Methods for treating cln2 disease in pediatric subjects

Abstract

This document provides a method for treating neurogenic cerebrospinal fluid disease (CLN2) in individuals under the age of 3 years. In an exemplary embodiment, the method includes administering to the individual a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) in an amount effective in treating CLN2 disease in the individual. A method for delaying the onset of CLN2 disease or its symptoms in individuals under the age of 3 years is also provided. In an exemplary embodiment, the method includes administering to the individual a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) in an amount effective in delaying the onset of CLN2 disease or its symptoms in the individual.

Description

(19) Intellectual Property Office, Republic of China f (12) Published Specification of Invention (11) Publication Number: TW 202122106 A 丿Instant Need' (43) Publication Date: June 16, 2021, Republic of China 110 (2021) (21) Application Number: 109129724 (22) Filing Date: August 31, 2020, Republic of China 109 (2020) (51) Int. Cl.: A61K38 / 46 (2006.01) A61P25 / 28 (2006.01) (30) Priority: August 29, 2019 United States 62 / 893,535 (71) Applicant: BIOMARIN PHARMACEUTICAL INC. (US), a company incorporated in the United States United States (72) Inventors: JACOBY, DAVID; HENSHAW, JOSHUA (US) (74) Agent: CHEN, Chang-Wen Application for Substantive Examination: None Number of Claims: 28 Number of Drawings: 19 Total Pages: 172 (54) Title Method for Treating CLN2 Disease in Pediatric Individuals (57) Abstract The present disclosure provides methods for treating neuronal ceroid lipofuscinosis (CLN2) in individuals less than 3 years of age. In exemplary embodiments, the method comprises administering to the individual a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) in an amount effective to treat CLN2 disease in the individual. Also provided are methods for delaying the onset of CLN2 disease or its symptoms in individuals less than 3 years of age. In exemplary embodiments, the method comprises administering to the individual a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) in an amount effective to delay the onset of CLN2 disease or symptoms in the individual. Methods of treating Neuronal Ceroid Lipofuscinosis (CLN2) disease in a subject less than 3 years old are provided herein. In exemplary embodiments, the method comprises administering to the subject a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPPl) in an amount effective to treat the CLN2 disease in the subject. Also provided are methods of delaying the onset of CLN2 disease, or a symptom thereof, in a subject less than 3 years old. In exemplary embodiments, the method comprises administering to the subject a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPPl) in an amount effective to delay the onset of the CLN2 disease or symptom in the subject. Designated representative figure: TW 202122106 A SYSPEPDQRR TLPPGWVSLG RADPEE1LSL TFALRQQNVE RLSELVQAVS DPSSPQYGKY LTLENVfiDLV RPSPLTLHTV QIOn^AAGAQ KCHSVITQDF LTCWLSIRQA EXiLLPGAEFH hyvggpteth wrsphpyql pqalaphvdf VGGLHRFPPT SSgRPEPQ VTGTVGLHLG VTPSVIRKRT NLTSQDVGSG TSWSQACAQ FBEQYFHDSD LAQBNRLFGG HFAHQASVAR GIEASBDVQY LMSAGANIST WVYSSPGRHB GQEPFLQWLM LLSKESALPH VHTVSYCTDE DSLSSAY 工皿 VNTELMKAA& RGLTLLFASG DSG&GCWSVS GRHQFRPTFP ASSPYVTTVG GTSgPFL 工 OTBIVDYISG 跖FSNVFPRP SYQEEAVTKF LSSSPHLPPS syfm&sgray PDVAALSDGY WWSNRVPIP WVSGTSMTP VFGGILSLIH EHRILSGRPP LGFUIPRLYQ QHGAGLFDVT RGCHESCLDE EVEGQGFCSG P®«DPVTGWG TPNFPALUCI? LLNP

Figure 1

Abstract

Chinese Invention Title

Chinese

English

[0001] This application claims U.S. Provisional Patent Application No. filed on August 29, 2019. Priority of application No. 62 / 893,535, which is incorporated herein by reference. Incorporate the materials submitted electronically by way of citation.

[0002] A list of computer-readable nucleotide / amino acid sequences, filed concurrently with this application and identified as follows, is incorporated herein by reference in its entirety: an 8,177-byte ASCII (text) file named "54735_Seqlisting.txtj" created on August 27, 2020.

[0003] This disclosure concerns the treatment of neurogenic lipofuscin in individuals under 3 years of age. Methods for treating (CLN2) and methods for delaying the onset of CLN2 or its related physiological symptoms. [Previous Technology]

[0004] Neurolipofuscinosis (CLN2) is a rare genetic disorder characterized by a deficiency of the lysosomal enzyme tripeptidyl peptidase-1 (TPP1) caused by a mutation in the TPP1 gene. CLN2 is an autosomal recessive genetic disorder. 5 The estimated incidence is 0.5 per 100,000 surviving newborns. In the absence of TPP1, lysosomal storage material, usually metabolized by enzymes, accumulates in many organs, and its accumulation in the central nervous system leads to the typical neurodegenerative symptoms of CLN2 disease. As indicated by natural history data from independent patient populations in North America and Europe, untreated CLN2 disease... (Page 1 of 94, Invention Specification) C232142PA.docx The disease has been fully characterized, and its natural history is clearly consistent and predictable.

[0005] CLN2 disease is primarily characterized by a 'classic' late-infant phenotype. Children with CLN2 typically develop until around 3 years of age, at which point they develop their first symptoms. Most commonly, CLN2 patients initially experience unexplained seizures and begin to lag behind normal language milestones. By age 3, all patients present with one or more symptoms, including, for example, seizures, dementia, loss of movement, motor impairment, blindness, clumsiness, ataxia, and cognitive decline. From the onset of clinical symptoms, the disease progresses rapidly and aggressively, typically leading to complete loss of language, cognition, gait, fine motor skills, medullary function, and vision within 2 to 4 years, rendering the patient immobile, aphonic, and blind. The patient remains in a vegetative state until death, which usually occurs between the ages of 6 and 12.

[0006] In assessing the severity of CLN2 disease, expert clinicians have developed two quantitative rating scales for use in natural history studies: (1) the Hamburg scale (Steifeld et al., *American Journal of Medical Genetics*, 2002; 112(4):347-54); and (2) the Weill Cornell Medical College (WCMC) scale (Worgall et al., *Neurology*, 2007; 69(6):521-35). The two scales are similar in structure and assessment method. Both scales measure the loss of previously achieved important neurological milestones in CLN2 patients, with each unit loss in the disease rating scale representing a basic milestone of progressive decline.

[0007] An analysis of the disease course in children affected by untreated CLN2 showed that, following the onset of the disease, they predictably lost all language and gait within 3 years, with an average loss of 2.1 milestone events per year (i.e., a loss of 2.1 points on the disease rating scale). Language decline usually precedes gait, so that the first year is characterized by the loss of clear speech, progressing to gait ataxia; the second year is characterized by the loss of walking ability and clear speech; and the third year is characterized by the loss of any motor or communication ability.

[0008] Recombinant human tripeptidyl peptidase-1 (rhTPPl) is being developed as a potential treatment for CLN2 disease. The rhTPPl protein is produced as a proenzyme in cell cultures and does not possess enzymatic activity. Page 2 of 94 (Invention Specification) Sex. Upon absorption into lysosomes, the proenzyme is self-activated at acidic pH (and by utilizing lysosomal proteases). The mature native TPP1 protein is a lysosomal serine protease and the only known mammalian member of the serine-carboxyl peptidase (sedolisin) family, characterized by a highly conserved Ser-Glu-Asp (SED) catalytic triad formed by S456, E253, and D341 on the °rhTPPl. The enzyme’s main activity is as a tripeptidyl exopeptidase with broad acceptor specificity. The enzyme’s activity on its acceptor leads to the sequential release of the tripeptide from the N-terminus of the protein acceptor (Oyama et al., Journal of Biochemistry (JBiochm.) 2005; 138(2):127-34). It has also been reported to have minor, significantly weaker endoprotein degradation activity at an optimal pH of 3 (Lm et al., Journal of Biochemistry, 2001; 276(3):2249-55).

[0009] The only commercially available treatment for CLN2 is symptomatic and supportive care; currently, there are no approved treatment options to slow or halt the unstoppable progression of CLN2, let alone reverse the harmful effects of the disease (Mole, SE, and Williams, RE, 2010, GeneReviews; Chang et al., The Neuronal Ceroid Lipofuscinoses (Batten Disease); 2011, Oxford Univ Press). Preserving the motor, language, and / or visual abilities of these children has clinically significant benefits for both patients and their parents / caregivers. Therefore, new therapies for CLN2 are needed to reduce or prevent the deterioration of disease-related physiological functions. [Summary of the Invention]

[0010] This disclosure relates to a method for treating CLN2 disease or one or more symptoms associated with CLN2 disease in an individual. In an exemplary embodiment, the individual is less than 3 years old. In an exemplary embodiment, the method includes administering to the individual a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPPl) in an amount that can effectively treat CLN2 disease in the individual. This disclosure also relates to a method for delaying the onset of CLN2 disease or its symptoms in an individual. In an exemplary embodiment, the individual is less than 3 years old. In an exemplary embodiment, the method includes... Page 3 of 94 (Invention Specification) C232142PA.docx This involves administering a formulation including rhTP1 to an individual in an amount that can effectively delay the onset of CLN2 disease or its symptoms. In exemplary cases, the formulation is administered to the individual via intraventricular, intrathecal, or intraocular administration. In exemplary cases, the formulation is administered once every 2 weeks. In various cases, the formulation is administered via infusion at a rate of approximately 2.5 mL / h. In all cases of the currently disclosed method, the individual is administered a dose of approximately 300 mg or less. In exemplary cases, the individual is older than or approximately 2 years old, and, as appropriate, is administered a dose of approximately 300 mg rhTP1. In various cases, the individual is older than or approximately 1 year old and less than 2 years old, and, as appropriate, is administered a dose of approximately 200 mg rhTP1. In the illustrative cases, individuals (e.g., those older than or approximately 1 year old and younger than 2 years old) were given approximately 200 mg rhTP1 for each of the first, second, third, and fourth doses, and for each of the fifth and subsequent doses, greater than approximately 200 mg rhTP1. In the illustrative case, individuals were given approximately 300 mg rhTP1 for each of the fifth and subsequent doses. In each case, individuals were older than or approximately 6 months old and younger than 1 year old, and were given a dose of approximately 150 mg rhTP1, depending on the situation. In each case, individuals were younger than 6 months old, and were given a dose of approximately 100 mg rhTP1, depending on the situation. In the illustrative cases, individuals showed decreased TPP1 enzyme activity based on blood tests. In the illustrative example, the individual was a sibling of an individual diagnosed with CLN2. In the exemplary cases, the individual's total score on the motor and verbal subscales was approximately 3 to 6. In the exemplary cases, the individual had not previously received stem cell therapy, gene therapy, or enzyme replacement therapy. In the exemplary cases, the method included administering an antihistamine to the individual, with or without an antipyretic, approximately 30 to 60 minutes prior to the administration of rhTP1, as appropriate. In each case, the formulation included rhTP1 and at least one pharmaceutically acceptable carrier, diluent, or excipient. In various cases, the formulation included diammonium hydrogen phosphate pentahydrate, monoammonium phosphate monohydrate, arginine chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or combinations thereof. In various cases, the method included administering a flushing solution to the individual after the administration of the formulation. In each case, the flushing solution included diammonium hydrogen phosphate pentahydrate, monoammonium phosphate monohydrate, arginine chloride, potassium chloride, Page 4 of 94 (Invention Specification) C232142PA.docx Magnesium chloride, calcium chloride hydrate, water for injection, or combinations thereof. In each formulation, the treatment period is at least 10 weeks, at least 20 weeks, at least 40 weeks, at least 80 weeks, or at least 96 weeks.

[0011] The foregoing summary is not intended to limit each aspect of the invention, and other features and advantages of this disclosure will become apparent from the following detailed description, including the accompanying drawings. This disclosure is intended to be consistent with other disclosures, and it should be understood that all combinations of features described herein may be covered even if no combination of features is found in the same sentence, paragraph, or section of this disclosure. Additionally, as an additional aspect, this disclosure encompasses all embodiments of the invention, the scope of which is narrower in any way compared to the variations specifically mentioned above. Regarding the various aspects of this disclosure described or claimed as “a” or “an,” it should be understood that such terms mean “one or more” unless the context explicitly requires a stricter meaning. Regarding the description of elements as one or more within a group, it should be understood that all combinations within that group may be covered. If a aspect of this disclosure is described as “comprising” features, it may also cover embodiments “consisting of features” or “substantially consisting of features.” As a whole, additional features and variations of this disclosure will be apparent to those skilled in the art, and all such features are intended to serve as the model of this disclosure. [Simplified Explanation of the Diagram]

[0012] Figure 1 depicts the amino acid sequence of the rhTPPl proenzyme lacking the relevant signal peptide. The first 176 amino acid residues of the enzyme are present, and the length of the mature enzyme starting from position 177 is 368 amino acids.

[0013] Figure 2 depicts the clinical progression of untreated individuals with CLN2 disease in the natural history study and shows the relationship between Hamburger Motor and Language Syndrome scores up to 6 and patient age. The median, quartiles, and 10% / 90% distributions are also shown; as well as the mean and 95% confidence intervals.

[0014] Figures 3A to 3F depict the cumulative clinical assessment of 24 patients during treatment and show the Hamburger Motor and Verbal Syndrome (HMS) scores up to 6. Hollow circles represent the scores after the first infusion of 300 mg. Page 5 of 94 (Invention Specification) C232142PA.docx CLN2 scores obtained before or after rhTPPl, with hollow circles representing CLN2 scores obtained after the first 300 mg rhTPPl infusion. The total score (circles) and the contributions of motor / gait (squares) and language (triangles) to the total score are also shown. Day 1 of the analysis is the date of the first infusion.

[0015] Figures 4A to 41 compare the disease scores of the six Hamburger Motor and Language Integration Scales. (Indicated by the prefix "HAM"), the changes in CLN2 scores of 9 patients who received rhTPPl treatment and untreated patients with natural history matched with the treated individuals are compared. Solid lines in each group represent the results of the treated patients, while dashed lines represent the results of the untreated patients with natural history matched with solid lines.

[0016] Figure 5 depicts the distribution of clinical changes from baseline in matched untreated patients with natural medical histories (circles) during the treatment period compared with the study individuals (squares).

[0017] Figures 6A to 61 depict the changes in disease scores on the nine Hamburger Motor / Verbal / Visual Overall Scales from 0 to 9, and the changes in CLN2 scores of nine matched patients with rhTP1 treatment to those with no natural history of illness. Solid lines in each group represent the outcomes of treated patients, while dashed lines represent the outcomes of patients with no natural history of illness, compared to the results of the matched untreated patients.

[0018] Figure 7 depicts the cerebrospinal fluid volume of all 24 patients measured during treatment. Area (top image) and proportion (bottom image). Each line represents one patient.

[0019] Figures 8A to 8L depict the brain volume of 24 treated patients. The volume (top) and proportion (bottom) of white matter are shown as the difference between the total brain volume (dotted line) and CSF and gray matter (dashed line), while gray matter is shown as the difference between CSF and gray matter (dashed line) and CSF (solid line).

[0020] Figures 9A and 9B depict the mean changes in CLN2 scores for patients treated with rhTP1 and untreated patients with natural medical histories. Figure 9A depicts the CLN2 scores of 23 patients (dashed line) treated with 300 mg rhTP1 for 48 weeks and the untreated natural medical histories group of 41 individuals (solid line). Figure 9B depicts the changes in CLN2 scores from baseline for the 23 patients treated with 300 mg rhTP1 for 48 weeks. Page 6 of 94 (Invention Specification) C232142PA.docx

[0021] Figures 10A to 10L depict the clinical assessment of 24 patients accumulated during the treatment period. The results show the combined scores for motor function (square), speech (triangle), seizures (cross), and visual function (diamond) for up to 12 combined hamburgers (left image). The combined scores for gait (square), speech (triangle), myoclonus (cross), and eating (diamond) for up to 12 combined hamburgers (right image) are also shown. Hollow circles represent the total CLN2 score obtained before or after the first rhTPPl 300 mg infusion, while open circles represent the total CLN2 score obtained after the first rhTPPl 300 mg infusion.

[0022] Figure 11 shows a table of clinical laboratory assessments and events tested in the studies described in Examples 4-10.

[0023] Figure 12 shows a table listing the Hamburg LINCL scale.

[0024] Figure 13 shows the median (range) PK parameters of cerliponase alfa in cells after single doses of 30, 100 and 300 mg via ICV infusion.

[0025] Figure 14 shows the median leptinase a value in cells after ICV infusion of 300 mg QOW (range) (encirclement) PK parameters.

[0026] Figure 15 shows the levels of cellularity in CSF and plasma after ICV infusion of 300 mg QOW. Mean concentration-time curve of ponase a. Time represents the start of infusion. SD = steady-state dose phase.

[0027] Figure 16 shows the plasma exposure of patient and access-matched CSF and cellular leptonatase a at 300 mg ICV QOW.

[0028] Figures 17A-17D show patient characteristics in CSF and plasma, and cellular leptonase a. PK. Individual patient data are displayed as circles. Figure 17A > Gender; Figure 17B > Baseline Age; Figure 17C > Baseline Weight; Figure 17D, Baseline CLN2 Score. The boxes represent the interquartile range (IQR) between the first (Q1) and third (Q3) quartiles, the bars inside the boxes represent the median, and the whiskers represent the minimum and maximum values ​​excluding outliers (i.e., values ​​outside the standard range are defined as ranging from Q1 - 1.5 * IQR to Q3 + 1.5 * IQR; hollow circles). Page 7 of 94 (Invention Specification) C232142PA.docx

[0029] Figures 18A-18B show the PK and ADA status matched for individual accesses of cellular leponase a. Figure 18a, CSF; Figure 18b, plasma / serum. Hollow circles indicate patients who were ADA-negative at the study access, and hollow circles indicate patients who were ADA-positive at the study access.

[0030] Figure 19 shows the changes from baseline in the CLN2 Clinical Assessment Scale and the combined motor and language function score of cellular leptokinase a PK in the CSF. Individual patient data are shown as circles. The box represents the interquartile range (IQR) between the first (QD) and third (Q3) quartiles, the bar inside the box represents the median, and the whiskers represent the minimum and maximum values ​​excluding outliers (i.e., values ​​outside the standard range are defined as ranging from Q1 - 1.5 * IQR to Q3 + 1.5 * IQR; hollow circles).

Implementation Method

[0031] The following definitions are intended to assist those skilled in the art in understanding this disclosure. Unless otherwise defined herein, the scientific and technical terms used in connection with this disclosure have meanings commonly understood by one of ordinary skill in the art. When providing ranges of values, it should be understood that the invention covers all intermediate values ​​between the upper and lower limits of the range (unless the context clearly indicates otherwise, up to one-tenth of the lower limit unit) and any other stated or intermediate values ​​within the stated range. The upper and lower limits of these smaller ranges may be independently included within the smaller range and are subject to any particular exclusive limitation within the stated range.

[0032] The term “family medical history” refers to individuals who have been diagnosed with CLN2 disease, such as siblings, parents, grandparents, great-grandparents, etc.

[0033] In one state, the term "fragment" refers to a recombinant protein comprising a portion of the rhTP1 preenzyme amino acid sequence as illustrated in SEQ ID NO:1 and Figure 1. For example, a fragment may contain at least about 60%, at least about 70%, at least about 80%, at least about 90%, or at least about 95% of the amino acid sequence as illustrated in SEQ ID NO:1. In another state, a fragment may comprise the full-length (368 amino acid length; amino acids 177-544 of SEQ ID NO:1) mature TPP1 enzyme amino acid sequence as illustrated in SEQ ID NO:2. Page 8 of 94 (Invention Specification) C232142PA.docx The fragment, a portion thereof, and / or at least includes a catalytic triplet formed by amino acid residues S456, E253, and D341. The fragment retains catalytic activity. For example, the fragment exhibits tripeptidyl exopeptidase activity and / or catalytic activity, which causes the tripeptide to be sequentially released from the N-terminus of the protein acceptor. In some states, the "fragment" of the rhTPPl proenzyme includes at least 500 consecutive amino acids of SEQ ID NO: 1, at least 450 consecutive amino acids of SEQ ID NO: 1, at least 400 consecutive amino acids of SEQ ID NO: 1, at least 368 amino acids of SEQ ID NO: 1, at least 350 amino acids of SEQ ID NO: 1, or at least 300 consecutive amino acids of SEQ ID NO: 1. In other states, the "fragment" of the rhTPPl proenzyme includes at least 350 consecutive amino acids of SEQ ID NO:2, at least 325 consecutive amino acids of SEQ ID NO:2, at least 300 consecutive amino acids of SEQ ID NO:2, at least 275 consecutive amino acids of SEQ ID NO:2, at least 250 consecutive amino acids of SEQ ID NO:2, or at least 200 consecutive amino acids of SEQ ID NO:2.

[0034] The term "ventricle" refers to the administration of the composition to the ventricular system, for example, by injection, infusion or implantation (e.g. into the ventricle).

[0035] The term "intraocular" means, for example, the application of a composition to the ocular area by injection, infusion or implantation (e.g. into the eyeball) or topical / ocular administration (e.g., using cream, ointment, gel or drop).

[0036] The term "intrathecal" refers to the administration of the composition to the lumbar region, for example, by injection, infusion or implantation (e.g., into the subarachnoid space of the spinal cord).

[0037] The term "therapeutic efficacy" means any therapeutic benefit resulting from the treatment method of the present invention. For example, such an effect may be a beneficial effect manifested in a suitable target tissue or organ, in which the beneficial physiological effect is compared with measured physiological parameters in the absence of enzyme replacement therapy. Such a therapeutic effect may be any reduction or elimination of one or more clinical or subclinical manifestations of CLN2 disease. For example, therapeutic efficacy improves, reverses, delays, prevents, or alleviates the deterioration of one or more physiological functions and / or neurological symptoms of CLN2 as described herein. Page 9 of 94 (Invention Specification) C232142PA.docx

[0038] The terms "stable" or "stabilized" refer to formulations containing proteins in which the protein components substantially retain their physical, functional, and / or chemical stability over time of storage. Stability can be measured at a selected temperature over a selected time period. Preferably, the formulation is stable for at least one month at room temperature (about 30°C) or at about 40°C and / or stable for at least one year, and more preferably at least two years, at about 2°C to about 8°C. For example, the degree of protein degradation or aggregation during storage can be used as an indicator of protein stability. Thus, a "stable" formulation may be one in which less than about 20%, more preferably less than about 10%, and most preferably less than about 5% of the protein components are present in the formulation in a degraded or aggregated form after storage. "Stable" formulations essentially retain the same functional or therapeutic characteristics as freshly prepared formulations. Various analytical techniques for measuring protein stability are available in this field and are reviewed in, for example, *Peptide and Protein Drug Delivery*, 247-301, edited by Vincent Lee, Marcel Dekker, New York, NY, Pubs. (1991) and *Advanced Drug Delivery Rev.*, Jones, A., 10: 29-90 (1993).

[0039] The terms “prevention” or “reduction” or their grammatical equivalents, when used to refer to the prevention or reduction of one or more symptoms or physiological consequences of CLN2 in an individual, mean that the rate of decline of one / other symptoms in a treated CLN2 individual is slower than the rate of decline observed in an untreated CLN2 individual. In this regard, untreated CLN2 may be the same individual subsequently treated with the compositions of the present invention, or it may be the average rate of decline of the symptom of interest as observed in the results of natural history studies as disclosed herein.

[0040] In the jurisdiction prohibiting patenting methods of human practice, "giving" rhTPPl or a formulation thereof to a human individual means, for example, the medical use of rhTPPl or a formulation thereof for treating CLN2 disease as described herein, or the use of rhTPPl for manufacturing a medicament for treating CLN2 disease as described herein. The broadest reasonable interpretation of the law or regulation defining the patentable subject matter is as required. In the jurisdiction not prohibiting patenting methods of human practice, "giving" rhTPPl or a formulation thereof includes both the method of human practice and the aforementioned activities. Page 10 of 94 (Invention Specification) C232142PA.docx

[0041] This disclosure provides formulations and kits including rhTPPl and methods of using them to treat CLN2 disease. Administration of rhTPPl allows for cellular uptake of proteins via a cationic-independent mannose-6-phosphate receptor (CI-MPR) and localization to lysosomes throughout the central nervous system. Enzyme uptake into lysosomes and subsequent activation promote increased degradation of stored material in affected tissues, reducing the progressive accumulation of lysosomal stored material and inhibiting disease progression. The formulations and methods of this disclosure provide therapeutic benefits exceeding those of currently approved treatments.

[0042] Ingredients

[0043] Regarding this disclosure, the formulation includes a certain amount of rhTPPl, and in an exemplary state, the formulation is suitable for intraventricular, intrathecal, and / or intraocular administration. In one state, rhTPPl includes SEQ ID NO:1 or a fragment thereof. The rhTPPl protein suitable for the formulations and methods described herein, and methods for obtaining the rhTPPl protein, are described in U.S. Patent Nos. 6,302,685 and 8,277,800, which are incorporated herein by reference in their entirety.

[0044] In one sample, rhTPPl includes the amino acid sequence of SEQ ID NO:1 (Figure 1) The amino acid sequence shown in Figure 1 (amino acids 1-544) or a fragment thereof with catalytic activity is included. In another state, rhTPPl includes the amino acid sequence of SEQ ID NO:2 (amino acids 177-544 of the amino acid sequence shown in Figure 1) or a fragment thereof with catalytic activity. In yet another state, rhTPPl has detectable enzyme activity, or is processed in vivo to form an enzyme with detectable enzyme activity (i.e., "functional"), and has at least about 70% sequence identity with SEQ ID NO:1 or SEQ ID NO:2. For example, the functional rhTPPl is at least about 70% identical, at least about 75% identical, at least about 80% identical, at least about 85% identical, at least about 90% identical, at least about 95% identical, or at least about 97% identical to SEQ ID NO:1 or SEQ ID NO:2. In one state 5 The formulation is a liquid formulation comprising rhTPPl at concentrations of approximately 1 mg / mL to approximately 10 mg / mL, such as approximately 10 mg / mL to approximately 50 mg / mL, approximately 25 mg / mL to approximately 40 mg / mL, or approximately 30 mg / mL to approximately 60 mg / mL. In each state, the formulation comprises approximately 1 mg / mL of rhTPPl. Page 11 of 94 (Invention Specification) C232142PA.docx Approximately 100 mg / mL, approximately 5 mg / mL, approximately 80 mg / mL, approximately 10 mg / mL, approximately 50 mg / mL, approximately rhTPPl o in a single state at concentrations of 20 mg / mL to about 40 mg / mL, about 25 mg / mL to about 35 mg / mL, more specifically about 1 mg / mL, about 10 mg / mL, about 20 mg / mL, about 30 mg / mL, about 40 mg / mL, about 50 mg / mL, about 60 mg / mL, about 70 mg / mL, about 80 mg / mL, about 90 mg / mL or about 100 mg / mL, wherein the pH of the formulation is about 5.5 to about 7.5, or about 6.0 to about 7.0, for example about 5.5, about 6.0, about 6.5, about 7.0 or about 7.5.

