, immunomodulating and lytic functions. A brief summary of The biological activities associated with complement activation is provided, for example, in The Merck Manual, 16 th edition.

While the normally functioning complement system provides a robust defense against infectious microorganisms, inappropriate regulation or activation of the complement pathway has been implicated in the pathogenesis of a variety of disorders, including atypical hemolytic uremic syndrome (aHUS). aHUS is a very rare disorder driven by chronic uncontrolled complement activation. The resulting inflammation and cellular damage leads to the destructive clinical manifestations of these diseases.

Hemolytic Uremic Syndrome (HUS) is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure. HUS are classified into one of two types: diarrhea-associated (D + HUS; also known as Shiga toxin-producing E.coli (STEC) -HUS or canonical HUS) and non-diarrheal or atypical HUS (aHUS). D + HUS is the most common form, accounting for more than 90% of cases, and is caused by previous diseases with Shiga-like toxin-producing bacteria (e.g., E.coli O157: H7).

aHUS may be genetic, acquired or idiopathic. The heritable form of aHUS may be associated with mutations in many human complement components, including, for example, complement factor h (cfh), Membrane Cofactor Protein (MCP), complement factor i (cfi), C4b binding protein (C4BP), complement factor b (cfb), and complement component 3 (C3). See, e.g., Capriol et al (2006) Blood108:1267-1279. Certain mutations in the gene encoding CD55, while not yet implicated in aHUS, correlate with the severity of aHUS. See, e.g., Escapza-Gordillo et al (2005) Hum Mol Genet14:703-712。

aHUS is rare and mortality is up to 25%. Many patients with this disease will persist with permanent neurological or renal damage, e.g., at least 50% of aHUS patients progress to end-stage renal failure (ESRF). See, e.g., Kavanagh et al (2006) British Medical Bulletin77 and 78:5-22. Until recently, treatment options for patients with aHUS were limited and generally involved plasma infusion or plasma replacement. In some cases, aHUS patients undergo unilateral or bilateral nephrectomy or kidney Transplantation (see Artz et al (2003) Transplantation76:821-826). However, disease recurrence is common in treated patients.

Patients with aHUS are at risk for high morbidity and mortality. Accordingly, it is an object of the present invention to provide improved methods for treating patients suffering from aHUS.

Disclosure of Invention

Provided herein are compositions and methods for treating aHUS in a human patient (e.g., an adult patient 18 years or older), the method comprising administering to the patient an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered (or is for administration) according to a particular clinical dosage regimen (i.e., at a particular dose and according to a particular dosing schedule).

Any suitable anti-C5 antibody or antigen-binding fragment thereof can be used in the methods described herein. An exemplary anti-C5 antibody is refolizumab (also known as refolizumab)ALXN1210 and antibody BNJ441) comprising heavy and light chains having the sequences set forth in SEQ ID NOs 14 and 11, respectively, or antigen-binding fragments and variants thereof. In other embodiments, the antibody comprises the heavy and light chain Complementarity Determining Regions (CDRs) or Variable Regions (VRs) of reflizumab. Thus, in one embodiment, the antibody comprises refrozumabThe CDR1, CDR2 and CDR3 domains of the heavy chain Variable (VH) region having the sequence shown in SEQ ID NO. 12, and the CDR1, CDR2 and CDR3 domains of the light chain Variable (VL) region having the sequence shown in SEQ ID NO. 8 of Ravulizumab. In another embodiment, the antibody comprises the CDR1, CDR2, and CDR3 heavy chain sequences as set forth in SEQ ID NOs 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences as set forth in SEQ ID NOs 4, 5, and 6, respectively. In another embodiment, the antibody comprises a VH region and a VL region having the amino acid sequences set forth in SEQ ID NO 12 and SEQ ID NO 8, respectively. In another embodiment, the antibody comprises a heavy chain constant region as set forth in SEQ ID NO 13.

In another embodiment, the antibody comprises a variant human Fc constant region that binds to a human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions, each with EU numbering, at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region.

In another embodiment, the antibody comprises a CDR1, CDR2, and CDR3 heavy chain sequence as set forth in SEQ ID NOs 19, 18, and 3, respectively, and a CDR1, CDR2, and CDR3 light chain sequence as set forth in SEQ ID NOs 4, 5, and 6, respectively, and a variant human Fc constant region that binds to a human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each using EU numbering.

In another embodiment, the antibody binds to human C5 at pH 7.4 and 25 ℃, affinity dissociation constant (K)_D) In the range of 0.1nM to 1 nM. In another embodiment, the antibody binds to human C5, K at pH 6.0 and 25 ℃_DIs more than or equal to 10 nM. In yet another embodiment, the [ (the antibody or antigen-binding fragment thereof at pH 6.0 and 25 ℃ K to human C5 ] of an antibody_D) /(K of the antibody or antigen binding fragment thereof to human C5 at pH 7.4 and 25 deg.C_D)]Greater than 25.

Another exemplary anti-C5 antibody is 7086 antibody described in U.S. patent nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 7086 antibody (see U.S. patent nos. 8,241,628 and 8,883,158). In another embodiment, the antibody or antigen binding fragment thereof comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 21, 22, and 23, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 24, 25, and 26, respectively. In another embodiment, the antibody or antigen-binding fragment thereof comprises the VH region of the 7086 antibody having the sequence set forth in SEQ ID NO 27 and the VL region of the 7086 antibody having the sequence set forth in SEQ ID NO 28.

Another exemplary anti-C5 antibody is the 8110 antibody also described in U.S. patent nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 8110 antibody. In another embodiment, the antibody or antigen binding fragment thereof comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 29, 30, and 31, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 32, 33, and 34, respectively. In another embodiment, the antibody comprises the VH region of the 8110 antibody having the sequence set forth in SEQ ID NO 35 and the VL region of the 8110 antibody having the sequence set forth in SEQ ID NO 36.

Another exemplary anti-C5 antibody is the 305LO5 antibody described in US2016/0176954A 1. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 305LO5 antibody. In another embodiment, the antibody or antigen binding fragment thereof comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 37, 38, and 39, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 40, 41, and 42, respectively. In another embodiment, the antibody comprises the VH region of the 305LO5 antibody having the sequence set forth in SEQ ID NO 43 and the VL region of the 305LO5 antibody having the sequence set forth in SEQ ID NO 44.

Another exemplary anti-C5 antibody is Fukuzawa t, et al, rep.2017, month 4, day 24; SKY59 antibody described in (7), (1) 1080). In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the SKY59 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises a heavy chain comprising SEQ ID NO 45 and a light chain comprising SEQ ID NO 46.

Another exemplary anti-C5 antibody is the REGN3918 antibody described in US20170355757 (also known as H4H12166 PP). In one embodiment, the antibody comprises a heavy chain variable region comprising SEQ ID NO 47 and a light chain variable region comprising SEQ ID NO 48. In another embodiment, the antibody comprises a heavy chain comprising SEQ ID NO. 49 and a light chain comprising SEQ ID NO. 50.

In another embodiment, the antibody competes for binding to and/or binds to the same epitope on C5 as the above-described antibodies (e.g., eculizumab, reflizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In another embodiment, the antibody has at least about 90% variable region amino acid sequence identity to an antibody described above (e.g., at least about 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% variable region identity).

In one embodiment, the dose of the anti-C5 antibody or antigen-binding fragment thereof is based on the weight of the patient. For example, in one embodiment, 2400mg or 3000mg of an anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 40 to <60 kg. In another embodiment, 2700mg or 3300mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 60 to <100 kg. In another embodiment, 3000mg or 3600mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 100 kg. In certain embodiments, the dosage regimen is adjusted to provide the optimal desired response (e.g., an effective response).

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered for one or more administration cycles. In one embodiment, the administration period is 26 weeks. In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered once on day 1 of the administration cycle, once on day 15 of the administration cycle, and every eight weeks thereafter. In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered once every eight weeks after the administration cycle for an extended period of up to two years (e.g., at a dose of 3000mg, 3300mg, or 3600 mg).

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered for one or more administration cycles. In one embodiment, the administration period is 26 weeks. In another embodiment, the treatment comprises at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11 cycles. In another embodiment, the treatment is continued for the life of the human patient.

In another embodiment, a method is provided for treating a human patient having aHUS comprising administering (e.g., during an administration cycle) to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising a CDR1, a CDR2, and a CDR3 heavy chain sequence as set forth in SEQ ID NOs 19, 18, and 3, respectively, and a CDR1, a CDR2, and a CDR3 light chain sequence as set forth in SEQ ID NOs 4, 5, and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof:

(a) once on day 1 in a patient weighing ≥ 40 to <60kg at a dose of 2400mg, in a patient weighing ≥ 60 to <100kg at a dose of 2700mg or in a patient weighing ≥ 100kg at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

3000mg is administered to a patient weighing ≥ 40 to <60kg, 3300mg to a patient weighing ≥ 60 to <100kg, or 3600mg to a patient weighing ≥ 100 kg.

In another embodiment, a method of treating a human patient having aHUS is provided, the method comprises administering (e.g., during an administration cycle) to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof, the anti-C5 antibody or antigen-binding fragment thereof comprises the amino acid sequences set forth in SEQ ID NOs: 19. 18 and 3, as set forth in SEQ ID NOs: 4.5 and 6, and a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each with EU numbering, wherein the anti-C5 antibody or antigen-binding fragment thereof:

(a) once on day 1 in a patient weighing ≥ 40 to <60kg at a dose of 2400mg, in a patient weighing ≥ 60 to <100kg at a dose of 2700mg or in a patient weighing ≥ 100kg at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

3000mg is administered to a patient weighing ≥ 40 to <60kg, 3300mg to a patient weighing ≥ 60 to <100kg, or 3600mg to a patient weighing ≥ 100 kg.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 to <60 kg:

(a) once on day 1 at a dose of 2400 mg; and

(b) on day 15 and every eight weeks thereafter

A dose of 3000 mg.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 60 to <100 kg:

(a) once on day 1 at a dose of 2700 mg; and

(b) on day 15 and every eight weeks thereafter

3300 mg.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 100 kg:

(a) once on day 1 at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

A dose of 3600 mg.

In some embodiments, the patient has not been previously treated with a complement inhibitor (e.g., the patient is a treatment naive patient to complement inhibitor treatment).

In other embodiments, the patient has been previously treated with one anti-C5 antibody or antigen-binding fragment thereof and is converted to another anti-C5 antibody during treatment. For example, in certain embodiments, a different anti-C5 antibody is administered during the course of treatment. In one embodiment, the anti-C5 antibody is administered separately during the treatment and extension phases. For example, in one embodiment, the patient is treated with eculizumab during a treatment period (e.g., 26 weeks), followed by treatment with another anti-C5 antibody (e.g., reflizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody), e.g., during an extension period. In another embodiment, eculizumab is administered to the patient at a dose of 600mg on days 1, 8, 15, and 22 of the administration cycle during the induction period, followed by a maintenance dose of 900mg eculizumab (e.g., for a total of 26 weeks) on day 19 of the administration cycle and every two weeks thereafter, followed by treatment with reflizumab for an extension period of up to two years. In another embodiment, the patient is treated with refolizumab (e.g., for 26 weeks) followed by treatment with another anti-C5 antibody (e.g., eculizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody), e.g., during an extension phase.

Exemplary alternative anti-C5 antibodies include, but are not limited to, (i) refrozumab; (ii) an antibody or antigen-binding fragment thereof comprising heavy chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs 21, 22, and 23, respectively, and light chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs 24, 25, and 26, respectively; (iii) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO 27 and a light chain variable region comprising SEQ ID NO 28; (iv) an antibody or antigen-binding fragment thereof comprising heavy chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs 29, 30, and 31, respectively, and light chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs 32, 33, and 34, respectively; (v) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO 35 and a light chain variable region comprising SEQ ID NO 36; (vi) an antibody or antigen-binding fragment thereof comprising heavy chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs 37, 38, and 39, respectively, and light chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs 40, 41, and 42, respectively; (vii) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO 43 and a light chain variable region comprising SEQ ID NO 44; (viii) an antibody or antigen-binding fragment thereof comprising a heavy chain comprising SEQ ID NO 45 and a light chain comprising SEQ ID NO 46; (ix) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO 47 and a light chain variable region comprising SEQ ID NO 48; and (x) an antibody or antigen-binding fragment thereof comprising a heavy chain comprising SEQ ID NO. 49 and a light chain comprising SEQ ID NO. 50.

In some embodiments, the patient has been previously treated with the anti-C5 antibody or antigen-binding fragment thereof (e.g., eculizumab) for at least 1 month, at least 2 months, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 7 months, at least 8 months, at least 9 months, at least 10 months, at least 11 months, at least 12 months, at least 18 months, or at least 24 months prior to conversion to another anti-C5 antibody or antigen-binding fragment thereof (e.g., reflizumab). In a particular embodiment, the patient has been previously treated with eculizumab for at least 6 months.

In another embodiment, wherein a patient (e.g., aHUS patient) is treated with a first anti-C5 antibody and then switched to treatment with a second, different anti-C5 antibody, particularly when the second, different anti-C5 antibody binds to a different epitope on C5 as compared to the first anti-C5 antibody, the administration regimen takes into account the half-life of the first anti-C5 antibody. For example, to ensure clearance (e.g., "wash out") of the first anti-C5 antibody from the patient prior to administration of the second (different) anti-C5 antibody (e.g., to avoid problems associated with aggregation, immune complex formation, etc.), the half-life of the first anti-C5 antibody is taken into account. In one embodiment, the second (different) anti-C5 antibody is not administered until a duration corresponding to 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, or 7.5 times the half-life of the first anti-C5 antibody has elapsed after the last administration of the first anti-C5 antibody.

In another embodiment, the patient has been previously treated with eculizumab and then switched to treatment with a second (different) anti-C5 antibody (e.g., reflizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In one embodiment where eculizumab is the first administered antibody, a second (different) anti-C5 antibody is not administered, e.g., until at least 36, 45, 54, 63, 72, 81, 90, 99, 108, 117, or 126 days have passed after the last administration of eculizumab.

In another embodiment, the patient has been previously treated with reflizumab and then switched to treatment with a different anti-C5 antibody (e.g., eculizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In one embodiment where reflizumab is the first administered antibody, for example, a second (different) anti-C5 antibody is not administered until at least 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 375, or 400 days have passed after the last administration of reflizumab.

Additionally or alternatively, techniques are used to clear the primary anti-C5 antibody or enhance the clearance of the primary anti-C5 antibody prior to switching to treatment with the second (different) anti-C5 antibody. Exemplary techniques include, but are not limited to, plasmapheresis or blood transfusion. In another embodiment, an antibody directed against a first anti-C5 antibody (e.g., an anti-eculizumab antibody, an anti-revlizumab antibody, an anti-7086 antibody, an anti-8110 antibody, an anti-305 LO5 antibody, an anti-SKY 59 antibody, or an anti-REGN 3918 antibody) is administered prior to administration of a second (different) anti-C5 antibody to clear the first anti-C5 antibody or enhance the clearing of the first anti-C5 antibody.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof (e.g., refolizumab) is administered to the patient, wherein treatment (e.g., the administration cycle) begins at least about two weeks, at least about three weeks, at least about four weeks, at least about six weeks, at least about seven weeks, or at least about eight weeks after the patient's last dose of eculizumab. In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof (e.g., reflizumab) is administered to the patient, wherein treatment (e.g., administration cycle) begins at least two weeks after the last dose of eculizumab by the patient.

In some embodiments, patients treated according to the methods described herein have been vaccinated against meningococcal infection within 3 years prior to or at the time of treatment initiation. In one embodiment, patients who receive treatment within less than 2 weeks after receiving a meningococcal vaccine are also treated with an appropriate prophylactic antibiotic until 2 weeks after vaccination. In another embodiment, patients treated according to the methods described herein are vaccinated against meningococcal serotype A, C, Y, W135 and/or B.