[0045] In a state 5Formulations of rhTPPl, including those disclosed herein, further include one or more excipients that maintain key electrolyte levels in cerebrospinal fluid (CSF) or ocular fluid. For example, in one formulation, in addition to rhTPPl or a fragment thereof, the formulation further includes potassium chloride at concentrations of about 0.01 mg / mL to about 1 mg / mL, such as about 0.1 mg / mL to about 0.5 mg / mL, about 0.2 mg / mL to about 0.8 mg / mL, about 0.2 mg / mL to about 0.4 mg / mL, about 0.15 mg / mL to about 0.25 mg / mL, or about 0.05 mg / mL to about 0.3 mg / mL. In another formulation, the formulation further comprises magnesium chloride hexahydrate at a concentration of about 0.01 mg / mL to about 1 mg / mL, such as about 0.1 mg / mL to about 0.5 mg / mL, about 0.1 mg / mL to about 0.8 mg / mL, about 0.1 mg / mL to about 0.3 mg / mL, about 0.15 mg / mL to about 0.25 mg / mL, or about 0.05 mg / mL to about 0.3 mg / mL. In another formulation, the formulation further comprises calcium chloride dihydrate at a concentration of about 0.01 mg / mL to about 1 mg / mL, such as about 0.1 mg / mL to about 0.5 mg / mL, about 0.2 mg / mL to about 0.8 mg / mL, about 0.15 mg / mL to about 0.25 mg / mL, about 0.1 mg / mL to about 0.3 mg / mL, or about 0.05 mg / mL to about 0.3 mg / mL. In another instance, the formulation includes all or any combination of the foregoing contents.

[0046] In another state, the formulation comprising rhTPPl further comprises one or more buffers. For example, in each state, the formulation further comprises diammonium hydrogen phosphate heptahydrate at concentrations of about 0.01 mg / mL to about 1 mg / mL, such as about 0.1 mg / mL to about 0.5 mg / mL, about 0.05 mg / mL to about 0.4 mg / mL, or about 0.1 mg / mL to about 0.3 mg / mL; and / or about 0.01 mg / mL to about 1 mg / mL. Page 12 of 94 (Invention Specification) C232142PA.docx For example, concentrations of dihydrogen phosphate monohydrate from about 0.01 mg / mL to about 0.2 mg / mL, from about 0.05 mg / mL to about 0.3 mg / mL, or from about 0.08 mg / mL to about 0.4 mg / mL.

[0047] In another embodiment, the formulation further comprises an isotonic agent, such as indium chloride, at concentrations of about 1 mg / mL to about 20 mg / mL, for example, about 1 mg / mL to about 10 mg / mL, about 5 mg / mL to about 15 mg / mL, or about 8 mg / mL to about 20 mg / mL. Other buffers and isotonic agents known in the art are suitable and can be conventionally applied to the formulations of this disclosure.

[0048] In one state, the formulation comprising about 30 mg / mL of rhTPPl further comprises about 0.11 mg / mL of dihydrogen phosphate heptahydrate, about 0.08 mg / mL of dihydrogen phosphate monohydrate, about 8.77 mg / mL of phosphate, about 0.22 mg / mL of potassium chloride, about 0.16 mg / mL of magnesium chloride hexahydrate, about 0.21 mg / mL of calcium chloride dihydrate, and a diluent, such as water for injection.

[0049] The rhTPPl formulations disclosed herein are stable and can be stored for an extended period without unacceptable changes in quality, efficacy, or purity. In one state, the formulation is stable at a temperature of about 5°C (e.g., 2°C to 8°C) for at least one month, such as at least one month, at least three months, at least six months, at least 12 months, at least 18 months, at least 24 months, or longer. In another state, the formulation is stable at a temperature below or equal to about -20°C for at least six months, such as at least six months, at least 12 months, at least 18 months, at least 24 months, at least 36 months, or longer. In yet another state, the formulation is stable at a temperature below or equal to about -40°C for at least six months, such as at least six months, at least 12 months, at least 18 months, at least 24 months, at least 36 months, or longer. In another state, the formulation is stable at a temperature of about -60°C for at least 6 months, for example, at least 6 months, at least 12 months, at least 18 months, at least 24 months, at least 36 months or longer.

[0050] In one sample, the formulations of this disclosure are free of preservatives and / or stabilizers, and therefore do not contain thimerosal, phenylmercuric acid, chlorhexidine, phenol, benzoic acid, sorbic acid, p-hydroxybenzoic acid esters, Page 13 of 94 (Invention Specification) C232142PA.docx Alcohols are any of the other preservatives commonly found in non-intestinal or non-ocular formulations.

[0051] In another embodiment, the formulations of the present invention may include one or more preservatives, stabilizers, or excipients. In this regard, a variety of well-known and conventionally used preservatives, stabilizers, and excipients suitable for intrathecal or ICV-delivered protein-containing formulations are known in the art. More specifically, examples of such additives suitable for intrathecal or ICV-delivered enzyme-containing formulations are described in WO2013 / 096899, which is incorporated herein by reference.

[0052] Method

[0053] This disclosure provides a method for treating CLN2 disease, comprising administering a therapeutically effective amount of a formulation including rhTP1 as described herein to an individual in need. This disclosure also provides compositions including rhTP1 for treating CLN2 disease as described herein, and the use of rhTP1 in the manufacture of a pharmaceutical agent for treating CLN2 disease as described herein. In one state, the severity and progression of CLN2 disease and the therapeutic benefit of administering rhTP1 to patients can be measured using the Hamburger or WCMC Clinical Disease Rating Scale. Both the Hamburger and WCMC scales consist of four disease-related domains, which are scored according to subscales from 0 to 3, where 3 is normal, 2 is abnormal but functional, 1 is abnormal and significantly functional, and 0 is no residual function. Two of the four domains, gait / motor and language, are shared between the two scales and have high internal content validity. Each scale captures changes that occur with both disease progression and disease management. Gait, speech, and visual acuity scales are used to assess disease progression. Seizure frequency, motor impairment, and feeding depend on nursing decisions, specifically anticonvulsant medications and feeding tube management. Clinical progression is typically assessed using the convergent speech and gait subscales; therefore, a score of 6 indicates a normal age. The classification is complete functional loss. Table 1 describes the WCMC and Hamburg CLN2 disease scales. Table 1 The Welch Cornell Health Scale (WCMC) Hamburger Gait Scale: 3. Normal movement; 3. Normal walking; 2. Abnormal but independent; 2. Frequent falls, marked clumsiness; 1. Abnormal, requires assistance; 1. Unable to walk or only able to walk without assistance. Page 14 of 94 (Invention Specification) C232142PA.docx 0 Unmovable soil and rocks fr □□□ 3 Normal 2 Abnormal 1 Rarely understandable 0 Speech unintelligible or no speech Myoclonus (motor) 3 Myoclonus, chorea / tremor / atheomysiomyopathy and ascending toes (moderate fever) 2 Myoclonus, chorea / tremor / atheomysiomyopathy and ascending toes (one of these) 1 Myoclonus, chorea / tremor / atheomysiomyopathy and ascending toes (two of these) 0 Myoclonus and chorea / tremor / atheomysiomyopathy and ascending toes (eating) 3 No swallowing dysfunction 2 Mild swallowing dysfunction 1 Moderate swallowing dysfunction 0 Dependence on gastric tube Crawling 0 Unable to move, mostly bedridden 5 = 3 Normal 2 Distinguished abnormality 1 Almost no understanding 0 Language incomprehensible or non-linguistic 3 Visual acuity 3 Recognizes desired object and grasps it 2 Unable to grasp objects in a coordinated manner 1 Responds to light 0 No response to visual stimuli Seizures 3 No seizures in 3 months 2 1-2 seizures in 3 months 1 Seizures once a month 0 More than 1 seizure per month

[0054] In various embodiments, this disclosure provides a method for treating CLN2 disease or one or more clinical symptoms of CLN2 disease, the use of rhTPPl in manufacturing an agent for treating an individual with CLN2 disease, or the use of rhTPPl in treating an individual with CLN2 disease, the method comprising administering to an individual in need a composition comprising a therapeutically effective amount of rhTPPl.

[0055] This disclosure also provides a method for preventing one or more clinical symptoms of CLN2 disease, comprising administering to an individual in need a formulation including the rhTPPl described herein, wherein the individual has a family history of CLN2 disease. In various embodiments, this disclosure provides a method for preventing one or more clinical symptoms of CLN2 disease, the use of rhTPPl in the manufacture of an agent for preventing one or more clinical symptoms of CLN2 disease in an individual, or the use of rhTPPl in preventing one or more clinical symptoms of CLN2 disease in an individual, the method comprising administering to an individual in need a composition comprising a therapeutically effective amount of rhTPPl, wherein the individual has a family history of CLN2 disease. Page 15 of 94 (Invention Specification) C232142PA.docx

[0056] This disclosure further provides a method for treating CLN2 disease, comprising administering rhTP1 to an individual at a dose that effectively maintains or slows or mitigates the deterioration of physiological function in an individual in need, wherein the physiological function is language function, motor function, vision, or eating function. This disclosure also provides the use of rhTP1 in the manufacture of a pharmaceutical preparation for maintaining or slowing or mitigating the deterioration of physiological function in an individual with CLN2, and the use of rhTP1 in maintaining or slowing or mitigating the deterioration of physiological function in an individual with CLN2 disease; wherein the physiological function is language function, motor function, vision, or eating function.

[0057] In one sample, the method of treating an individual with CLN2 disease or a family history of CLN2 disease includes administering to the individual a dose of rhTPPl that effectively maintains or slows or reduces the deterioration of language function. In one sample, as measured using the WCMC or Hamburger Disease Rating Scale, the deterioration of language function is reduced by at least one point compared to a previous rating measured before or during treatment. In both the WCMC and the Hamburger Scale, a rating of 3 indicates normal language; 2 (discernibly) indicates abnormal language; 1 indicates little / almost incomprehensible language; and . indicates incomprehensible or no language. In one sample, the dose of rhTPPl effectively maintains the individual's language rating at the same level as a previous rating measured before or during treatment, such as 3, 2, or 1. In another sample, the dose of rhTPPl effectively slowed or reduced the decline in language function associated with CLN2 in individuals, which was supported by maintaining language assessments at the same level for a longer period of time or by less decline in language function assessments compared to what was expected given the natural progression of the disease.

[0058] In another sample, treatment of individuals with CLN2 or a family history of CLN2 includes administering a dose of rhTP1 that effectively maintains motor function or slows or mitigates the deterioration of motor function. In one sample, as measured using the WCMC or Hamburger Disease Rating Scale, the deterioration of motor function is reduced by at least one point compared to a previous assessment measured before or during treatment. Clinical rating scales for gait in the WCMC or movement in the Hamburger Disease Rating Scale can be used to assess motor function. In the WCMC and Hamburger Disease Rating Scale... Page 16 of 94 (Invention Specification) C232142PA.docx In both categories of the rhTP1 scale, a score of 3 indicates normal walking; 2 indicates abnormal walking but not dependent, such as frequent falls or marked clumsiness; 1 indicates abnormal walking requiring assistance, such as being unable to walk without assistance or only able to crawl; and 3 indicates immobility / inability to move, such as individuals who are mostly bedridden. In one category, the dose of rhTP1 effectively maintained an individual's motor function assessment at the same level as the previous assessment measured before or during treatment, such as 3, 2, or 1. In another category, the dose of rhTP1 effectively slowed or reduced an individual's CLN2-related motor function deterioration, which can be confirmed by maintaining the motor assessment at the same level for a longer period of time or by a smaller decline in motor function assessment compared to what is expected considering the natural progression of the disease.

[0059] In another sample, the method of treating an individual with CLN2 or a family history of CLN2 includes administering to the individual a dose of rhTPPl that effectively maintains vision or slows or reduces the deterioration of vision. In one sample, as measured using the Hamburger Disease Rating Scale, the deterioration of vision is reduced by at least one point compared to a previous rating measured before or during treatment. According to the Hamburger Scale, a rating of 3 indicates that the individual recognizes and grasps the desired object; 2 indicates that the individual cannot grasp the object in a coordinated manner; 1 indicates that the individual responds to light, and . 3 indicates that the individual does not respond to visual stimuli. In one sample, the dose of rhTPPl effectively maintains the individual's visual acuity rating at the same level as a previous rating measured before or during treatment, such as 3, 2, or 1. In another case, the dose of rhTPPl effectively slowed or reduced CLN2-related visual deterioration in individuals, which was supported by maintaining visual acuity at the same level for a longer period of time or by less decline in visual acuity compared to what was expected given the natural progression of the disease.

[0060] In another category, treatment of individuals with CLN2 or a family history of CLN2 includes administering a dose of rhTP1 that effectively maintains or slows or mitigates the deterioration of eating function. In one category, eating function is reduced by at least one point compared to a previous assessment measured before or during treatment, as measured using the WCMC rating scale. A WCMC rating of 3 indicates no dysphagia; 2 indicates mild dysphagia; and 1 indicates moderate dysphagia. Page 17 of 94 (Invention Specification) C232142PA.docx Furthermore, the score indicates individual dependence on the gastric tube. In one outcome, the rhTP1 dose effectively maintained an individual's eating function at the same level as a previous assessment measured before or during treatment, such as 3, 2, or 1. In another outcome, the rhTP1 dose effectively slowed or mitigated the individual's CLN2-related decline in eating function, which was evidenced by maintaining eating function at the same level for a longer period or by a smaller decline in eating assessment compared to what was expected given the natural progression of the disease.

[0061] This disclosure further provides a method for treating CLN2 disease, comprising administering rhTP1 to an individual in need at a dose that effectively improves physiological function, wherein the physiological function is language function, motor function, vision, or eating function. This disclosure also provides the use of rhTP1 in the manufacture of a pharmaceutical preparation for improving the physiological function of an individual with CLN2 or in the use of rhTP1 to improve the physiological function of an individual with CLN2; wherein the physiological function is language function, motor function, vision, or eating function. Given the progressive degenerative nature of the disease, improvement in language function, motor function, vision, and / or eating function is particularly desirable, indicating that the individual has recovered lost functions, but which are difficult to achieve with current treatment options.

[0062] In one sample, the method of treating an individual with CLN2 disease includes administering to the individual a dose of rhTPPl that effectively improves language function. In one sample, as measured using the WCMC or Hamburger Disease Rating Scale, the improvement in language function is at least one point higher than a previous rating measured before or during treatment. For example, an individual may improve from a rating of 1 or 2 to a rating of 3, indicating a return to normal language, or from a rating of 1 to a rating of 2.

[0063] In another scenario, the method of treating an individual with CLN2 disease includes administering an amount of rhTPPl that effectively improves motor function. In one scenario, as measured using the WCMC or Hamburger Disease Rating Scale, the improvement in motor function is at least one point higher than a previous rating measured before or during treatment. For example, an individual may improve from a rating of 1 or 2 to a rating of 3, indicating a return to normal walking, or from a rating of 1 to a rating of 2.

[0064] In one state, a method of treating an individual with CLN2 disease includes administering to the individual... Page 18 of 94 (Invention Specification) C232142PA.docx A dose of rhTPPl o that can effectively improve vision in a single sample, as measured using the Hamburger Disease Rating Scale, shows an improvement of at least one point in vision compared to a previous rating measured before or during treatment. For example, an individual may improve from a rating of 1 or 2 to a rating of 3, or from a rating of 1 to a rating of 2.

[0065] In another category, the method of treating an individual with CLN2 disease includes administering an amount of rhTPPl that effectively improves eating function. In one category, as measured using the WCMC Disease Rating Scale, the improvement in eating function is an increase of at least one point compared to a previous rating measured before or during treatment. For example, an individual may improve from a rating of 1 or 2 to a rating of 3, indicating a return to normal swallowing, or improve from a rating of 1 to a rating of 2 or 3.

[0066] This disclosure further provides a method for treating CLN2 disease, comprising administering rhTPPl to an individual in need at a dose that can effectively prevent or treat neurological symptoms of the disease, wherein the neurological symptoms are seizures, decreased brain volume, decreased gray matter, or increased cerebrospinal fluid (CSF). This disclosure also provides the use of rhTPPl in the manufacture of a pharmaceutical preparation for the prevention or treatment of neurological symptoms in individuals with CLN2 or a family history of CLN2, and the use of rhTPPl in the prevention or treatment of neurological symptoms in individuals with CLN2 or a family history of CLN2; wherein the neurological symptoms are seizures, decreased brain volume, decreased gray matter, or increased CSF.

[0067] In one state, a method of treating an individual with CLN2 or a family history of CLN2 includes administering to the individual a dose of rhTP1 that effectively maintains or reduces the frequency of seizures. In one state, the dose effectively reduces the monthly frequency of seizures experienced by the individual. In another state, as measured using the Hamburger Disease Rating Scale, the dose effectively increases the seizure rating by at least one point compared to a previous rating measured before or during treatment. According to the Hamburger Scale, a rating of 3 indicates no seizures in 3 months; 2 indicates 1 to 2 seizures in 3 months; 1 indicates 1 seizure per month; and 0 indicates more than 1 seizure per month. In one state, the dose of rhTP1 is effective Page 19 of 94 (Invention Specification) C232142PA.docx The individual's seizure rating was maintained at the same level as the previous rating measured before or during treatment, such as 3, 2, or 1. In another case, the rhTP1 dose was effective in maintaining or reducing the individual's seizures, which could be confirmed by maintaining the monthly seizure frequency for a longer period or reducing the seizure rating less than expected considering the natural progression of the disease.

[0068] In another aspect, a method of treating an individual with CLN2 or a family history of CLN2 includes administering a dose of rhTPPl that effectively maintains or slows or reduces brain volume loss. Brain atrophy increases as the disease progresses, resulting in a correlated increase in brain volume loss and the volume and relative proportion of intracranial CSF. Brain volume can be measured using methods known in the art, including imaging techniques such as magnetic resonance imaging (MRI), computed tomography / cataract surgery (CT / CAT), positron emission tomography (PET), single-photon emission computed tomography (SPECT), electroencephalography (EEG), magnetoencephalography (MEG), and near-infrared spectroscopy (NIRS). In one aspect, a dose of rhTPPl can effectively slow or reduce CLN2-related brain volume loss in an individual, which can be demonstrated by maintaining brain volume for a longer period of time or by less brain volume loss compared to what would be expected given the natural progression of the disease.

[0069] In another aspect, a method of treating an individual with CLN2 or a family history of CLN2 includes administering a dose of rhTPPl that effectively maintains or slows or reduces gray matter loss. Gray matter loss due to brain atrophy occurs as the disease progresses, resulting in a decrease in the percentage of gray matter in brain volume. The amount of gray matter in the brain can be assessed using methods known in the art, such as imaging techniques like MRI, CT / CAT, PET, SPECT, EEG, MEG, and NIRS. In one aspect, a dose of rhTPPl can effectively slow or reduce gray matter loss in an individual, which can be demonstrated by maintaining gray matter volume for a longer period or by less gray matter loss compared to what is expected considering the natural progression of the disease.

[0070] In another state, the treatment of individuals with CLN2 or a family history of CLN2... Page 20 of 94 (Invention Specification) C232142PA.docx The method involves administering an individual a dose of rhTPPl that effectively maintains or slows the increase in cranial CSF volume. Due to brain atrophy, the total volume and proportion of cranial CSF increase. The amount and proportion of cranial CSF can be assessed using methods known in the art, such as imaging techniques like MRI and CT / CAT. In one state, a dose of rhTPPl can effectively slow or reduce the increase in cranial CSF in an individual, which can be confirmed by maintaining cranial CSF volume for a longer period or by a smaller increase in cranial CSF compared to what is expected considering the natural progression of the disease.

[0071] The aforementioned methods, compositions and uses may further include, individually and in combination, any of the following features.

[0072] In one embodiment, the method, composition or use of this disclosure includes continuously or intermittently administering to an individual a formulation, composition or dose comprising rhTPPl for a period of time of at least about 1 hour, such as at least about 1 hour, at least about 2 hours, at least about 3 hours, at least about 4 hours, at least about 5 hours, at least about 6 hours or longer. In another embodiment, the method or use of this disclosure includes administering to an individual in need an formulation, composition or dose of rhTPPl comprising about 20 mg to about 500 mg, about 30 mg to about 500 mg, about 50 mg to about 500 mg, about 100 mg to about 500 mg, about 200 mg to about 400 mg, about 250 mg to about 350 mg or about 275 mg to about 325 mg, such as about 20 mg, about 30 mg, about 50 mg, about 100 mg, about 200 mg, about 300 mg, about 400 mg or about 500 mg of rhTPPl. In one embodiment, the method or use of this disclosure includes administering a preparation, composition or dose in a volume of about 20 mL or less, about 15 mL or less, about 10 mL or less, about 7.5 mL or less, or about 5 mL or less per dose or administration event, such as about 20 mL, about 15 mL, about 10 mL, about 9 mL, about 8 mL, about 7 mL, about 6 mL, about 5 mL, about 4 mL, about 3 mL, about 2 mL, about 1 mL, or about 0.5 mL.

[0073] In each of the various forms, the methods, compositions, or uses of this disclosure include preparations, compositions, or doses of less than or equal to about 2.5 mL per hour, or less than or equal to about 75 mg per hour. Page 21 of 94 (Invention Specification) C232142PA.docx RhTPPl, or a formulation, composition, or dose comprising rhTPPl, may be administered to an individual at a rate of less than or equal to about 75 mg rhTPPl per 2.5 mL of formulation or composition per hour. The formulation, composition, or dose may be administered continuously or intermittently over a period of at least about 4 hours, as appropriate.

[0074] In one embodiment, the method, composition, or use of this disclosure includes administering a formulation, composition, or dose comprising rhTPPl weekly or at a lower frequency, such as weekly, every other week, or monthly. More specifically, the method, composition, or use of this disclosure includes administering a formulation, composition, or dose comprising rhTPPl once every 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, or 31 days. In one embodiment, the formulation, composition, or dose is administered intraventricularly. In another embodiment, the formulation, composition, or dose is administered intrathecally. In yet another embodiment, the formulation, composition, or dose is administered intraocularly. In one embodiment, a formulation, composition, or dose is administered intravenously, intrathecally, or intraocularly. Intraventricular delivery allows penetration into deep gray matter structures of the brain, such as the thalamus, striatum, and midbrain, due to the physiological mechanisms of CSF flow. Intraventricular delivery in CSF flow allows flow into the third and fourth ventricles and also infiltrates from the ventricles into the subarachnoid space via the neural fiber network of the cerebral hemispheres along a small pressure gradient. Intrathecal and intraventricular administration of recombinant enzymes for the treatment of lysosomal storage diseases is described in U.S. Patent No. 7,442,372, which is incorporated herein by reference in its entirety.

[0075] The formulations, compositions, or doses of rhTPPl disclosed herein can be administered via a single rapid injection or a series of injections (e.g., to the brain, lumbar region, or eye), or via continuous or sustained infusion, such as using an infusion pump or other implantable device. In one embodiment, the formulations, compositions, or doses of rhTPPl are administered using an infusion system comprising tubing, an in-line filter (e.g., about 0.2 / zm), a reservoir (e.g., intrathecal or intraventricular), and a catheter. Typically, when administering the composition intrathecally or intraventricularly, to prevent adverse side effects caused by artificially increased intracranial or intrathecal pressure, a volume of CSF equivalent to the volume of the composition to be administered is removed from the individual before administering the composition. However, Page 22 of 94 (Invention Specification) C232142PA.docx As described in Example 3, this document demonstrates that the formulation, composition, or dose of the rhTPPl disclosed herein can be administered just before the administration of the rhTPPl formulation, composition, or dose, without removing any volume of CSF from the individual.

[0076] In one embodiment, the method or use of this disclosure includes administering approximately 10 mL of a formulation, composition or dose comprising approximately 300 mgrhTPPl to the ventricle of an individual with CLN2 every week for a period of approximately 4 hours.

[0077] The formulations and compositions of the present invention can be directly administered to individuals in need (i.e., non-isotonic), or can be administered after a defined volume of CSF has been removed from a previous individual, wherein the defined volume is approximately the same as the volume of the composition subsequently administered to the individual (i.e., isotonic).

[0078] In one embodiment, the method, composition, or use of this disclosure further includes administering a flushing solution to the individual after administration of rhTPPl. The flushing solution is administered via the same route as rhTPPl and using the same delivery system (e.g., infusion system) to remove any residual rhTPPl in the delivery system and to ensure that the individual receives the full intended dose of rhTPPl. In one embodiment, the flushing solution is administered to the individual in an amount between about 0.5 mL and about 5 mL, such as about 0.5 mL, about 1 mL, about 2 mL, about 3 mL, or about 5 mL (e.g., using the same catheter previously used to administer compositions including rhTPPl). In one embodiment, the flushing solution comprises the same components as formulations or compositions including rhTPPl, but without rhTPPl. In one sample, the rinsing solution comprises approximately 0.11 mg / mL of dihydrogen phosphate heptahydrate, approximately 0.08 mg / mL of dihydrogen phosphate monohydrate, approximately 8.77 mg / mL of phosphate, approximately 0.22 mg / mL of potassium chloride, approximately 0.16 mg / mL of magnesium chloride hexahydrate, approximately 0.21 mg / mL of calcium chloride dihydrate, and a diluent such as water for injection.

[0079] In various embodiments, the time to the maximum concentration (Ti) of rhTPP in cerebrospinal fluid after the infusion is completed is between 4 hours and 10 hours. In various embodiments, the elimination half-life (Ti) of rhTPP in cerebrospinal fluid is between 5 hours and 20 hours. Page 23 of 94 (Invention Specification) C232142PA.docx

[0080] Individual Children

[0081] This disclosure also relates to methods for treating an individual with CLN2 disease or one or more symptoms related to CLN2 disease, and methods for delaying the onset of CLN2 disease or its symptoms in an individual, wherein the illustrative individual is a child, for example, under about 18 years of age. In various categories, the individual is under 3 years of age. In various categories, the individual is under 2 years of age. In various categories, the individual is under 1 year of age. In various categories, the individual is older than or about 1 month of age to about 3 months of age, or older than or about 1 month of age to about 6 months of age, or older than or about 1 month of age to about 9 months of age, or older than or about 1 month of age to about 12 months of age. In various categories, the individual is under or about 12 months of age, but is at least or about 2 weeks of age, 4 weeks of age, 6 weeks of age, 12 weeks of age, or 16 weeks of age. In various cases, the individual is under 12 months of age, but is at least or about 5 months of age, 6 months of age, 7 months of age, 8 months of age, 9 months of age, 10 months of age, or 11 months of age. In all cases, the individual is at least 12 months old, but less than or about 24 months old, or less than or about 23 months old, or less than or about 22 months old, or less than or about 21 months old, or less than or about 20 months old, or less than or about 19 months old, or less than or about 18 months old, or less than or about 17 months old, or less than or about 16 months old, or less than or about 15 months old, or less than or about 14 months old, or less than or about 13 months old. In all cases, the individual is less than 24 months old and is at least or about 13 months old, or at least or about 14 months old, or at least or about 15 months old, or at least or about 16 months old, or at least or about 17 months old, or at least or about 18 months old, or at least or about 19 months old, or at least or about 20 months old, or at least or about 21 months old, or at least or about 22 months old, or at least or about 23 months old. In all cases, the individual is older than or about 24 months of age and younger than or about 36 months of age, or younger than or about 35 months of age, or younger than or about 34 months of age, or younger than or about 33 months of age, or younger than or about 32 months of age, or younger than or about 31 months of age, or younger than or about 30 months of age, or younger than or about 29 months of age, or younger than or about 28 months of age, or younger than or about 27 months of age, or younger than or about 26 months of age, or younger than or about 25 months of age.