In another aspect, the described treatment regimen is sufficient to maintain a particular serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof. For example, in one embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen binding fragment thereof of 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 200, 205, 210, 215, 220, 225, 230, 240, 245, 250, 255, 260, 265, 270, 280, 290, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345, 350, 355, 360, 365, 370, 375, 380, 385, 390, 395, or 400 μ g/ml or greater during the treatment. In one embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 100 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 150 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 200 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 250 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 300 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof between 100 μ g/ml and 200 μ g/ml. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of about 175 μ g/ml.

In another embodiment, to obtain an effective response, the anti-C5 antibody is administered to the patient in an amount and at a frequency to maintain at least 50 μ g, 55 μ g, 60 μ g, 65 μ g, 70 μ g, 75 μ g, 80 μ g, 85 μ g, 90 μ g, 95 μ g, 100 μ g, 105 μ g, 110 μ g, 115 μ g, 120 μ g, 125 μ g, 130 μ g, 135 μ g, 140 μ g, 145 μ g, 150 μ g, 155 μ g, 160 μ g, 165 μ g, 170 μ g, 175 μ g, 180 μ g, 185 μ g, 190 μ g, 195 μ g, 200 μ g, 205 μ g, 210 μ g, 215 μ g, 220 μ g, 225 μ g, 230 μ g, 235 μ g, 240 μ g, 245 μ g, 250 μ g, 255 μ g, or 260 μ g of antibody per milliliter of patient's blood. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and at a frequency to maintain between 50 μ g and 250 μ g of antibody per ml of patient blood. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and at a frequency to maintain between 100 μ g and 200 μ g of antibody per ml of patient blood. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and at a frequency to maintain about 175 μ g of antibody per ml of patient blood.

In another embodiment, to obtain an effective response, the anti-C5 antibody is administered to the patient in an amount and at a frequency that maintains a minimum concentration of free C5. For example, in one embodiment, the anti-C5 antibody is administered to the patient in an amount and at a frequency to maintain a concentration of free C5 of 0.2 μ g/mL, 0.3 μ g/mL, 0.4 μ g/mL, 0.5 μ g/mL, or less. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and at a frequency to maintain a concentration of free C5 of 0.309 to 0.5 μ g/mL or less. In another embodiment, the treatment described herein reduces the concentration of free C5 by greater than 99% during the entire treatment period. In another embodiment, the treatment reduces the concentration of free C5 by greater than 99.5% throughout the treatment period.

The anti-C5 antibody or antigen-binding fragment thereof can be administered to the patient by any suitable means. In one embodiment, the antibody is formulated for intravenous administration.

Any suitable means may be used to assess the efficacy of the treatment methods provided herein. In one embodiment, for aHUS patients, the treatment produces at least one therapeutic effect selected from the group consisting of: severe hypertension, proteinuria, uremia, lethargy/fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and reduction or cessation of renal function impairment (e.g., acute renal failure).

In other embodiments, the treatment results in terminal complement inhibition.

In other embodiments, the treatment results in a shift to normal levels of a hemolysis-related blood biomarker selected from the group consisting of: free hemoglobin, haptoglobin, reticulocyte count, PNH Red Blood Cell (RBC) clone, and D-dimer.

In another embodiment, the treatment results in an increase in hemoglobin stability from the patient's pre-treatment baseline. In another embodiment, the treatment produces an increase of ≧ 20g/L of hemoglobin. In another embodiment, the treatment avoids a decrease in hemoglobin levels from baseline by ≧ 2g/dL without transfusion from baseline to day 183.

In other embodiments, the treatment normalizes platelets (> 150X 10)⁹L). In other embodiments, the treatment normalizes platelets (> 150X 10)⁹/L) for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

In other embodiments, the treatment normalizes LDH (< 246U/L). In other embodiments, the treatment normalizes LDH (< 246U/L) for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

In other embodiments, the treatment results in an increase in serum creatinine of greater than or equal to 25% from baseline. In other embodiments, the treatment results in an increase in serum creatinine of ≧ 25% from baseline for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

In other embodiments, the treatment results in complete TMA response (i.e., normalization of platelets (. gtoreq.150X 10)⁹/L), normalization of LDH (< 246U/L) and increase of serum creatinine > 25% from baseline. In other embodiments, the treatment produces a complete TMA response for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

In other embodiments, the treatment results in an improved complete TMA response (i.e., platelet normalization (> 150X 10)⁹/L), LDH normalized (≦ 246U/L), and the patient stopped dialysis if the patient had dialysis at baseline, or increased serum creatinine by ≧ 25% from baseline for patients who stopped dialysis at baseline. In other embodiments, the treatment results in an improved complete TMA response for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

In other embodiments, the treatment results in a reduction in the need for blood transfusion. In another embodiment, the treatment increases avoidance of blood transfusion by greater than 70%. In another embodiment, the treatment avoids transfusion from baseline to day 183.

In other embodiments, the treatment results in elimination of breakthrough hemolysis during the treatment period. In another embodiment, the treatment results in a reduction in breakthrough hemolysis as compared to a baseline amount of breakthrough hemolysis prior to treatment.

In other embodiments, the treatment results in a reduction in Major Adverse Vascular Events (MAVEs).

In other embodiments, the treatment produces a change in quality of life from baseline as assessed by the functional assessment of chronic disease therapy (FACIT) -fatigue scale version 4 and the european cancer research and treatment organization, quality of life questionnaire-core 30 scale. In one embodiment, the treatment produces a change in quality of life from baseline, as assessed by one or more (e.g., 1, 2, or 3) points via the FACIT-fatigue scale. In another embodiment, the treatment produces a change in quality of life from baseline as assessed by the FACIT-fatigue scale through 3 points for 150 or more days (e.g., 150 days, 151 days, 152 days, 153 days, 154 days, 155 days, 156 days, 157 days, 158 days, 159 days, 160 days, 161 days, 162 days, 163 days, 164 days, 165 days, 166 days, 167 days, 168 days, 169 days, 170 days, 171 days, 172 days, 173 days, 174 days, 175 days, 176 days, 177 days, 178 days, 179 days, 180 days, 181 days, 182 days, 183 days, 184 days, 185 days, 186 days, 187 days, 188 days, 189 days, 190 days, 191 days, 192 days, 194 days, 195 days, 196 days, 197 days, 198 days, 199 days, 200 days, 205 days, 210 days, 215 days, 220 days, or 225 days) after initiation of treatment.

Chronic Kidney Disease (CKD) staging chronic kidney disease staging is classified based on the national kidney foundation. The stage of CKD and corresponding estimated glomerular filtration rate (eGFR) values are as follows: stage 1: eGFR > -90 (normal), stage 2: eGFR 60-89, phase 3A: eGFR 45-59, phase 3B: eGFR 30-44, stage 4: eGFR 15-29, and stage 5: eGFR <15 (including dialysis: end stage). Stage 1 was considered the best category. Stage 5 was considered the worst category. An improvement in eGFR (e.g., >15) corresponds to an improvement in CKD staging (e.g., lower CKD staging). Thus, in other embodiments, the patient's Chronic Kidney Disease (CKD) improves one or more stages after treatment is initiated. For example, CKD of a patient improves by one, two, three, four, or five stages). In another embodiment, the patient's CKD improves one or more subperiods for 150 or more days (e.g., 150 days, 151 days, 152 days, 153 days, 154 days, 155 days, 156 days, 157 days, 158 days, 159 days, 160 days, 161 days, 162 days, 163 days, 164 days, 165 days, 166 days, 167 days, 168 days, 169 days, 170 days, 171 days, 172 days, 173 days, 174 days, 175 days, 176 days, 177 days, 178 days, 179 days, 180 days, 181 days, 182 days, 183 days, 184 days, 185 days, 186 days, 187 days, 188 days, 189 days, 190 days, 191 days, 192 days, 193 days, 194 days, 195 days, 196 days, 197 days, 198 days, 199 days, 200 days, 205 days, 210 days, 215 days, 220 days, or 225 days) after initiation of treatment.

In other embodiments, the treatment results in an increase in eGFR compared to baseline. In other embodiments, the treatment produces a shift to normal eGFR levels (e.g., > 90). In other embodiments, the treatment results in an increase in eGFR and improvement in CKD in the patient by one or more stages as compared to baseline. In other embodiments, the treatment produces a shift to normal eGFR levels (e.g., ≧ 90) as compared to baseline, and the patient's CKD improves one or more stages.

In other embodiments, the treatment results in an EQ-5D-3L time tradeoff setting (US TTO) >0.94 for the united states.

In another aspect, there is provided an anti-C5 antibody or antigen-binding fragment thereof for administration to a patient having aHUS, the anti-C5 antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 domains of the heavy chain variable region having the sequence set forth in SEQ ID No. 12, and the CDR1, CDR2, and CDR3 domains of the light chain variable region having the sequence set forth in SEQ ID No. 8:

(a) once on day 1 in a patient weighing ≥ 40 to <60kg at a dose of 2400mg, in a patient weighing ≥ 60 to <100kg at a dose of 2700mg or in a patient weighing ≥ 100kg at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

3000mg is administered to a patient weighing ≥ 40 to <60kg, 3300mg to a patient weighing ≥ 60 to <100kg, or 3600mg to a patient weighing ≥ 100 kg.

In one embodiment, the antibodies are determined to be safe, tolerable and safe after multiple IV doses for aHUS patients

Sufficiently non-immunogenic.

Further provided is a kit comprising a therapeutically effective amount of a pharmaceutical composition comprising an anti-C5 antibody or antigen-binding fragment thereof (e.g., the antibody reflizumab) and a pharmaceutically acceptable carrier suitable for use in the methods described herein. In one embodiment, the kit comprises:

(a) a dose of an anti-C5 antibody or antigen-binding fragment thereof comprising the CDR1, CDR2 and CDR3 domains of the heavy chain variable region having the sequence set forth in SEQ ID No. 12 and the CDR1, CDR2 and CDR3 domains of the light chain variable region having the sequence set forth in SEQ ID No. 8: and

(b) instructions for using the anti-C5 antibody or antigen-binding fragment thereof in the methods described herein.

In one embodiment, 2400 or 3000mg of an anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 40 to <60 kg. In another embodiment, 2700mg or 3300mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 60 to <100 kg. In another embodiment, 3000mg or 3600mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 100 kg.

Drawings

FIG. 1 depicts the study design for ALXN 1210-aHUS-311.

FIG. 2 summarizes the primary, secondary and safety endpoints of ALXN 1210-aHUS-311.

FIG. 3 summarizes the inclusion and exclusion criteria for ALXN 1210-aHUS-311.

FIG. 4 shows patient treatment of ALXN 1210-aHUS-311.

Figure 5 lists data for derivative instances with confirmed full TMA responses.

Figure 6 is a wien diagram showing key efficacy data related to a primary full TMA response during a primary evaluation.

Figure 7 is a graph depicting the time to reach a full TMA response.

FIG. 8 is a graph depicting mean serum concentration (μ g/mL) versus time (linear scale). Administration based on body weight resulted in maximum, steady-state and trough exposure, as predicted, with no unexpected pharmacokinetic results.

Figure 9 is a series of bar graphs depicting key efficacy data related to primary full TMA response during primary evaluation and by data slicing. The 95% confidence interval is represented by the line at the top of each bar.

Figure 10 shows total and subset full TMA responses during the initial 26 week evaluation period.

Figure 11 depicts key efficacy results for complete TMA response status over time (open circles) including normalization of platelet counts (open triangles), normalization of hematology (+), 25% increase in serum creatinine over baseline (open squares), and normalization of LDH (X).

Fig. 12 shows the mean eGFR change (mL/min/1.73m2) and 95% confidence intervals over time from baseline.

Fig. 13 shows the staging transition of Chronic Kidney Disease (CKD) from baseline to day 183.

FIG. 14 shows the mean change observed over time relative to baseline and model-based platelets (10)⁹/L) and 95% confidence interval.

FIG. 15 shows mean platelets (10) observed over time⁹/L) and 95% confidence interval.

Figure 16 shows the mean change (U/L) and 95% confidence intervals for observed and model-based LDHs over time relative to baseline.

FIG. 17 shows the average LDH (U/L) and 95% confidence intervals observed over time.

Figure 18 shows the mean change (g/L) and 95% confidence intervals for Hemoglobin (HGB) observed and model-based over time relative to baseline.

FIG. 19 shows the average HGB (g/L) and 95% confidence intervals observed over time.

Figure 20 shows the mean FACIT fatigue change and 95% confidence interval over time relative to baseline. FACIT scores are in the range of 0-52, with higher scores indicating less fatigue.

FIG. 21 shows the mean EQ-5D-3L change and 95% confidence interval over time relative to baseline.

FIG. 22 depicts serum free complement C5 concentration (μ g/L) over time from baseline to day 183.

FIG. 23 compares the study population and results between study ALXN1210-aHUS-311 and the Ekulizumab adult study (C10-004).

Detailed Description

I.anti-C5 antibodies

The anti-C5 antibodies described herein bind to complement component C5 (e.g., human C5) and inhibit cleavage of C5 into fragments C5a and C5 b. As described above, such antibodies also have improved pharmacokinetic properties, e.g., relative to other anti-C5 antibodies (e.g., eculizumab) used for therapeutic purposes.

The term "antibody" describes a polypeptide comprising at least one antigen-binding site (e.g., a VH/VL region or Fv, or CDR) from which an antibody is derived. Antibodies include known forms of antibodies. For example, the antibody can be a human antibody, a humanized antibody, a bispecific antibody, or a chimeric antibody. The antibody may also be Fab, Fab' 2, ScFv, SMIP, or,Nanobodies or domain antibodies. The antibody may also have any of the following isotypes: IgG1, IgG2, IgG3, IgG4, IgM, IgA1, IgA2, IgAsec, IgD, and IgE. The antibody may be a naturally occurring antibody or may be an antibody that has been altered by protein engineering techniques (e.g., by mutation, deletion, substitution, conjugation to a non-antibody moiety). For example, an antibody can include one or more variant amino acids (as compared to a naturally occurring antibody) that alter a property (e.g., a functional property) of the antibody. For example, numerous such changes are known in the art, e.g., affecting half-life, effector function, and/or immune response to an antibody in a patient. The term antibody also includes artificial or engineered polypeptide constructs comprising at least one antigen-binding site from which the antibody is derived.

anti-C5 antibodies (or VH/VL domains derived therefrom) suitable for use in the present invention may be generated using methods well known in the art. Alternatively, art-recognized anti-C5 antibodies may be used. Antibodies that compete with any of these art-recognized antibodies for binding to C5 can also be used.

Ekulizumab (also known as) Is an anti-C5 antibody comprising heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 1, 2, and 3, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 4, 5, and 6, respectively. Ekulizumab comprises a heavy chain variable region having the amino acid sequence set forth in SEQ ID NO. 7 and a light chain variable region having the amino acid sequence set forth in SEQ ID NO. 8. The variable regions of eculizumab are described in PCT/US1995/005688 and U.S. patent No. 6,355,245, the teachings of which are hereby incorporated by reference. Ekulizumab comprises a heavy chain comprising the amino acid sequence set forth in SEQ ID NO 10 and a light chain having the amino acid sequence set forth in SEQ ID NO 11. The complete heavy and light chains of eculizumab are described in PCT/US2007/006606, the teachings of which are hereby incorporated by reference.

An exemplary anti-C5 antibody is reflizumab, or antigen-binding fragments and variants thereof, comprising a heavy chain and a light chain having the sequences set forth in SEQ ID NOs 14 and 11, respectively. Ravulizumab (also known as Ravulizumab)BNJ441 and ALXN1210) are described in PCT/US2015/019225 and U.S. patent nos.: 9,079,949, the teachings of which are hereby incorporated by reference. The terms refranuzumab, BNJ441, and ALXN1210 are used interchangeably in this document, but all refer to the same antibody. Raflizumab selectively binds to human complement protein C5, inhibiting its cleavage to C5a and C5b during complement activation. This inhibition prevents the release of pro-inflammatory mediators C5a and the formation of the cytolytic pore Membrane Attack Complex (MAC) C5b-9, while retaining the proximal or early components of complement activation (e.g., C3 and C3b) that are essential for opsonization of the microorganism and clearance of immune complexes.