[0082] In an exemplary embodiment, the method includes administering an effective amount of a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPPl) to an individual to obtain a desired outcome, such as treatment of CLN2 disease or Page 24 of 94 (Invention Specification) C232142PA.docx Its symptoms or delay the onset of CLN2 disease or its symptoms. In various cases of the methods disclosed in this invention... 5 Administer a dose of approximately 300 mg or less of rhTPPl to the individual. In the exemplary cases, the individual is older than or approximately 2 years old, and is administered a dose of approximately 300 mg rhTPPl, depending on the circumstances. In various exemplary cases, the individual is older than or approximately 1 year old and less than 2 years old, and is administered a dose of approximately 200 mg rhTPPl, depending on the circumstances. In the exemplary cases, the individual is administered multiple doses of rhTPPl. In the exemplary cases, the method includes administering an initial dose, followed by subsequent doses. In various exemplary cases, the initial dose is lower than the subsequent dose. In various exemplary cases, the initial dose is higher than the subsequent dose. In various exemplary cases, the initial dose is approximately 20 mg rhTPPl, and the subsequent dose is higher. In the exemplary cases, the initial dose is approximately 200 mg rhTPPl, and the subsequent dose is at least 50% higher, for example, at least or approximately 300 mg rhTPPl. In the exemplary cases, individuals (e.g., those older than or about 1 year old and younger than 2 years old) were given approximately 200 mg rhTPPl for each of the first, second, third, and fourth doses, and for each of the fifth and subsequent doses, more than approximately 200 mg rhTPPl. In the exemplary cases, individuals were given approximately 300 mg rhTPPl for each of the fifth and subsequent doses. In each case, individuals older than or about 6 months old and younger than 1 year old were given a dose of approximately 150 mg rhTPPl, depending on the situation. In each case, individuals younger than 6 months old were given a dose of approximately 1 mg rhTPPl, depending on the situation. In each case, the preparation was administered every 2 weeks, every two weeks, every other week, or approximately every 14 days (±3 days). In each case, the preparation was administered by infusion at a rate of approximately 2.5 mL per hour or less.

[0083] In the exemplary case, based on blood tests, individuals, such as children, exhibited decreased TPP1 enzyme activity. In the exemplary case, the individual, such as a child, was a sibling of an individual diagnosed with CLN2. In the exemplary case, the individual, such as a child, was not a sibling of an individual diagnosed with CLN2. In the exemplary case, the individual, such as a child, had a total score of approximately 3 to approximately 6 points (e.g., approximately 3, approximately 4, approximately 5, approximately 6) on the motor and verbal subscales. In the exemplary case, based on the scores described in Table 1, the scores of individuals who had been assigned to rhTPPl were closer to those of the individuals who had been assigned to rhTPPl. Page 25 of 94 (Invention Specification) C232142PA.docx A rating related to "healthy" or "normal".

[0084] In exemplary cases, the individual, such as a child, has not previously been treated with stem cell therapy, gene therapy, or enzyme replacement therapy. In exemplary cases, the method includes administering an antihistamine to the individual, with or without the antipyretic, approximately 30 to 60 minutes prior to administration of rhTPPl. In various cases, the formulation includes rhTPPl and at least one pharmaceutically acceptable carrier, diluent, or excipient. In various cases, the formulation is any of the aforementioned formulations, including, but not limited to, formulations comprising, but not limited to, diammonium hydrogen phosphate pentahydrate, monoammonium phosphate monohydrate, ammonium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or combinations thereof. In various cases, the method includes administering a flushing solution to the individual after administration of the formulation. In various cases, the flushing solution is any of those described herein. In each of the various formulations, the flushing solution includes diammonium hydrogen phosphate pentahydrate, monoammonium phosphate monohydrate, ammonium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or combinations thereof. In each of the various formulations, the treatment period is at least 10 weeks, at least 20 weeks, at least 40 weeks, at least 80 weeks, or at least 96 weeks. In each of the various formulations, the treatment period is longer than 96 weeks. In each of the various formulations, these methods treat CLN2 disease or delay the onset of CLN2 disease or its symptoms without causing serious adverse events (SAEs). In each of the various formulations, the individual has an ICV device. In each of the various formulations, the method includes implanting an ICV device into the individual.

[0085] Set

[0086] This disclosure further provides kits suitable for administering to patients in doses and forms including the rhTP1 described herein. In one embodiment, the kit includes a formulation comprising about 30 mg / mL of rhTP1, about 0.11 mg / mL of dihydrogen phosphate heptahydrate, about 0.08 mg / mL of dihydrogen phosphate monohydrate, about 8.77 mg / mL of cadmium chloride, about 0.22 mg / mL of potassium chloride, about 0.16 mg / mL of magnesium chloride hexahydrate, about 0.21 mg / mL of calcium chloride dihydrate, and a diluent such as water for injection. In one embodiment, the kit further includes, in addition to the therapeutic formulation, administration of the present invention intravenously, intrathecally, and / or intraocularly. Page 26 of 94 (Invention Specification) C232142PA.docx The kit includes a description of the compound. In another embodiment, the kit further includes a flushing solution as described herein. In yet another embodiment, the kit further includes a system for dispensing the compound, comprising any or all of the following components: tubing, in-line filter, reservoir for implantation, and catheter. In one embodiment, the kit may include a catheter, reservoir, or other device preloaded with the therapeutic compound of this disclosure. For example, particularly covered are pharmaceutically acceptable compounds preloaded with approximately 100 mg hTPPl, approximately The kit may contain 200 mg rhTPPl, approximately 300 mg rhTPPl, approximately 400 mg rhTPPl, or approximately 500 mg rhTPPl. Alternatively, the kit may include refillable tubing, reservoirs, or other devices, and an appropriate amount of enzyme for refilling such devices.

[0087] In some embodiments, the kit of the present invention may include one or more of the following components: Extension tubing (e.g., product number 536040 > Smiths Medical, Dublin OH), in-line filter (e.g., product number FS116, Smiths Medical), port needle (e.g., product number 21-2737-24, Smiths Medical), one or two or more syringes (e.g., product number 309604 > Becton Dickinson, Franklin Lakes, NJ), or one or two or more syringe needles. (e.g., product number 305196) Becton Dickinson.

[0088] The present disclosure will be more easily understood by referring to the following examples, which are provided by way of illustration and are not intended to be limiting. Example

[0089] The following examples describe formulations for intraventricular (ICV) administration of rhTPPl and Results of administering the compound to human patients compared to matched, untreated patients with a natural medical history. Example] For intraventricular administration of its formulation containing rhTP1

[0090] rhTPPl is produced in genetically engineered CHO host cell lines and purified using standard chromatography methods, such as US Patent No. 6,302,685 and Sleat et al., 1997, Science. Page 27 of 94 (Invention Specification) C232142PA.docx The references described in 277:1802-1805 are incorporated herein by reference in their entirety. rhTPPl is produced as an inactive proenzyme that undergoes self-activation at acidic pH upon absorption into lysosomes. The calculated isotopic average molecular weight of the proenzyme form of rhTPPl is approximately 59 kDa. The apparent molecular weight of the mature enzyme is approximately 46 kDa. The amino acid sequence of the rhTPPl proenzyme is described in SEQ ID NO:1 and is shown in Figure 1. The initial segment of the enzyme consists of the first 176 amino acid residues, and the mature enzyme consists of 368 amino acids starting at position 177 and is described in SEQ ID NO:2.

[0091] The rhTPPl formulation used in this example is a sterile solution for ICV infusion. It is a clear and colorless to pale yellow liquid containing rhTPPl protein at a concentration of 30 mg / mL. The formulation is encapsulated in a container closure system consisting of a Type I clear borosilicate glass vial sealed with a fluoropolymer-coated butyl rubber stopper and an aluminum seal. The formulation is stored at -40°C ± 10°C and supplied frozen. The target pH of the formulation is pH 6.5.

[0092] The composition of the rhTPPl formulation used in the examples is provided in Table 2. Table 2 Component Concentration (mg / mL) Per Vial Composition Functional Pharmacopoeia Grade rhTPPl 30 30 mg Active Ingredient Na Dihydrogen Phosphate Heptahydrate 0.11 0.11 mg Buffer USP / Ph.Eur Dihydrogen Phosphate Monohydrate 0.08 0.08 mg Buffer USP / Ph.Eur Alkyl Chloride 8.77 8.77 Antidote USP / Ph.Eur / JP Potassium Chloride 0.22 0.22 mg Maintaining Key CSF Electrolyte Content USP / Ph.Eur / JP Magnesium Chloride Hexahydrate 0.16 0.16 mg Maintaining Key CSF Electrolyte Content USP / Ph.Eur Page 28 of 94 (Invention Specification) C232142PA.docx Calcium chloride dihydrate 0.21 mg Maintaining key CSF electrolyte levels USP / Ph.Eur / JP Water for injection (qs) NA 1.00 mL Diluent USP / Ph.Eur / JP

[0093] The rhTPPl formulation is carefully designed to mimic the characteristics of human CSF, such as the concentration of key electrolytes being similar to those found in human CSF in vivo, and the formulation does not contain any known preservatives or stabilizers as excipients. No safety issues, i.e., serious adverse reactions, that could not have been previously predicted, have been reported or observed after administration of the rhTPPl formulation.

[0094] In accordance with ICH guidelines and protocols, stability studies were conducted under long-term (M-60°C) and accelerated conditions (5 ± 3°C) to monitor time-temperature stability. Stability samples were stored in small vials made of the same material as the full-size package. Stability data collected from supportive and clinical batches confirmed that the rhTPPl formulation was stable for at least 36 months at M-60°C and for at least 6 months at 5 ± 3°C, which was unexpected considering the formulation lacked preservatives and stabilizers commonly found in pharmaceutical products. Table 3 shows the results of the stability tests. Table 3 Test Specification Storage Time Point (Month) 0 3 6 9 12 18 24 36 Quality Appearance Colorless to pale yellow liquid Long-term accelerated XXXXXXXXXXX Sialic acid 2-7 mol / mol Long-term accelerated XXXXXXXX Potency Specific activity, acid activation 5-15 U / mg Long-term accelerated XXXXXXXXXXX Specific activity No acid activation < 0.075 U / mg Long-term accelerated XXXXXXXXXXX Oligosaccharide characteristics comparable to long-term reference Accelerated XXXXXXXXXXX Page 29 of 94 (Invention Specification) C232142PA.docx 10-26% Bis-mannose-6-phosphate oligomannose 7 Cellular uptake <10 nM Long-term accelerated XXXXXXXX Intensity Protein concentration 27-33 mg / mL Long-term accelerated XXXXXXXXXXX Purity Reported results from RP-HPLC Long-term XXXXXXXX Related substances (main peak %) Accelerated XXX Molecular size > 95% Monomer Long-term XXXXXXXX Variant Accelerated XXX Charge heterogeneity comparable to reference Long-term accelerated XXXXXXXXXXX > 95% Main peak Related substances comparable to reference Long-term accelerated XXXXXXXXXXX Composition pH 6.0-7.0 Long-term accelerated XXXXXXXXXXX Osmolarity 270-330 mOSm / Kg Long-term accelerated XXXXXXXXXXX Example 2 Natural History of Disease

[0095] A quantitative assessment of the natural history of CLN2 disease progression was analyzed in a cohort of 41 untreated CLN2 patients. The Hamburg Clinical Scale was used to assess age-appropriate neural and functional domains affected by the disease.

[0096] A quantitative description of clinical decline in untreated natural history CLN2 individuals is shown in Figure 2. Natural history analysis confirms a clear and predictable relationship between age and disease severity. Following the onset of motor and language symptoms, a generally rapid linear decline trend is observed, with children losing an average of approximately 2 milestone events per year (a linear rate of 2.1 points per year). The course of the disease is largely predictable, but... Page 30 of 94 (Invention Specification) C232142PA.docx There are still some "late-onset" cases, which account for less than 20% of the total population. These patients often have later-onset symptoms and a longer period of mild illness, but subsequently die from rapid and active decline, usually 2 to 3 years later than the typical form.

[0097] Quantitative clinical progression from the Hamburg group was confirmed by superimposing clinical grade assessments from a non-dependent (patient and rater) cohort (n = 49) from the WCMC. Although the clinical descriptions of the non-dependent CLN2 cohorts are similar, this is the first confirmation of a strong quantitative relationship in disease progression between different patient groups. Both cohorts of CLN2 patients had the vast majority of typical late-onset infantile onset and progression, and a smaller proportion of children with a "late-onset" phenotype, typically presenting with early disease at age 5 rather than 3. Neurodegeneration in CLN2 patients was reproducibly captured using scales for motor (gait) and language function. Based on the foregoing analysis, the cohort of naturally occurring study individuals was determined as an appropriate untreated control group. The average rate of symptom decline in CLN2 disease in this untreated, naturally occurring cohort can be used as an effective and informative comparative example for any prevention or reduction of the rate of symptom decline in individuals with CLN2 disease induced by administration of the compositions of the present invention. Example 3 Phase 1 / Phase 2 Open Label Dose Escalation Study in CLN2 Patients

[0098] This study is an open-label clinical trial designed to evaluate the safety, tolerability, and efficacy of the rhTPPl formulation disclosed herein, delivered every other week at a dose of 300 mg (10 mL total volume) via an ICV catheter to children with CLN2 disease. The study was designed to assess the safety and tolerability starting at low doses (30 mg and 100 mg), but all patients were escalated to the highest expected treatment dose (300 mg) when the non-dependency monitoring committee indicated that the lower dose was safe. All enrolled patients were treated for 48 weeks at a stable expected treatment dose of 300 mg ICV every other week. The primary study objective was to evaluate the safety and tolerability of the rhTPPl formulation disclosed herein administered to individuals with CLN2 disease via an implanted ICV reservoir and catheter, and to compare the results with natural history data after 12 months of treatment. Page 31 of 94 (Invention Specification) C232142PA.docx The efficacy of the treatment was assessed using a CLN2-specific rating scale. A secondary objective was to evaluate the impact of treatment on the measurement of brain atrophy by comparing the results with CLN2 natural history data after 12 months of treatment.

[0099] The primary inclusion criterion was a CLN2 diagnosis and registration age of at least 3 years. Patients with a baseline disease assessment score less than 3 (using the Hamburger-6 convergent motor / verbal scale) at screening were excluded from the study. Patients younger than 3 years of age may be non-progressive due to age rather than treatment, as depicted by a horizontal line on the progression curve. Patients with a score of 2 or lower at screening were also less linear, more variable, and may be considered more difficult to treat due to disease stage. Therefore, the treatment group was defined solely by age and score to include early and highly predictable decline.

[0100] The mean age of enrollees was 4.0 years, with slightly more girls than boys, and the majority were Caucasian. Clinical CLN2 scores at screening and baseline are shown in Table 4 below, which illustrates the hamburger movement / language scores of each study group. The total score is based on the evaluation, screening, and baseline. Table 4 CLN2 Assessment - 6-point Hamburger Scale - Final Assessment Analysis Groups During Each Dosing Period: Intention to Treatment Analysis Set: Dosing Period 1 XIZ Group = 3 Groups (n Group 2 (n = 3) Group 3 (n = 3) Stable Dosing Only (n = 14) Total = n Screening 6 1 (33%) 0 1 (33%) 0 2 (9%) 5 0 0 0 2 (14%) 2 (9%) 4 0 0 0 6 (43%) 6 (26%) 3 2 (67%) 3 (100%) 2 (67%) 6 (43%) 13 (57%) Post-Study Base 6 1 (33%) 0 1 (33%) 0 2 (9%) 5 0 0 0 2 (14%) 2 (9%) 4 0 0 0 5 (36%) 5 (22%) 3 2 (67%) 3 (100%) 1 (33%) 6 (43%) 12 (52%) 2 0 0 1 (33%) 1 (7%) 2 (9%) 1 0 0 0 0 0 0 0 0 0 Page 32 of 94 (Invention Specification) C232142PA.docx

[0101] Overall, pretreatment CLN2 scores tended to indicate more advanced disease. Given the rapid progression and difficulty in diagnosis of this disease, lower scores were expected. Furthermore, scores decreased at screening and during baseline assessment (exactly before ICV reservoir placement) for up to two weeks. Four patients in the screening group with a score of 3 experienced a decrease of ~ points at baseline, and two patients in the screening group with a score of 4 lost points to 3 at baseline. Two patients who entered at age 6 (i.e., grossly normal) were siblings of the affected children. The deployment, demographics, and characteristics of individual groups are summarized in Table 5 below. Table 5 Overall deployment registration: 24 individuals; Treatment: 24 individuals; Completion: 23 individuals; Interruption: 1 individual. a Age (years) Mean (SD) 4.3 (1.24) 6 2 5 2 Baseline CLN2 score 4 6 Motor / verbal total 3 12 2 2 Mean (SD), Median 3.6 (1.06), 3.0 Genotype - General* 9 (37.5%) General x Other 8 (33.3%) Other 7 (29.2%) Patients 1287-1007 who were enrolled withdrew from the study due to failure to adhere to the procedures after receiving a single dose. MW. The distribution of divination is similar to that of natural disease history groups. *Common genotypes: C.622OT and c.509-lG>C Page 33 of 94 (Invention Specification) C232142PA.docx

[0102] All enrolled patients received a stable dose of 300 mg ICV every other week. Group 1 patients were exposed to 30 mg ICV every other week for N 1 month, then increased to 100 mg ICV every other week for >4 weeks, while Group 2 patients started receiving 100 mg ICV every other week for N 4 weeks. Both Group 1 and Group 2 patients increased to 300 mg ICV every other week, and all subsequent patients, including Group 3 patients, started a stable dose of 300 mg ICV every other week for N 48 weeks. The 300 mg dose was administered via the ICV catheter in 10 mL infusions over approximately 4 hours. It was atypical that a certain volume of CSF, e.g., equal to the amount of rhTPPl to be administered, was not removed just before the infusion began, but unexpectedly, no adverse effects were observed. Immediately after the 300 mg dose, approximately 2 mL of flushing solution was administered to the individual via the same ICV catheter. The flushing solution was consistent with the formulation in Table 2, but did not contain rhTPPl. The single dose of 300 mg of enzyme in each administration event was significantly higher than previous intrathecal or ICV administrations of this enzyme replacement therapy, and therefore the safety and efficacy profile observed after such a high dose could not have been predicted previously. More specifically, the absence of associated serious, unmanageable adverse events after a single 300 mg dose of rhTPPl could not have been predicted previously. result

[0103] Gait and speech: The primary assessment tool for quantitatively assessing clinical severity was the 0-6 aggregate of the gait and speech subscales, which are shared by both Hamburger and WCMC disease rating scales. This scale was used to extract predictable, rapid, and progressive clinical decline in matched, untreated patients with a natural history, serving as a comparative example for the primary efficacy analysis.

[0104] Gait / language disorder scores of 23 patients with treatment duration exceeding 42 weeks are shown in Figures 3A to 3F. Of these 23 patients, 3 (1244-1001, 1244-1002, and 1244-1003) were from group 1 (C1), 3 (1244-1004, 1244-1006, and 1247-1005) were from group 2 (C2), 3 (1244-1008, 1244-1009, and 1244-1010) were from group 3 (C3), and 14 (0119-1020, 0146-1021, 0146-1022, 0146-1023, 1244-1011, ...) were from group 2 (C2). Page 34 of 94 (Invention Specification) C232142PA.docx (1244-1012, 1244-1017, 1244-1024, 1323-1013, 1323-1014, 1323-1015, 1323-1016, 1323-1018, and 1323-1019) were from the 300 mg stable-only (SBO) group. As expected, language deficits typically occurred earlier than gait deficits. Entry scores were not randomly distributed; 12 patients showed significant disease progression with a combined entry score of 3, and 2 patients had a combined entry score of 6. Given the rapid progression and disease confirmation, children often exhibited significant regression or significant regression in their siblings.

[0105] Following treatment with the rhTPPl formulation disclosed herein (shown in Table 2 above), as shown in Figures 3A to 3F, the CLN2 gait / language disorder scores remained stable. Eleven of the 23 patients did not experience irreversible decline during the treatment period. Four patients experienced a single-unit decline early in treatment but did not subsequently experience irreversible decline. Two patients (1244-1008 and 1323-1013) decreased by one unit from 3 to 2 points between screening and baseline, but did not experience any additional loss in the assessment during treatment. Based on the results, significant treatment benefits were observed in all patients, regardless of the cohort (starting dose) or entry score. In many patients, the decline in scores was reversible. For example, patient 1287-1005 (Figure 3B) experienced a 2-unit decline in scores within the first month of treatment, indicating loss of both gait and language function. However, this patient recovered one unit on day 60 of treatment, and there was no net change thereafter until day 440 of analysis. The recovery score was based on language acquisition, highlighting the clinical significance of even a single unit of change.

[0106] Neither of the two patients with an entry score of 6 lost a single rating unit. Of the 12 patients with an entry score of 3, 7 did not experience irreversible decline, and 2 remained stable after the initial single-unit decline. Therefore, the treatment benefit was evident in patients with significant deficiencies and disease progression.

[0107] As confirmed by the CLN2 Natural History Institute, the median rate of decline in the untreated natural history population was estimated to be 2.1 units per year. Therefore, all patients in the treatment group showed improved outcomes compared to the expected outcomes in the untreated natural history population.

[0108] In order to establish a connection between treated patients and matched untreated patients with a natural medical history, page 35 of 94 (Invention Specification). C232142PA.docx A clearer understanding of the disease progression was achieved by matching study patients with untreated natural history patients using parameters such as baseline CLN2 score, age, and genotype. While no clear subgroup or factor predicts CLN2 disease progression, these parameters are most commonly used to define disease severity. Individual treated patients were compared with members of natural history groups with similar baseline gait / language assessment scores, as shown in Figures 4A to 41. Patients in the study were matched using baseline CLN2 scores as follows: For a given study patient with a given baseline score, all natural history patients reporting one or more CLN2 assessments with the same CLN2 score were identified. If the study patient's baseline CLN2 score was 2, 3, 4, or 5, the CLN2 comparison time profiles for each natural history patient were shifted left or right to overlap with the study patient's baseline score. If a natural history patient had multiple assessments equal to the study patient's baseline CLN2 score, the intermediate time points of the multiple assessments were used for time shifting. If the baseline CLN2 score of the patients in the study was 6, then the final score of patients with a natural medical history of 6 was used for time-shifting. Sensitivity analyses were performed using other matching criteria, and the results from these analyses were consistent with those from score-matching analyses.

[0109] Figures 4A to 41 show the results from individuals treated with the rhTPPl formulation of this disclosure, plotted against matched untreated patients with natural medical histories. Treated individuals and untreated patients with natural medical histories were matched using disease assessment scores, with gait and language subscales of up to 6 units as clusters. Assessments were compared over a one-year treatment period. Individuals receiving rhTPPl showed a treatment benefit compared to all members of the matched untreated patient group. After 120 days of treatment, the assessment score of individual 1244-1001 (Figure 4A) decreased from 3 units to 2 units, but recovered by one unit, with no net change thereafter. The assessment score of individual 1244-1002 (Figure 4B) increased from 3 units to 4 units, decreased from 4 units to 2 units, and increased from 2 units to 3 units, resulting in an overall unchanged disease assessment score compared to day 1 at the end of the study. Individuals 1244-1003 (Figure 4C) and 1244-1010 (Figure 41) maintained a rating of 6 units throughout the study, i.e., normal motor and language functions. Individuals 1244-1004 (Figure 4D) and 1244-1009 (Figure 4H) maintained a rating of 3 units throughout the study. Page 36 of 94 (Invention Specification) C232142PA.docx Individual 1244-1006 (Figure 4E) was initially rated from 3 units to 2 units, but recovered by one unit before decreasing again from 3 units to 2 units, after which there was no net change. Individual 1244-1008 (Figure 4G) was initially rated from 3 units to 2 units, after which there was no net change.

[0110] In contrast to all treated individuals, by the end of the comparison period, the majority of matched untreated patients with a natural history experienced an irreversible decline in their assessment scores from 3 units to [number missing] units, indicating complete loss of combined gait and language functions. Matched analyses confirmed the treatment benefits for those patients who maintained their disease assessment scores and also had an initial decline followed by stabilization.

[0111] The most complex response (individual 1287-1005) is shown in Figure 4F. Although this patient experienced a rapid decline of 2 units within the first month of the study, from a baseline score of 3 to a study score of 1, the patient was able to recover one unit and stabilize at 2. This course is explained by comparison with score-matched untreated natural history patients. The clinical course was worse in 15 of the 18 score-matched untreated natural history patients, and identical in only 2 score-matched untreated natural history patients (single untreated natural history matches are not evaluable). The clinical course in untreated patients was consistently worsening, with virtually no time between milestones of loss. Lost function and subsequent stability were never restored. Therefore, matching with the most complex treated profile also indicates significant treatment benefit.

[0112] Figure 5 shows the distribution of clinical changes from baseline for patient-matched duration of treatment compared to the study individuals in matched untreated natural history patients. As previously stated, 7 out of 9 patients (>75%) showed no change in baseline disease rating scales. For these 7 patients during treatment, all matched untreated natural history patients experienced a decrease of at least one unit, but more commonly multiple units or 2 to 4 units. As an example, patients 1244-1001 had 1 match with a single-point loss, 3 matches with a 2-point loss, and 14 matches with a loss of all 3 points on available language / gait disease assessments. Therefore, while there was no change in treated patients over the same time period, 14 out of 18 matched untreated natural history patients (>75%) experienced loss of all gait and language functions. Page 37 of 94 (Invention Specification) C232142PA.docx The baseline entry score exhibited a lower limit effect of 3 points, with many matched untreated natural history patients losing all available assessment units. However, two patients with entry scores of 6 (patients 1244-1003 and 1244-1010) significantly demonstrated that even these matches actively decreased, with some experiencing reductions of 4 and 5 points during the treatment period. This observation provides clear clinical confirmation of the significant treatment effect; most treated children retained entry clinical assessments in the untreated natural history match, actively losing language and independent gait over the same time period, with many experiencing complete functional loss. The remaining two treated patients who lost a single point (individuals 1287-1005 and 1287-1006) maintained better clinical assessments during the treatment period compared to the vast majority of matches. Overall, among untreated patients with natural medical histories and score-matched individuals, 97% had worse scores than treated individuals.

[0113] Using multiple matching criteria (e.g., baseline, age, and genotype), nearly 100% of the comparisons showed a favorable treatment effect compared to matched untreated patients with a natural disease history. The mean treatment difference based on matching criteria among all treated patients compared to those with a natural disease history ranged from 1.9 to 2.1 points, depending on the matching criteria used.

[0114] Figure 9A shows the mean change in motor-verbal ratings for patients treated for >48 weeks (n = 21; dashed line) and the natural history group (n = 41; solid line). The mean decrease in disease ratings for treated patients was 0.43 (standard deviation 0.839), with a median decrease of 0.00 units over 48 weeks. In contrast, the mean decrease in disease ratings for the natural history group was 2.09 (standard deviation 0.966), with a median decrease of 1.87 units over 48 weeks. Overall, the expected clinical decline was significantly reduced (pO. 0001) by 79% in treated patients. Figure 9B shows the change in motor-verbal ratings for patients (n = 23) from the first 300 mg dose (baseline) to the last measurement before the last 300 mg dose at week N 48. Overall, 65% (15 out of 23) of patients experienced improvement or no clinical disease progression during treatment, and 87% (20 out of 23) of patients performed better during treatment than untreated individuals from natural history studies (i.e., a change in score of -1 or more). These analyses consistently support the conclusion that, compared to rapid and... Page 38 of 94 (Invention Specification) C232142PA.docx Compared with matched members of the untreated natural history group who were expected to decline, treated patients showed significant CLN2 scores and clinically meaningful stability.

[0115] Impact of Treatment on Clinical Assessment of Visual Acuity • In untreated CLN2 patients, visual loss occurs later than the decline in language and gait, but once symptoms appear, the course is predictably rapid and progresses to blindness. Therefore, preserving visual acuity is an important treatment outcome. Visual loss can be assessed on a subscale of 0 to 3 in a manner similar to other subscales, where 3 is normal and 0 represents functional blindness. During treatment, most treated patients did not experience irreversible loss in the visual acuity subscale domain. When treated patients were matched with untreated individuals with natural histories by score, age, and genotype using a combination of gait, language, and visual acuity subscales (0 to 9 units), it was clear that untreated matched individuals with natural histories lost additional points compared to the treatment group.

[0116] Figures 6A to 61 show the results from nine individuals treated with the rhTPPl formulation disclosed herein, using up to nine units of the gait, speech, and visual acuity subscales as aggregates against disease assessment scores for matched untreated patients with natural medical histories. Individual 1244-1001 (Figure 6A) had a score that decreased by one unit from 6 to 5, but then immediately recovered by one unit to a score of 6, with no further net change. Individual 1244-1002 (Figure 6B) had a score that increased from 5 to 6, then decreased from 6 to 4, and then increased from 4 to 5, so that the overall disease assessment remained unchanged at the end of the study compared to day 1. Individuals 1244-1003 (Fig. 6C) and 1244-1010 (Fig. 61) maintained a rating of 9 throughout the study, with normal gait, language function, and vision. Individuals 1244-1004 (Fig. 6D) and 1244-1009 (Fig. 6H) maintained a rating of 6 throughout the study, and individual 1244-1008 (Fig. 6G) maintained a rating of 5 throughout the study. Individual 1244-1006 (Fig. 6E)'s initial rating decreased by one unit from 6 to 5, then decreased again to 4, but recovered by one unit to a rating of 5, and thereafter there was no net change. Individual 1287-1005 (Fig. 6F)'s rating decreased from 6 to 4, then increased from 4 to 5, then decreased to 4, but recovered by one unit to a final rating of 5. Page 39 of 94 (Invention Specification) C232142PA.docx

[0117] During treatment, adding the visual acuity subscale did not change the scores of the nine treated patients. However, visual acuity loss in the score-matched untreated natural history patients contributed significantly to the aggregate score. Several untreated natural history matches showed differences greater than 3 points compared to the treated patients, indicating a contribution of visual acuity decline to the aggregate score during the study period. Therefore, adding the visual acuity subscale would increase the difference between the treated patients and the matched untreated natural history patients. Since there was no irreversible loss of disease assessment units in the matched untreated natural history patients, the observation of the treatment effect of rhTPPl related to preventing disease progression and stabilizing function can be extended from motor / gait and speech to the clinical domain including visual acuity.

[0118] Impact of Treatment on Overall Disease Assessment 1 During the study, patients were also assessed using a 12-point scale consisting of a combination of the complete hamburger or WCMC scores. The scores on the 12-point scale were the sum of individual patient scores for (1) motor / gait, (2) language, (3) seizures / myoclonus, and (4) vision / eating. Figures 10A to 10L show the results of individuals treated with the rhTPPl formulation disclosed herein using the combination hamburger (left) and WCMC scale (right) of up to 12 units. Sixteen of the 23 patients showed no irreversible decline according to at least one scale, and eight patients showed an increase in scores on at least one scale at the end of the treatment period compared to baseline, confirming the overall treatment benefit of patients receiving rhTPPl.

[0119] Effects of treatment on brain volume. • MRI is used to assess secondary endpoints in treated patients. The disease process is characterized by atrophy, cell loss, and signal abnormalities. These parameters, individually or as a composite score, are correlated with patient age and disease assessment scores. Therefore, disease progression is generally considered to be associated with MRI indices of atrophy, and multiple MRI parameters have been shown to be correlated with age and disease severity in CLN2 disease (Dyke et al., American Journal of Neuroradiology, 2013: 34(4):884-9); (Paniagua et al., Clinical Neuroradiology, 2013: 23(3):189-96). The imaging databases supporting these conclusions are based on cross-sectional correlations of a large number of patients; however, longitudinal acquisitions of MRI images within patients are not available. Therefore, MRI analyses derived from longitudinal studies and similar derivatives cannot be matched in the same way. Page 40 of 94 (Invention Specification) C232142PA.docx Natural medical history database.

[0120] To analyze treated patients, MRI acquisition parameters were standardized across the entire hardware platform at the study site. Data were locally acquired, edited identification information that had been transmitted to the central imaging core laboratory. Images were randomized to ensure that independent radiologists were unaware of the patient's condition or its temporal relationship to baseline. Changes in brain volume were reconstructed from randomized, independent central readings. Data were analyzed to provide a longitudinal comparison of the study with the baseline of the treated population. Figure 7 shows an overview of MRI measurements of brain volume in treated patients. Brain atrophy resulted in a larger intracranial CSF volume and proportion. This increase in atrophy measurements was associated with age and severity in CLN2 patients. The longitudinal plot of CSF volume and proportion in treated patients indicates that CSF parameter measurements also appear to have little change (if any). MRI volume measurements were constant and consistent with the stability of the assessment in all patients.

[0121] Figures 8A to 8L show longitudinal MRI assessments of brain volume in treated patients. Active neurodegeneration in CLN2 patients is characterized by significant gray matter loss and compensatory increases in CSF. However, brain volume in treated patients remained very stable during the assessment period, and there was no evidence of a neurodegenerative process. The differences between the CSF and gray matter curves (dashed lines) and the CSF curves (solid lines) in the upper and lower figures of Figures 8A to 8L are shown. Gray matter volume remained stable throughout the study in each of the treated patients. The change in the percentage of cortical gray matter volume to total brain volume measured before the first 300 mg infusion (baseline) compared to the last observation after >48 weeks of treatment is shown in Table 6 below. Sound 6 (n = 23) Change from baseline to the last observation N 23 Average (SD) -2.3 (2.01) Median -2.6 Min, Max -5.8, 3.1 Page 41 of 94 (Invention Specification) C232142PA.docx In normal children aged 4–12 years, the longitudinal change in cortical volume is -1% per year, but in untreated CLN2 patients it is -12.5% ​​per year. During rhTPPl treatment, the volumes of CSF, gray matter, and white matter remained relatively constant, thereby reducing disease-related cortical volume loss by 89%.

[0122] Adverse Events: One patient withdrew from the study due to inability to adhere to the protocol. The remaining 23 patients remained in the study and tolerated treatment with rhTPPl via the ICV route. There were no deaths, treatment-related withdrawals, or study interruptions for safety-related reasons. Consistent with the minimal impact of device implantation, all patients were administered medication within one week of the procedure. Of the total 325 infusions, only 5 (1.5%) were interrupted for any reason, and only 2 (0.6%) were interrupted for reasons related to adverse events. The most common non-CLN2-related adverse events observed in the study were fever, allergic reactions, and upper respiratory tract infections (each accounting for 25% of the total individuals). These events were generally mild, self-limiting, and medically managed. Allergic events, as defined by the investigator, were rarely associated with peripheral manifestations and were medically managed using a combination of antipyretics, antihistamines, and / or steroids. Laboratory data confirmed a lack of clinically relevant changes in peripheral laboratories. In the cerebrospinal fluid, some patients experienced a mild, transient increase in cerebrospinal fluid cells, while CSF glucose or protein levels remained unchanged. In summary, assessment of safety parameters confirmed that treatment with the rhTPPl formulation disclosed herein via ICV infusion was well-tolerated in all patients. in conclusion

[0123] Clinical studies have confirmed that each patient with treatment exposure for more than 36 weeks has significant clinical benefit, characterized by complete inhibition of the progression of CLN2 disease. This constitutes the greatest therapeutic benefit because no functional gain is expected in patients with moderate progression and activity deterioration over time.

[0124] This finding is even more compelling when patients are matched with members of a natural history database based on multiple parameters, including baseline disease assessment, age, and genotype. This matching revealed that, during the same period that treated individuals treated with rhTP1 experienced cessation of disease progression, matched untreated natural history patients experienced significant functional loss. Therefore, compared with matched untreated... Page 42 of 94 (Invention Specification) C232142PA.docx Compared to patients with a natural history of illness who showed no active disease progression, all treated patients exhibited inhibition of disease progression. Based on available natural history data, the median rate of decline in the untreated natural history population was estimated at 2.1 units per year, with each unit of decline representing a significant milestone loss of physiological function. For most patients entering the study, retaining 2 units transitioned them to continued independent walking and meaningful communication.

[0125] Overall, the results confirm that the rhTP1 formulation and treatment method disclosed herein have an acceptable safety / tolerability profile. No individual discontinued the study or treatment due to adverse events. One individual withdrew from the study after one treatment dose due to inability to adhere to the protocol. PK and immunogenicity analysis revealed high CNS transduction and no antibody formation in CSF.

[0126] The foregoing examples demonstrate that the formulations and methods described herein, including rhTPPl, can effectively prevent or treat CLN2 disease and / or one or more clinical symptoms of CLN2. In diseases characterized by rapid, unalterable, and irreversible neurodegenerative disease progression, the cessation of disease progression is a significant and unexpected clinical benefit, particularly in each treated patient. Example 4

[0127] This example describes a phase 2 open-label study to evaluate the safety, tolerability, and efficacy of formulations including rhTPPl for intraventricular administration to pediatric patients under 18 years of age with CLN2 disease.

[0128] Research Objectives

[0129] The main objectives of this study include the following: (1) to evaluate the safety and tolerability of TPP1 administered via intraventricular (ICV) device, and (2) to evaluate the therapeutic efficacy as a delay in the progression of the CLN2 motor-language clinical scale.

[0130] The secondary objectives of this study included the following: (1) assessing the immunogenicity of CSF and serum, (2) assessing MRI parameters of disease progression, and (3) assessing the effect of treatment on the Total Hamburger Clinical Rating Scale. Page 43 of 94 (Invention Specification) C232142PA.docx The impact of this.

[0131] The exploratory objectives of this study include the following: (1) assessing developmental achievement, (2) assessing abnormal involuntary movements, (3) assessing retinal anatomy using optical coherence tomography (OCT), (4) determining the seizures, types and frequencies, (5) assessing quality of life, and (6) analyzing putative molecular biomarkers from CSF and plasma.

[0132] Research Plan: Overall Research Design and Planning

[0133] This will be a Phase 2 open-label study in a patient with confirmed CLN2 gene mutation and impaired TPP1 activity. A formulation including rhTPPl (referred to herein as "TPP1") will be administered every two weeks via ICV infusion. Due to practical and ethical considerations, concurrent or untreated control individuals were excluded; therefore, findings can be compared with existing CLN2 disease registry records and / or data from siblings (if necessary). An overview of the events is provided by the visit in Figure 11.

[0134] Study applicability will be determined before the individual is admitted for surgical implantation of the ICV access device (M21 days). Baseline access for collecting clinical scores and clinical laboratory parameters will be completed no more than two days before the first infusion.

[0135] This study is planned to enroll a maximum of 5 individuals. Eligible patients for enrollment in this study must have a sibling with a confirmed CLN2 diagnosis who is enrolled in the previous study described in Example 3. All individuals will be administered a dose of TPP1 (300 mg) every 14 days for at least 96 weeks, starting from the first infusion day (+3 days). During the trial, dosing may be adjusted to suit the investigator's assessment of adverse events by reducing the dose to 150 mg and / or by decreasing the infusion rate.

[0136] Patients requiring this study will undergo surgical implantation of an ICV reservoir for TPP1 administration. An MRI will be performed prior to the procedure to ensure proper planning and placement of the ICV access device. Patients will be closely monitored in a nursing-intensive environment for 48 hours post-procedure. Following ICV access device placement, a written instruction manual will be provided to the individual and their caregiver, detailing the signs and symptoms of potential device complications. Page 44 of 94 (Invention Specification) C232142PA.docx Information, including instructions on when to return to the study site for device evaluation. Hospitalized patients will be followed up by a telephone call within 48 hours of discharge.

[0137] The first infusion will be performed at least 14 days from the date of the ICV reservoir implantation surgery and no more than 28 days post-surgery. Thereafter, study visits will be conducted every two weeks ± 3 days from the date of the first infusion (+3 days). Generally, functional and QOL assessments should be performed before MRI and sampling, which in turn should be performed before infusion; sample collection may be conducted while the individual is sedated for MRI. If an individual prematurely discontinues the study, an early termination of visit should be arranged within 3 days.

[0138] For all infusions, the individual must be monitored in an inpatient setting for at least 24 hours from the start of the infusion. For the first infusion only, the individual must also return to the clinic for a follow-up visit 72 hours after the infusion begins. Following all visits, the parent or legal guardian will be contacted within 48 hours to confirm the individual's health status.

[0139] Vital signs will be measured 30 (±5) minutes before each infusion, every 60 (±5) minutes during each infusion, and 1 and 4 hours (±5 minutes) after each infusion. For the first dose, vital signs will be measured 30 (±5) minutes before the infusion begins (or restarts), every 30 (±5) minutes during the infusion, 0.5 and 1 hour (±5 minutes) after the infusion ends, and every 4 hours (±15 minutes) until discharge.

[0140] The CLN2 motor-verbal clinical assessment scale will be used to measure efficacy. Total hamburgers will be collected. The CLN2 scale will be updated to 12 points. Other secondary efficacy measures will include developmental status, seizure frequency, involuntary movements, and retinal anatomy and quality of life. The safety and tolerability of the treatment will be assessed by collecting adverse events (AEs), physical findings, vital signs, ECG, EEG, and clinical laboratory tests. Researchers will assess the severity, severity, and relationship of AEs to the study drug and / or ICV delivery device.

[0141] Because allergic reactions may be related to ERT administration, it should be done approximately 30 minutes before infusion. Page 45 of 94 (Invention Specification) C232142PA.docx Pre-treatment of individuals may be administered with age-appropriate doses of antihistamines (and, if appropriate, antipyretics). Following facility standard operating procedures, researchers may pre-treatment of individuals with age-appropriate sedatives approximately 30 minutes prior to TPP1 infusion, as appropriate.

[0142] The time relationship of drug infusion will be used to define TRE. This should be distinguished from the clinical assessment of infusion response. Therefore, adverse events occurring within 24 hours of the initiation or restart of TPP1 infusion are defined as TRE.

[0143] Certain events occurring within 24 hours after infusion may be mediated by allergies. An allergic reaction is characterized by an adverse local or systemic reaction following exposure to an allergen. Symptoms of an allergic reaction may include fever, chills / rigidity, skin symptoms (measles, angioedema, rash), respiratory symptoms (dyspnea, wheezing, stridor), gastrointestinal symptoms (nausea, vomiting, abdominal pain), and / or cardiovascular changes (hypotension / hypertension).

[0144] In severe cases, severe anaphylaxis (systemic anaphylactic reaction) may occur. Severe anaphylaxis is the most serious form of anaphylactic reaction, in which symptoms may appear during infusion or within hours; if left untreated, severe anaphylaxis may lead to death.

[0145] Symptoms of severe allergy may include skin and / or mucous membrane tissue involvement (e.g., generalized hives, itching or facial flushing, swelling of the lips, tongue and larynx), breathing difficulties (e.g., difficulty breathing, wheezing-bronchospasm, stridor, decreased peak expiratory flow, hypoxemia), and decreased blood pressure or peripheral organ dysfunction (e.g., hypotonia, syncope, incontinence).

[0146] To date, no severe or anaphylactic reactions have been reported in the TPP1 study. However, if a severe anaphylactic reaction, a serious anaphylactic event, or a severe anaphylaxis (defined as a grade 3 or higher anaphylactic event) is suspected, blood samples will be collected within 1 hour of the event to assess C4, serum trypsinoids, and total IgE; to assess drug-specific IgE, blood samples will be collected no more than 8 hours after the event (or before the next infusion). Page 46 of 94 (Invention Specification) C232142PA.docx

[0147] Another possible adverse event (AE) is infection of the indwelling ICV catheter. If infection is suspected, blood and CSF samples will be drawn for evaluation. Subsequent treatment may include antibiotic therapy and catheter reset or withdrawal. If TPP1 treatment is interrupted, it may be resumed if no more than four consecutive doses are missed since the last given dose.

[0148] The evaluation arrangements for the research plan will be provided in Figure 11.

[0149] Filtering

[0150] Before any study-related procedures are performed, informed consent will be obtained from the parents or legal guardians of eligible patients. Patients will be evaluated to determine if they meet the study entry criteria (Example 5) and are suitable candidates for ICV access device implantation. A diagnosis of CLN2 disease determined by TPP1 enzyme activity (dried blood spot) should be available at screening. Regardless of the availability of this genotype information, blood will be collected at the screening visit for CLN2 gene analysis. Additionally, blood (dried blood spot) for TPP1 enzyme activity will be collected at the screening visit and analyzed centrally. The screening procedure should be completed 21 days prior to the ICV reservoir implantation surgery.

[0151] If suitable for the individual, the CLN2 rating scale will be fully performed. The rating assessment guidelines provide detailed instructions on rating scale assessment, and the Imaging Charter (see Denver Development Scale II) provides instructions on MRI assessment using a centralized facility. Additionally, a complete physical examination will be performed.

[0152] Surgery and First Dose

[0153] The study individual will be transported to a hospital for surgical implantation of an MRI-compatible ICV access device in the right hemisphere lateral ventricle; the surgery and anesthesia will be performed under the guidance of a neurosurgeon (for information on the compatible ICV reservoir and catheter, please refer to the Study Pharmacy Manual). An MRI will be performed preoperatively to ensure proper planning and placement of the ICV access device. Generally, surgical and postoperative care will be determined by the research center's nursing standards and the individual's specific clinical needs. The procedure will be performed in intensive care. Page 47 of 94 (Invention Specification) C232142PA.docx Individuals will undergo at least 48 hours of postoperative monitoring in a controlled environment. Following ICV placement, a written instruction sheet will be provided to the individual and their caregiver, detailing the signs and symptoms of potential device complications and instructing when to return to the study site for device evaluation. Hospitalized patients will be followed up by telephone within 48 hours of discharge.

[0154] The first infusion will be performed at least 14 days from the date of surgery to implant the ICV reservoir, and no more than 28 days post-surgery. With the first (and subsequent) study drug administration, the investigator will assess reservoir patency, placement, and skin integrity. Strict aseptic technique will be used for device access. The appropriate needle insertion site on the skin covering the reservoir will be examined. The needle insertion site must be intact, without signs of rupture, wound, infection, or rash. Small-gauge, un-perforated needles will be used. Once the reservoir is accessed, the needle will be secured to minimize the risk of movement or removal. Guidelines regarding leakage and replacement of reservoir devices are provided in the Investigational Pharmacy Handbook. The reservoir may be replaced during clinical trials at the discretion of the investigator and / or neurosurgeon.

[0155] Discussion of the study design, including the selection of the control group.

[0156] This study must be conducted in patients with CLN2 disease because the potential development of ICV-mediated device implantation or TPP1 autoimmunity, along with its unknown long-term health consequences, poses an acceptable risk to healthy volunteers. However, the near certainty of severe disability and death within a few years would offset such risks in the patient population.

[0157] Diagnosis of CLN2 disease is usually based on enzyme activity analysis, which will be required for participation in this study. A diagnosis of CLN2 disease determined by TPP1 enzyme activity (dried blood spot) should be available at screening. Regardless of whether genotype information is available, blood will be collected at screening access for CLN2 gene analysis.

[0158] Because CLN2 disease is fatal in childhood, the study population must be children. Since treatment benefits are unlikely to be obtained in advanced CLN2 disease, and considering the significant depletion of cortical neurons, participation in the study requires a lack of substantial CLN2 disease progression, resulting in a study population similar to that of TPP1 gene therapy research. Page 48 of 94 (Invention Specification) C232142PA.docx The study population was relatively large (Worgall, 2008, Human Gene Therapy). Safety assessments will also be limited in late-stage patients who are essentially in a nutritional state. This study is limited to affected children aged 1 year or older.

[0159] A clinical assessment scale, the Hamburger Scale, was developed to record the natural history of CLN2 disease. (Stemfeld, 2002, American Journal of Medical Genetics).

[0160] Although all four domains of the Hamburger Rating Scale will be completed (Figure 12), the motor and language domains are most useful for this study. Language and motor are the domains most prone to loss of function; therefore, the CLN2 Motor-Language Scale is an appropriate measure of efficacy. The efficacy endpoint will be a comparison of motor and language subscale scores between treated and untreated patients, obtained from natural history data from the CLN2 disease registry and / or, as needed, from sibling data.

[0161] The other two domains in the rating scale (Figure 12) are unlikely to provide information for this study. To capture the seizure and motor dysfunction manifestations of CLN2 disease in more detail, an adaptation domain from the Unified Batten Disease Rating Scale (UBDRS) was incorporated into the protocol. The UBDRS domains record involuntary movements and seizures according to type, frequency, and severity (Kwon, 2011, Neurology).

[0162] Due to practical (limited number of available patients) and ethical (neurosurgery of children with fatal neurological diseases), this study design could not include concurrent, matched, randomized, blinded, or untreated control individuals (Arkin, 2005, Human Gene Therapy); (Crystal, 2004, Human Gene Therapy). Motor and verbal subscales and total scores of the Hamburg CLN2 Disease Scale will be compared with natural history data from the registry of the University Medical Center Hamburg, Germany, and / or data from siblings (as needed). Example 5

[0163] This example describes the research group in the second phase of open-label research described in Example 4. Page 49 of 94 (Invention Specification) C232142PA.docx The choice.

[0164] Research Plan: Selection of Research Group

[0165] Patients with confirmed CLN2 disease progression may be eligible to participate in this study. Participants in this study... Additional criteria are detailed below. Individuals must meet the following criteria to participate in the study (Table 7): Table 7 Inclusion Criteria & Exclusion Criteria: • Diagnosis of CLN2 disease based on TPP1 enzyme activity available at screening • At least one sibling with confirmed CLN2 disease participating in Example 3 study • Age > 1 year at the time of informed consent • Written informed consent from a parent or legal guardian, and individual consent (if appropriate) • Ability to comply with protocol requirements for assessment (laboratory sample collection, EEG, ECG, MRI, etc.) Individuals meeting any of the following exclusion criteria will not be eligible to participate in the study: • Another inherited neurological disorder, such as other forms of CLN or seizures unrelated to CLN2 disease (patients with febrile seizures may be eligible) • Percutaneous feeding tube placement • Received stem cell, gene therapy, or ERT for CLN2 disease • Contraindications to neurosurgery (e.g., congenital heart disease, severe respiratory distress, or coagulation disorders) • Contraindications to MRI scans (e.g., pacemaker, metal fragments or debris in the eye, aneurysm clip in the brain) • Events of generalized tonic-clonic seizures within 4 weeks prior to the first dose visit • First dose visit (may delay enrollment) The following conditions must be met: • Severe infection (e.g., pneumonia, pyelonephritis, or meningitis) within the previous 4 weeks; • Presence of ventricular abnormalities (hydrocephalus, malformation); • Presence of ventricular shunt; • Known hypersensitivity to any component of TPP1; • Received any investigational drug within 30 days prior to the first infusion of the investigational drug, or are scheduled to receive any investigational drug other than TPP1 during the study. Page 50 of 94 (Invention Specification) C232142PA.docx • Conditions that researchers believe may impair an individual's ability to adhere to the required tests or procedures, or that may impair an individual's health, safety, or clinical interpretability, or that may alleviate symptoms. • Pregnancy at any time during the study period; women deemed fertile by the researchers will undergo pregnancy testing. Example 6

[0166] This example describes the duration of individual participation in the studies described in Examples 4 and 5.

[0167] Individual participation will involve surgical implantation of the ICV access device, followed by recovery 14 to 28 days post-procedure, and will continue for at least 96 weeks for all individuals. Treatment will continue until all procedures are completed, the individual withdraws their consent and discontinues the study, or the investigator discontinues or terminates the study. A safety follow-up visit will be conducted 6 months after the final TPP1 infusion, but if the individual participates in an extension study, enrolls, or otherwise continues to have access to TPP1 within 6 months of the last infusion, a safety follow-up visit is not required (see section 1021 for AE / SAE reporting instructions). Example 7

[0168] This example describes the treatment administered in the studies described in Examples 4 to 6.

[0169] TPP1 should be administered to all study individuals via ICV infusion every two weeks, preferably in the morning after a fast of at least 2 hours. When using a feeding tube, the tube should be closed 2 hours before infusion. All individuals will be administered 300 mg of TPP1 via infusion, but for safety reasons, the dose may be reduced to 150 mg as needed.

[0170] Investment and Guidance

[0171] Surgical implantation of the ICV reservoir will be performed before administration of the study drug. The investigator will assess the reservoir's patency, location, and skin integrity at each administration of the study drug (see the *Study Drug Handbook*). At each administration, the investigator will insert 1-2 ml of CSF into the inhalation device cannula to check patency before administering the study drug. Strict aseptic technique will be used for device insertion. See page 51 of 94 (Invention Specification). C232142PA.docx Appropriate needle insertion site on the skin of the reservoir. The needle insertion site must be intact, without any signs of breakage, wound, infection, or rash. A small-caliber, un-drilled needle should be used. Once inserted into the reservoir, the needle should be secured to minimize the risk of movement or removal. The reservoir may be replaced during clinical trials at the discretion of the investigator and / or neurosurgeon.

[0172] TPP1 should be administered to all study individuals via ICV infusion every two weeks, preferably in the morning after a fast of at least 2 hours. When using a feeding tube, the tube should be closed 2 hours before infusion. Unless otherwise specified, the study procedure for each study visit should precede the infusion of the study drug. The date, time, volume, and concentration of each dose of the study drug administered to each individual will be recorded in the drug preparation log provided for the study and on the appropriate CRF. The Study Drug Handbook provides further instructions on the preparation and administration of study drugs.

[0173] The individual will be admitted to the hospital for each TPP1 infusion. For all infusions, the individual will be monitored in an inpatient setting for at least 24 hours from the start of the infusion. For the first infusion only, the individual will also return to the clinic for a follow-up visit 72 hours after the start of the infusion. Following all visits, the parent or legal guardian will be called within 48 hours to confirm the health status.