In other embodiments, the antibody comprises the heavy and light chain CDRs or variable regions of refolizumab. For example, in one embodiment, the antibody comprises the CDR1, CDR2, and CDR3 domains of the VH region of refolizumab having the sequence set forth in SEQ ID No. 12, and the CDR1, CDR2, and CDR3 domains of the VL region of refolizumab having the sequence set forth in SEQ ID No. 8. In another embodiment, the antibody comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 19, 18, and 3, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 4, 5, and 6, respectively. In another embodiment, the antibody comprises a VH region and a VL region having the amino acid sequences set forth in SEQ ID NO 12 and SEQ ID NO 8, respectively.

Another exemplary anti-C5 antibody is antibody BNJ421, which comprises heavy and light chains having the sequences set forth in SEQ ID NOs 20 and 11, respectively, or antigen-binding fragments and variants thereof. BNJ421 (also referred to as ALXN1211) is described in PCT/US2015/019225 and U.S. Pat. No. 9,079,949, the teachings of which are hereby incorporated by reference.

In other embodiments, the antibody comprises the heavy and light chain CDRs or variable regions of BNJ 421. Thus, in one embodiment, the antibody comprises the CDR1, CDR2, and CDR3 domains of the VH region of BNJ421 having the sequence set forth in SEQ ID No. 12, and the CDR1, CDR2, and CDR3 domains of the VL region of BNJ421 having the sequence set forth in SEQ ID No. 8. In another embodiment, the antibody comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 19, 18, and 3, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs 4, 5, and 6, respectively.

The exact boundaries of the CDRs have been defined differently according to different approaches. In some embodiments, the position of the CDR or framework region within the light or heavy chain variable domain may be as described in Kabat et al [ (1991) "Sequences of Proteins of Immunological interest" [ NIH publication No. 91-3242, department of health and public service, Bethesda, MD]As defined. In such cases, the CDRs may be referred to as "Kabat CDRs" (e.g., "Kabat LCDR 2" or "Kabat HCDR 1"). In thatIn some embodiments, the CDRs of the light or heavy chain variable region may be positioned by Chothia et al (1989) Nature342877-883. Thus, these regions may be referred to as "Chothia CDRs" (e.g., "Chothia LCDR 2" or "Chothia HCDR 3"). In some embodiments, the positions of the CDRs of the light and heavy chain variable regions may be defined by the Kabat-Chothia combination definitions. In such embodiments, these regions may be referred to as "combined Kabat-Chothia CDRs". Thomas et al [ (1996) Mol Immunol33(17/18):1389-1401]The identification of CDR boundaries is exemplified according to the Kabat and Chothia definitions.

In another embodiment, the antibody comprises a VH region and a VL region having the amino acid sequences set forth in SEQ ID NO 12 and SEQ ID NO 8, respectively. In another embodiment, the antibody comprises a heavy chain constant region as set forth in SEQ ID NO 13. In another embodiment, the antibody comprises a heavy chain polypeptide as set forth in SEQ ID NO. 14 and a light chain polypeptide as set forth in SEQ ID NO. 11. In another embodiment, the antibody comprises a variant human Fc constant region that binds to a human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions, each with EU numbering, at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region.

In another embodiment, the anti-C5 antibody described herein comprises a heavy chain CDR1, which heavy chain CDR1 comprises or consists of the amino acid sequence: gHIFSNYWIQ (SEQ ID NO: 19). In another embodiment, the anti-C5 antibody described herein comprises a heavy chain CDR2, which heavy chain CDR2 comprises the following amino groupsThe sequence or the amino acid sequence of the following: EILPGSGHTEYTENFKD(SEQ ID NO:18)。

In some embodiments, the anti-C5 antibodies described herein can comprise a variant human Fc constant region that binds with greater affinity to a human neonatal Fc receptor (FcRn) than a native human Fc constant region from which the variant human Fc constant region is derived. For example, the Fc constant region can comprise one or more (e.g., two, three, four, five, six, seven, or eight or more) amino acid substitutions relative to a native human Fc constant region from which the variant human Fc constant region is derived. The substitutions can increase the binding affinity of IgG antibodies containing the variant Fc constant region to FcRn at pH 6.0 while maintaining the pH dependence of the interaction. Methods for testing whether one or more substitutions in the Fc constant region of an antibody increases the affinity of the Fc constant region for FcRn at pH 6.0 (while maintaining the pH dependence of the interaction) are known in the art and exemplified in the working examples. See, e.g., PCT/US2015/019225 and U.S. patent No. 9,079,949, the disclosures of each of which are incorporated herein by reference in their entireties.

Substitutions that enhance the binding affinity of the Fc constant region of an antibody for FcRn are known in the art and include, for example, (1) Dall' Acqua et al (2006) J Biol Chem281M252Y/S254T/T256E triple substitutions as described in 23514 and 23524; (2) hinton et al (2004) J Biol Chem2796213-6216 and Hinton et al (2006) J Immunol176346-356 for substitution M428L or T250Q/M428L; and (3) Petkova et al (2006) Int Immunol18(12)Substitution N434A or T307/E380A/N434A as described in 1759-69. Additional substitution pairing: P257I/Q311I, P257I/N434H and D376V/N434H are described, for example, in Datta-Mannan et al (2007) J Biol Chem282(3)1709-1717, the disclosure of which is incorporated herein by reference in its entirety.

In some embodiments, the variant constant region has a substitution of valine at EU amino acid residue 255. In some embodiments, the variant constant region has an asparagine substitution at EU amino acid residue 309. In some embodiments, the variant constant region has a substitution of isoleucine at EU amino acid residue 312. In some embodiments, the variant constant region has a substitution at EU amino acid residue 386.

In some embodiments, the variant Fc constant region comprises no more than 30 (e.g., no more than 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, or 2) amino acid substitutions, insertions, or deletions relative to the native constant region from which it is derived. In some embodiments, the variant Fc constant region comprises one or more amino acid substitutions selected from the group consisting of: M252Y, S254T, T256E, N434S, M428L, V259I, T250I and V308F. In some embodiments, the variant human Fc constant region comprises a methionine at position 428 and an asparagine at position 434, each with EU numbering. In some embodiments, the variant Fc constant region comprises a 428L/434S double substitution as described, for example, in U.S. patent No. 8.088,376.

In some embodiments, the precise location of these mutations may be offset from the native human Fc constant region location due to antibody engineering. For example, when used in an IgG2/4 chimeric Fc, the 428L/434S double substitution may correspond to 429L and 435S in the M429L and N435S variants as found in BNJ441 (refrozumab) and described in U.S. patent No. 9,079,949, the disclosures of which are incorporated herein by reference in their entirety.

In some embodiments, the variant constant region comprises a substitution at amino acid position 237, 238, 239, 248, 250, 252, 254, 255, 256, 257, 258, 265, 270, 286, 289, 297, 298, 303, 305, 307, 308, 309, 311, 312, 314, 315, 317, 325, 332, 334, 360, 376, 380, 382, 384, 385, 386, 387, 389, 424, 428, 433, 434, or 436(EU numbering) relative to the native human Fc constant region. In some embodiments, the substitution is selected from the group consisting of: a methionine for glycine at position 237; alanine for proline at position 238; a lysine substituted for serine at position 239; isoleucine for lysine at position 248; an alanine, phenylalanine, isoleucine, methionine, glutamine, serine, valine, tryptophan, or tyrosine substituted for threonine at position 250; a phenylalanine, tryptophan, or tyrosine substituted for methionine at position 252; a threonine in place of serine at position 254; a glutamic acid for arginine at position 255; an aspartic acid, glutamic acid, or glutamine substituted for threonine at position 256; alanine, glycine, isoleucine, leucine, methionine, asparagine, serine, threonine, or valine at position 257 in place of proline; a histidine for glutamic acid at position 258; alanine for aspartic acid at position 265; a phenylalanine at position 270 in place of aspartic acid; alanine or glutamic acid for asparagine at position 286; a histidine for threonine at position 289; alanine for asparagine at position 297; a glycine substituted for serine at position 298; alanine for valine at position 303; alanine for valine at position 305; alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, methionine, asparagine, proline, glutamine, arginine, serine, valine, tryptophan, or tyrosine for threonine at position 307; alanine, phenylalanine, isoleucine, leucine, methionine, proline, glutamine, or threonine for valine at position 308; alanine, aspartic acid, glutamic acid, proline, or arginine for leucine or valine at position 309; alanine, histidine or isoleucine for glutamine at position 311; an alanine or histidine for aspartic acid at position 312; a lysine or arginine at position 314 in place of leucine; an alanine or histidine for asparagine at position 315; alanine for lysine at position 317; glycine substituted asparagine at position 325; a valine for isoleucine at position 332; a leucine substituted for lysine at position 334; histidine for lysine at position 360; an alanine for aspartic acid at position 376; alanine for glutamic acid at position 380; alanine for glutamic acid at position 382; an alanine for asparagine or serine at position 384; an aspartic acid or histidine for glycine at position 385; proline in position 386 for glutamine; glutamic acid for proline at position 387; an alanine or serine substituted for asparagine at position 389; alanine for serine at position 424; alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, asparagine, proline, glutamine, serine, threonine, valine, tryptophan, or tyrosine for methionine at position 428; a lysine substituted histidine at position 433; (iii) an alanine, phenylalanine, histidine, serine, tryptophan, or tyrosine substituted for asparagine at position 434; and histidine for tyrosine or phenylalanine at position 436, all with EU numbering.

In some embodiments, a suitable anti-C5 antibody for use in the methods described herein comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO. 14 and/or a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO. 11. Alternatively, in some embodiments, the anti-C5 antibody used in the methods described herein comprises a heavy chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO. 20 and/or a light chain polypeptide comprising the amino acid sequence depicted in SEQ ID NO. 11.

In one embodiment, the antibody has an affinity dissociation constant (k.k.775, 0.8, 0.825, 0.85, 0.875, 0.9, 0.925, 0.95, or 0.975) nM at pH 7.4 and 25 ℃ (and, in other aspects, under physiological conditions) of at least 0.1 (e.g., at least 0.15, 0.175, 0.2, 0.25, 0.275, 0.3, 0.325, 0.35, 0.375, 0.4, 0.425, 0.45, 0.475, 0.5, 0.525, 0.55, 0.575, 0.6, 0.625, 0.65, 0.675, 0.7, 0.725, 0.75, 0.775, 0.8, 0.825, 0.85, 0.875, 0.9, 0.925, 0.95, or 0.975)_D) Bound to C5. In some embodiments, the K of the anti-C5 antibody or antigen-binding fragment thereof_DNot greater than 1 (e.g., not greater than 0.9, 0.8, 0.7, 0.6, 0.5, 0.4, 0.3, or 0.2) nM.

In other embodiments, [ (K of the antibody to C5 at C at pH 6.0)_D) /(K of the antibody to C5 at 25 ℃ at pH 7.4_D)]Greater than 21 (e.g., greater than 22, 23, 24, 25, 26, 27, 28, 29, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300, 350, 400, 450, 500, 600, 700, 800, 900, 1000, 1500, 2000, 2500, 3000, 3500, 4000, 4500, 5000, 5500, 6000, 6500, 7000, 7500, or 8000).

Methods for determining whether an antibody binds to a protein antigen and/or the affinity of an antibody for a protein antigen are known in the art. For example, various techniques can be used to detect and/or quantify antibodies andbinding of protein antigens by techniques such as, but not limited to, western blotting, dot blotting, Surface Plasmon Resonance (SPR) methods (e.g., BIAcore system; Pharmacia Biosensor AB, Uppsala, Sweden and Piscataway, N.J.) or enzyme-linked immunosorbent assay (ELISA). See, e.g., Benny K.C.Lo (2004) "Antibody Engineering: Methods and Protocols," Humana Press (ISBN: 1588290921); john et al (1993) J Immunol Meth160191 and 198; jonsson et al (1993) Ann Biol Clin5119-26; and Jonsson et al (1991) Biotechniques11:620-627. Furthermore, methods for measuring affinity (e.g., dissociation and association constants) are set forth in the working examples.

As used herein, the term "k_a"refers to the rate constant at which an antibody associates with an antigen. The term "k_d"refers to the rate constant at which an antibody dissociates from an antibody/antigen complex. And the term "K_D"refers to the equilibrium dissociation constant of an antibody-antigen interaction. The equilibrium dissociation constant being the ratio K from the kinetic rate constant_D＝k_a/k_dAnd (4) deducing. Such assays are preferably measured at 25 ℃ or 37 ℃ (see working examples). For example, the kinetics of antibody binding to human C5 can be determined by immobilizing the antibody using an anti-Fc capture method on a BIAcore 3000 instrument by Surface Plasmon Resonance (SPR) at pH 8.0, 7.4, 7.0, 6.5 and 6.0.

In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof blocks the production or activity of a C5a and/or C5b active fragment of a C5 protein (e.g., a human C5 protein). Through this blocking effect, antibodies inhibit, for example, the pro-inflammatory effects of C5a and the production of C5b-9 Membrane Attack Complex (MAC) at the cell surface.

Methods for determining whether a particular antibody described herein inhibits cleavage of C5 are known in the art. Inhibition of human complement component C5 reduces the cytolytic capacity of complement in a body fluid of a subject. This reduction in the cytolytic capacity of complement present in body fluids can be measured by methods well known in the art, such as for example by conventional hemolytic assays, such as Kabat and Mayer (eds), "Experimental biochemistry, 2 nd edition," 135-240, Springfield, IL, CC ThThe hemolysis assay described in omas (1961), pp.135-139, or conventional variants of said assay such as, for example, Hillmen et al (2004) N Engl J Med350(6)552. Methods for determining whether a candidate compound inhibits the cleavage of human C5 into C5a and C5b forms are known in the art and described in Evans et al (1995) Mol Immunol32(16)1183-95. For example, the concentration and/or physiological activity of C5a and C5b in a bodily fluid can be measured by methods well known in the art. For C5b, a hemolytic assay as discussed herein or an assay for soluble C5b-9 may be used. Other assays known in the art may also be used. Using these or other suitable types of assays, candidate agents that are capable of inhibiting human complement fraction C5 can be screened.

Immunological techniques such as, but not limited to, ELISA can be used to measure the protein concentration of C5 and/or its split products to determine the ability of an anti-C5 antibody or antigen-binding fragment thereof to inhibit the conversion of C5 to a biologically active product. In some embodiments, C5a production is measured. In some embodiments, a C5b-9 neo-epitope specific antibody is used to detect the formation of terminal complement.

A hemolytic assay may be used to determine the inhibitory activity of the anti-C5 antibody or antigen binding fragment thereof on complement activation. To determine the effect of anti-C5 antibodies or antigen-binding fragments thereof on classical complement pathway-mediated hemolysis in vitro serum test solutions, for example, sheep red blood cells coated with hemolysin or chicken red blood cells sensitized with anti-chicken red blood cell antibodies were used as target cells. The percent lysis was normalized by considering that 100% lysis was equal to lysis that occurred in the absence of inhibitor. In some embodiments, the classical complement pathway is activated by human IgM antibodies, e.g., as inClassical pathway complement kit (COMPL CP310, Euro-diagnostic, Sweden). Briefly, test sera were combined with anti-C5 antibody or antigen-binding fragment thereof in the presence of human IgM antibodyThe sections are incubated together. The amount of C5b-9 produced is measured by contacting the mixture with an enzyme conjugated anti-C5 b-9 antibody and a fluorogenic substrate and measuring the absorbance at the appropriate wavelength. As a control, the test sera were incubated in the absence of anti-C5 antibody or antigen-binding fragment thereof. In some embodiments, the test serum is a C5-deficient serum reconstituted with a C5 polypeptide.

To determine the effect of anti-C5 antibodies or antigen-binding fragments thereof on alternative pathway-mediated hemolysis, unsensitized rabbit or guinea pig erythrocytes were used as target cells. In some embodiments, the serum test solution is a C5-deficient serum reconstituted with a C5 polypeptide. The percent lysis was normalized by considering that 100% lysis was equal to lysis that occurred in the absence of inhibitor. In some embodiments, the alternative complement pathway is activated by a lipopolysaccharide molecule, e.g., as inAlternative pathway complement kit (COMPL AP330, Euro-diagnostic, Sweden). Briefly, test sera were incubated with anti-C5 antibody or antigen-binding fragment thereof in the presence of lipopolysaccharide. The amount of C5b-9 produced is measured by contacting the mixture with an enzyme conjugated anti-C5 b-9 antibody and a fluorogenic substrate and measuring the fluorescence at the appropriate wavelength. As a control, the test sera were incubated in the absence of anti-C5 antibody or antigen-binding fragment thereof.

In some embodiments, the C5 activity or inhibition thereof is quantified using a CH50eq assay. The CH50eq assay is a method for measuring total classical complement activity in serum. This test is a lysis assay that uses antibody-sensitized erythrocytes as activators of the classical complement pathway and various dilutions of test serum to determine the amount required to give 50% lysis (CH 50). The percentage of hemolysis can be determined, for example, using a spectrophotometer. The CH50eq assay provides an indirect measurement of Terminal Complement Complex (TCC) formation, as TCC itself is directly responsible for the measured hemolysis.

Such assays are well known and commonly practiced by those skilled in the art. Briefly, to activate the classical complement pathway, an undiluted serum sample (e.g., a reconstituted human serum sample) is added to a microassay well containing antibody-sensitized red blood cells to thereby generate TCCs. Next, the activated serum is diluted in a microassay well coated with a capture reagent (e.g., an antibody that binds to one or more components of TCC). TCC present in the activated sample binds to the monoclonal antibody coating the surface of the microassay wells. The wells were washed and a detection reagent that detectably labeled and recognized bound TCC was added to each well. The detectable label may be, for example, a fluorescent label or an enzymatic label. The results are expressed as CH50 units equivalent/mL (CH 50U Eq/mL).

Inhibition (e.g., when it relates to terminal complement activity) includes at least a 5% reduction in terminal complement activity (e.g., at least 6%, 7%, 8%, 9%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, or 60%) as compared to the effect of a control antibody (or antigen-binding fragment thereof) under similar conditions and equimolar concentrations, e.g., in a hemolytic assay or CH50eq assay. As used herein, significantly inhibited refers to at least 40% (e.g., at least 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, or 95% or more) inhibition of a given activity (e.g., terminal complement activity). In some embodiments, the anti-C5 antibodies described herein contain one or more amino acid substitutions relative to the CDRs of eculizumab (i.e., SEQ ID NOs: 1-6), but still retain at least 30% (e.g., at least 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90% or 95%) of the complement inhibitory activity of eculizumab in a hemolytic assay or CH50eq assay.

The anti-C5 antibodies described herein have a serum half-life in humans of at least 20 (e.g., at least 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, or 55) days. In another embodiment, the anti-C5 antibody described herein has a serum half-life in humans of at least 40 days. In another embodiment, the anti-C5 antibody described herein has a serum half-life of about 43 days in humans. In another embodiment, the anti-C5 antibody described herein has a serum half-life in humans of between 39-48 days. Methods for measuring the serum half-life of an antibody are known in the art. In some embodiments, the anti-C5 antibodies or antigen-binding fragments thereof described herein have a serum half-life that is at least 20% (e.g., at least 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 125%, 150%, 175%, 200%, 250%, 300%, 400%, 500%) greater than that of eculizumab, e.g., as measured in one of the mouse model systems described in the working examples (e.g., C5 deficient/NOD/scid mouse or hFcRn transgenic mouse model system).

In one embodiment, the antibody competes for binding to and/or to the same epitope on C5 as the antibody described herein. The term "binding to the same epitope" with respect to two or more antibodies refers to the binding of the antibodies to the same segment of amino acid residues as determined by a given method. Techniques for determining whether an antibody binds to the same epitope on "C5" as the antibody described herein include, for example, epitope mapping methods such as x-ray analysis of the antibody complex crystals, which provide atomic resolution of the epitope and hydrogen/deuterium exchange mass spectrometry (HDX-MS). Other methods monitor binding of antibodies to peptide antigen fragments or mutant variants of antigens, where loss of binding due to modification of amino acid residues within the antigen sequence is often considered an indicator of epitope composition. Furthermore, computational combinatorial methods for epitope mapping can also be used. These methods rely on the ability of the antibody of interest to affinity isolate specific short peptides from combinatorial phage display peptide libraries. Antibodies with the same VH and VL or the same CDR1, 2, and 3 sequences are expected to bind to the same epitope.

An antibody that "competes for binding to a target with another antibody" refers to an antibody that inhibits (partially or completely) the binding of the other antibody to the target. Whether two antibodies compete with each other for binding to the target (i.e., whether and to what extent one antibody inhibits the binding of the other antibody to the target) can be determined using known competition experiments. In certain embodiments, the antibody competes with another antibody and inhibits binding of the other antibody to the target by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100%. The level of inhibition or competition may vary depending on which antibody is the "blocking antibody" (i.e., the cold antibody that is first incubated with the target). The competing antibodies bind to the same epitope, an overlapping epitope, or an adjacent epitope (e.g., as evidenced by steric hindrance).

The anti-C5 antibodies or antigen-binding fragments thereof described herein for use in the methods described herein can be generated using a variety of art-recognized techniques. Monoclonal antibodies can be obtained by a variety of techniques familiar to those skilled in the art. Briefly, spleen cells from animals immunized with the desired antigen are immortalized, typically by fusion with myeloma cells (see, Kohler & Milstein, Eur. J. Immunol.6:511-519 (1976)). Alternative methods of immortalization include transformation with epstein-barr virus, oncogenes or retroviruses, or other methods well known in the art. Colonies produced by a single immortalized cell are screened to produce antibodies with the desired specificity and affinity for the antigen, and the production of monoclonal antibodies produced by such cells can be enhanced by various techniques including injection into the peritoneal cavity of a vertebrate host. Alternatively, the DNA sequence encoding the monoclonal antibody or binding fragment thereof can be isolated by screening a DNA library from human B cells according to the general protocol outlined by Huse, et al, Science 246:1275-1281 (1989).

II.Composition comprising a metal oxide and a metal oxide

Further, provided herein are compositions comprising an anti-C5 antibody or antigen-binding fragment thereof. In one embodiment, the composition comprises an anti-C5 antibody comprising the CDR1, CDR2 and CDR3 domains in the heavy chain variable region having the sequence set forth in SEQ ID No. 12 and the CDR1, CDR2 and CDR3 domains in the light chain variable region having the sequence set forth in SEQ ID No. 8. In another embodiment, the anti-C5 antibody comprises a heavy chain and a light chain having the sequences set forth in SEQ ID NOS: 14 and 11, respectively. In another embodiment, the anti-C5 antibody comprises a heavy chain and a light chain having the sequences set forth in SEQ ID NOS: 20 and 11, respectively.

The compositions can be formulated as pharmaceutical solutions, e.g., for administration to a subject to treat or prevent a complement-associated disorder, such as aHUS. The pharmaceutical composition will generally comprise a pharmaceutically acceptable carrier. As used herein, "pharmaceutically acceptable carrier" refers to and includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like that are physiologically compatible. The composition may comprise a pharmaceutically acceptable salt, such as an acid or base addition salt, a sugar, a carbohydrate, a polyol and/or a tonicity modifier.

The compositions may be formulated according to standard methods. Pharmaceutical preparations are well established technology and are described, for example, in Gennaro (2000) "Remington: The Science and Practice of Pharmacy," 20 th edition, Lippincott, Williams & Wilkins (ISBN: 0683306472); ansel et al (1999) "Pharmaceutical document Forms and Drug Delivery Systems," 7 th edition, Lippincott Williams & Wilkins Publishers (ISBN: 0683305727); and Kibbe (2000) "Handbook of Pharmaceutical Excipients American Pharmaceutical Association," 3 rd edition (ISBN: 091733096X). In some embodiments, the composition can be formulated, for example, as a buffer solution of suitable concentration and suitable for storage at 2 ℃ -8 ℃ (e.g., 4 ℃). In some embodiments, the composition may be formulated for storage at a temperature of less than 0 ℃ (e.g., -20 ℃ or-80 ℃). In some embodiments, the composition can be formulated for storage at 2 ℃ to 8 ℃ (e.g., 4 ℃) for up to 2 years (e.g., one month, two months, three months, four months, five months, six months, seven months, eight months, nine months, 10 months, 11 months, 1 year, 11/2 years, or 2 years). Thus, in some embodiments, the compositions described herein are stable for storage for at least 1 year at 2 ℃ -8 ℃ (e.g., 4 ℃).

The pharmaceutical composition may be in a variety of forms. These forms include, for example, liquid, semi-solid, and solid dosage forms, such as liquid solutions (e.g., injectable and infusible solutions), dispersions or suspensions, tablets, pills, powders, liposomes, and suppositories. The preferred form will depend in part on the intended mode of administration and therapeutic application. For example, a composition containing a composition intended for systemic or local delivery may be in the form of an injectable or infusible solution. Thus, the compositions can be formulated for administration by parenteral modes (e.g., intravenous, subcutaneous, intraperitoneal, or intramuscular injection). As used herein, "parenteral administration," "parenterally administered," and other grammatically equivalent phrases, refer to modes of administration other than enteral and topical administration, typically by injection, and include, but are not limited to, intravenous, intranasal, intraocular, pulmonary, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intrapulmonary, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal, epidural, intracerebral, intracranial, cervical, and intrasternal injection and infusion.

In one embodiment, the composition comprises ranibizumab for injection (also known asAntibody BNJ441 or ALXN 1210). In one embodiment, the injection solution is a sterile, clear to translucent, whitish solution for intravenous use that is preservative-free. In another embodiment, each single dose vial contains 300mg of rivastigmine for injection at a concentration of 10mg/mL and a pH of 7.0. In another embodiment, the raflizumab for injection is required to be diluted to a final concentration of 5 mg/mL. In another embodiment, each mL further comprises polysorbate 80(0.2mg) (of plant origin), sodium chloride (8.77mg), disodium hydrogen phosphate (1.78mg), sodium dihydrogen phosphate (0.46mg), and water for injection.

III.Method of treatment

Provided herein are methods for treating aHUS in a human patient, the methods comprising administering to the patient an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered (or is for administration) according to a particular clinical dosage regimen (i.e., at a particular dose and according to a particular dosing schedule).

As used herein, the terms "induction" and "induction phase" are used interchangeably and refer to the first treatment stage in a clinical trial.

As used herein, the terms "maintenance" and "maintenance phase" are used interchangeably and refer to the second treatment phase in a clinical trial. In certain embodiments, treatment continues as long as clinical benefit is observed or until uncontrollable toxicity or disease progression occurs.

As used herein, the term "subject" or "patient" is a human patient (e.g., a patient suffering from a complement-associated disorder). In one embodiment, the complement-associated disorder is atypical hemolytic uremic syndrome (aHUS). The pathology and clinical presentation of patients with aHUS is also driven by terminal complement activation. More specifically, deregulation of C5 activation and complement activation leads to endothelial injury, platelet depletion, and Thrombotic Microangiopathy (TMA) events characterized by thrombocytopenia, mechanical intravascular hemolysis, and renal injury. Importantly, approximately 20% of patients also experience extrarenal manifestations of the disease, including central nervous system, heart, gastrointestinal, distal extremities and severe systemic organ involvement (Loirat, et al, orphanet.j. rare dis.2011; 6: 60). Symptoms of aHUS are well known to those skilled in the medical field of rare or renal disease and include, for example, severe hypertension, proteinuria, uremia, lethargy/fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and impairment of renal function (e.g., acute renal failure).

aHUS may be genetic, acquired or idiopathic. An aHUS can be considered genetic when two or more (e.g., three, four, five, or six or more) members of the same family are affected by the disease at least six months apart and exposure to common triggers has been excluded, or when one or more aHUS-associated gene mutations (e.g., one or more mutations in CFH, MCP/CD46, CFB, or CFI) are identified in the subject. For example, the subject may have CFH-associated aHUS, CFB-associated aHUS, CFI-associated aHUS, or MCP-associated aHUS. Up to 30% of the inherited aHUS is associated with mutations in CFH, 12% with mutations in MCP, 5% -10% with mutations in CFI, and less than 2% with mutations in CFB. The genetic aHUS can be multiple (i.e., familial; two or more affected family members) or single (i.e., a single event in a family). aHUS can be considered acquired when a potential environmental factor (e.g., a drug, a systemic disease, or a viral or bacterial factor that does not cause a shiga-like exotoxin) or trigger can be identified. aHUS can be considered idiopathic when there is no obvious trigger (genetic or environmental).

Laboratory tests may be performed to determine whether a human subject has thrombocytopenia, microangiopathic hemolytic anemia, or acute renal insufficiency. Thrombocytopenia may be diagnosed by a medical professional as one or more of the following: (i) platelet count below 150,000/mm³(e.g., less than 60,000/mm)³) (ii) a (ii) Decreased platelet survival time, reflecting increased platelet destruction in circulation; (iii) giant platelets are observed in the peripheral smear, consistent with secondary activation of thrombopoiesis. The medical professional may diagnose microangiopathic hemolytic anemia as one or more of the following: (i) hemoglobin concentrations below 10mg/dL (e.g., below 6.5 mg/dL); (ii) increase in serum Lactate Dehydrogenase (LDH) concentration: (>460U/L); (iii) hyperbilirubinemia, reticulocytosis, circulating free hemoglobin and low or undetectable haptoglobin concentration; (iv) fragmented erythrocytes (erythrocytes) with typical aspects of zigzag or pericytes were detected in the peripheral smear, negative with the Coombs test (Coombs test). See, for example, Kaplan et al (1992) "thermal urea synthetic and thermoplastic Thrombocystic purple Purpura," information Health Care (ISBN 0824786637) and Zipfel (2005) "complementary and kinetic Disease," Springer (ISBN 3764371668). Blood concentrations of C3 and C4 can also be used as a measure of complement activation or dysregulation. In addition, the subject's condition can be determined by identifying the subject as having a gene associated with aHUS (e.g., CFI, CFB, C)FH or MCP (supra)) carry one or more mutations for further characterization. Suitable methods for detecting mutations in genes include, for example, DNA sequencing and nucleic acid array techniques. See, e.g., Breslin et al (2006) Clin Am Soc Nephrol188-99 and Goicoechea de Joge et al (2007) Proc Natl Acad Sci USA104:240-245。

As used herein, "effective treatment" refers to treatment that produces a beneficial effect, e.g., ameliorating at least one symptom of a disease or disorder. The beneficial effect may be in the form of an improvement relative to baseline, i.e., an improvement relative to a measurement or observation obtained prior to initiation of treatment according to the method. In the case of aHUS, for example, effective treatment may refer to alleviation of one or more symptoms selected from the group consisting of: severe hypertension, proteinuria, uremia, lethargy/fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and/or renal impairment (e.g., acute renal failure)).

The term "effective amount" refers to an amount of an agent that provides the desired biological, therapeutic and/or prophylactic result. The result can be a reduction, amelioration, palliation, alleviation, delay and/or remission of one or more of the signs, symptoms or causes of a disease, or any other desired alteration of a biological system. In one example, an "effective amount" is an amount of an anti-C5 antibody or antigen-binding fragment thereof that is clinically proven to alleviate at least one symptom of aHUS (e.g., severe hypertension, proteinuria, uremia, lethargy/fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and impairment of renal function (e.g., acute renal failure)). An effective amount may be administered in one or more administrations.

In another embodiment, there is provided a method of treating a human patient having aHUS comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising a CDR1, a CDR2, and a CDR3 heavy chain sequence as set forth in SEQ ID NOs 19, 18, and 3, respectively, and a CDR1, a CDR2, and a CDR3 light chain sequence as set forth in SEQ ID NOs 4, 5, and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof:

(a) once on day 1 in a patient weighing ≥ 40 to <60kg at a dose of 2400mg, in a patient weighing ≥ 60 to <100kg at a dose of 2700mg or in a patient weighing ≥ 100kg at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

3000mg is administered to a patient weighing ≥ 40 to <60kg, 3300mg to a patient weighing ≥ 60 to <100kg, or 3600mg to a patient weighing ≥ 100 kg.