[0174] Because allergic reactions may be associated with ERT administration, individuals should be pretreated with age-appropriate antihistamines (and antipyretics, if appropriate) approximately 30 minutes prior to TPP1 infusion. According to institutional standard operating procedures, investigators may pretreat individuals with age-appropriate sedatives approximately 30 minutes prior to TPP1 infusion, as appropriate. Clinical, developmental, and QOL assessments should be performed prior to pre-infusion medication administration.

[0175] For a 300 mg dose, TPP1 will be infused at an ICV of 2.5 mL / h to deliver the full volume over approximately 4 (±1) hours. An infusion pump should be used to ensure a uniform infusion rate, and the pump should have appropriate delivery range, delivery rate accuracy, and alarms for incorrect delivery or blockage. If the dose needs to be terminated for safety or other reasons, it can be restarted at the same rate and completed. Page 52 of 94 (Invention Specification) C232142PA.docx Successfully administer the total dose within 1 hour of preparing the dosing syringe.

[0176] The normal infusion will be 300 mg, administered over 4 (±1) hours. If an individual experiences an adverse event (AE), the investigator may, in consultation with the medical supervisor, reduce the dose or infusion rate for future infusions. Changes in infusion should be made in the following order:

[0177] (I) Reduce the infusion rate and administer the drug over a total of 6 hours.

[0178] (II) Reduce the dose administered at the standard time of 4 (±1) hours to 150 mg.

[0179] (III) Reduce the infusion rate and administer 150 mg over a total of 6 hours.

[0180] Security Monitoring

[0181] After ICV insertion, a written instruction sheet will be provided to the individual and their caregiver, providing detailed information on the signs and symptoms of device complications, and instructions on when to return to the study site for device evaluation. The individual will be hospitalized for each TPP1 infusion. For all infusions, the individual will be monitored in an inpatient setting for at least 24 hours from the start of the infusion. For the first infusion only, the individual will also return to the clinic for a follow-up visit 72 hours after the start of the infusion. Following all visits, a parent or legal guardian will be contacted within 48 hours to confirm the individual's health status.

[0182] For the first infusion, vital signs will be measured within 30 (±5) minutes before the infusion begins or restarts, every 30 (±5) minutes during the infusion, 0.5 and 1 hour (±5) minutes after the infusion ends, and every 4 hours (±15 minutes) until discharge (see Vital Signs).

[0183] For each subsequent infusion, vital signs will be measured within 30 (±5) minutes before the infusion begins, every 60 (±5) minutes during the infusion, and 1 and 4 hours (±5 minutes) after the infusion ends.

[0184] Individuals need to be monitored regularly for adverse events and epileptic seizures by appropriately trained personnel throughout the infusion duration. If an epileptic seizure occurs, the infusion may be interrupted at the investigator's discretion. Because allergic reactions (severe or mild) may occur, appropriately trained personnel and equipment are required at the bedside during the study drug infusion for any available emergency resuscitation (including renal resuscitation). Page 53 of 94 (Invention Specification) C232142PA.docx (Adenosine). In case of emergency treatment, all individuals should have an intravenous line during infusion.

[0185] Symptoms of an allergic reaction may include fever, chills / shivering, skin symptoms (measles, angioedema, rash), respiratory symptoms (dyspnea, wheezing, stridor), gastrointestinal symptoms (nausea, vomiting, abdominal pain), and / or cardiovascular changes (hypotension / hypertension). If more severe symptoms occur, such as angioedema (swelling of the tongue or throat) or stridor, the infusion should be discontinued.

[0186] To date, no severe or anaphylactic reactions have been reported in the TPP1 study. However, if severe anaphylaxis is suspected, local guidelines should be followed. If a severe anaphylactic reaction, severe TRE, or severe TRE (defined as grade 3 or higher) is suspected, blood samples should be collected within 1 hour of the event to assess C4, serum trypsinoids, and total IgE; to assess drug-specific IgE, blood samples should be collected no more than 8 hours after the event (or before the next infusion).

[0187] Safety assessments should be performed during and after each infusion. Individuals may require longer observation periods at the investigator's discretion. If an adverse event (AE) consistent with the TRE is observed (Section 7.4.1), appropriate interventions may include infusion interruption, reduction of the infusion rate, or administration of antihistamines, oxygen, fluids, or steroids. If infusion is restarted after interruption, the initial rate should be approximately half the rate at which the response occurs. More details on infusion improvements are available in the Handbook of Investigational Pharmacology.

[0188] Instruct the parents or legal guardians to contact the researcher after discharge to discuss any adverse events (AEs).

[0189] ICV insertion can lead to infection, and prolonged use of the reservoir can cause cerebral hemorrhage, reservoir leakage, and seizures (Karavelis, 1996, *Neurosurgery*) (Kronenberg, 1998, *Pain*). Additional surgery may be required to fix or replace the device. Throughout the study, patients will be monitored for potential infection (high temperature, cough, rash, headache, swelling or drainage at the incision site) and signs of ICV reservoir leakage or malfunction (see *Handbook of Investigational Pharmacology*).

[0190] Due to inherent safety considerations around the implanted device, Page 54 of 94 (Invention Specification) C232142PA.docx

[0191] Individuals should have their ICV access device removed no more than 4 weeks after completing the study visit or terminating the visit early. If an individual intends to continue receiving TPP1 after participating in this study (e.g., via a commercially available product, registered use, or other TPP1 studies), device removal is not required. After device removal, individuals should return to the study site for a safety follow-up visit 4 weeks (±3 days).

[0192] Method for assigning individuals to treatment groups

[0193] Individuals will participate whenever they are available, without regard to any entry criteria or other patient characteristics.

[0194] Dosage selection

[0195] The planned dose is 300 mg.

[0196] The recommended dose levels are derived from the dose levels used in the TPP1 empty dachshund study (Vuillemenot, 2011, *Molecular Genetics and Metabolism*). Pharmacological effects, including functional improvement and lifespan extension, have been well demonstrated in empty dachshunds at doses of 4 mg and 16 mg of TPP1. Since TPP1 activity in brain tissue is associated with proximal CNS lysosomal storage material, proportional adjustments based on brain mass can predict the human therapeutic dose. The human equivalent dose was calculated using proportional adjustments based on brain mass. The human brain reaches approximately 75% of adult body weight by age 2 and 100% by age 5 (Giedd, 1996, *Cereb. Cortex*). If the adult brain mass is 1400 g, the range for healthy children aged 2 to 7 years is 1050 to 1400 g. Considering the progressive brain atrophy in CLN2 patients, assuming an average mass of 1000 g, and based on the average brain mass of a 50 g dachshund, the resulting scaling factor is adjusted by a factor of 20.

[0197] The unobserved adverse effect level (NOAEL) in a non-clinical study of dachshunds was also found to be 48 mg, which would correspond to 960 mg in humans.

[0198] Preliminary analysis of the study in Example 3 confirmed that all participating children who received 300 mg every two weeks via an intraventricular ventricle (ICV) device had a positive benefit-risk profile. Furthermore, Page 55 of 94 (Invention Specification) In contrast to the matched, untreated control group (in most matches, the decline was rapid and profound), clinical scores remained stable in children who had received TPP1 for more than 36 weeks.

[0199] Timing selection of dosage for each individual

[0200] The average CNS half-life is approximately 2 weeks, indicating that bi-weekly dosing can maintain therapeutic TPP1 levels in the CNS. In species with CSF kinetics similar to those in humans, TPP1 concentrations in the CSF remain higher than lysosomal Kuptake for approximately 48 hours following a single ICV or IT-L infusion (Vuillemenot, 2014, *Toxicol. Appl. Pharmacol.*), (Vuillemenot, 2011, *Molecular Genetics and Metabolism*); 0190-09-071). In these same species (dogs and monkeys), TPP1 is widely distributed in many brain regions within the CNS.

[0201] Speed ​​Selection

[0202] In non-clinical studies in dachshunds and cynomolgus monkeys, the infusion rate used was approximately 5% of the total CSF volume per hour. This is expected to represent a safe infusion rate that minimizes changes in total CSF volume and intracranial pressure. Dachshunds received ICV infusions at a rate of 0.6 mL / h for 2–4 hours, while monkeys received 0.88 mL / h for 3.6 hours. No effects were observed in these studies indicating safety concerns due to the infusion rate. In the CLN2 patient population, the estimated CSF volume is approximately 100 mL. For the proposed clinical trial, an infusion of 10 mL over a 4-hour period represents an infusion rate of 2.5% of the total CSF volume per hour, which is approximately half the rate that had no safety effect in the non-clinical studies. Therefore, we expect an infusion of 10 mL over 4 hours to be safe in CLN2 patients.

[0203] Unaware

[0204] This is a single-arm, open-label study. The study site will be assessed for safety and clinical severity, and participants and treatments will be unaware of their eligibility.

[0205] As defined in the Imaging Charter, supervision of MRI evaluations will be conducted by independent radiologists at a central imaging facility. The interpreting radiologists and software analysis will be used to assess the individuals and timeframes of the study. Page 56 of 94 (Invention Specification) Unaware. All individual identification information will be re-edited before the endpoints are evaluated.

[0206] Prior and concomitant medications

[0207] Medications (prescription drugs, over-the-counter drugs, and herbal supplements) taken during the 30 days prior to informed consent will be recorded in the CRF at the time of screening. Any changes to medications (dosage, frequency, new drugs, or discontinuation) due to previous visits will be recorded in the CRF at each subsequent visit (or within one week of early termination of the visit).

[0208] Any concomitant medications added or discontinued during the study should be recorded in the CRF (or within one week of early termination of access).

[0209] Individuals may be taking anticonvulsants and medications for myoclonus, tremor, agitation, and pain. Researchers will be asked to maintain these protocols throughout the study unless changes are necessary due to lack of efficacy or toxicity.

[0210] Treatment adherence

[0211] The study drug will be administered to individuals at the study site by qualified professionals. The date, time, volume, and concentration of each dose must be recorded in the dispensing log and on the appropriate CRF. In the event of a missed or incomplete dose of the study treatment, the investigator should record the reason and any other relevant information on the CRF as necessary.

[0212] Dietary or other program restrictions

[0213] There are no dietary or other protocol restrictions for this study. Individuals who require a PEG (percutaneous endoscopic gastrostomy) tube as a standard of care during the study will continue to participate. When using a feeding tube, it should be closed 2 hours before infusion. Example 8

[0214] This example describes the efficacy and safety variables of the studies in Examples 4-7.

[0215] Efficacy Variables Page 57 of 94 (Invention Specification)

[0216] Although this study was designed primarily to assess safety and tolerability, the CLN2 Motor-Language Clinical Assessment Scale will be used to measure efficacy. Total hamburger counts will be collected. MRI measurements of disease progression up to 12 points on the CLN2 scale and other indicators will be used as secondary endpoints. Other exploratory efficacy measures will include developmental status, seizure frequency, involuntary movements, retinal anatomy, and quality of life.

[0217] CLN2 Clinical Rating Scale

[0218] Disease severity will be assessed using the CLN2 Clinical Rating Scale (Stemfeld, 2002, *American Journal of Medical Genetics*); (Worgall, 2008, *Human Gene Therapy*). This scale consists of four domains with inherent content validity. Within each domain, a score of 0 to 3 is assigned, and the final score is calculated by adding the scores from the four domains to arrive at a rating of 0 (severely impaired) to 12 (normal).

[0219] Since the motor and language domains are most associated with the progression of CLN2 disease (section 9.2), they will be used to evaluate efficacy (Appendix 1).

[0220] Raters will be certified as qualified practitioners who have received training on the definition and implementation of the CLN2 Disease Assessment Scale. Prior to study evaluation, all raters at all study sites will need to complete a training course designed to standardize the definitions and scale anchors throughout the study. Whenever possible, a rater should assess the duration of treatment for each participating patient. Furthermore, patient scoring should be conducted during study visits, preferably in the morning before the procedure and / or infusion. The CLN2 scale assessment should be performed before pretreatment for TPP1 infusion.

[0221] Denver Developmental Scale H

[0222] Denver II is a revision and update of the Denver Developmental Screening Test.

[0223] Both tests are designed to monitor the development of infants and preschool children. The tests cover four basic functions: personal social interaction (such as smiling), adaptive motor skills (such as grasping and drawing), language (such as combining words), and gross motor skills (such as walking). The ages covered by the tests range from birth to 6 years. Page 58 of 94 (Invention Specification) C232142PA.docx

[0224] Modified Unified Bartholomew's Disease Rating Scale Involuntary Movement Scale

[0225] The modified Unified Bartholomew's Disease Rating Scale (mUBDRS) Involuntary Movement Scale is a rating scale that measures the type, frequency and severity of common involuntary movements associated with CLN2 diseases (such as myoclonus and dystonia).

[0226] Magnetic resonance imaging

[0227] All imaging data will be acquired on a 1.5 Tesla MRI platform. The study MRI will include the positioner specified in the Imaging Charter, 3D T1-weighted sagittal, T2-weighted gradient echo, diffusion-weighted axial, and FLAIR axial acquisition. The total scanning time is less than 60 minutes and is expected to be completed in most sedated individuals.

[0228] The volumetric analysis of the image will be accomplished by estimating the volume of total cortical gray matter and the proportion of cranial CS.

[0229] All patients will undergo an MRI without any contrast agents prior to the implantation of the ICV access device to ensure proper planning and placement. No MRI-related research evaluations will be conducted during this MRI, and any readings obtained during the MRI will not be included in the analysis of research data.

[0230] MRI scans should also be performed when researchers suspect infection or shunt dysfunction. In this case, according to Imaging Charter > at least T1-weighted axial and sagittal images should be available > MRI should be performed with or without intravenous angiography. For suspected meningitis, according to the Imaging Charter, MRI of the brain should be performed with or without contrast agent.

[0231] Optical coherence tomography (OCT) technology

[0232] Optical coherence tomography (OCT) is a non-invasive imaging test that uses light waves to capture cross-sectional images of the layers of the retina to measure their thickness. These measurements can aid in the early detection and treatment of retinal diseases. OCT is performed locally and should be performed before infusion.

[0233] Modified Unified Bartholomew's Disease Rating Scale Seizure Scale Page 59 of 94 (Invention Specification) C232142PA.docx

[0234] The mUBDRS Seizure Scale was used to measure the type and frequency of seizures in CLN2 patients within a 3-month interval prior to the study. The scale was completed with the help of caregivers / family members during the time intervals between study visits.

[0235] PedsQL

[0236] The PedsQL™ Universal Core Scale is designed to measure quality of life in children and adolescents. The assessment is simple, practical, and developmentally appropriate. The instrument responds to clinical changes over time (Msall, 2005, Review of Research on Intellectual Disability and Developmental Disorders). Four parent reports cover ages 1–12 months, 13–24 months, 2–4 years, and 5–7 years, and include questions about physical, emotional, and social functioning, as well as school functioning where applicable. Patients older than 7 years of age during the study period will not be assessed using this tool.

[0237] EQ-5D-5L

[0238] The EQ-5D-5L instrument is a self-reporting questionnaire designed to measure general health status (EuroQol Group, 1990, Health Policy) (Brooks, 1996, Health Policy). The EQ-5D-5L consists of two parts: a descriptive system that assesses overall health status across five dimensions and five levels of perceived problems (motor, self-care, daily activities, pain / discomfort, and anxiety / depression) using the EQ Visual Analogue Scale (EQVAS).

[0239] CLN2-specific QoL questionnaire

[0240] The CLN2-Specific QoL Questionnaire is a disease-specific supplement to the PedsQL using the same format and quantification. This questionnaire is a new instrument designed in collaboration with patient families and advocacy groups to capture basic care and quality-of-life issues in late-stage infants with CLN2 disease.

[0241] Infant and Toddler Quality of Life Questionnaire

[0242] The Infant and Toddler Quality of Life Questionnaire (ITQOL) is used to assess the health of children aged 2 months to 5 years. This tool requires parents of preschool children to reflect on the physical and psychosocial domains. Page 60 of 94 (Invention Specification) C232142PA.docx Such as the impact of development, pain, emotions, and children's health on parents.

[0243] Immunogenicity

[0244] Immunogenicity testing will be performed in the central laboratory using validated immunogenicity assays for serum and CSF samples. Blood samples (serum) will be collected for TAb testing, and CSF samples will be collected for TAb and NAb testing prior to the first infusion (at baseline or one week prior to infusion), every 12 weeks thereafter, and at safety follow-up (or within one week of early termination of visit). Collection must be prior to infusion. NAb will be tested in CSF at baseline, and at subsequent time points only if TAb is positive in CSF.

[0245] If ​​an allergic reaction occurs in the future and additional laboratory work is required, the baseline total IgE and drug-specific IgE content will be obtained using the baseline sample.

[0246] To date, no severe or anaphylactic reactions have been reported in the TPP1 study. However, if a severe anaphylactic reaction, a serious anaphylactic event, or a severe anaphylaxis (defined as a grade 3 or higher anaphylactic event) is suspected, blood samples will be collected within 1 hour of the event to assess C4, serum trypsinoids, and total IgE; to assess drug-specific IgE, blood samples will be collected no more than 8 hours after the event (or before the next infusion).

[0247] Clinical Laboratory Assessment

[0248] Collect blood and urine samples for routine clinical laboratory assessments (blood chemistry, hematology, urinalysis) and perform centralized analysis. Collection should be performed before infusion.

[0249] Any abnormal test result determined by the investigator to be clinically significant should be repeated until the cause is determined, the value returns to baseline or within normal limits, or the investigator determines that the abnormal value is no longer clinically significant.

[0250] All abnormal clinical laboratory pages should be initialized and dated by the investigator, along with comments on their clinical significance. Each clinically significant laboratory result will be considered during screening. Page 61 of 94 (Invention Specification) C232142PA.docx It was recorded as a medical history and subsequently as an adverse event (AE).

[0251] If known, then the clinical laboratory results that the investigator considers to be clinically significant should be compared with those of the investigator. Abnormal diagnostic records on AE CRF°

[0252] The table below shows the clinical laboratory tests performed (Table 8): Table 8 Blood chemistry, hematology, urine analysis, albumin, heme, appearance, alkaline phosphatase, hematocrit, color, ALT (SGPT), WBC count, pH, AST (SGOT), RBC count, specific gravity, direct bilirubin, platelet count, ketones, total bilirubin, differential cell count, protein, blood urea nitrogen, glucose, calcium, bilirubin, carbon dioxide, nitrite, chloride, urobilinogen, total cholesterol, heme, C-reactive protein, myokinase, creatine kinase, glucose (GGT), LDH, phosphorus, potassium, total protein, uric acid.

[0253] Cerebrospinal fluid monitoring

[0254] Within 30 (±5) minutes prior to each infusion, a standard clinical laboratory CSF sample (differential cell count, protein, and glucose) for routine monitoring will be collected. A small amount will be collected from the ICV reservoir. Page 62 of 94 (Invention Specification) C232142PA.docx The volumetric CSF should be collected and analyzed locally. Collection should be performed prior to the study of drug infusion.

[0255] Biomarkers

[0256] Samples of plasma and CSF will be collected for analysis of hypothetical molecular / biochemical biomarkers. Collection should be performed prior to the administration of the study drug. Samples will be centrally tested.

[0257] Other laboratory assessments

[0258] Individuals who have experienced a SAE that may be related to TPP1 or other associated AEs may need additional blood samples to assess immunogenicity or safety parameters.

[0259] Vital signs, physical examination and other observations

[0260] Vital signs

[0261] For the first infusion, vital signs (SBP, DBP, heart rate, respiratory rate and body temperature) will be measured within 30 (±5) minutes before the infusion starts or restarts, every 30 (±5) minutes during the infusion, 0.5 and 1 hour (±5 minutes) after the infusion ends and every 4 hours (±15 minutes) until discharge.

[0262] For each subsequent infusion, vital signs will be measured within 30 (±5) minutes before the start of the infusion, every 60 (±5) minutes during the infusion, and 1 and 4 hours (±5 minutes) after the end of the infusion.

[0263] Physical examination

[0264] A complete physical examination will include general appearance (head, eyes, ears, nose and throat), cardiovascular, dermatology, lymphatic, respiratory, gastrointestinal, genitourinary, musculoskeletal, and weight and height.

[0265] A simple physical examination will include an assessment of overall appearance, cardiovascular, respiratory, neurological and gastrointestinal tract.

[0266] When using an ICV reservoir device for intraventricular drug administration, patients need to be monitored for potential infections throughout the study (high temperature, cough, rash, headache, changes in mental status, swelling at the incision site). Page 63 of 94 (Invention Specification) (swelling or drainage) and signs of leakage or malfunction of the ICV reservoir (swelling of the skin around the reservoir site, difficulty in CSF extraction, scalp erythema, swelling of the reservoir device or leakage of fluid during infusion).

[0267] Investigators will assess reservoir patency, location, and skin integrity at each administration of the study drug. Prior to infusion, investigators will examine the reservoir site for scalp edema, erythema, or skin rupture. Patency will be reassessed during pre-infusion sampling and during infusion. Difficulty obtaining the required CSF volume for the pre-infusion sample or signs of ICV reservoir leakage (skin swelling around the reservoir site, scalp erythema, bulging of the reservoir device, or fluid leakage) will prompt further evaluation of reservoir malfunction before continuing infusion. Further surgical consultations, including surgical intervention to fix or replace the device, may be necessary.

[0268] Clinically significant abnormalities will be recorded as AEs under "Medical History" or later during screening.

[0269] Neurological examination

[0270] A complete neurological examination will include level of consciousness, speech, language, cranial nerves, motor intensity, motor tone, abnormal movement, reflexes, upper limb sensation, lower limb sensation, gait, Romberg, nystagmus, and coordination.

[0271] Electrocardiogram

[0272] A standard 12-lead electrocardiogram includes heart rate, rhythm, time interval, axis, conduction defects, and anatomical abnormalities. The ECG will be performed within 15 (±5) minutes after the infusion is completed.

[0273] If a clinically significant abnormality is found, the investigator or designated person will assess whether the individual is suitable to participate in or continue the study; the clinically significant abnormality will be recorded in the medical history during the screening period and subsequently recorded as an AE.

[0274] Electroencephalogram (EEG)

[0275] Record the standard awakened EEG. If clinically significant abnormalities are found, the researcher or... Page 64 of 94 (Invention Specification) Selected personnel will assess whether the candidate is suitable to participate in or continue the study; during the screening period, any clinically significant abnormalities will be recorded under "Medical History".

[0276] Pregnancy Test

[0277] At any time during the screening and study period, female individuals deemed fertile by the researcher (defined by the onset of menstruation) will undergo a urine pregnancy test; additional urine tests will be performed if there are any problems with the pregnancy at any time. If the urine test result is positive or ambiguous, a serum pregnancy test will be performed. Example 9

[0278] This example describes the research procedure of the study in Examples 4-8.

[0279] After explaining the nature of the study, written informed consent from the parents or legal guardians must be obtained before any procedures related to the study. The following procedures will be performed within 21 days of the hospitalization for ICV implantation: • Informed Consent Form • Confirmation of the diagnosis of CLN2 disease based on TPP1 enzyme activity (dried blood spots) • Blood used for N2 gene analysis • Hamburg CLN2 disease assessment scale with video (Figure 12) • Validation standards used for research entry points • Cranial MRI • A complete physical examination, including medical history • CLN2-specific QoL questionnaire • Pregnancy test (for women of childbearing age) • After obtaining informed consent, assess SAEs related to the prescribed interventions and history of epileptic seizures. • Accompanying medications Page 65 of 94 (Invention Specification) C232142PA.docx

[0280] Surgical visit

[0281] Eligible research candidates will be admitted to the hospital for surgical implantation of the ICV access device into the right ventricle. An MRI will be performed preoperatively to ensure proper planning and placement of the ICV access device. Individuals should be monitored in a nursing-intensive environment for at least 48 hours postoperatively. The following procedures will also be performed: • AE assessment, including a history of persistent seizures. • Accompanying medications

[0282] After ICV insertion, a written instruction manual will be provided to the individual and their caregiver, providing detailed information on the signs and symptoms of device complications, as well as instructions on when to return to the study site for device evaluation. Hospitalized patients will be followed up by telephone within 48 hours of discharge.

[0283] Baseline access and the _th infusion

[0284] Baseline Access

[0285] The following line values ​​will be recorded within 2 days prior to the first infusion (which will occur at least 14 days and no more than 28 days after the procedure): • Hamburg CLN2 Disease Assessment Scale with Video (Appendix 1) • ECG (12 leads) (heart rate, rhythm, time interval, axis, conduction defects and anatomical abnormalities) • EEG (Standard Wake-up) • Cranial MRI • CSF (TAb and NAb in all individuals) and serum (TAb and drug-specific IgE in all individuals) for immunogenicity • Complete physical examination • Neurological examination • Clinical laboratory tests (hematology, blood chemistry, and urine analysis) Page 66 of 94 (Invention Specification) C232142PA.docx • Revised Unified Bartholomew's Disease Rating Scale Involuntary Movement Scale (mUBDRS-Movement) • Revised Universal Bartholomew's Disease Assessment Scale Seizure Scale (mUBDRS-Seizure Scale) • Optical coherence tomography (OCT) technology • Infant and Toddler QOL Questionnaire • PedsQL • EQ-5D-5L • Denver II Developmental Scale • CLN2-specific QoL questionnaire • Ophthalmological assessment • AE assessment, including a history of persistent seizures. • Accompanying medications

[0286] The _th infusion

[0287] Typically, for all infusions, functional and QOL assessments should be performed prior to MRI and blood collection; blood samples may be collected when an individual is sedated for an MRI examination.

[0288] First Infusion - Day 1

[0289] The following process will be performed on day 1 of the first infusion: • CSF monitoring (cell count, protein, glucose) • Equipment working properly / infection • Study drug infusion • Cerebrospinal fluid and plasma are used for biomarkers • Within 30 (±5) minutes before the start of infusion, every 30 (±5) minutes during infusion, and 0.5 after the end of infusion. Vital signs and vital signs every 1 hour (±5 minutes) and every 4 hours (±15 minutes) until discharge. • Simple physical examination Page 67 of 94 (Invention Specification) C232142PA.docx • AE assessment (investigators may collect additional blood samples for safety or immunogenicity testing of any AE of concern) and a history of persistent seizures. • Accompanying drug evaluation • Perform post-infusion monitoring for at least 24 hours in a hospital setting.

[0290] First infusion - Days 2-6

[0291] The following procedure will be performed from day 2 to day 6 after the first infusion: • Vital signs (Day 2) (every 4 to 20 hours after the infusion ends) • Clinical laboratory tests (hematology, blood chemistry, and urinalysis) (Day 2) • CSF monitoring (cell count, protein, glucose) (Day 6) • Simple physical examination (Day 6) • Equipment working properly / Infection (Day 6) • AE assessment (investigators may collect additional blood samples for safety or immunogenicity testing of any AE of concern) (daily) and a history of persistent seizures. • Accompanying medication assessment (daily)

[0292] After the first infusion, hospitalized patients will be followed up by a telephone call with their parents / guardians within 48 hours of discharge.