(a) once on day 1 in a patient weighing ≥ 40 to <60kg at a dose of 2400mg, in a patient weighing ≥ 60 to <100kg at a dose of 2700mg or in a patient weighing ≥ 100kg at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

3000mg is administered to a patient weighing ≥ 40 to <60kg, 3300mg to a patient weighing ≥ 60 to <100kg, or 3600mg to a patient weighing ≥ 100 kg.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 to <60 kg:

(a) once on day 1 at a dose of 2400 mg; and

(b) on day 15 and every eight weeks thereafter

A dose of 3000 mg.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 60 to <100 kg:

(a) once on day 1 at a dose of 2700 mg; and

(b) on day 15 and every eight weeks thereafter

3300 mg.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 100 kg:

(a) once on day 1 at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

A dose of 3600 mg.

In some embodiments, the patient has not been previously treated with a complement inhibitor (e.g., the patient is a treatment naive patient to complement inhibitor treatment).

Additionally or alternatively, techniques are used to clear the primary anti-C5 antibody or enhance the clearance of the primary anti-C5 antibody prior to switching to treatment with the second (different) anti-C5 antibody. Exemplary techniques include, but are not limited to, plasmapheresis or blood transfusion. In another embodiment, an antibody directed to the first anti-C5 antibody is administered to clear the first anti-C5 antibody or enhance the clearing of the first anti-C5 antibody (e.g., an anti-eculizumab antibody, an anti-lefralizumab antibody, an anti-7086 antibody, an anti-8110 antibody, an anti-305 LO5 antibody, an anti-SKY 59 antibody, or an anti-REGN 3918 antibody), followed by administration of a second (different) anti-C5 antibody.

In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof (e.g., refolizumab) is administered to the patient, wherein the administration cycle begins at least about two weeks, at least about three weeks, at least about four weeks, at least about six weeks, at least about seven weeks, or at least about eight weeks after the patient's last dose of eculizumab. In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof (e.g., reflizumab) is administered to the patient, wherein treatment (e.g., administration cycle) begins at least two weeks after the last dose of eculizumab by the patient.

As used herein, the term "serum trough level" refers to the minimum level of an agent (e.g., an anti-C5 antibody or antigen-binding fragment thereof) or drug present in serum. Conversely, "peak serum level" refers to the highest level of the agent in the serum. "average serum level" refers to the average level of an agent in serum over time.

In one embodiment, the described treatment regimen is sufficient to maintain a specific serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof. For example, in one embodiment, the treatment maintains a serum trough concentration of 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 200, 205, 210, 215, 220, 225, 230, 240, 245, 250, 255, 260, 265, 270, 280, 290, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345, 350, 355, 360, 365, 370, 375, 380, 385, 390, 395, or 400 μ g/ml or greater anti-C5 antibody or antigen binding fragment thereof. In one embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 100 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 150 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 200 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 250 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of 300 μ g/ml or greater. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof between 100 μ g/ml and 200 μ g/ml. In another embodiment, the treatment maintains a serum trough concentration of anti-C5 antibody or antigen-binding fragment thereof of about 175 μ g/ml.

IV.Results

Provided herein are methods for treating aHUS in a patient, comprising administering to the patient an anti-C5 antibody or antigen-binding fragment thereof.

Symptoms of aHUS include, but are not limited to, severe hypertension, proteinuria, uremia, lethargy/fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and impaired renal function (e.g., acute renal failure). Patients treated according to the methods disclosed herein preferably experience an improvement in at least one sign of aHUS.

In other embodiments, the treatment results in terminal complement inhibition.

In other embodiments, the treatment results in a reduction in Major Adverse Vascular Events (MAVEs).

In other embodiments, the treatment results in an EQ-5D-3L time tradeoff setting (US TTO) >0.94 for the united states.

V.Pharmaceutical kit and unit dosage form

Also provided herein is a kit comprising a therapeutically effective amount of a pharmaceutical composition comprising an anti-C5 antibody or antigen-binding fragment thereof (e.g., ranibizumab) and a pharmaceutically acceptable carrier suitable for use in the methods described herein. The kit can also optionally include instructions, e.g., including an administration schedule, to allow a practitioner (e.g., a physician, nurse, or patient) to administer the composition contained therein to administer the composition to a patient having aHUS. The kit may further comprise a syringe

Optionally, the kit comprises multiple packages of single dose pharmaceutical compositions, each package containing an effective amount of an anti-C5 antibody or antigen-binding fragment thereof for a single administration according to the methods provided above. The kit may also include the equipment or devices necessary for administration of the pharmaceutical composition. For example, the kit may provide one or more pre-filled syringes containing an amount of an anti-C5 antibody or antigen-binding fragment thereof.

In one embodiment, the present invention provides a kit for treating aHUS in a human patient, the kit comprising:

(b) instructions for using the anti-C5 antibody or antigen-binding fragment thereof according to any of the methods described herein.

In one embodiment, the kit comprises a dose of an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 to <60 kg:

(a) once on day 1 at a dose of 2400 mg; and

(b) on day 15 and every eight weeks thereafter

A dose of 3000 mg.

In another embodiment, the kit comprises a dose of an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧ 60 to <100 kg:

(a) once on day 1 at a dose of 2700 mg; and

(b) on day 15 and every eight weeks thereafter

3300 mg.

(a) once on day 1 at a dose of 3000 mg; and

(b) on day 15 and every eight weeks thereafter

A dose of 3600 mg.

The following examples are illustrative only and should not be construed as limiting the scope of the disclosure in any way, as many variations and equivalents will become apparent to those skilled in the art upon reading the disclosure.

The contents of all references, Genbank entries, patents and published patent applications cited in this application are expressly incorporated herein by reference.

Examples

Example 1: phase 3, one-armed, multicenter study of Raftilizumab (ALXN1210) in naive adult patients with complement inhibitors of atypical hemolytic uremic syndrome (aHUS)

One-arm studies of reflizumab (ALXN1210-aHUS-311) were performed in naive adults and adolescent patients with complement inhibitor treatment of atypical hemolytic uremic syndrome (aHUS). Figure 1 shows the study design.

aHUS is a Thrombotic Microangiopathy (TMA), most often caused by mutations in genes encoding proteins involved in the complement replacement pathway (APC) or by autoantibodies directed against APC regulatory proteins (Noris, et al, clin.j.am.soc.nephrol.2010; 5: 1844-59). Patients with aHUS are at risk for life-threatening disease manifestations due to endothelial injury, including thrombocytopenia, intravascular hemolysis, acute renal failure, and extrarenal tissue injury. Importantly, approximately 20% of patients experience extrarenal manifestations of the disease, including central nervous system, heart, gastrointestinal, distal extremities and severe systemic organ involvement (Loirat, et al, Orphanet J. Rare Dis.2011; 6:60 and Brodsky, blood.2015; 126: 2459-65). Patients with aHUS had a mortality rate of up to 15% during the acute progressive phase of disease before eculizumab was available (Noris, et al, clin.j.am.soc.nephrol.2010; 5: 1844-59) and Sellier-Leclerc, j.am.soc.nephrol.2007; 18:2392-2400). Up to 50% of patients typically progress to end stage renal disease (ESKD) within one year of onset and require dialysis or kidney transplantation to sustain life. Chronic, uncontrolled terminal complement activation, particularly activation of complement component 5(C5) and dysregulation of complement activity, are central to the pathogenesis of aHUS and the destructive manifestations of this disease. Thus, targeted blockade of C5 while selectively inhibiting the production of C5a and C5b-9 represents an important therapeutic mechanism for therapy.

1.Target

The primary goal of the study was to assess the efficacy of refletuzumab in inhibiting complement-mediated TMA, characterized by thrombocytopenia, hemolysis and renal damage, in treatment naive adolescent and adult patients with complement inhibitor of aHUS.

The secondary goals of the study were (1) to characterize the safety and tolerability of rivarozumab in this patient population, (2) by additional measures (e.g., dialysis need status, time to complete TMA response, complete TMA response status over time, observed and change from baseline in estimated glomerular filtration rate (eGFR), Chronic Kidney Disease (CKD) staging (as assessed on selected target days and classified as improved, stable (no change) or worsening compared to baseline), observed and change from baseline in hematological parameters (platelets, LDH, hemoglobin), increased by ≧ 20g/L of hemoglobin from baseline (sustained at least 2 consecutive measurements taken at least 4 weeks apart), change in quality of life (QoL) from baseline (as measured by eurol 5 dimensionality 3 (EQ-5D-3L; all patients); qor), Functional assessment of chronic therapy (FACIT) -fatigue version 4 (patient <18 years) and pediatric FACIT fatigue (patient <18 years) questionnaire)) to evaluate the efficacy of refrazumab, (3) characterize the PK/Pharmacodynamics (PD) of refrazumab by changes in serum refrazumab concentration over time and changes in free C5 concentration over time, and (4) evaluate the long-term safety and efficacy of refrazumab.

2.Terminal point

The primary, secondary and safety endpoints of the study are summarized in figure 2. The primary efficacy endpoint was complete TMA response over the 26-week initial evaluation period as evidenced by normalization of hematological parameters (platelet count and LDH) and > 25% improvement in serum creatinine over baseline, and confirmed by 2 consecutive measurements obtained at least 4 weeks apart.

Secondary efficacy endpoints of the study were as follows:

A. a dialysis demand state;

B. time to complete TMA response;

C. full TMA answer state over time;

observed values and changes from baseline for egfr;

ckd staging, as assessed by the investigator on selected target days, and classified as improved, stable (no change) or worsening compared to baseline;

F. observed values and changes from baseline for hematological parameters (platelets, LDH, hemoglobin);

G. an increase of hemoglobin relative to baseline of ≥ 20g/L, with at least 2 consecutive measurements obtained at intervals of at least 4 weeks;

changes in QoL from baseline as measured by EQ-5D-3L (all patients), FACIT tiredness version 4 (patients ≧ 18 years), and pediatric FACIT tiredness (patients <18 years) questionnaire).

The Pharmacokinetic (PK) and Pharmacodynamic (PD) endpoints of this study were the change in serum rivularizumab concentration over time and the change in free C5 concentration over time.

Safety and tolerability of raflizumab was assessed by physical examination, vital signs, Electrocardiogram (ECG), laboratory assessments, and incidence of AE and SAE. The proportion of patients who produced anti-drug antibodies (ADA) was also evaluated.

Exploratory biomarkers of PD action include, but are not limited to, markers of complement dysregulation (e.g., factor Ba), markers of vascular inflammation (e.g., soluble tumor necrosis factor receptor 1[ sTNFR1]), markers of endothelial activation/injury (e.g., soluble vascular adhesion molecule 1[ sVCAM1], thrombomodulin), changes in the levels of coagulation (e.g., D-dimer) and renal injury (e.g., cystatin C) relative to baseline. Additional assessments may include measurement of raflizumab excretion in urine, chicken red blood cell (cRBC) hemolysis, total C5, autoantibodies to complement proteins (e.g., anti-factor H), and APC activity (e.g., modified hams test, complement deposition assay).

Exploratory genetics can be performed to study genetic variants in genes known to be associated with aHUS, and to identify new genetic variants associated with aHUS, complement dysregulation, or metabolism or efficacy of reflinzumab. Patients may choose not to provide samples for exploratory genetics, but may still participate in the study.

3.Summary of the study design

Study ALXN1210-aHUS-311 is a phase 3, open label, one arm, multi-center study to evaluate the safety and efficacy of refrazumab administered by Intravenous (IV) infusion to patients with aHUS in adolescents (12 to <18 years) and adults (. gtoreq.18 years). The study is recruiting approximately 55 patients to receive revascularized antibody. Figure 1 shows the study design. All patients were naive to complement inhibitor therapy and included at least 6 and up to 10 adolescent (12 to <18 years of age at screening) patients and at least 10 and up to 25 patients who previously received a kidney transplant.

The study included a screening period of up to 7 days, an initial evaluation period of 26 weeks, and an extension period of up to 2 years. The dose was based on the last recorded study follow-up body weight of the patient (table 5). Patients received a loading dose of refranzumab IV on day 1 (2400 mg for patients weighing ≥ 40 to <60kg, 2700mg for patients weighing ≥ 60 to <100kg, 3000mg for patients weighing ≥ 100 kg), followed by a maintenance dose of refranzumab IV (3000 mg for patients weighing ≥ 40 to <60kg, 3300mg for patients weighing ≥ 60 to <100kg, 3600mg for patients weighing ≥ 100 kg) once every 8 weeks (q8w) on day 15 and thereafter for a total of 26 weeks of treatment. After the initial evaluation period, patients entered the extension period and received reflizumab until product registration or approval (according to country-specific regulations) or up to 2 years, whichever comes first. The end of the trial was defined as the last follow-up of the last patient.

This phase 3, open label, one arm study evaluated the safety and efficacy of treatment with raflizumab. Although this study did not plan a formal comparative analysis, results from raflizumab-treated patients were evaluated in the context of the results observed in historical control group patients treated with eculizumab. The historical control group consisted of aHUS patients treated with eculizumab in a prospective enrollment study of C08-002A/B, C10-003 and C10-004, for which study design and implementation, target characteristics likely to affect the magnitude of the effect were similar to the current study. In addition, the control group was limited to patients aged > 12 years and subjected to PE/PI for 4 weeks or less prior to Ekulizumab treatment to further meet the eligibility criteria of the current study.

The evaluation schedule for the screening and initial evaluation periods is shown in table 1. The evaluation schedule for the extension period is shown in table 2. Additional (unscheduled) follow-ups were allowed beyond the specified follow-up visit, at the discretion of the investigator. Procedures, tests and assessments were performed at the discretion of the investigator. Any tests, procedures or assessments performed during the unplanned follow-up are recorded on an electronic case report form (eCRF). Local laboratory or central laboratory analyses are used for unplanned follow-up tests. However, if local laboratory testing is to be used, duplicate samples are collected at the unscheduled follow-up for central laboratory testing.

Table 1: study follow-up and evaluation schedules: screening to end of initial evaluation period

Abbreviations: ADA ═ anti-drug antibodies; ADAMTS13 ═ disintegrins and metalloproteases with thrombospondin type 1 motifs, member 13; aHUS ═ atypical hemolytic uremic

A syndrome; APC ═ complement alternative pathway; ECG as an electrocardiogram; EQ-5D-3L ═ EuroQol5 dimension 3; ET-early termination; FACIT is a functional assessment of chronic disease therapy; HUS ═ hemolytic uremic syndrome; LDH ═ lactate dehydrogenase; N/A is not applicable; PD ═ pharmacodynamics; PK ═ pharmacokinetics; QoL is quality of life; ST-HUS ═ shiga toxin associated hemolytic uremic syndrome.

^aAll patients were vaccinated against meningococcal infection within 3 years prior to or at the time of starting study drug. Patients who started study drug treatment less than 2 weeks after receiving the meningococcal vaccine received treatment with the appropriate prophylactic antibiotic until 2 weeks after vaccination. Patients who were not vaccinated prior to the initiation of raflizumab treatment received prophylactic antibiotics before and at least 2 weeks after meningococcal vaccination.

^bHuman immunodeficiency virus type 1 and human immunodeficiency virus type 2.

^cStool samples for shiga toxin enzyme immunoassay.

^dThere are only female patients with fertility potential. Serum pregnancy test at screening and day 183; urine pregnancy test at all other desired time points. Negative urine test results are required prior to administration of study drug to female patients with fertility potential at the time of potential study follow-up.

^eFACIT FATIGUE version 4 was used to screen patients aged 18 years or older. Pediatric FACIT fatigue for screening age-per-year<Patients 18 years old.

^fOn the day of dosing, patient reported assessments were made prior to dosing.

^gSimplified physical examination includes patient-based decision making and patient identificationPhysical system-related examination of symptoms. At least 1 body system is examined for a simplified examination.

^hVital sign measurements are taken after the patient has rested for at least 5 minutes and include systolic and diastolic BP (mmHg hg mmHg)]) Pulse oximetry, heart rate (beats/minute), respiratory rate (beats/minute), and oral or tympanic temperature (deg c)]Or degrees Fahrenheit [ < F >]). On the day of dosing, vital signs were measured prior to dosing.

ⁱSingle 12 lead ECGs were collected at screening, before dosing on day 57 and on day 183. The patient is supine approximately 5 to 10 minutes prior to the ECG acquisition and remains supine but awake during the ECG acquisition.

^jClinical safety laboratory measurements were collected prior to dosing on the dosing day. Qualifying LDHs were determined from chemical evaluations. Follicle stimulating hormone levels were measured only during the screening period to confirm the postmenopausal state.

^kSerum samples for LDH isoenzyme testing were only collected at selected sites at any/all time points prior to refrozumab administration depending on sample testing availability.

^lSafety was assessed, as well as primary and secondary endpoints.

^mSerum samples for PK/PD analysis on days 1, 15, 71 and 127, before dosing (within 0.5 hours before infusion started) and at the end of infusion (EOI) (within 0.5 hours after EOI); and at any time on days 29, 43, 57, 85, 99, 113, 141, 155, and 169; and collected prior to dosing on day 183 (note that additional samples for PK/PD were collected on day 183 as part of the expansion period). End of infusion samples were taken from the opposite uninfusion arm of the patient. All acquisition times are recorded in the eCRF.

ⁿUrine samples for drug measurements were taken on day 1, day 15 and day 71 and at the end of infusion (EOI) (within 0.5 hours post EOI) and at any time on day 29.

^oThe serum sample is collectedThe day of administration is prior to administration and at any time of day for the days of non-administration. All acquisition times are recorded in the eCRF.

^pSerum, plasma and urine collection for exploratory biomarker analysis were collected at baseline and at post-treatment time points just prior to refletuzumab administration.

^qA single whole blood collection may be collected at any time during the study for those patients who consented to the genetic test.

^rADA serum samples were collected prior to dosing on days 1, 71 and 127. Day 183 harvest occurred prior to the first dose of the extended period. All acquisition times are recorded in the eCRF. If the test result is positive, the test is repeated every 3 months until the result becomes negative or stable based on the measured titer and safety assessment.

^sConcomitant medications must be collected at all study visits and checked against a list of forbidden medications.

^tThe dose of raflizumab was based on the last recorded study follow-up body weight of the patient.

^uLocal laboratory or central laboratory analysis may be used to determine eligibility for screening. However, if local laboratory testing is used, duplicate samples of LDH, platelet count, hemoglobin and serum creatinine are collected at this visit for central laboratory testing.

^vThe primary efficacy endpoint was assessed prior to dosing on day 183. Day 183 dosing was the beginning of the extension period.

Table 2: study follow-up and evaluation schedules: extended period of time

Abbreviations: ADA ═ anti-drug antibodies; aHUS ═ atypical hemolytic uremic syndrome;

ECG as an electrocardiogram; EOS — end of study; EQ-5D ═ EuroQol five-dimensional; ET ═

Terminating in advance; FACIT is a functional assessment of chronic disease therapy; PD (photo diode)

Pharmacodynamics; PK ═ pharmacokinetics; QoL-quality of life

^aThere are only female patients with fertility potential. Serum pregnancy test only at ET; urine pregnancy test at all other desired time points. Negative urine test results were required prior to administration of refolizumab to female patients with fertility potential at the indicated study follow-up.

^bFACIT FATIGUE version 4 was used to screen patients aged 18 years or older. Pediatric FACIT fatigue for screening age-per-year<Patients 18 years old.

^cOn the day of dosing, patient reported assessments were made prior to dosing.

^dSimplified physical examinations include physical system-related examinations based on investigator judgment and patient symptoms.

^eVital sign measurements are taken after the patient has rested for at least 5 minutes and include systolic and diastolic BP (mmHg hg mmHg)]) Pulse oximetry, heart rate (beats/minute), respiratory rate (beats/minute), and oral or tympanic temperature (deg c)]Or degrees Fahrenheit [ < F >]). On the day of dosing, vital signs were measured prior to dosing.

^fA single 12 lead ECG was acquired on day 911 or ET. The patient must lie supine approximately 5 to 10 minutes prior to the ECG acquisition and remain supine but awake during the ECG acquisition.

^gSafety assessments, and primary and secondary endpoints.

^hFor PK/PD typingSerum samples were analyzed on days 351, 575 and 743 before dosing (within 0.5 hours before starting infusion) and EOI (within 0.5 hours after EOI); EOI on day 183 (within 0.5 hours after EOI); and any time at day 911 or ET. End of infusion samples were taken from the opposite uninfusion arm of the patient. All acquisition times are recorded in the eCRF.

ⁱSerum, plasma and urine used for exploratory biomarker analysis immediately prior to refletuzumab administration at the indicated time points; and any time at day 911 or ET. All acquisition times are recorded in the eCRF.

^jPre-dose serum samples were collected on days 351, 575 and 743. Serum samples were also collected at day 911 or at any time of ET. All acquisition times are recorded in the eCRF. If the test result is positive, the test is repeated every 3 months until the result becomes negative or stable based on the measured titer and safety assessment.

^kConcomitant medications were collected at all study visits and checked against a list of forbidden medications.

^lThe extension period started at the beginning of the 183 th day dosing. The dose of raflizumab was based on the last recorded study follow-up body weight of the patient.

4.Study population

A total of approximately 55 patients with documented aHUS were enrolled and assigned to treatment with reflizumab at approximately 200 study sites worldwide. At least 6 and up to 10 adolescent (12 to <18 years of age at screening) patients and at least 10 and up to 25 patients who previously received a kidney transplant were enrolled in the study.

Individuals who did not meet the criteria for participation in the study (failure to screen) may be rescreened. Patients can be rescreened a maximum of 2 times. Deviation from the protocol, also referred to as protocol exemption or exemption, that does not allow for prospective approval of recruitment and enrollment criteria.

A summary of inclusion and exclusion criteria is set forth in fig. 3. Patients were eligible for inclusion in the study if they met all of the following criteria and did not meet any exclusion criteria:

male or female patients with age ≥ 12 years and body weight ≥ 40kg when agreeing.

Evidence of TMA, including thrombocytopenia, evidence of hemolysis and renal dysfunction, based on the following screening follow-up laboratory findings: platelet count <150,000/microliter (. mu.L), and LDH ≧ 1.5 times the Upper Limit of Normal (ULN), and hemoglobin ≦ the lower limit of normal for age and gender (LLN), and serum creatinine levels ≧ ULN for adults (. gtoreq.18 years), or age ≧ 97.5 percentile at adolescent (12 to <18 years) screening (patients requiring dialysis due to acute kidney injury are also eligible).

In renal transplant patients: evidence of TMA persists for a minimum of 4 days and a maximum of 7 days after discontinuation of calcineurin inhibitors ([ CNI ]; e.g., cyclosporine, tacrolimus) or mammalian target of rapamycin inhibitors ([ mTORi ]; e.g., sirolimus, everolimus) prior to current kidney transplantation, or no history of aHUS known.

Evidence of continued presence of TMA in patients who develop TMA post partum for >3 days after the current day of labor.

To reduce the risk of meningococcal infection (neisseria meningitidis), all patients were vaccinated against meningococcal infection within 3 years before or at the time of starting study drug. Patients who received the meningococcal vaccine less than 2 weeks before initiating raflizumab treatment received treatment with the appropriate prophylactic antibiotic until 2 weeks after vaccination. Patients who were not vaccinated prior to the initiation of raflizumab treatment received prophylactic antibiotics before and at least 2 weeks after meningococcal vaccination.

Patients <18 years of age must have been vaccinated against haemophilus influenzae type b (Hib) and streptococcus pneumoniae according to the national and local vaccination schedule guidelines.

Female patients with fertility potential and male patients with female partners with fertility potential must follow protocol-specified guidelines for avoiding pregnancy during the treatment period and within 8 months after the last dose of study drug.

Willingness and ability to give written informed consent and follow the study follow-up schedule. For patients <18 years of age, the patient's legal guardian must be willing and able to give written informed consent, and the patient must be willing to give written informed consent.

Samples collected at the time of screening may be tested at a local or central laboratory. If the local laboratory tests are for LDH, platelet count, hemoglobin, and serum creatinine, replicate samples are taken for central laboratory testing to ensure that baseline and post-baseline measurements for analysis are obtained by the central laboratory. While local laboratory results may be used to expedite qualification evaluation, the final determination of these inclusion criteria is based on central laboratory results.

Patients were excluded from study inclusion if they met any of the following criteria:

A. "disintegrins and metalloproteinases with thrombospondin type 1 motifs, member 13" (ADAMTS13) are known to be deficient (< 5% activity).

B. Shiga toxin-associated hemolytic uremic syndrome (ST-HUS).

C. Streptococcus pneumoniae-associated Hemolytic Uremic Syndrome (HUS), as demonstrated by positive direct coomb's test and streptococcus pneumoniae infection (e.g., culture, antigen testing).

D. Known as Human Immunodeficiency Virus (HIV) infection.

E. Non-resolved systemic meningococcal disease.

F. Patients diagnosed with persistent sepsis were defined as positive blood cultures within 7 days before the start of the screening and were not treated with antibiotics.

G. The presence or suspected presence of activity and untreated systemic bacterial infections would appear to confuse researchers with the accurate diagnosis of aHUS or hamper the ability to control aHUS disease.

H. During pregnancy or lactation.

I. Heart, lung, small intestine or liver transplantation.

J. In a kidney transplant patient, any one of:

a. acute renal dysfunction within 4 weeks of transplantation in line with diagnosis of acute antibody-mediated rejection (AMR) according to Banff 2013 criteria, or

b. Acute renal dysfunction within 4 weeks of transplantation, consistent with clinical diagnosis of acute AMR, and elevated donor-specific antibodies (DSA).

c. History of polycystic kidney disease.

K. In patients aged 18 or older exhibiting Systolic Blood Pressure (SBP) of 170mmHg or 12 to <18 years old exhibiting clinical diagnosis of hypertension, any one of the following:

a. continued evidence of TMA (Inclusion Standard No. 2) after Blood Pressure (BP) had decreased to 140mmHg for less than 4 days.

b. Left ventricular hypertrophy is known.

c. The small and highly echogenic kidneys are known at ultrasound.

Identified drug exposure-associated HUS.

M. PE/PI acceptance for 28 days or longer before screening of the current TMA begins.

N. history of malignancy within 5 years of screening, except for non-melanoma skin cancer or cervical carcinoma in situ that has received treatment and no evidence of recurrence.

Bone Marrow Transplantation (BMT)/Hematopoietic Stem Cell Transplantation (HSCT) was performed within the last 90 days before the start of screening.

HUS associated with vitamin B12 deficiency.

Known systemic sclerosis (scleroderma), Systemic Lupus Erythematosus (SLE), or anti-phospholipid antibody positive or syndrome.

Chronic dialysis (defined as regular dialysis as renal replacement therapy for ESKD).

S. patients who received chronic intravenous immunoglobulin (IVIg) within 8 weeks prior to the start of screening, unless there was an unrelated medical condition (e.g. hypogammaglobulinemia); or receive chronic rituximab therapy within 12 weeks prior to the start of the screening.

Patients receiving other immunosuppressive therapies such as steroids, mTORi (e.g. sirolimus, everolimus), CNI (e.g. cyclosporine or tacrolimus) were excluded except: a) part of an established post-transplant anti-rejection protocol, or b) the patient has been identified as requiring anti-complement factor antibodies for immunosuppressive therapy, or c) the steroid is being used to treat a disease other than aHUS (e.g., asthma).

U. participate in another interventional therapy study or use of any experimental therapy within 30 days before study drug start on day 1 of this study or within 5 half-lives (whichever is greater) of the study product.

V. prior use of eculizumab or other complement inhibitors.

W. allergy to murine protein or one of the excipients.

Any medical or psychological condition that it appears to be possible for a researcher to increase the risk of a patient or confound the results of a study by participating in the study.

Y. history of known or suspected drug or alcohol abuse or dependence within 1 year before the start of screening.

The laboratory results excluding standard No. 1 may not be available prior to the first dose. The late results of excluding standard number a may lead to patient withdrawal and replacement.

Patients were entitled to withdraw from the study at any time. If the patient withdraws consent, the assessment designated for Early Termination (ET) follow-up is performed. Patients who exited the study will not be replaced. The patient may discontinue the study drug if the researcher or sponsor has reason to believe that stopping treatment is most beneficial to the patient.

Patients for whom AMR (C4d positive kidney biopsy) was developed from previous kidney transplantation and for which rituximab was considered an appropriate therapy had to be withdrawn from the study and receive standard of care therapy. The primary reason for the abort and any other reasons are recorded on the eCRF.

If patients discontinue the study due to an ongoing AE or an unreduced laboratory result that is significantly outside of the reference range and clinically significant, the investigator attempts to provide follow-up until a satisfactory clinical regression of the laboratory result or adverse event is achieved.

The sponsor or competent authority may terminate the study for reasonable reasons. Cases warranting termination of the study include, but are not limited to: (1) finding unexpected, severe, or unacceptable risk to patients participating in a study, (2) the investigator deciding to pause or abort testing, evaluation, or development of a study drug, (3) the investigator failing to comply with approved protocols, relevant guidelines, and/or regulations, and (4) the investigator intentionally submitting false information to the investigator and/or regulatory agencies.

If at any time it is determined that the patient's screening data does not meet one or more of the following inclusion/exclusion criteria (inclusion criteria number 2 or exclusion criteria number 1), the patient will abort the study and may be replaced upon receiving at least 1 dose of the study product (e.g., the patient's local laboratory data for validation of eligibility criteria is then determined by the central laboratory to no longer meet the eligibility criteria). Patients who terminated prematurely were subjected to a premature termination procedure and all AEs were collected until 60 days after the patient's last dose of study drug.

The end of the study was defined as the date of the last follow-up of the last patient during the extended period.

5.Study treatment

Ravelizumab (a humanized anti-C5 monoclonal antibody consisting of two 448 amino acid heavy chains and two 214 amino acid light chains) is an IgG2/4 kappa immunoglobulin consisting of human constant regions and murine complementarity determining regions grafted onto the variable regions of the human framework light and heavy chains. Rivlizumab and eculizumab share over 99% primary amino acid sequence identity and have very similar pharmacology.

The ranibizumab drug product was provided as a sterile, preservative-free 10-mg/mL solution in disposable vials for clinical studies and was designed for infusion by dilution into commercially available saline (0.9% sodium chloride injection; national specific pharmacopoeia) for administration by intravenous infusion. Table 3 and the current IB provide additional information.

Table 3: research medicine

Rivlizumab is packaged in a borosilicate glass vial of the United States Pharmacopeia (USP)/european union pharmacopeia (EP)1 type and stoppered with a butyl rubber stopper with an aluminum outer seal and an inverted cap. The study drug is provided in kit form. According to applicable regulations, the ranibizumab is delivered to each site after all the required basic files are received.

Upon arrival of the study drug cassettes at the study site, the pharmacist (or trained personnel) immediately removed the study drug cassettes from the transport cooler and stored them in the original carton under refrigerated conditions of 2 ℃ to 8 ℃ (35 ° f to 47 ° f) and protected from light. The rivlizumab was not frozen. Study drugs were stored in a safe, limited access storage area and temperature was monitored daily.

The drug product is at room temperature prior to administration. The material is not heated except for ambient air temperature (e.g., by using microwaves or other heat sources).

Rivlizumab is not administered as an intravenous bolus or bolus injection. Infusion solutions of the study drugs were prepared using sterile techniques. The patient required dose of refrozumab is further diluted into commercial saline (0.9% sodium chloride; national pharmacopoeia) in the volumes specified in table 4. A solution of rivlizumab in a diluent is administered to the patient by an infusion pump using an intravenous tube administration set up. Infusion using an in-line filter is required.