[0293] Every 2 weeks

[0294] During the study, the following assessments and procedures should be performed every 2 weeks. All study visits should be conducted every 2 weeks from the date of the first infusion (±3 days). Unless otherwise specified, all assessments and procedures should be completed before the infusion of the study drug. Generally, functional and QOL assessments should be completed before MRI and blood sampling; blood samples may be collected when the individual is sedated for MRI.

[0295] For all visits, if no safety issues are observed and the individual is medically stable, discharge may be arranged after 24 hours. A follow-up phone call will be made to the parents or legal guardian approximately 48 hours after discharge. Page 68 of 94 (Invention Specification) C232142PA.docx To determine a person's health status. • Simple physical examination • CSF monitoring (differential cell count, protein, glucose) • Device patency / infection assessment • Study drug administration • Within 30 (±5) minutes before the start of infusion, every 60 (±5) minutes during the infusion, and 1 minute after the end of the infusion. and vital signs for 4 hours (±5 minutes). • AE assessment (investigators may collect additional blood samples for safety or immunogenicity testing of any AE of concern) and a history of persistent seizures. • Accompanying drug evaluation • Call the parents / guardians within 48 hours after the visit.

[0296] Every 4 weeks

[0297] The following assessments and procedures should be performed every 4 weeks during the study. Where applicable, blood sampling may be performed during MRI sedation.

[0298] Routine clinical laboratory tests (hematology, blood chemistry, and urine analysis)

[0299] Every 12 weeks

[0300] The following assessments and procedures should be performed every 12 weeks during the study. Unless otherwise specified, all assessments and procedures should be completed before the infusion of the study drug. Generally, functional and QOL assessments should be completed before MRI and blood sampling; blood samples may be collected when the individual is sedated for MRI. • Record the Hamburg CLN2 disease assessment scale (Figure 12). • Neurological examination • Used for immunogenic CSF and serum sampling Page 69 of 94 (Invention Specification) C232142PA.docx • mUBDRS - Sports • mUBDRS - Seizures • Optical coherence tomography (OCT) technology • Infant and Toddler Quality of Life Questionnaire • PedsQL • Denver II Developmental Scale • CLN2-specific QoL questionnaire • EQ-5D-5L

[0301] Every 24 weeks

[0302] During the study, the following assessments and procedures should be performed every 24 weeks: • ECG (12 leads) within 15 (±5) minutes after infusion (heart rate, rhythm, time interval, axis, conduction defects and anatomical abnormalities) • EEG (Standard Wake-up) • Cranial MRI • CSF and plasma used for biomarker analysis • Complete physical examination

[0303] Every 48 weeks

[0304] During the study period, the following assessments and procedures should be performed every 48 weeks: • Ophthalmological assessment

[0305] Research completed or visit terminated early

[0306] Upon completion of the study or early termination, the individual will return to the study location within 3 days. The following process will be completed: • The Hamburg CLN2 disease assessment scale was recorded (Appendix 1). Page 70 of 94 (Invention Specification) • ECG (12 leads) heart rate, rhythm, time interval, axis, conduction defects, and anatomical abnormalities. [If infusion is performed, 15 (±5) minutes after the infusion is completed.] • Cranial MRI • CSF monitoring (cell count, protein, glucose) • CSF and plasma used for biomarker analysis • Used for immunogenic CSF and serum sampling • Vital signs (SBP, DBP, heart rate, oral temperature, and respiratory rate) • Complete physical examination • Neurological examination • Routine clinical laboratory tests (hematology, blood chemistry, and urine analysis) • Denver II Developmental Scale • CLN2-specific QoL questionnaire • Ophthalmological assessment • AE assessment (investigators may collect additional blood samples for safety or immunogenicity testing of any AE of concern) and a history of persistent seizures. • Accompanying drug evaluation

[0307] The ICV access device should be removed from individuals who will not continue to receive TPP1 under other circumstances (e.g., commercial use, enrollment, participation in another TPP1 clinical study, etc.) after the study is completed or early termination of access. Device removal should be performed no more than 4 weeks after the study completion access or ETV.

[0308] Device and Safety Follow-up

[0309] After completing the following steps, the individual will return to the study site 4 weeks (±3 days) after the removal of the ICV access device: • Vital signs (SBP, DBP, heart rate, oral temperature, and respiratory rate) Page 71 of 94 (Invention Specification) • A simple physical examination (including a thorough examination of the previous device site to check for signs of infection, etc.) • Serum sampling for immunogenicity • Neurological examination • Routine clinical laboratory tests (hematology, blood chemistry, and urine analysis) • AE assessment (Investigators may collect additional blood samples for safety or immunogenicity testing for any AEs of concern) • Accompanying drug evaluation

[0310] Individuals who have not undergone device removal will be exempt from the 4-week device safety follow-up visit, as they will continue to receive TPP1 in other settings (e.g., commercial use, registration participation, participation in another TPP1 clinical study, etc.).

[0311] Safety follow-up

[0312] If an individual participates in an extension study or register, or continues to use TPP1 within 6 months after the final infusion, a safety follow-up visit is not required. If necessary, the individual will return to the study site 6 months after the last study treatment after completing the following procedures: • ECG (12 leads) (heart rate, rhythm, time interval, axis, conduction defects, and anatomical abnormalities) [if infusion, within 15 (±5) minutes after infusion completion] • Serum sampling for immunogenicity • Vital signs (SBP, DBP, heart rate, oral temperature, and respiratory rate) • Complete physical examination • Routine clinical laboratory tests (hematology, blood chemistry, and urine analysis) • AE assessment (Investigators may collect additional blood samples for the safety of any AE of concern or • Immunogenicity testing and a history of persistent epileptic seizures • Accompanying drug evaluation Page 72 of 94 (Invention Specification) C232142PA.docx

[0313] Research terminated

[0314] The study will end after the last individual completes their final safety follow-up visit. BioMarm reserves the right to terminate the study at any time for clinical or administrative reasons, and the right to terminate individual investigators or study sites for clinical or administrative reasons, including but not limited to participation in procedures that are poor or non-compliant with protocols or GCP. Additionally, BioMarm may terminate the study if it deems it potentially jeopardizing the safety of the study individuals. Example 1.

[0315] This example describes the results, modifications, and discussion of the studies described in Examples 4-9.

[0316] Research and development of pharmaceuticals, rinsing solutions, components and formulations

[0317] The drug studied in Examples 4-9 is a lyophilized injectable formulation containing 150 mg of cellular leptokinase A per 5 mL solution in a single 10 mL glass vial. The drug contains the following excipients: diammonium hydrogen phosphate pentahydrate, monoammonium phosphate monohydrate, ammonium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, and water for injection. A flushing solution is supplied to completely dispose of any drug remaining in the dosing line, in order to maintain line patency after intraventricular administration of the drug. The composition of the flushing solution is the same as that of the drug, except that the flushing solution does not contain the active ingredient and is supplied in 5 mL solutions in single 10 mL glass vials. Mechanism of action of I-leader > An, cellular leptokinase a

[0319] Cellular leponase a is a recombinant hTPPl precursor composed of 544 amino acids. The amino acid sequence is identical to that of the in vivo hTPPl precursor. N-linked oligomers (such as diphosphorylated high-mannose chains) bind to aspartic acid residues (Asn191, Asn203, Asn267, Asn294, and Asn424) in the five N-linked oligomer sequences, and are absorbed into target cells or lysosomes via CI-M6PR (J Biol Chem 2001: 276: 2249-55). Subsequently, the propeptide fragment is cleaved by in vivo proteases in an acidic environment to produce the active enzyme (e.g., *Biological Journal of Chemistry* 2001: 276: 2249-55). Page 73 of 94 (Invention Specification) C232142PA.docx (Journal of Biochemistry, 2004: 279, 31058-67; Journal of Biochemistry, 2009: 284: 3985-97), and the tripeptide cleaved from polypeptides accumulated in lysosomes, prevents the accumulation of storage material and thus prevents the progression of CLN2 disease.

[0320] Pharmacokinetics

[0321] In this study, Brmeura was administered to non-Japanese CLN2 patients (target sample size: 5). The following table (Table 9) shows the CSF and plasma pharmacokinetic parameters of individual patients who received 200 or 300 mg intraventricular doses. Table 9 Individuals receiving 200 or 300 mg intraventricular doses Patient's CSF and plasma pharmacokinetic parameters Patient ID (baseline age) Dosage (mg) Measured substance Cmax (g / mL) at measurement time point AUCo. t (g·h / mL) Patient 1 (2 years old) 300 Week 97 Plasma 6.4 216 Patient 2 (2 years old) 300 Week 97 Plasma 3.19 66.9 Patient 3 (2 years old) 300 First dose CSF Plasma 508 10.3 2380 115 Week 25 S CSF Plasma 1540 11 6130 128 Patient 4 (1 year old) 200 First dose CSF Plasma 511 9.46 2720 72.7 300 Week 25 S CSF Plasma 2.97 21.8 36 237 Patient 5 (1 year old) 300 Week 25 S CSF Plasma 659 15 3720 148 Cmax: The maximum concentration of CSF or plasma. AUCo. t Area at CSF or plasma concentration - time curve from initial administration to the last quantification point t a) In this study, pharmacokinetic assessments were performed after the data cutoff date; the results presented... Page 74 of 94 (Invention Specification) C232142PA.docx Pharmacokinetic parameters of cellular leptonase a were obtained from 5 patients who received Brmeura for between 2 days. Pharmacokinetic parameters data. b) Dose 49; c) Dose 13

[0322] Discussion of this study

[0323] The key inclusion criteria for this study were reduced TPP1 enzyme activity based on blood tests, age 1 year or older, having a sibling who participated in the study in Example 3, a total score of 3 to 6 on the motor and verbal subscales, and no prior treatment with stem cell therapy, gene therapy or enzyme replacement therapy.

[0324] This study consists of the following: a 14 to 28-day postoperative recovery period following the implantation of the device for intraventricular drug delivery and a 96-week study drug treatment period.

[0325] The dosage and administration are as follows: 300 mg of TPP1 (Brineura) intracerebrospinal dose, administered over approximately 4 hours, once every 2 weeks (infusion rate: 2.5 mL / h). The treatment period is 96 weeks. 2.

[0326] Furthermore, the study protocol was revised shortly after the data cutoff to ensure that participation was no longer limited to siblings of CLN2 patients participating in Example 3. The eligibility age for participation was changed to birth to <18 years, and the dosage and administration for patients under 2 years of age were changed as follows: 10 mg for patients from birth to <0.5 years of age; 15 mg for patients >0.5 years of age and <1 year of age; and 200 mg for the first four doses for patients <1 year of age and <2 years of age, followed by 300 mg every two weeks thereafter. All doses were administered intracerebroventricularly at an infusion rate of 2.5 mL / h.

[0327] Both the safety and efficacy analysis groups included four treated patients (baseline age: 2 to 5 years). For efficacy, Table 10 shows data from the CLN2 clinical scoring scale. 21 Baseline scores on the motor and verbal subscales and their sum (ML score), as well as changes from baseline to the last assessment time point, were recorded. No baseline decline was observed on any of the clinical rating scales; all remained unchanged. Table 1. 19 This study (or part thereof) was conducted in Germany and the United States. 20 The duration of exposure (mean ± SD) up to the data cutoff date (month) was 30.5 ± 11.30 weeks. 21 The CLN2 clinical rating scale was assessed every 12 weeks. Page 75 of 94 (Invention Specification) C232142PA.docx Baseline scores for each clinical assessment scale and changes from baseline to the last assessment point. (Research 109-203) Baseline score 0 1 2 3 4 5 6 Baseline Motor component scale (0 to 3 points) (4 patients) 0 (0) 2(50) 0 (0) 2 (50) Language subscale (0 to 3 points) (3 patients) a) 0 (0) 1(33) 0 (0) 2 (67) ML subscale (0 to 6 points) (3 patients) a> 0 (0) 0 (0) 1(33) 0 (0) 0 (0) 0 (0) 2(67) Change from baseline to the last assessment point -3 -2 -1 0 1 2 3 Qu Junci's evaluation time point Motor subscale (4 patients) Verbal subscale (3 patients) 0 (0)0 (0) 0 (0) 4(100)0 (0)0 (0)0 (0) 0 (0)0 (0) 0 (0) 3(100)0 (0)0 (0)0 (0) ML subscale (3 patients) 0 (0)0 (0) 0 (0) 3(100)0 (0)0 (0)0 (0) Number of patients (%) a) Of the four patients who participated as of the data cutoff date, one had a baseline ML subscale score of [missing information]. 1. Furthermore, because this patient also has autism, this patient was excluded from the language and ML subscale assessment. In addition.

[0328] Regarding safety, AE 22 was reported in all 4 patients (upper respiratory tract infection, upper respiratory tract infection, malaise, seizures, partial seizures, partial seizures, constipation and abdominal pain; fever, sleep disturbances and fever; influenza, fever and gastroenteritis; and vomiting, allergic reactions, falls, bronchitis, generalized tonic-clonic seizures, upper respiratory tract infection, upper respiratory tract infection, generalized tonic-clonic seizures, generalized tonic-clonic seizures and gastroenteritis). In these events, 3 patients (2 with fever and 1 with allergy) were considered as having upper respiratory tract infection.

[0329] No deaths were reported. It was reported that 3 patients had severe acute exacerbations (AEs) (2 patients had fever and 1 patient...). (Page 76 of 94 (Invention Specification)) C232142PA.docx (Patient allergy), and all such events were considered adverse reactions (ADRs). No adverse events leading to treatment interruption were reported.

[0330] Anti-cytokine leptonase A antibodies were positive in the serum of all four patients up to 13 weeks after the start of treatment. Anti-cytokine leptonase A antibodies were not detected in the CSF of any patient up to 37 weeks after the start of treatment.

[0331] No clinically significant changes were reported in vital signs or 12-lead ECG.

[0332] Efficacy

[0333] Regarding the efficacy of Brmeura in CLN2 patients under 3 years of age, the study protocol was revised after the data cutoff to include patients aged from birth to <18 years in the eligible study population. Based on the most recent data, Brmeura was administered to 11 patients, 5 of whom were under 3 years of age (3 were 2 years old and 2 were 1 year old). Table 11 shows the ML score at baseline age. From baseline to the last assessment point, the ML score remained unchanged in 8 patients (4 patients maintained a score of 6, 3 patients maintained a score of 4, and 1 patient maintained a score of 2), 2 patients showed improvement (1 patient's score improved from 5 to 6, and 1 patient's score improved from 1 to 2), and 1 patient's score decreased by 1 point (from 4 to 3). Among the 3 patients over 2 years of age, 2 maintained a ML score of 6, and the other patients' scores improved by 1 point (from 5 to 6). Two patients under 2 years old maintained an ML score of 6. 27The recent exposure duration (mean ± SD) was 67.2 ± 32.48 weeks. The exposure duration for patients < 2 years of age and for patients 2 years of age were 43.2 ± 0.91 weeks and 72.6 ± 33.80 weeks, respectively. Page 77 of 94 (Invention Specification) C232142PA.docx Table 11 Distribution of ML scores at baseline and final assessment time points Baseline age group ML score 0 1 2 3 4 5 6 <3 years <2 years (2 patients before) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (100) Baseline (5 patients) 2 years (3 patients) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (33.3) 2 (66.7) N 3 years (6 patients) 0 (0) 1 (16.7) 1 (16.7) 1 (16.7) 3 (50.0) 0 (0) 0 (0) Total (11 patients) 0 (0) 1 (9.1) * 1 (9.1) 1 (9.1) 3 (27.3) 1 (9.1) 4 (36.4) <3 years <2 years (2 patients 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (100) Take the next assessment, day-to-day interval (5 patients) 2 years (3 patients) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 3 (100) N3 years (6 patients) 0 (0) 0 (0) 2 (33.3) b) 1. (16.7) 3 (50.0) 0 (0) 0 (0) Total (11 patients) 0 (0) 0 (0) 2 (18.2) b, 1 (9.1) 3 (27.3) 0 (0) 5 (45.5) Number of patients (%) a) The baseline age of the two patients who were less than 2 years old was 1 year. b) This data includes MS scores for autistic patients as described in Table 29, a). Page 78 of 94 (Invention Specification) C232142PA.docx Form number AO2O2 1093346636-0

[0334] Regarding efficacy in patients under 3 years of age, results confirmed no symptom exacerbation during Brineura treatment.

[0335] In view of the above, it is expected that the use of Brmeura can effectively prevent the progression of CLN2 disease in younger patients.

[0336] Safety and serious adverse events

[0337] Regarding the safety of CLN2 patients <3 years of age: In this study, based on the latest data, Brmeura was administered to 11 patients (6 patients <3 years of age, 3 patients <2 years of age, and 2 patients <1 year of age), and all 11 patients reported adverse events (AEs). Among them, the events in 3 patients >3 years of age (each patient experienced 1 to 3 episodes of fever) and 3 patients <3 years of age (2 patients with fever and allergic reactions; 1 patient with drug allergy and drug allergy) were assessed as adverse drug reactions (ADRs), and all such events had a "recovery" outcome. SAEs were reported in 6 patients >3 years of age (Escherichia urinary tract infection, gastrointestinal tract infection and pneumonia; positive Propionibacterium test; fever, adenoid hypertrophy and rhinitis; device insertion complications; periorbital hematoma; and fever, toothache and fever) and 3 patients <3 years of age (persistent seizures and infection in a 2-year-old patient; fever, influenza and influenza; and allergies and medical device site hematoma). Among these, events in 2 patients >3 years of age (fever and fever; and fever) and events in 2 patients <3 years of age (fever and allergy in a 2-year-old patient) were assessed as adverse drug reactions (ADRs), and all of these events had a "recovery" outcome. Based on the above, no new clinically significant AEs were observed in patients <3 years of age in this study.

[0338] Based on clinical research and overseas port marketing experience, the incidence of adverse events (AEs) is observed in Brineura. Note that the security measures are considered acceptable.

[0339] In summary, efficacy of Brineura at certain levels is expected, and the safety profile of Brineura appears acceptable when administered intraventricularly based on previous studies in CLN2 patients aged >3 years and this study including CLN2 patients aged <3 years. Page 79 of 94 (Invention Specification) C232142PA.docx

[0340] Dosage and administration

[0341] By using a surgically implantable intraventricular device, the intraventricular route of Brmeura is determined to bypass the blood-brain barrier, and the enzyme is delivered directly and fully to the central nervous system, thereby achieving the effect of targeting neurological symptoms.

[0342] In the primary pharmacodynamic study, in TPP1-deficient dogs (dachshunds), intraventricular administration of 16 mg of cellular leptokinase a every 2 weeks prolonged the onset of neurological symptoms and showed a trend toward long-term survival. Based on the fact that TPP1 activity in brain tissue is more closely related to the accumulation of lysosomal substances in the central nervous system, clinical doses were studied based on a human dose-adjusted factor according to brain weight. Considering that the human brain reaches 75% of adult brain weight before age 2 and almost 100% before age 5 (Cereb Cortex 1996; 6:551-60), and based on an average adult brain weight of 1400 g, the brain weight of children aged 2 to 7 years could be in the range of 1050 to 1400 g. Considering the possibility of progressive brain atrophy in CLN2 patients, the applicant assumes that the brain weight of CLN2 patients in this age group may be approximately 1000 g. Because the average brain weight of dachshunds is estimated to be 50 g (Peptide Drug Delivery to the Brain, Raven Press, 1991:112), the proportional adjustment factor for the human dose was determined to be 20 times. Based on the brain weight ratios between species, the dose of 16 mg of cellular leptonase a administered to 2-year-old TPP1-deficient dogs (dachshunds) was considered to be 320 mg. Subsequently, the study described in Example 3 was initiated in >3-year-old CLN2 patients, starting with, for example, a group starting at 30 mg, and titrated to 300 mg after confirming tolerability, taking safety into account. 5 Evaluating the efficacy and safety of 300 mg > Including fixed-dose time periods. The protocol was revised for this study (after data cutoff). Dose 39 was selected based on brain weight in patients <2 years of age to study the efficacy and safety of Brmeura: <100 mg for patients from birth to 0.5 years, 150 mg for patients from 0.5 to <1 year, and 200 mg for the first four doses followed by 300 mg for patients from 1 to <2 years. In patients from 1 to <2 years of age, the dose was estimated based on brain weight. The brain weight of the 39 female / male pediatric patients has been reported to range from 360 / 380g to 580 / 640g in the age range from birth to <0.5 years, and in the age range from 0.5 to <1 year. The range was 640 / 680 g to 940 / 970 g, and 940 / 970 g to 1040 / 1120 g in the age range of 1 year to < 2 years (Annals of Neurology 1978;4:345-56). Page 80 of 94 (Invention Specification) C232142PA.docx The initial dose was 300 mg. However, the initial dose was set at 200 mg as an intermediate dose for patients aged 0.5 to < 1 year starting treatment with Brineura, and the dose was increased from 150 mg to 300 mg based on safety considerations according to age. Regarding dosing intervals, Brineura was administered at a two-week interval in clinical studies, as tissue distribution results from non-clinical pharmacokinetic studies, etc., indicate that exposure to the active pharmaceutical ingredient in the CNS is expected to be maintained at a two-week interval.

[0343] For children under 2 years of age, the dosage reduction should be based on the table below (Table 12). Table 12 Age group and dosage: Birth to <6 months: 100 mg; 6 months to <1 year: 150 mg; 1 year to <2 years: 200 mg up to the first 4 doses; from the 5th dose onwards: 300 mg

[0344] Normally, this drug is infused at a rate of 2.5 ml / hour using an infusion pump, but the infusion rate may be reduced depending on the patient’s condition.

[0345] Allergic reactions, including severe allergies, may occur when this medication is administered. To relieve symptoms, consider pre-treating the patient with antihistamines 30 to 60 minutes before the infusion begins, with or without antipyretics.

[0346] For the infusion rate in the clinical study, Brineura was administered intracerebroventricularly at an infusion rate of 2.5 mL / h across all ages. If the infusion rate was estimated to be approximately 100 mL CSF in patients aged 2 to 7 years and approximately 50 mL CSF in patients < 1 year of age (Peptide Drug Delivery to the Brain, Raven Press 1991:112), then the infusion volume of Brineura was estimated to be less than approximately 10% of CSF. The rate of CSF production in the human body is typically about 20 mL / h (American Journal of Physiology 1962; 203:763-74), which is approximately 12% of the Brineura infusion rate (2.5 mL / h) and 0.5 years of age. Page 81 of 94 (Invention Specification) C232142PA.docx The intraventricular CSF production rate (estimated to be approximately 2.5–4.7 mL / h) was also assumed to be greater than the Brmeura infusion rate (2.5 mL / h). Based on this data, the Brmeura intraventricular infusion rate appears to have no significant effect on human CSF production rate.

[0347] Based on the above, and based on the results of previous studies of intraventricular administration of 300 mg to CLN2 patients aged >3 years every 2 weeks and this study of intraventricular administration of 300 mg or less to CLN2 patients aged <3 years every 2 weeks, Brmeura can effectively inhibit disease progression without causing any significant safety issues.

[0348] References cited in Example 4-9

[0349] The following references are cited in this document under the following numbers and / or incorporated herein by reference. Arkm, LM, Sondhi, D, Worgall, S, Suh, LH, et al., “Confronting the issues of therapeutic misconception, enrollment decisions, and personal motives in genetic medicine-based clinical research studies for fatal disorders.” Human Gene Therapy, 16[9], 1028-1036. 2005 ° Awano, T, Katz, ML, O'Brien, DP, Sohar, I, et al., "A frame shift mutation in canine TPP1 (the ortholog of human CLN2) in a juvenile Dachshund with neuronal ceroid lipofuscinosis." Molecular Genet Metabolism, 89[3], 254-260. 2006. Brooks R. (EuroQol: the current state of play.) A study of 100 children with hydrocephalus (61 males, 39 females, aged 0.02 to 15.7 years) showed that CSF production (mean ± SD) based on ventricular outflow was 8.1 ± 5.2 ml / hour, and was correlated with age and weight (Pediatr Neurosurg 2002;36:22-8). Therefore, the estimated CSF production rate at 0.5 years of age was based on the regression equation: CSF production per hour = 2.78 - 2.23 (males = 0, females = 1) + 0.97 log (age [years]) + 2.26 log (weight [kg]). Page 82 of 94 (Invention Specification) C232142PA.docx Health Policy 37[1], 53-72. 1996. Chang, M. CLN2. *The Nueronal Ceroid Lipofuscinoses*. New York: Oxford University Press, 2011: 80^109 ° Crystal, RG, Sondhi, D, Hackett, NR, Kaminsky, SM et al. Clinical protocol. Administration of a replication-deficient adeno-associated virus gene transfer vector expressing the human CLN2 cDNA to the brain of children with late infantile neuronal ceroid lipofuscinosis. Human Gene Therapy 15

[11] , 1131-1154. 2004. Dierenfeld, AD, McEntee, MF, Vbgler, CA, Vite, CH et al. Replacing the enzyme alpha-L-iduronidase at birth ameliorates symptoms in the brain and periphery of dogs with mucopolysaccharidosis type I. Sci Transl Med 2

[60] , 60ra89. 2010. Dyke, JP, Sondhi, D, Voss, HU, Shungu, DC, et al., "Assessment of Disease Severity in Late Infantile Neuronal Ceroid Lipofuscinosis Using Multiparametric MR Imaging," *American Journal of Neuroradiology*, 2012. EuroQol Group. (EuroQol - a new facility for the measurement of health-related quality of life.)《Health Policy》 16[3], 199-208. 1990. Giedd, JN, Snell, JW, Lange, N, Rajapakse, JC, et al., Quantitative Magnetic Resonance Imaging of Human Brain Development ： 4-18 years old (Quantitative magnetic resonance imaging of human brain development: Page 83 of 94 (Invention Specification) Ages 4-18.)《Cerebral Cortex》6[4], 551-560. 1996 ° Karavelis A, Foroglou G, Selviaridis P et al., “Intraventricular administration of morphine for control for intractable cancer pain in 90 patients.” Neurosurgery 39[1], 57-62. 1996. Kronenberg MF, Laimer I, Rifici C et al. "Epileptic seizure associated with intracerebroventricular and intrathecal morphine bolus." Pain 75[2], 383-387. 1998. Kurachi, Y, Oka, A, Mizuguchi, M, Ohkoshi, Y, et al. Rapid immunologic diagnosis of classic late infantile neuronal ceroid lipofuscinosis. Neurology 54[8], 1676-1680. 2000 ° Kwon JM, Adams H, Rothberg PG, et al. Quantifying physical decline in juvenile neuronal ceroid lipofuscinosis (Batten disease). Neurology 77

[20] , 1801-1807. 2011. Lishner M, Perrin RG, Feld R, et al. "Complications Associated with Ommaya Reservoirs in Patients with Cancer: The Princess Margaret Hospital Experience and a Review of the Literature." Arch Intern Med 150[l], 173-176. 1990. Msall ME. "Measuring functional skills in preschool children at risk for neurodevelopmental disabilities." Review of research on intellectual disability and developmental disorders. 11, 263-273. 2005. Seitz, D, Grodd, W, Schwab, A, Seeger, U, et al., MR imaging and localized proton MR spectroscopy in late-stage infantile neurogenic lipofuscin disease. Page 84 of 94 (Invention Specification) C232142PA.docx Spectroscopy in late infantile neuronal ceroid lipofuscinosis.)《American Journal of Radiology》19[7], 1373-1377. 1998. Sleat, DE, El-Banna, M, Sohar, I, Kim, KH, et al., “Residual levels of tripeptidyl-peptidase I activity dramatically ameliorate disease in late-infantile neuronal ceroid lipofuscinosis.” *Molecular Gene Metabolism*, 94, 222-233. 2008. Sleat, DE, Wiseman, JA, El-Banna, M, Kim, KH, et al. "A mouse model of classical late-infantile neuronal ceroid lipofuscinosis based on targeted disruption of the CLN2 gene results in a loss of tripeptidyl-peptidase I activity and progressive neurodegeneration." Journal of Neuroscience, 24

[41] , 9117-9126. 2004 ° Steinfeld, R, Heim, P, von Gregory, H, Meyer, K et al. "Late infantile neuronal ceroid lipofuscinosis: quantitative description of the clinical course in patients with CLN2 mutations." American Journal of Medical Genetics 112[4], 347-354. 2002. Vuillemenot, BR, Katz, ML, Coates, JR, Kennedy, D et al. "Intrathecal tripeptidyl-peptidase 1 reduces lysosomal storage in a canine model of late infantile neuronal ceroid lipofuscinosis." Molecular Gene Metabolism 104[3], 325-337. 2011. Vuillemenot, BR, Kennedy, D, Reed, RP, Boyd, RB, et al., "Recombinant human tripeptidyl peptidase-1 infusion to the monkey CNS: safety, pharmacokinetics, and distribution." Page 85 of 94 (Invention Specification) C232142PA.docx Toxicology Applied Pharmacology, 277[1], 49-57. 2014 ° Worgall, S., Kekatpure, MV., Heier, L., Ballon, D. et al., "Neurological deterioration in late infantile neuronal ceroid lipofuscinosis," *Neurology* 69[6], 521-535. 2007 ° Worgall, S., Sondhi, D., Hackett, NR., Kosofsky, B. et al. Treatment of late infantile neuronal ceroid lipofuscinosis by CNS administration of a serotype 2 adeno-associated virus expressing CLN2 cDNA. Human Gene Therapy 19[5], 463-474. 2008 ° Xu, S, Wang, L, El-Banna, M, Sohar, I, et al., “Large-volume intrathecal enzyme delivery increases survival of a mouse model of late infantile neuronal ceroid lipofuscinosis.” Molecular Therapy, 19

[10] , 1842-1848. 2011 ° Example 11

[0350] This example describes additional pharmacokinetic and pharmacodynamic analyses performed on patient samples from the Phase 1 / Phase 2 study in Example 3.

[0351] Pharmacokinetic Analysis 1. CSF and blood (plasma) samples were collected for pharmacokinetic analysis after the first dose at each new dose level during the initial dose, the dose escalation phase, and at weeks 5 and 13 of the steady-dose phase. Samples were collected before administration (0.25 hours before the start of infusion) and at 0.25, 4, 8, 20, 72, and 120 hours after the end of infusion. Additional CSF and blood (plasma) samples were collected before the start of administration and every 4 weeks during the steady-dose phase; continuous samples were not collected at any time. CSF samples were obtained from the lateral ventricle using the ICV port.

[0352] Utilizing the validated electrochemiluminescence immunoassay (ECLA) method (BioMarm) Page 86 of 94 (Invention Specification) C232142PA.docx A pharmaceutical company (Novato, CA, US) analyzed cellular leptokinase a concentrations in CSF and plasma samples. The lower limit of quantitation (LLOQ) in CSF was 20 ng / mL and in plasma was 16 ng / mL. Throughout the sample testing process, the interanalytical accuracy (relative error, absolute %) and precision (coefficient of variation, %) for the quality control group were <13.2% in CSF and <17.2% in plasma.

[0353] PK parameters were estimated based on concentration-time data in CSF and plasma using non-compartmental analysis (NCA) with Phoenix WinNonlin 6.4 (Pharsight, Cary, NC, USA). Directly observed data recorded the maximum concentration (Cgx) and time to maximum concentration (Tmx). Other estimated PK parameters included elimination half-life (ti / 2); area under the concentration-time curve (AUC) at the time to the last measurable concentration, estimated using the linear trapezoidal rule; area under the concentration-time curve at infinity (AUCo-oo); clearance of absorbed and dissolved components (CL); volume of distribution at the end of the phase (Vz); and steady-state volume of distribution (Vss).

[0354] Immunogenicity Assay 1. CSF and blood (serum) samples were collected for immunogenicity analysis at baseline, every 4 weeks during the dose escalation phase, and at the start of the dose phase and every 4 weeks after the stable dose phase. CSF and serum samples were tested for total anti-drug antibodies (TAb) specific to cellular liponase a using a validated bridging electrochemiluminescence assay (BioMarin Pharmaceutical, Novato, CA, US). TAB-positive samples in CSF were further characterized using a validated cell-based flow cytometry assay (BioMarin Pharmaceutical, Novato, CA, US) for neutralizing antibodies (NAb) that prevent the uptake of cellular liponase a into lysosomes. NAB testing was performed only in CSF samples because the target site of action is the CNS, and TAB-positive samples were tested for NAB reactions. The complete immunogenicity method and the results of this study have been previously reported [Cherukuri-2018].

[0355] 7*: Demographic profile of the PK population. PK parameters are descriptively summarized using biomatrix, dosage groups, and study interviews. The relationship between PK parameters and demographic characteristics, immunogenicity, safety, and efficacy parameters is assessed graphically, as statistical analysis of the PK population is not possible. Page 87 of 94 (Invention Specification) C232142PA.docx Significance. For analyses without time as a covariate, the mean PK parameters for each patient during the period of treatment with 300 mg QOW were used as a representative measure of individual patient exposure. The mean PK parameters were derived by calculating the mean C^x and AUCo-t values ​​during the study visit period using 300 mg QOW dosing and intensive PK sampling (i.e., the first dose of 300 mg and weeks 5 and 13 of the steady-dose phase).

[0356] Result

[0357] PK parameters were estimated in all patients across various dose concentrations and study visits. At 300 mg QOWT, 24 patients had evaluable PK data in CSF, compared to 15 patients with evaluable PK data in plasma.

[0358] Single-dose PK data were available from patients who received an initial dose of 30 (n=3), 100 (n=3), or 300 mg (n=17) (4 / 4 from dose and 13 / 14 directly involved in the steady-dose phase) of cellular leptokinase a (Figure 13).

[0359] In CSF, peak concentrations were observed at the first sampling time point after the 4-hour infusion, and they appeared to exhibit a biphasic decline. CSF exposure increased proportionally to the smaller dose increase from 30 to 300 mg, with median Cmax and AUC increasing approximately 5 to 7 times. One patient in the 100 mg group was highly exposed after their initial dose, and therefore exposure parameters for doses >100 mg were highly variable due to the small sample size. This patient's Cg and AUC (as indicated by the maximum values ​​reported for the 100 mg group) were higher than the median in the 300 mg group. Although no conclusive findings suggest considering this outlier exposure, this patient's CSF exposure after a subsequent 300 mg infusion was lower than their exposure after the initial 100 mg dose.

[0360] During the initial phase of the study, plasma PK samples were stored outside the stability range, and therefore no data were available for the 30 mg group, and only one patient in the 100 mg group. Based primarily on the 300 mg dose, plasma concentrations peaked between 8 and 20 hours after the completion of the 4-hour ICV infusion and appeared to exhibit a biphasic decline, remaining above the aforementioned lower limit of quantitation (LLOQ) for 72 hours. Page 88 of 94 (Invention Specification) C232142PA.docx

[0361] Multidose PK data were assessed from patients (n=14) who were directly involved in the stable dose phase. These patients received 300 mg of cellular leptinase a QOW throughout the study (Figures 14-15).

[0362] PK parameters in CSF were similar between the visits at day 1, week 5, and week 13. Although variable, plasma Tg, Cg, and AUCo-t showed no discernible trend during the visits. With ICV administration of 300 mg QOW, the median plasma Cg was approximately 1000 times lower than in CSF, and the median plasma AUCo-t was also lower. tThe levels were approximately 300 to 1000 times lower than in CSF. Based on patient-matched and visit-matched pharmacokinetic (PK) studies, there was no significant correlation between Cmx and AUCo-t levels in CSF and plasma (Figure 16). During the visit, inter-individual variations in Cmx and AUCo-t were 26%–73% and 31%–49% in CSF, respectively, compared to 54%–89% and 59%–103% in plasma. During the visit, intra-individual variations in Cg and AUC°_t were 33% and 24% in CSF, respectively, compared to 69% and 80% in plasma.

[0363] Pharmacokinetics and Patient Characteristics: The potential impact of baseline patient characteristics on cellular liponase a PK was assessed for the 300 mg QOW regimen. Mean estimates of Cmx and AUCo-t were used to represent individual patient exposure during the treatment course and were considered appropriate due to lack of drug accumulation or time-dependent PK with 300 mg QOW. Baseline sex, age, weight, or CLN2 score had no significant effect on cellular liponase a exposure in CSF or plasma (Figures 17A-17D). Plasma Cgx showed a slight increasing trend with decreasing age, but this did not reflect plasma AUC.

[0364] Sandy's "Uncle" and Immunogeneous Moisture: During the study duration, total antibodies (TAb) against cellular leptokinase a were detected in the CSF of 5 / 24 (21%) patients and in the serum of 19 / 24 (79%) patients. The CSF TAb response was first detected at week 13 of the steady-dose phase, while the serum TAb response was detected at the earliest sampling point (week 5 of the dose escalation phase). Neutralizing antibodies (NAb) were not detected in the CSF of any of the 5 patients who were positive for CSF TAb and therefore could not be used for further analysis.

[0365] To determine whether cellular leptokinase a PK is affected by the development of anti-drug antibodies (ADA) Page 89 of 94 (Invention Specification) C232142PA.docx The impact was assessed by comparing Cmx and AUC04 of visits with positive TAb responses with those with negative TAb responses. All patients starting treatment at 300 mg with evaluable PK and ADA data were assessed for matched exposure parameters and ADA status (i.e., stable dose at day 1, week 5, and week 13). Eighteen patients with CSF data (4 / 4 from the dose escalation phase, and 14 / 14 directly involved in the stable dose phase) and 14 patients with plasma / serum data (1 / 4 from the dose escalation phase, and 13 / 14 from the stable dose phase) were included for analysis.

[0366] As shown in Figure 18a, there was no discernible trend in CSF (2μ) and AUC0-t using CSF ADA status in patients. The CSF (2μ) and AUC0-t values ​​of accesses with positive ADA responses were exactly within the distribution of exposure values ​​of accesses with negative ADA responses. For two access-matched patients with positive PK and CSF ADA, the CSF AUC0 of the ADA-positive access was 0. t The exposure was reduced by 17–27% compared to ADA-negative access. No association was observed between plasma Gnax and AU*t in patients with serum ADA status, both in the individual and within patients (Figure 18b). Plasma exposure in patients with positive serum ADA access spanned the exposure range of patients with negative ADA access.

[0367] From the start of the study with 300 mg QOW until the end of the study, changes in motor-verbal scores were used to assess the relationship between cellular leptokinase a PK and efficacy outcomes. Of the 23 patients in this analysis, after 48 weeks of treatment, 2 patients showed an increase of one point, 13 showed no change, 5 patients lost one point, and 3 patients lost two points, for a total response rate of 87% (20 / 23). Changes in patient motor-verbal scores at week 48 were not correlated with individual mean CSF scores or AUCo-t (Figure 19). Patients with decreased scores had CSF exposure parameters within the distribution of patients with no change or increased scores. Similarly, no correlation was shown when assessing the maximum decrease in patient scores during the 48-week treatment period.

[0368] The relationship between pharmacokinetic (PK) and adverse events was also analyzed. As noted above, investigational drug-related events occurring in at least 10% of the study population were included in the analysis: fever 46% (11 / 24), allergic reaction 33% (8 / 24), seizure 33% (8 / 24), epilepsy 17% (4 / 24), headache 13% (3 / 24). Page 90 of 94 (Invention Specification) C232142PA.docx And vomiting occurred in 13% (3 / 24). There were no significant differences in Cmax and AUCO-t in CSF or plasma between patients with or without fever, allergy, seizures, or epilepsy. Patients with headache showed a slightly higher tendency for CSF exposure compared to those without events, and patients with vomiting were more likely to be exposed to both CSF and plasma. Exposure in patients with headache or vomiting generally did not exceed the highest exposure observed in patients without events.

[0369] The above results indicate that after initial ICV infusions of 30, 100, and 300 mg, cellular leptokinase a showed a lower-dose increase in CSF exposure. Single dose ranges (2.08 x 10⁻⁶ mg, respectively) 5^6.65x10 5 The CSF Cg dose of 1.42 x l (6 ng / mL) is usually the same as the ICV dose administered to approximately 100 mL of CSF in the human brain (3.00 x 10⁵ and 1.00 x l O, respectively). 6 The expected value of 3.00 x 10⁻⁶ ng / mL was consistent (Pardridge et al., *Journal of Cereb. Blood Flow Metab.*, 17, 713-731, 1997). At 300 mg QOW, no significant accumulation of CSF or plasma PK was observed in the study visits based on comparable values ​​of AUC, CL, and Vss, and no time-dependent CSF or plasma PK. Considering the bi-weekly dosing frequency, this is consistent with a CSF half-life of 6.2–7.7 hours in patients and a calculable plasma half-life of 11.8 hours in one patient. It should be emphasized that the CSF half-life does not directly reflect the target site, as the CNS tissue half-life (from assessments in monkeys) and lysosomal half-life (from isolated human fibroblasts) are most relevant to the basic principles of bi-weekly dosing of the therapeutic agent. In patients, CSF concentrations greater than lysosomal PK absorption lasted for approximately 4 days, based on animal data, showing the widespread distribution of surface enzymes to CNS tissues. This is supported by estimates of CSF distribution volume, which exceed the typical CSF volume of approximately 100 mL. Direct administration of cellular leptokinase a to the internal CSF space of the brain produces approximately three orders of magnitude higher exposure compared to the periphery, with no correlation between CSF and plasma Cg or AUC values; indicating that plasma PK is not a good substitute for CSF PK. Plasma Tg was observed 8 hours after a 4-hour ICV infusion, compared to CSF ​​Tg immediately following the end of infusion. Compared to the blood-CSF barrier leakage at BBB, ICV-administered drugs are transported out of the brain via the CSF flow pathway and absorbed into the periphery via the arachnoid villi. Page 91 of 94 (Invention Specification) C232142PA.docx In the bloodstream (Pardridge et al., Fluids Barriers CNS. 8:7, 2011).

[0370] Changes in CSF and plasma PK among patients could not be explained by patient demographic data, as intrinsic factors did not appear to be related to cellular leptonase a exposure. The ICV dose of cellular leptonase a was designed based on brain mass, and therefore, CSF exposure was not expected to vary significantly across age (3–8 years) and weight (14.5–26.0 kg) in this study. The human brain reaches approximately 75% of adult weight on average before age 2 and 100% before age 5, with the brain-to-body weight ratio progressively decreasing during development (Giedd et al., *Cereb. Cortex.* 6:551-560, 1996). Between the ages of 3 and 8–9, compared to body weights of 14.1–26.0 kg and 15.6–27.5 kg, the average brain weight in disease-free humans was 1.09–1.18 kg for males and 1.27–1.37 kg for females (Annals of Neurology 4, 345–356, 1978). Therefore, compared to an 80% change in body weight, the change in brain weight within the age range in this study was only 8%. Notably, the slight increasing trend in plasma C^x with decreasing age may be attributed to the disproportionate change in body weight relative to brain weight during early childhood. Although age and brain weight were matched, the amount of ICV dose absorbed was concentrated in significantly smaller body weights and correspondingly smaller blood volumes, resulting in more concentrated systemic exposure.

[0371] The patient-to-patient variation in CSF exposure is likely attributable to differences in disease severity rather than to inherent variations in ICV administration to the enzyme, as intra-patient variation is much smaller than inter-patient variation (CSF ≥ 33%, and CSF ≥ AUCo). t (24%). Although no association was shown between CSF exposure and baseline CLN2 score, pathological effects on the CNS can be observed, which are translated in CSF PK but not translated into changes in clinical assessment scores. Due to subsequent systemic absorption, the inter- and intra-patient changes in plasma PK were significantly higher than those in CSF, partly due to the insufficient number of plasma samples with quantifiable concentrations.

[0372] Based on patient-matched and access-matched analysis of 300 mg QOW, the presence of ADA in CSF and serum appeared to have no effect on PK in CSF and plasma, respectively. Most treated patients... Page 92 of 94 (Invention Specification) C232142PA.docx The presence of ADA in serum indicates that plasma exposure to cellular liponase a may result in a positive serum ADA level, consistent with other ERTs, as patients lack the endogenous protein (Long et al., Clinical Therapy 39:118-129, 2017). In this study, the occurrence of ADA response has previously been shown not to predict adverse safety profiles or adverse treatment outcomes (Cherukuri et al., Clinical Immunology 197:68-76, 2018). For the most common adverse events associated with cellular liponase a, CSF was not significantly associated with plasma exposure or the occurrence of fever, allergic reactions, seizures, or epilepsy. Given the small sample size (3 / 24 patients) and low frequency of both events, the interpretation of the subtle trend of increased exposure associated with headache and vomiting is limited.

[0373] As measured by changes in CLN2 scores after 48 weeks of 300 mg QOW, the response to treatment appeared to be uncorrelated with the magnitude of CSF exposure, indicating maximum benefit within the 300 mg QOW exposure range. Notably, CSF exposure in CLN2 patients exceeded that associated with an effective 16 mg dose in TPP1 empty dogs, suggesting that these exposures occurred within a plateau phase of the exposure-response relationship (Katz et al., *Journal of Neuroscience Research* 92, 1591-1598, 2014; Vuillemenot et al., *Molecular Genet. Metab.* 114, 281-293, 2015). Regardless of inter- and intra-patient PK variations, the 91% (62 / 68) accesses to reportable CSF AUCo_t at the clinical 300 mg dose were higher than the mean CSF AUCo in treated TPP1 empty dogs. t (6.45xl0) 6 (ng-hours / mL) (Vuillemenot 2015, see above). Low levels of TPP1 have been shown to significantly alleviate disease in CLN2 mutant mice, where only 6% of normal TPP1 activity in the brain increases lifespan to almost the same level as wild-type mice (leat 2008, see above). In summary, these non-clinical and clinical data indicate that cellular leptospirase CPV at 300 mg QOW provides sufficient TPP1 exposure in the CNS to achieve meaningful therapeutic benefits. This is the first clinical CSF and plasma pharmacokinetic characteristic of ICV administration of this protein.

[0374] All publications, patents and patent applications cited in this specification are incorporated herein by reference as if each individual publication or patent application specifically and individually indicated to be cited. Page 93 of 94 (Invention Specification) C232142PA.docx The manner of use is incorporated into the general. Although the invention has been described in considerable detail by means of illustration and examples for the purpose of clear understanding, it will be apparent to those skilled in the art, based on the teachings of this disclosure, that certain changes and modifications may be made thereto without departing from the spirit or scope of the appended claims. [Symbol Explanation] Page 94 of 94 (Invention Specification) C232142PA.docx [Sequence List] <110> Lester et al., BIOMARIN PHARMACEUTICAL <120> Methods for treating CLN2 disease in children <130> 30610 / 54735 <150> US 62 / 893,535 <151> 2019-08-29 <160> 2 <170> Patentin version 3.5 <210> 1 <211> 544 <212> PRT <213> Homo sapiens <400> 1 Ser Tyr Ser Pro Glu Pro Asp Gin Arg Arg Thr Leu Pro Pro Gly Trp 1 5 10 15 Vai Ser Leu Gly Arg 20 Ala Asp Pro Glu Glu Glu 25 Leu Ser Leu Thr Phe 30 Ala Leu Arg 35 Gin Gin Asn Vai Glu Arg Leu Ser 40 Glu Leu Vai Gin Ala 45 Vai Ser Asp 50 Pro Ser Ser Pro Gin Tyr Gly Lys 55 Tyr Leu Thr Leu Glu 60 Asn Vai Ala 65 Asp Leu Vai Arg Pro Ser Pro Leu 70 75 Thr Leu His Thr Vai 80 Gin Lys Trp Leu Leu 85 Ala Ala Gly Ala Gin Lys 90 Cys His Ser Vai He 95 Thr Gin Asp Phe Leu 100 Thr Cys Trp Leu Ser He 105 Arg Gin Ala Glu Leu 110 Leu Leu Pro Gly Ala Glu Phe His His Tyr Vai Gly Gly Pro Thr Glu 115 120 125 Thr His Vai Vai Arg Ser Pro His Pro Tyr Gin Leu Pro Gin Ala Leu 130 135 140 Allah Pro His Go Phe Go Gly Gly Leu Hi s Phe Pro Pro Thr Ser Ser Leu Arg Gin Arg Pro Glu Pro Gin Vai Thr Gly Thr Vai Gly Leu His Leu Gly Vai Thr Pro Ser Vai He Arg Lys Arg Tyr Asn Leu Thr Ser Gin Asp Vai Gly Ser Gly Thr Ser Asn Asn Ser Gin Ala Cys Ala Gin Phe Leu Glu Gin Tyr Phe His Asp Ser Asp Leu Ala Gin Phe Met Arg Leu Phe Gly Gly Asn Phe Ala His Gin Ala Sir Vai Ala Arg Vai Vai Gly Gin Gin Gly Arg Gly Arg Ala Gly He Glu Ala Ser Leu 245 250 255 Asp Vai Gin Tyr Leu Met Ser Ala Gly Ala Asn lie Ser Thr Trp Vai 260 265 270 Tyr Ser Ser Pro Gly Arg His Glu Gly Gin Glu Pro Phe Leu Gin Trp 275 280 285 Leu Met Leu Leu Ser Asn Glu Ser Ala Leu Pro His Vai His Thr Vai 290 295 300 Ser Tyr Gly Asp Asp Glu Asp Ser Leu Ser Ser Ala Tyr He Gin Arg Vai Asn Thr Glu Leu Met Lys Ala Ala Ala Arg Gly Leu Thr Leu Leu Phe Ala Ser Gly Asp Ser Gly Ala Gly Cys Trp Ser Vai Ser Gly Arg His Gin Phe Pro Thr Phe Pro Ala Ser Ser Pro Tyr Vai Thr Thr Vai Gly Gly Thr Ser Phe Gin Glu Pro Phe Leu lie Thr Asn Glu He Vai Asp Tyre He Ser Gly Gly Gly Phe Ser Asn Vai Phe Pro Arg Pro Ser Tyr Gin Glu Glu Ala Vai Thr Lys Phe Leu Ser Ser Ser Pro His Leu Pro Pro Ser Ser TyrPhe Asn Ala Ser Vai Ala Ala He Pro He Leu Ser Asp Gly Tyr Trp Vai Trp Vai Leu Ser Leu Ser He Gly Asn Thr Ser Ala Ser GluHis He Leu Gly Phe Leu Asn Pro Arg Leu Tyr Gly Arg Ala Tyr Pro Vai Ser AsnArg Vai Pro Thr Pro Leu Ser Gin Gin His Vai Phe Gly Gly Gly Arg Pro Pro Gly Ala Gly Leu Phe Asp Vai Thr Arg Gly Cys His Glu Ser Cys Leu Asp Glu Glu Vai Glu Gly Gin Gly Phe Cys Ser Gly Pro Gly Trp Asp Pro Vai 520 525 Thr Gly Trp Gly Thr Pro Asn Phe Pro Ala Leu Leu Lys Thr Leu Leu 535 540 Asn Pro <210> 2 <211> 368 <212> PRT <213> Homo sapiens <400> 2 Leu His Leu Gly Vai Thr Pro Ser Vai He Arg Lys Arg Tyr 5 10 Asn Leu Thr Ser Gin Asp Vai Gly Ser Gly Thr Ser Asn Asn Ser Gin 20 25 30 Ala Cys Ala Gin Phe Leu Glu Gin Tyr Phe His Asp Ser Asp Leu Ala 40 45 Gin Phe Met Arg Leu Phe Gly Gly Asn Phe Ala His Gin Ala Ser Vai 55 60 Argentinian Wing Vai Vai Gly Gin Gin Gly Arg Gly Arg Ala Gly He Glu Ala 70 75 Be Read Asp Vai Gin Tyr Leu Met Ser Ala Gly Ala Asn lie Ser Thr 85 90 Trp Vai Tyr Ser Ser Pro Gly Arg His Glu Gly Gin Glu Pro Phe Leu 100 105 110 Gin Trp Leu Met Leu Leu Ser Asn Glu Ser Ala Leu Pro His Vai His 120 125 Thr Vai Ser Tyr Gly Asp Asp Glu Asp Ser Leu Ser Ser Ala Tyr He Gin Arg Go Asn Thr Glu Leu Met Lys Allah Wing Wing Arg Gly Leu Thr Leu Leu Phe Ala Ser Gly Asp Ser Gly Ala GlyCys Ser Vai Ser Gly Arg His Gin Phe Arg Pro Thr Phe Pro Ala Ser Ser Pro Tyr Vai Thr Thr Vai Gly Gly Thr Ser Phe Gin Glu Pro Phe Leu He Thr Asn Glu He Vai Asp Tyr He Ser Gly Gly Gly Phe Ser Asn Vai Phe Pro Pro Ser Tyr Gin Glu Glu Ala Vai Thr Lys Phe Leu Ser Ser Ser Pro His Leu Pro Pro Ser Ser Tyr Phe Asn Ala Ser Gly Arg Ala Tyr Pro Vai Ala Ala Leu He Pro Trp Vai Ser Asp Gly Tyr Trp Vai Vai Ser Asn Arg Vai Pro Ser Gly Thr Ser Ala Ser Thr Pro Vai Phe Gly Gly He Leu Ser Leu He Asn GluHis He Leu Ser Gly Arg Pro Pro Leu Gly Phe Leu Asn Pro Arg Leu Tyr Gin Gin His Gly Ala Gly Leu Phe Asp Vai Thr Arg Gly Cys His Glu Ser 325 330 Cys Leu Asp Glu Glu Vai Glu Gly Gin Gly Phe Cys Ser Gly Pro Gly Trp Asp Pro Vai Thr Gly 345 350 Trp Gly Thr Pro Asn Phe Pro Ala Leu Leu Lys Thr Leu Leu Asn Pro 355 360 365

Claims

【Scope of invention patent application】

1. A method for treating neurogenic celipofuscinosis (CLN2) in an individual less than 3 years old, comprising administering to the individual an amount effective for treating CLN2 disease in the individual comprising: Formulations of recombinant human tripeptidyl peptidase-1 (rhTPPl).

2. A method for delaying the onset of neurogenic celipofuscinosis (CLN2) or its symptoms in an individual younger than 3 years old, comprising administering to the individual an intracerebroventricular, intrathecal, or Formulations comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) for intraocular administration.

3. The method according to claim 1 or 2, wherein the formulation is administered to the individual via intracerebroventricular, intrathecal or intraocular administration.