Table 4: dosing reference chart for preparing Ravulizumab doses

For further dose preparation instructions, reference is made to pharmacy manuals.

^aBody weights recorded at the last study visit.

The dose of study drug is prepared and dispensed only by a pharmacist or medically qualified worker. Study medication was only assigned to enrolled patients identified as eligible to participate in the study. Once a patient is prepared for a study drug, it can only be administered to the patient. The vial of study drug is for single use only and any drug product remaining in the vial is not available for another patient. Any drug remaining in the infusion tube or bag must not be used in another patient.

All clinical study materials are stored in safe places and distributed by suitably trained personnel. A detailed record of the amount of research product received, dispensed, and destroyed is maintained. Unless otherwise notified, empty vials and vials with residual material are stored prior to destruction for review and accountability by a research supervisor, or processed according to the local pharmacy Standard Operating Procedure (SOP) for clinically studied drugs. To meet regulatory requirements regarding drug accountability, at the end of the study, all remaining stock of reflizumab will be reconciled and destroyed or returned to Alexion according to applicable regulations.

Patients received refrozumab for 26 weeks. Ravulizumab is administered as a slow intravenous infusion over approximately 2 hours. Rivlizumab is not administered as an intravenous bolus or bolus injection.

The dose regimen of refrozumab during the initial evaluation was based on the last recorded study follow-up body weight of the patient (table 5). Patients received a loading dose of refrozumab intravenously on day 1, followed by a maintenance dose of refrozumab intravenously on day 15 and thereafter q8w (every eight weeks).

Table 5: loading and maintenance treatment regimen

^aBody weights recorded at the last study visit.

After the initial evaluation period, all patients had transferred to an extension period of up to 2 years during which all patients received refrozumab q8w (once every eight weeks). The actual time of all dose administrations was recorded in the patient's eCRF.

This is an open label study. Patients meeting all inclusion criteria were assigned to study treatment with refletuzumab at baseline follow-up (day 1). An interactive voice or web response system (IxRS) is used to dispense vials containing raflizumab to each patient.

Infusion of other monoclonal antibodies has been associated with infusion reactions, usually during infusion or shortly after completion of infusion.

Patients were scored on the patients' eCRF for 28 days prior to the start of screening (or for 3 years from the time of enrollment of meningococcal vaccination) until the first dose of previous drugs (including vitamin and herbal preparations) taken or experienced by refuzumab, including those discussed in exclusion criteria and procedures (any therapeutic intervention, such as surgery/biopsy or physical therapy).

For analytical purposes, any dialysis during the period of 14 days immediately following the first refuzumab dose is not considered "new dialysis".

All medication use and procedures performed during the study are recorded in the patient's source files/medical records and eCRF. This record includes all prescribed medications, herbal products, vitamins, minerals, over-the-counter medications, and current medications. Concomitant medications were recorded 56 days from the first infusion of study medication to the patient's last dose of study medication. Any changes accompanying the medication are also recorded in the patient's source files/medical records and eCRF. Any concomitant medication deemed necessary for the standard of care of the patient or treatment of any AE during the study, as well as the allowable medications described below, were given at the discretion of the investigator. However, researchers are responsible for ensuring that detailed information about all medications is completely recorded in the patient's source files/medical records and eCRFs.

Patients were prohibited from receiving any of the following drugs and procedures at any time after the first dose of study drug: eculizumab or other complement inhibitor, using any other investigational drug or device as part of a clinical trial, IVIg (unless used for unrelated medical needs, such as hypogammaglobulinemia), rituximab, PE/PI after the first dose, and new dialysis within the first 48 hour period after the first dose of refuzumab, unless there is an urgent medical need as assessed by (1) hypervolemia that is not responsive to diuretics, (2) refractory electrolyte disorders, or (3) new uremic encephalopathy. Exceptions must be approved case by the sponsor before dialysis is administered.

The following concomitant medications and procedures are allowed in some cases, but with the following limitations: no other immunosuppressive therapy (such as steroids, mTORi [ e.g., sirolimus, everolimus ], CNI [ e.g., cyclosporine or tacrolimus ]) was allowed prior to screening or during the study unless: a) part of an established post-transplant anti-rejection protocol, or b) the patient has confirmed the need for anti-complement factor antibody antibodies for immunosuppressive therapy, or c) the steroid is being used for a disorder other than aHUS (e.g., asthma).

Any patient receiving other complement inhibitors (including eculizumab) or PE/PI after the first dose of study drug was withdrawn from the study.

Because of its mechanism of action, the use of reflizumab increases the susceptibility of a patient to infection. To reduce the risk of infection, all patients were vaccinated against neisseria meningitidis, Hib and streptococcus pneumoniae.

Patients were vaccinated against neisseria meningitidis within 3 years prior to or at the time of receiving the first dose of refrozumab. Patients treated with the drug less than 2 weeks after receiving the meningococcal vaccine received treatment with the appropriate prophylactic antibiotic until 2 weeks after vaccination. Vaccines against serotypes A, C, Y, W135 and B are proposed where applicable to prevent the common pathogenic meningococcal serotypes. Patients are vaccinated or re-vaccinated according to current national vaccination guidelines or local vaccination practices using complement inhibitors (e.g., eculizumab).

It is recognized that some patients who were not vaccinated against neisseria meningitidis within 3 years before receiving the first dose of refrozumab may not receive vaccination at the time of the first dose. Patients who were not vaccinated prior to the initiation of raflizumab treatment received prophylactic antibiotics before and at least 2 weeks after meningococcal vaccination.

Vaccination may be insufficient to prevent meningococcal infection. The antibacterial agent should be suitably used in accordance with official guidelines and local practical considerations. All patients were monitored for early signs of meningococcal infection, and if suspected, evaluated immediately and treated with the appropriate antibiotics if necessary.

To improve risk awareness and promote rapid disclosure of any potential signs or symptoms of infection experienced by the patient during the course of the study, the patient is provided with a security card to carry around at any time. Additional discussion and explanation of potential risks, signs and symptoms occurred at specific time points as part of the patient safety card review and overall study, as described in the evaluation timetables (tables 1 and 2).

Before or at the time of receiving the first dose of reflizumab, patients were vaccinated against haemophilus influenzae type b (Hib) and streptococcus pneumoniae according to the national and local vaccination schedule guidelines. The vaccination status of neisseria meningitidis, Hib and streptococcus pneumoniae was recorded on the patients eCRF.

The study medication is administered to the patient in a controlled environment under the supervision of the researcher or designated personnel to ensure compliance with study medication administration. The investigator or designated personnel ensure that all patients are adequately informed of the particular dosing regimen required to comply with the study protocol, that the patients receive the appropriate dose at the designated time point during the study, and that adequate safety monitoring is performed during infusion.

Before receiving study medication, female patients thought to be self-menopausal had to provide menopausal evidence based on a combination of amenorrhea for at least 1 year and elevated serum Follicle Stimulating Hormone (FSH) levels (>30IU/L) (e.g., in the absence of hormone replacement therapy, dietary phytoestrogens).

Female patients with fertility potential use a highly effective contraceptive method (as defined below) starting from screening and lasting at least 8 months after the last dose of study drug. A method of high-efficiency contraception comprising: hormonal contraception associated with ovulation inhibition, intrauterine contraceptive, intrauterine device, intrauterine hormone release system, bilateral tubal occlusion, partner to excise vas deferens (provided that the partner is the only sexual partner of the patient), sexual abstinence (defined as avoiding sexual intercourse of opposite sex throughout the risk period associated with study medication; the need to assess the reliability of abstinence according to the duration of clinical studies and the preference and usual lifestyle of the patient), male condom in combination with any cervical cap, diaphragm or sponge with spermicide (dual barrier approach). Male patients with female couples/partners or pregnant or lactating couples or partners with fertility potential consented to the use of dual barrier contraception (a suitable barrier method for male condoms plus female partners) during the treatment period and for at least 8 months after the last dose of study drug. Even with medical evaluation of records of operative success of vasectomy, dual barrier contraception is required.

Male patients did not donate sperm during the treatment period and for at least 8 months after the last dose of study drug.

6.Efficacy assessment

The primary efficacy assessment was complete TMA response over an initial evaluation period of 26 weeks. The criteria for complete TMA response were (1) normalization of platelet counts, (2) normalization of LDH, and (3) an increase of serum creatinine of > 25% over baseline.

Patients who met all of the full TMA response criteria, confirmed by 2 consecutive measurements taken at least 4 weeks apart, were classified as reaching the primary efficacy endpoint.

The following secondary efficacy assessments were measured during the study:

A. dialysis demand status

B. Time to full TMA response

C. Full TMA response status over time

Observed value and change from baseline of egfr

Stage of CKD, as assessed by investigator on selected target days, and classified as improved, stable (no change) or worsening compared to baseline

F. Observations and changes from baseline of hematological parameters (platelets, LDH, hemoglobin)

G. An increase of hemoglobin from baseline of ≥ 20g/L, and at least 2 consecutive measurements obtained at intervals of at least 4 weeks

Change in qol from baseline as measured by EQ-5D-3L (all patients), FACIT fatigue version 4 (patient <18 years old), and pediatric FACIT fatigue (patient <18 years old)) questionnaire.

7.Security assessment

The investigator or their designated personnel are interviewed with the patient to address the potential safety risks of revaprepizumab and to give the investigator an opportunity to address any safety issues with the patient with respect to the study.

Collection of AEs was monitored from the time informed consent was obtained to study completion. Investigators followed any AE until the end (resolution or stabilization). In the case of patient withdrawal from the study, AE monitoring continued until the last study visit of the last patient, if possible. The timing of clinical and laboratory assessments was performed according to the assessment schedule (tables 1 and 2). Any clinically significant abnormal outcome is followed until resolution or stabilization.

Demographic parameters including age, gender, race, and ethnicity were reviewed. A complete medical history is obtained and recorded. Record weight and height. Height was measured only at screening.

Patient history of aHUS (including onset of first aHUS symptoms and date of diagnosis) was recorded at the screening visit.

Patient history, including previous and concomitant disorders/conditions, was recorded at the screening visit. In addition to meningococcal vaccination, drug (prescription or non-prescription, including vitamin and/or herbal supplements) use during the 28 days before screening began (or 3 years of meningococcal vaccination) was recorded.

The physical examination included the following evaluations: the overall appearance; skin; head, ears, eyes, nose and throat; a neck; lymph nodes; a chest; a heart; the abdominal cavity; four limbs; the central nervous system; and the musculoskeletal system. Simplified physical examinations include physical system-related examinations based on investigator judgment and patient symptoms. Vital sign measurements are taken after the patient has rested for at least 5 minutes, and include systolic and diastolic BP (millimeters of mercury [ mmHg ]), pulse oximeter, heart rate (beats/minute), respiratory rate (times/minute), and oral or tympanic temperature (degrees Celsius [ ° C ] or F ]).

Samples for serum pregnancy, hematology, chemistry, coagulation and urinalysis were performed at the times specified in the evaluation schedules (tables 1 and 2). Samples for laboratory evaluation were collected prior to each study drug administration.

Samples collected at the time of screening may be tested at a local or central laboratory. If the local laboratory tests are for LDH, platelet count, hemoglobin, and serum creatinine, replicate samples are taken for central laboratory testing to ensure that baseline and post-baseline measurements for analysis are obtained by the central laboratory. In the case of duplicate samples from local and central laboratories, the results from the central laboratory were used for analysis.

It is expected that some laboratory values may be outside of normal values due to underlying disease. Researchers should use medical judgment in assessing the clinical significance of these values. Clinical significance is defined as any change in laboratory measurements that has medical relevance and leads to changes in healthcare. If clinically significant laboratory changes from baseline values were noted, the changes were recorded as AEs on the AE eCRF. Researchers evaluated the relationship to study treatment for all clinically significant out-of-range values. The investigator continues to monitor the patient through additional laboratory assessments until either (1) the values have returned to the normal range or baseline level, or (2) the values outside the normal range are, at the investigator's discretion, independent of the procedure specific to administration of the study drug or other protocol.

For women with fertility potential, a serum or urine pregnancy test (i.e., β -human chorionic gonadotropin [ β -hCG ]) was performed according to the evaluation schedule (tables 1 and 2). Blood samples are analyzed for hematological parameters.

Blood samples were analyzed for serum chemistry parameters. Indirect bilirubin is calculated from the total bilirubin value and the direct bilirubin value; thus, if direct bilirubin is below the quantitation limit, indirect bilirubin results cannot be obtained. Serum FSH levels of postmenopausal female patients were measured during the screening to confirm their postmenopausal status.

Chemical evaluations were performed at the time points specified in the evaluation timetables (tables 1 and 2). The eGFR was calculated for all follow-up visits to serum chemistry collected using a nephropathy diet modified formula for patients aged 18 and a nephropathy diet modified Schwartz formula for patients < 18.

Blood samples were analyzed for coagulation parameters.

Urine samples were analyzed. If the result of the macroscopic analysis is abnormal, the urine sample is subjected to microscopic examination. Urine samples were also analyzed to measure protein and creatinine to calculate the urine total protein to creatinine ratio.

For each patient, a single 12-lead digital ECG was acquired according to the evaluation schedule (tables 1 and 2). The patient must lie supine approximately 5 to 10 minutes prior to the ECG acquisition and remain supine but awake during the ECG acquisition. The investigator or prescriber is responsible for reviewing the ECG to assess whether the ECG is within normal limits and to determine the clinical significance of the results. These evaluations are shown on CRF.

Prior to study drug administration, blood samples were collected to test the serum for the presence and titer of ADA against refuzumab as shown in the evaluation schedule (see tables 1 and 2). If the test result is positive, the test may be repeated every 3 months until the result becomes negative or stable, based on the titer measured and the safety assessment. Further characterization of antibody responses, including binding and neutralizing antibodies, PK/PD, safety, and activity of reflinzumab, may be performed as appropriate.

An AE is any adverse medical event in a patient administered a pharmaceutical product and is not necessarily causally related to such treatment. Thus, an AE can be any adverse or unexpected sign (e.g., abnormal laboratory finding), symptom, or disease temporally associated with the use of a drug product, whether or not considered related to the drug product.

The expected daily fluctuation of one or more pre-existing diseases or conditions present or detected at the start of the study without worsening is not an AE in the event that no adverse medical event occurs (e.g., admission for social reasons or convenience if elective surgery is scheduled for hospitalization prior to the start of the study).

The lack of drug effect is not an AE in clinical studies, as the aim of clinical studies is to establish drug effects.

Medication errors (including intentional misuse, abuse, and overdose of the product) or use other than that defined in a regimen are not considered AE unless there is an adverse medical event resulting from the medication error.

Pregnancy cases occurring during maternal or paternal exposure to study products should be reported within 24 hours after the investigator/study center is aware. Data on fetal fates and breastfeeding were collected for regulatory reporting and safety assessments.

Adverse events were recorded starting from the time the consent was signed. AEs reported after informed consent but prior to study drug administration were considered pre-treatment AEs.

The following events were identified as important risks in this study: meningococcal infection.

The severity of AE was graded using the common terminology for adverse events standard (CTCAE) version 4.03 or higher. A rating (severity) scale is provided for each AE term. Each CTCAE term is based on a supervised active medical dictionaryThe Lowest Level Term (LLT). Each LLT is coded as a MedDRA preferred term. The grade refers to the severity of the AE. CTCAE was graded from 1 to 5, with each AE having a unique clinical profile of severity (table 6).

Table 6: adverse event severity rating scale

Abbreviations: ADL is an activity of daily living; AE is an adverse event

^aThe instrumental ADL refers to preparing meals, purchasing groceries or clothes, using a telephone, managing money, and the like.

^bSelf-care ADL refers to bathing, dressing and undressing, self-eating, going to the toilet, taking medicine, and not being bedridden.

Any change in AE severity was recorded according to a particular guideline of the eCRF completion guideline. The severity and severity are differentiated: severity describes the intensity of an AE, while the term severity refers to an AE that meets certain criteria for Serious Adverse Events (SAE).

The investigator must provide a causal assessment (unrelated, unlikely, likely, or unambiguous) for all AEs (severe and non-severe) based on the investigator's medical judgment and observed symptoms associated with the event (table 7). Such an assessment is recorded in the eCRF and any additional tables (as appropriate).

Table 7: causal relationship assessment description

A Severe Adverse Event (SAE) is any adverse medical event:

cause death

Life threatening (i.e. the patient is at risk of death at the time of the event)

Requiring hospitalization of inpatients or extending existing hospitalization times

Cause persistent or severe disability/disability

Is congenital abnormality/birth defect

Significant medical events that may not result in death, be immediately life threatening, or require hospitalization may be considered serious adverse events that, when judged in accordance with appropriate medical judgment, may harm the patient or may require intervention to prevent one of the above listed outcomes.

Suspected Unexpected Severe Adverse Reactions (SUSAR) were serious events not listed in IB and identified by the investigator as being relevant to the study product or procedure. Federal Regulations (CFR) title 21 in the united states 312.32 and eu clinical trial directive 2001/20/EC and related detailed guidelines or national regulatory requirements of participating countries require that SUSAR be reported.

All AEs (severe and non-severe) were collected from the signing of ICF until 60 days after the ET patient's last dose of study drug or until 56 days after the patient completed the study's last dose of study drug. All AEs were recorded on the eCRF after the investigator or their staff realized their occurrence.

All SAEs were recorded regardless of the investigator's assessment of causal relationships. There is no time limit to reporting SAE which is considered to have a causal relationship with the study drug. Researchers are free to report SAEs at any time, regardless of causal relationships.

For all SAEs, the investigator must provide the following information: appropriate and required follow-up information, causal relationships of the SAE, treatment/intervention of the SAE, outcome of the SAE, and supporting medical records and laboratory/diagnostic information.

Pregnancy data was collected for female spouse/partner of all patients and male patients during the study. Exposure during pregnancy (also known as intrauterine exposure) may be the result of the transmission of the drug product through semen following maternal or paternal exposure. Pregnancy itself is not considered an AE unless it is suspected that the study product may interfere with the effectiveness of the contraceptive drug. However, pregnancy complications and pregnancy abnormalities result in AEs and may meet SAE criteria (e.g., ectopic pregnancy, spontaneous abortion, intra-uterine fetal death, neonatal death, or congenital abnormalities). Selective abortion without complications should not be reported as AE.

8.Pharmacokinetic and pharmacodynamic evaluation

Blood samples for determination of serum drug concentration and PD assessment were collected before and after study drug administration at the time points indicated in the assessment time tables (see tables 1 and 2). The actual date and time of each sample (24 hours system) was recorded. The PK sample time points for any given patient do not exceed the currently scheduled time points.

Blood samples for PK and PD assessment were taken from the arm opposite the arm used for drug infusion. For PK/PD evaluation the following were used: (1) changes in serum rivularizumab concentration over time and (2) changes in free C5 concentration.

9.Exploratory assessment

For exploratory biomarker analysis, summary statistics of actual, change, and percent change from baseline are provided.

The relationship between rivlizumab concentration and exploratory biomarkers or the correlation between clinical benefit and key exploratory biomarkers can be assessed by graphical display. Exploratory analyses and potential relationships between clinical outcome, PK/PD, genetic profile and biomarker levels can also be performed. If evaluated, APC activity and autoantibody results are summarized.

Known clinically relevant genetic mutations in aHUS are communicated to the patient or patient's guardian by the investigator along with appropriate genetic counseling. Genetic variants of unknown clinical significance are not communicated to the patient or to the investigator thereof.

Additional signs or symptoms of aHUS were assessed using the resource utilization patient questionnaire and the patient-reported aHUS symptom questionnaire.

The components of the extrarenal signs or symptoms of aHUS, including vital signs and clinical laboratories, can be summarized descriptively at baseline and post-baseline time points, as well as for changes from baseline. A list sorted by patient may be provided.

Analysis of signs, symptoms, and resource utilization may include standard methods of classification with or without repeated measurements.

If day 1 assessments were missing, the screening assessment was used as a baseline assessment.

For the assessment of complete TMA response during the 26-week initial assessment period (primary endpoint), patients missing the efficacy assessment in the study as a defined part of complete TMA response used Last Observation Carry Forward (LOCF). For patients who discontinued the study before week 26, their data as of termination were used to assess complete TMA response.

Missing data of the QoL tool is processed as specified in the description of each tool.

The study was scheduled for interim analysis at the end of the 26-week initial evaluation period after all patients completed or exited the 26-week initial evaluation period. In addition, a second analysis was performed at the end of the 2 year extension to summarize long term efficacy, safety and PK parameters.

Example 2: data from phase 3, one-armed, multicenter studies of Raftilizumab (ALXN1210) in naive adult patients with complement inhibitors of atypical hemolytic uremic syndrome (aHUS)

The following is a summary of data from a one-armed study of reflizumab (ALXN1210-aHUS-311) in complement inhibitor naive patients with atypical hemolytic uremic syndrome (aHUS), conducted essentially according to the protocol described in example 1 above. The initial evaluation period was 26 weeks followed by an extended period of up to 2 years. The study design is shown in figure 1.

The objective of the study was to evaluate the efficacy of refletuzumab in inhibiting complement-mediated Thrombotic Microangiopathy (TMA), which is characterized by thrombocytopenia, hemolysis and renal damage, in complement inhibitor therapy naive adult patients with aHUS. The primary endpoint was complete TMA response over the initial 26-week evaluation period. The primary, secondary and safety endpoints of the study are summarized in figure 2. A summary of inclusion and exclusion criteria is set forth in fig. 3.

The enrollment requirements were (1) at least 6 adolescents (delayed until ALXN1210-aHUS-312), (2) at least 10 patients of previous kidney transplantation (8 enrollment), and (3) at least 30 patients met TMA laboratory criteria on day 1 based on central laboratory results (32 enrollment).

The data cut included data from the initial evaluation period for all patients, plus any available extension period data up to 2019, month 10.

Fifty-eight (58) subjects enrolled and received at least one dose (included in the safety group), two subjects enrolled and replaced (considered disqualified after the first dose and discontinued as pre-specified in the protocol), fifty-six (56) subjects in the full analysis group, eleven (11) subjects discontinued treatment, and nine (9) subjects discontinued the study. A schematic of the patient treatment is listed in fig. 4. Treatment compliance was 100%. Baseline demographics are listed in table 8, baseline disease characteristics are listed in table 9, and baseline laboratory values are listed in table 10.

Table 8: baseline demographic data

Table 9: baseline disease characteristics

Table 10: baseline laboratory values

TMA Standard: platelet count <150x109/L, LDH ≧ 1.5 × Upper Limit of Normal (ULN), hemoglobin ≦ Lower Limit of Normal (LLN), and serum creatinine level ≧ ULN.

TMA response definitions are listed in table 11. A response is achieved when all criteria are met simultaneously and each criterion is met for at least 28 days. Platelet values obtained from the day of platelet transfusion to 3 days post transfusion were excluded from all analyses. All serum creatinine values obtained during dialysis of the patient were excluded from all analyses. When the patient is dialyzed at baseline, then the first effective creatinine value used as the baseline value is the first assessment of ≧ 6 days post-dialysis. If the patient is undergoing dialysis throughout the 26 week initial assessment period, baseline creatinine is not calculated.

Table 11: full TMA response definition

The key efficacy results are listed in tables 12-14. FIG. 5 is a derivative example showing the results of confirmed complete TMA responses at day 57, including platelet normalization at day 112, LDH normalization at day 35, and creatinine increase ≧ 25% at day 70.

The criterion for full TMA response is met when all criteria are met simultaneously and each criterion is met for at least 28 days. The component of complete TMA response and other secondary efficacy endpoints showed consistent response to treatment. As shown in fig. 9, 53.6% (30/56) of patients reached full TMA response during the initial evaluation. Patients of 33.9% (19/56) had partial responses.

Normalization of hematology included simultaneous normalization of platelet counts and normalization of LDH. Each criterion was met for at least 28 days. The subject at 73.2% (41/56) achieved normalization of hematology during the initial evaluation (see table 12). 83.9% (47/56) of the subjects achieved normalization of platelet counts during the initial evaluation (see table 12, figure 10, figure 14, and figure 15).

76.8% (43/56) of the subjects achieved normalization of LDH during the initial evaluation (see table 12, fig. 10, fig. 16 and fig. 17).

Table 12: key efficacy results: primary complete TMA response during initial evaluation

As shown in fig. 6, there are thirty (30) full TMA responders. Forty (40) (71.4%) of fifty-six (56) subjects achieved a Hemoglobin (HGB) response (increase ≧ 20 g/L). Of thirty (30) complete TMA responders, four (4) did not have a Hemoglobin (HGB) response. Figure 10 shows the overall complete TMA response subdivided by subgroups during the 26 week initial evaluation period.

Figure 7 shows the time to reach full TMA response. The median time to complete TMA response was 86 days. Patients who did not respond were reviewed on the date of the last follow-up or study discontinuation.

Figure 11 shows complete TMA status over time (open circles) including normalization of platelet counts (open triangles), normalization of hematology (+), increase of 25% serum creatinine relative to baseline (open squares), and normalization of LDH (X).

There are seven (7) non-responders. The data for non-responders are listed in table 13.

Table 13: key efficacy results: non-responders during primary evaluation (0/3 component)

As shown in table 14, 58.6% (17/29) of patients undergoing dialysis at baseline were weaned by the last available follow-up. Of the 27 patients who stopped dialysis at baseline, 21 (78%) still stopped dialysis at the last follow-up.

Table 14: key efficacy results: dialysis status over time

With respect to pharmacokinetics/pharmacodynamics, 99.53% ≦ 0.5mg/mL of all free C5 results obtained after the first dose to the initial evaluation period, a defined threshold for terminal complement inhibition (see FIG. 22). Administration based on body weight resulted in maximum, steady-state and trough exposure, as predicted, with no unexpected pharmacokinetic findings (see figure 8).

A summary of the key safety results is listed in table 15. Patients for safety assessments included all patients receiving ≧ 1 dose of study drug (N ═ 58). Due to failure (identification of STEC-HUS), two of these patients were excluded from the efficacy analysis according to the protocol.

Table 15: key safety results: overview of Critical Security

(1) Overall, 4 deaths were observed: 1 from pre-treatment AE (cerebral arterial thrombosis), 3 from non-relevant treatment emergency AE, 2 of them being septic shock and 1 intracranial hemorrhage)

There were 4 deaths: 1 from a pre-treatment adverse event (cerebral arterial thrombosis) and 3 from a non-relevant treatment emergent adverse event (2 septic shock, 1 intracranial hemorrhage). The deaths of patients who received the least one dose of refrozumab are summarized in table 16.

Table 16: summary of deaths in patients receiving a minimum of one Raffolizumab dose

As shown in table 17, the most common adverse events were headache (N ═ 21), diarrhea (N ═ 18), vomiting (N ═ 15), nausea (N ═ 13), and hypertension (N ═ 13). As shown in table 18, the most common serious adverse event was pneumonia (N ═ 3). Three subjects discontinued the study due to adverse events. There were no meningococcal cases.

Table 17: key safety results: overview of Critical safety [ AE present in at least 4 patients ]

Table 18: key safety results: overview of Critical safety [ SAE Presence in at least 2 patients ]

71.4% (40/56) of the subjects achieved a Hemoglobin (HGB) response during the initial evaluation (see Table 19 and FIG. 6). Figure 18 shows the mean change and 95% confidence intervals for HGB observed and model-based over time relative to baseline. Figure 19 shows the mean HGB and 95% confidence intervals observed over time.

Table 19: key efficacy results: HGB response (increase of HGB relative to baseline ≧ confirmation results)

Fig. 12 shows the mean eGFR and 95% confidence intervals relative to baseline. FIG. 13 shows the change in CKD/eGFR class from baseline to day 183. Data are presented as n (%). eGFR classification in mL/min/1.73m²And (6) displaying. Baseline is based on the last available before starting treatmenteGFR. The lower triangle (represented by the slanted black line) represents improvement from baseline to day 183, the upper triangle (represented by the dot) represents deterioration, and the white cell represents no change.

Furthermore, as shown in table 20 and fig. 13, thirty-two (32) out of forty-seven (47) subjects improved the staged change in CKD from baseline to day 183 (six to grade 5, seven to grade 4, five to grade 3, four to grade 2, and ten to grade 1). Thirteen (13) of forty-seven (47) subjects remained unchanged. Two (2) out of thirteen (13) worsened.

Table 20: key safety results: secondary, CKD transition

(a) Compared to CKD staging at baseline.

(b) Those at level 1 at baseline were excluded as they could not improve.

(b) Those at grade 5 at baseline were excluded because they were unlikely to deteriorate.

(d) The 95% confidence interval (95% CI) for the ratio is based on the exact confidence limit using the Clopper-Pearson method.

Table 21 and fig. 20 show changes in fatigue with time. The data in fig. 20 are shown as mean values (error bars, 95% CI). A rapid improvement in fatigue was observed, i.e. a median improvement of 9 points by day 8. Clinically meaningful improvement in fatigue (score ≧ 3) was observed in 84.1% (37/44) of the patients on day 183. The median increase from baseline to day 183 was 20 points.

Table 21: key safety results: FACIT-3 points increase over baseline

EQ-5D-3L is evaluated using an index that scores responses to Visual Analog Scale (VAS) questions according to a time weighted value (US TTO) set for the united states. US TTO >0.94 indicates complete health. Baseline values were from day 1. FIG. 21 shows the mean EQ-5D-3L and the 95% confidence interval. With respect to immunogenicity, one patient was observed to have a treatment-emergent positive result with anti-drug antibodies (ADA), no neutralizing antibodies and no significant impact on pharmacokinetics/pharmacodynamics (see table 22).

Table 22: key safety results: safety overview: immunogenic anti-drug antibodies

Figure 22 depicts serum free complement C5 concentration over time (semi-log scale). The horizontal dotted line indicates that the concentration of serum free C5 is 0.5. mu.g/mL and complete inhibition of terminal complement is defined as a concentration of serum free C5. mu.g/mL or less than 0.5. mu.g/mL. The following day 1 free C5 samples were excluded because they were considered to be biologically suspect. Exclusion was confirmed by pairing PK data, since PK and free C5 samples were taken from the same blood draw. [ N-2, pre-dose sample/N-1 on day 1, end of infusion on day 1 ]. As demonstrated in figure 22, refuzumab showed immediate, complete and sustained terminal complement inhibition within the 8 week dosing interval.

Finally, the study population between the current study with refletuzumab (ALXN1210-aHUS-311) and the adult Ekulizumab study (C10-004) was similar on day 183. However, as shown in figure 23, raflizumab produced improved readings compared to eculizumab for the following secondary clinical parameters: a) a category of eGFR/stage of Chronic Kidney Disease (CKD) and (b) an estimated increase in glomerular filtration rate (eGFR). Specifically, in patients treated with refrozumab in this study, 68% achieved an improvement in at least one stage of eGFR class/CKD stage and mean increase in eGFR of 35 ± 35. In contrast, only 63% of patients treated with eculizumab in study C10-004 achieved an improvement of at least one stage of the eGFR class/CKD stage, and the mean increase in eGFR was 29 ± 24. The "complete TMA response" in the current study corresponded to the "improved complete TMA response" in C10-004.

In summary, rivlizumab provided sustained immediate and complete inhibition of C5 within the 8-week dosing interval. Full TMA response was achieved in 54% of patients, similar to the data for eculizumab (56% in study C10-004). Platelet count increases rapidly. In addition, renal function is significantly improved. Specifically, 58.6% of patients dialyzed at baseline did not require dialysis at the end of the study. Furthermore, no unexpected safety issues were identified. Thus, the results from this study support the use of reflizumab at 8 week dosing intervals in adult patients with complement-mediated TMA.

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Dosage and administration of anti-C5 antibody for treatment of Atypical Hemolytic Uremic Syndrome (AHUS)

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