4. The method according to any one of the preceding claims, wherein the formulation is administered once every 2 weeks.

5. The method of any one of the preceding claims, wherein the formulation is administered by infusion at a rate of about 2.5 mL per hour.

6. The method of any one of the preceding claims, wherein a dose of about 300 mg or less is administered to the individual.

7. The method of claim 6, wherein the individual is greater than or about 2 years old.

8. The method of claim 7, wherein a dose of about 300 mg rhTPP1 is administered to the individual.

9. The method of claim 6, wherein the individual is greater than or about 1 year old and less than 2 years old.

10. The method of claim 9, wherein a dose of about 200 mg rhTPP1 is administered to the individual.

11. The method of claim 10, wherein each of the 1st, 2nd, 3rd and 4th doses administered to the individual is about 200 mg rhTPP1, and the 5th and 4th doses administered to the individual Each of the subsequent doses is greater than about 200 mgo Page 1 of 3 (Scope of Patent Application for Invention) C232142PA.docx

12. The method of claim 11, wherein in the fifth and subsequent doses administered to the individual each of about 300 mg rhTPPl° [request item 13] [request item 14] The method of claim 6, wherein the individual is greater than or about 6 months old and less than 1 The method of claim 13, wherein about 150 mg of rhTPPl is administered to the individual dose. [request item 15] The method of claim 6, wherein the individual is less than 6 months old. [request item 16] The method of claim 15, wherein about 100 mg of rhTPPl is administered to the individual dose. [request item 17] The method of any one of the preceding claims, wherein based on a blood test, the individual Decreased TPP1 enzymatic activity was present.

18. The method of any one of the preceding claims, wherein the individual is diagnosed with CLN2 siblings of individuals.

19. The method according to any one of the preceding claims, wherein the individual The total score for the subscales ranges from about 3 to about 6 points.

20. The method according to any one of the preceding claims, wherein the individual has not previously used stem cells therapy, gene therapy, or enzyme replacement therapy.

21. The method according to any one of the preceding claims, which includes before administering the rhTPP1, Optionally, from about 30 to about 60 minutes prior to administering the rhTPP1, with or without an antipyretic agent Antihistamine is administered to the individual.

22. The method according to any one of the preceding claims, wherein the formulation includes the rhTPP1 And at least one pharmaceutically acceptable carrier, diluent or excipient. [Request item 23] The method according to claim item 22, wherein the formulation includes diindium hydrogen phosphate pentahydrate, Page 2 of 3 (invention application patent scope) Indium phosphate monohydrate, indium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or combinations thereof.

24. The method according to any one of the preceding claims, comprising after administering the formulation A flushing solution is administered to the individual. [Request item 25] The method of claim item 24, wherein the flushing solution includes indium hydrogen phosphate pentahydrate, indium monohydrate phosphate, indium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection or a combination thereof .

26. The method of any one of the preceding claims, wherein the treatment period is at least 10 weeks, at least 20 weeks, at least 40 weeks, at least 80 weeks, or at least 96 weeks.

27. ​​A composition comprising a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) for intracerebroventricular, intrathecal or intraocular administration, the composition is used to treat children less than 3 years old Neurogenic celipofuscinosis (CLN2) in individuals.

28. A use of a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPPl) for intracerebroventricular, intrathecal or intraocular administration, which is used for the manufacture of a treatment for individuals younger than 3 years old A drug for celipofuscinoid neuropathy (CLN2). Page 3 of 3 (Scope of Patent for Invention Application) C232142PA.docx 【Invention schema】 SYSPEPDQRR DPSSPQYGKY LTCWLSIRQA VGGLHRFPPT TSNNSQACAQ GIEASLDVQY VHTVSYGDDE GRHQFRPTFP SYQEEAVTKF WVSGTSASTP RGCHESCLDE TLPPGWVSLG LTLENVADLV ELLLPGAEFH SSLRQRPEPQ FLEQYFHDSD LMSAGANIST DSLSSAYIQR ASSPYVTTVG LSSSPHLPPS VFGGILSLIN EVEGQGFCSG RADPEEELSL RPSPLTLHTV HYVGGPTETH VTGTVGLHLG LKQFMRLFGG WVYSSPGRHE VNTELMKAAA GTSFQEPFLI SYFNASGRAY EHRILSGRPP PGWDPVTGWG 【figure 1】 TFALRQQNVE QKWLLAAGAQ WRSPHPYQL VTPSVIRKRY NFAHQASVAR GQEPFLQWLM RGLTLLFASG TNEIVDYISG PDVAALSDGY LGFLNPRLYQ TPNFPALLKT RLSELVQAVS KCHSVITQDF PQALAPHVDF NLTSQDVGSG WGQQGRGRA LLSNESALPH DSGAGCWSVS GGFSNVFPRP WWSNRVPIP QHGAGLFDVT LLNP Overall percentiles for Hamburg motor and language by age 24 48 72 96 age (months) 【figure 2】 120 144 0- 1 60 120 ISO 240 SOO 360 420 480 MO 1 60 120 180 240 300 360 420 480 540 analysis day ・・2・・・ CLN2 score - at or before first 300 mg infusion —.・ - CLN2 score - after first 300 mg infusion —Q—Motion component A-A ——Language component 【Figure 3A】 ・・・. ・• • CLN2 score - at or before first 300 mg infusion - CLN2 score - after first 300 mg infusion …-£3…-motor pack a f a •language pack 【Figure 3B】 O SDO: 1244.1017 SDO: 1244-1024 \ 1 » ———gold —£ — —A— — A- — -4- — —— A—·gold •80 -240 O 36 so SDO: 1323-1013 SDO; 1323-1014 wall 3 2 0- 1 60 120 180 240 300 560 420 480 540 I 60 120 180 240 300 360 420 480 540 analysis day ---G - - - CLN2 score at or before first 300 mg infusion I. - CLN2 score - after first 300 mg infusion - Motor component - - A Language component 【Figure 3E】 s3M42DA.Pdf CLN2 Score Comparative Analysis Day Among the paired natural history patients, the baseline scores of the study individuals were aligned Instance: C1: 1244-1001 Si AO2O2 6 4 2 0 6 4 2 0 6 4 2 0 Shi Qi NJU IIAM00220001 IIAM00720001 IIAM01200001 1 IIAMO1540001 IIAM0158 0001 I-IAMOL 630001 *& - c ~ -Qv % leaf, ^y* * * * * * 6 .ql . .y n -QlV **v* … f p-…-- HAM01640001 HAMO168ODO1 HAMO17OOO61 HAMQ1800Q01 HAM02I >00001 HAM02CM3001 吴v •.一q - -C--- -9. .一、0--Q— —O— &- -D- -a TJJ— —Q-— w .one p _ m — -©- e *°w * .p — « — f:..... , 0 - -Q- one.one- G HAMO23HJOU1 HAM(J32y0U02 HAMU342UOU1 | HAM(J4550U01 HAMU467tXJ01 HAMU477UOU1 9 nv Q. '0, Xh - • - w w •Ol^; V … •^Y* ・・・ K dr 一a—壮— .・• "*" (& . .. Hv* ・ Seven--------- 120 240 S6O 4S0 J20 244) 360 480 120 240 360 480 120 240 360 480 120 240 360 480 120 240 March 480 research day 【Figure 4A】 1093346636—0 s3M42DA.Pdf Si AO2O2 CLN2 Score Comparative Analysis Day Among the paired natural history patients, the baseline scores of the study individuals were aligned Instance: C1: 1244-1002 IIAM <k> 22tWl IIAM0072(m)()1 llAMOIXMXMJl II AX 101540001 nAXt01580(MI| *T>-・Ot . P・ - B f 9 O™ 0 HAM916-UMM)1 HAMOlhKiKMIl HAMO l7(M)tK)1 HAMOlHOtMXII KAXUCi lOi JOnl H \Mi>2(N0(MH J 9 _ "O--O- — G , * S--O- —O-— 0 — -O--Q , P——O - P- -seam--© -G **^v^-* piece--- , w V--O--O — • HAM02310001 H E032W002 H AX 103420001 II AX 104550001 ILAMO-1^70001 HAMO477O(MJ1 tD— 1.va> _ , - - fi — 9--& _ ~ r. * -------< / k> 120 240 360 4B0 120 240 360 480 120 240 360 480 120 240 360 480 120 240 560 480 120 240 360 -430 research day 1093346636—0 s3M42DA.Pdf Si AO2O2 1093346636—0 CLN2 Score Comparative Analysis Day Among the paired natural history patients, the baseline scores of the study individuals were aligned Instance: C1: 1244-1003 6 4 2 0 642。 IIAM002200D1 | HAM00720001 II AMO 1540001 IIAM0168000L IIAM0200000I lfAM02090001, 5---0--0--0^-----L. - OBty J' J, "tt——o--e--o^P-E p,. • 6'o., HAM Heart 6. Yinggan Gezi 1 return) 1 H AMI foot oom HAMO45500C]L HAM04610002 HAM0473<)OOI 1, T>. Ml, , , Kuang- 3 — Q = — Qi * o , 日 —- A. Pr \ 一 8 , , , •*e - ®-- 1 120 240 360 480 120 240 360 4S0 120 240 360 480 120 240 360 480 120 240 36D 460 L20 240 360 480 research day 【Figure 4C】 s3M42DA.Pdf Si AO2O2 CLN2 Score Comparative Analysis Day where the paired natural history patients' were aligned under the baseline scores of the study individuals Instance: C1: 1244-1004 ilAK10022000l I1AM00720001 IIAMO1200001 UAM01540001 IIAMO 1530001 IIAMO 1630001 . - c «oc«v« . . . . 640001 HAMO 17 (X)001 HAM0180000I HAM0W Trouble 1 • . d J# - -o- -e 、P- -Q V G — -C— —O-— 丄- -O- - ft , r -O——O- _ p - search -g-Q s g- - e -- r F , * storage—o--®—and HAM02310001 HAM03290002 HAM03420001 HAM0455000I HAM04670001 HAM04770001 one if 'faint-c - -O—one'. ,07----..___ 120 240 360 4B0 120 240 360 480 120 240 360 480 research day 【Figure 4D】 1093346636—0 s3M42DA.Pdf Si AO2O2 CLN2 Score Comparative Analysis Day where the paired natural history patients' were aligned under the baseline scores of the study individuals Instance: C1: 1244-1006 2 0 6 4 2. 6420 Second seat ZNqo f … * «* * p-• «-- HAMOI64t>nOI HAMontKXMH HAM01K0(kj»L HAMU2<J<KJ<HJJ HAM03W<H)(H X\・・専* p.. , - * — 9- respect・ 9 - -ft SevenP- »O - y^"・・y • , j, • - V" ~9 - • HAM02310001 HAM03290002 HAM03420CW1 HAN ¢0455000 L HAM04670001 HAM04770001 w TA.———_- .. C--- - ----- o - a — -<3—& — 120 240 %0 480 120 240 360 480 120 240 360 480 120 2-W 160 -WO 120 240 360 480 research day 【Figure 4E】 1093346636—0 s3M42DA.Pdf CLN2 Score Comparative Analysis Day The paired natural history patients were aligned under the baseline score of the study individual Subject: C2: 1287-1005 Si AO2O2 6 4 r-D 6 4 2 064 2 D pro-clNg 1IAMW220001 IIAM00720001 II AUDI 200001 IIAMO1540001 HAM01580Q01 HAM0163OOQI. g 9 - O- P ~o — **o Zun* inch HAMoiTimoi HaM01hd(h)ih HAMii3xm)(h)i HAM02i»y*XKJ| p f — Q-Yu Zunyi.i — 、一Q—1 、P - 9 f No., - Q— 0 -6 1IAM021KMM)] ILWtfB29(XM}2 IIAMr)M2(MK*l EIAMO455OOOJ HAM0477(XM)l 1 6 _ * _ 120 Wei 40 360 480]% 240 360 480 120 240 560 480 130 240 360 480 120 240 360 480 130 240 360 430 research day 【Figure 4F】 1093346636—0 s3M42DA.Pdf CLN2 Score Comparative Analysis Day Among the paired natural history patients, the baseline scores of the study individuals were aligned Instance: C3: 1244-1008 Si AO2O2 1093346636—0 64 2. 642 0 6420 64 Step one. Xuanzhnu HAN 100220001 IIAM00230002 HAM0065000L II AX [00720001 IIAX10163000 L HAK1C1680001 «> - f -Q _ * -Q-- % . O = T, -w = E3 1 ', "XJ w w < Qi •» *^3 — HaXtlJlIWHMXH HAM020000CH HAKHi20y(MM>l HA\|D2(WO<JO2 HAM(]23l»0l HAM<)2S5(XM>I J... J when..billionXK --- - -o - -o- -e - 、 V G — — 一— "-e- -o—a 『p ・_ 一Pr r IQ---- 、会------ HAM03290001 HAM03290002 HAM04540001 HAA (04550001 HA\ ( 04570001 HAM04610002 L 「一…. 4_, , T J - 、~v -w a —v d. ,"_ _ -O • Ml 、 、 ft — ~C>--O — B — hC—- _ _ _ r O HA\ 104670001 HA\fO468nmi HAM047VMX}| HA\ff)477(K)GI f --------- Xm • , • • r -Q- 、 6----"___ 1?0 240 360 480 120 240 560 480 13} 240 360 480 120 240 360 480 120 240 360 4S0 research day 【Figure 4G】 s3M42DA.Pdf CLN2 Score Comparative Analysis Day Among the paired natural history patients, the baseline scores of the study individuals were aligned Instance: C3: 1244-1009 Si AO2O2 IIAM00220001 IIAM00720001 IIAM01200001 IIAM01540001 I LAMO 1580001 HAMO1630001 % -C- <k -a 、 7二*« % b Tk P - c- XJ" —" o =p , Q ^Jtw [JI "'1^ w Q w T HAMO I 6401) 01 HAM016BCKKH HAMOLfiOOOOi HAM02(K»L)06i HAMD2II9O0O1 K 、V--Q —E • -F 6 ft- -O -Q, f % s - -o— - e •3 一U— _strong— ' C— -A - p - - B — —Q—No. 18 HAM023 IODOL 11AM03290002 HAM03420001 HAM04550001 HAM04670001 HAM04770001 nQ— 一* 0 " " " pQu - - w - '0-r r -£ X *O- — fll — -Q——{J - — r 6 120 240 360 480 120 240 360 430 120 240 360 480 120 240 360 480 120 240 360 4A0 120 240 360 480 research day [Figure 4H] 1093346636—0 s3M42DA.Pdf Si AO2O2 CLN2 Score Comparative Analysis Day Among the paired natural history patients, the baseline scores of the study individuals were aligned Subject: C3: 1244-1010 6 4 2 0 6 4 2 0 Hemorrhoids NUO IIAM00220d01 hakffl0720001 iam0154000L IIAM0 3680001 HAM02000001 IIAM020900Q1 — "—— O _ _ %, F -Xuan J -F * T> -—C <, G- • • •. , % HAM020WiH)2 100()1 HAM03290001 HAM. Book 50.] HAM(M750ODl r g , p- -a * 5 - ' J 0 i F , , 0 f, 0 , , -9 , % , , % % G — -Q-- •*^**^… 1 1 1 1 1 -1 1 1 1 ~1 1 1 1 ~ ~i i i ~1 1 1 1 ~ ~i i i 120 XB0 120 2JO 360 480 120 240 360 480 120 240 360 4S0 110 240 360 480 120 240 360 1093346636—0 Paired natural history patients, aligned at baseline scores of study individuals CI: 1244-1001 (BL=3)・ Cl: 1244-1002 (BL=3)- Cl: 1244-1003 (BL=6)- C2: 1244-1004 (BL=3)- C2:1287-1005 (BL=3)- C2: I244 IOO6(BL=3)- C3: I2441OO8(BL=2)- C3: 1244-1009 (BL=3)- Study individual • Natural history Patient C3: 1244-1010 (BL=6)- -1 change from baseline 【Figure 5】 s3M42DA.Pdf Si AO2O2 9 points score comparison analysis day Among the paired natural history patients, the baseline scores of the study individuals were aligned Instance: C1: 1244-1001 963。 9 6 3 0 9630 longer 6 riAM0022000l HAM007200Q1 HAN 10120X)01 HANrOl 580001 [JAN 101630001 I lAMO 1640001 rfX, ・w ..... HA W(XM)I HaM<)2(mxkm>I HAN(02C)9<XXI| HAM()2rw( >0o2 HAM02M0001 00 v • 1 • f f %- A - .y , a • , • f p - A Whole -- —w . •・・• f , *a- -o- -e 宀• • • •o- - e , 1 HAM03290IX11 HAM0342(M)01 HAM0455(KX)l HAMD4670001 HAK104680001 .・・・ y2一一_ _ , .y..... _ D - <O_ J* 0 " 120 240 560 480 120 240 360 480 120 240 36。480 120 240 360 480 120 240 360 480 120 244) 360 4^0 research day 【Figure 6A】 1093346636—0 【m9sl】 mi 08-r09m OfC Rich One with 095 otzoN- HAM01580001 1 9 0 > a ?! f : 1 4 1 1 !; j / 1 6 r': i 1 9 f J 1; * § |> «< ! 9 E r : i; 1 {> 1 ! < I 6 1 9 F = i !; 1 6 j pj i u T 1 !; r 1 9 r : H p I I i I iiii iiii 6 9 ED 59EU 69EO Z00I43I 2o・Strike 4 极益』0½ Xuan Hu N Li Si Station Bw "God e punishment sleep age dish kiln fluorine to any H EfeRd5^Rls^6 s3M42DA.Pdf Si AO2O2 1093346636—0 9 points score comparison analysis day The paired natural history patients were aligned under the baseline score of the study individual Instance: C1: 1244-1003 0 Pro White 6 HAM0022000I HAM00720001 HAN!OI54(KX)1 HAM0200000I 11AM0209t»01 UAM0231000I ・. . . 9 — -O- - 4 、 f •. f 、 . O - -O- — Bh — O ., IIAM04610002 H.AMtM730 «01 y :two: , . . ------6 I I-----------1-----------1--------------------1--- ---------1-----------1 120 240 360 480 120 240 360 480 120 240 36.4«0 120 240 360 4«0 120 240 360 480 120 240 360 -WG research day [Figure 6C] s3M42DA.Pdf 9 points score comparison analysis day Among the paired natural history patients, the baseline scores of the study individuals were aligned Instance: C2: 1244-1004 Si AO2O2 b HAM0 21W0001 HAM (S90 Add HAM<)23I(X)O1 e- -a, v:.: two' e - -o-- 0 . 'O -- p, 9 - -O- .gold― A "~P "O. — - * p KAM03290n01 UAMO342OOO1 HAM04550(X)1 HAN 104670001 HAMO468D00】 *O - ® » - . _ _n II: r, .© - -O- , f - 120 240 S60 4^0 120 240 360 4B0 research day 【Figure 6D】 1093346636—0 s3M42DA.Pdf 9 points score comparison analysis day where the paired natural history patients' were aligned under the baseline scores of the study individuals Subject: C2: 1244-1006 Si AO2O2 1L\N100220001 IIANRM)720001 1IAM01200001 1 LIMO 1580001 I LYN (016300()1 !1A\1O164«(K)1 Q* - ^***V*-^* - 'O-. ... * p . e . .- HAMOIhMOlKJI H AMO 1700001 HAM02090001 ITAKfl)21] (XK)l A YL A-J. y・.-o- •a 、P- - & - H0>.0 p HAM0^2WfX>l HAMOWOOO] HAN [04550001 HAM0467OW HAMO468n0OI ... 、~0" 1--------1--------1------------------1--------1--------1-------T~ 120 240 360 4S0 120 240 360 480 120 240 360 480 120 240 360 480 120 240 360 480 1 20 240 360 480 research day s3M42DA.Pdf 9 points score comparison analysis day Among the paired natural history patients, the baseline scores of the study individuals were aligned Subject: C2: 1287-1005 Si AO2O2 0 horse to 6 NAM00220001 NAM00720001 HAM012W00! II AX <01580001 IIAM0I630001 I! AMO164O (X) 1 © --- * 0 4} * q j P -O -• Q, »HA \ FOI6M (X) ol Ham (H7O (KX) 1LAM0H0H XM - 'O. O - "(X. v**^-^* •- 6 120 240 360 480 120 240 360 480 120 240 360 480 120 240 360 480 120 240 360 480 120 240 360 4«0 research day 【Figure 6F】 1093346636—0 【09 pictures】 mi Dry rich - Xue 09 £ OTC rich one Zun O9E 0TE rich one Xue 09E 0K 0 block 0 hand 0 * though. ironing 0 years 09E 0 trolling HAM01580001 | 1 9 t G 1 4 1 1 1 0 f » 1 , 1 1 1 1 € i g 1 0 「 < 1 4 I 1 1 f> r ? , * bl r J > g i > * 9 g 1 1 i 1 1 i 4 i ® i / r / 1 ( 1 9 1 i a / h 1 >: »t 0 > \ | IL1N101200001 | 1 § t 0 t put 1 f 1 • 1 4 1 q i 0 1 § P r | « / BU / 9 i 1 i> 1 9 E / i ; * 1 6 f i 9 1 1 1 (in I) 1 1 1 4 1 q i , i r ' BU I i e r r 0 r t 9 1 J P » 'i BU I i 1 il i , - , 1 d t r t f? J 1 r a 1 4 1 q i e * , t * i I I That is, t J 4 1 1 1 1 1 1 ' t * , 0 • 6 i f 1 0 l f i i t 9 i t 0 1 § I 'Q BU r t & r I Q [ V I 1 1 1 k t 9 g 1 I * ,p ! ,f 800 14 inch ZI -EU -driver mfc owes field and sweeps away Xibai 6 s3M42DA.Pdf Si AO2O2 1093346636—0 9 points score comparison analysis day Among the paired natural history patients, the baseline scores of the study individuals were aligned Instance: C3: 1244-1009 9 6 3 0 9 6 3 0 9 6 3 0 Chairwoman 6 JI.\M()D220001 ILAM(K)720<)0l HAW l Hu 00. I HAMQ163000I 1LVU0164000] J… "" 9- — — — O<» P * 9 - "Q- _ p-J 、 'O- 4 o q hQ* - Spy ,p - o. I. P • \> • IIAM017<XMKJl IIAXI02[MH)tKH HANION )90001 MAN magic 2090002 HAM(I23IIMK)1 , f, meeting_-Qk , '9 -^0-- -~f p f one., • - -o—❷ , •-……-M o.p IL\MO329ODO1 HAM0342GO01 t LIN 104550001 HAX104670001 tL\M0468000I 、-.------ - --0 * J —r J j., 120 240 360 480 120 240 36. 4«0 120 240 360 -W0 120 240 S60 480 120 240 360 spider 120 240 360 paring research day [Figure 6H] 【19 pictures】 mf 0 Year 09 £Although Yi Drought 0# OTE will 1 0 Year 09m GTE 0M- I Lu Fu I Drought O9 £ WZ contains 1 Drought 0K Fu 1 i t 専 I b * § . 1 1 t A t 1 * J 4 i f 9 r 1 6 ) / f IP * i > t o I 4 1 1 , ), » f i IIAM01540(X)1 i 1 i 1 i § r t . , § ) f a house 1> 6 1 1 1 1 1 r 4 f . / 1 Ip f 1 1 t , 1 / r 1 t e r 4 1 .D $ I A 9 i 6 r , o f § ,f t 0SI4 inch cattle-EO-ffiB -WW flawed oh algae dish hoi area frM m worms ugly looting worms 6 1« 【畐】 . Steel career *N^ffi single invasion photo . British ftNtt line bosom-feminine S base § 0 Fu § 098 00». Inch CM Yap Yap 09 l Fu -SCM --gz -0« loooooeN <00900» >00000^ Group: C1 , Individuals: 1244-1001 1250000- 1000000- 750000- 500000- 250000- 0- 10()- 240 300 analysis day 4M0 Group: C1 > Individuals: 1244-1002 1250000- [000000- 750000- 500000- 250000- 20- 0- 100- %0 M0 240 300 analysis day ― Cerebrospinal fluid A CSF+ gray matter - Total brain volume (CSF+ white matter on gray matter) --- Cerebrospinal fluid .......... Gray matter ------ White sale 【Figure 8A】 Group: C2 - Individuals: 1244-1004 1250000， paint az? 1000000- 75(XX)0- 500000- 2S4XMX>- 20- •MO MO 240 W0 analysis day ——cerebrospinal fluid A CSF+gray matter -whole brain volume (CSF+gray matter+white matter) ---cerebrospinal fluid .......... gray matter —* - * - • white matter 【Figure 8B】 Erji stork Ertu rhyme gray matter Ererding ^ quantity g Russian quality, white matter) 【Figure 8C】 —^―Listen to 'Stomach Rong...',·…Drilling into Quality -2·Speaking of Quantity (CSF+Gray Matter+White Matter) 【Figure 8D】 1250000- 1000000- 750000- 500000 - 250000- 20- 0- «00000- 600000- 400000- 200000- 0 - Chat booth t=E3 Group: C3 » Individuals: 1287-1007 1000000- 40- analysis day 1 I 60 120 1 180 1 1 240 300 Analysis day 1 360 1 420 ―*—cerebrospinal fluid---cerebrospinal fluid A -CSF+ gray matter....... Gray matter area 2 volume 3+ gray matter + white matter) 【Figure 8E】 C232142DA.pdf Page 33 of 67 (Schema of the invention) analysis day Group: SDO, Instance: 0146-1021 Cerebrospinal fluid village,: enough" , second volume (CSF+gray matter+white matter) "Second gray matter 1000000- 800000- 600000- 400000- 200000- 20- 0- analysis day ••A CSF+ gray matter .......... gray matter - Whole brain volume (CSF + gray matter + white matter) -------white matter 【Figure 8G】 C232142DA.pdf Page 35 of 67 (invention diagram) I25WW- 1000000- 750000- 500000- 250000- 40- 20- 0- -28 4S0 analysis day Group: SDO, Instance: 1244-1012 1250000- move 55E loooono- 750000- -J 500000- X 250000- f 1 -28 1 1 60 120 1 1J«) 1 1 240 300 T 1 420 1 480 1 540 Days of analysis——cerebrospinal fluid A••…CSF+gray matter-•whole brain volume (C8F+gray matter+white matter) --- Cerebrospinal fluid... Gray matter 【Figure 8H】 C232142DA.pdf Page 36 of 67 (invention diagram) mail net t==z 1000000- 800000- 600000 - 400000 - 2 <xxx> 0-< / xxx> 0- ,X 60- 40- 20' 0- Group: SDO, Individuals: 1244-1024 analysis day 1250000- KXXKXM)- 750000- 500000- 250000- f 1 60 120 1 180 1 1 244) 300 days of analysis I 360 420 ——cerebrospinal fluid A CSF+gray matter Whole brain volume (CSF+gray matter+white matter) ---cerebrospinal fluid … • gray matter • white matter 【Figure 81】 analysis day nss 22 diamond gray matter 22 cage capacity + gray nest white matter) 【Figure 8J】 HE? 1000000- «00000- 600000- 400000- 20000U- %0 4RO analysis day Group: SDO, Instances: 1323-1016 800000- 600000- 200000- move 0- 1 « •28 1 1 1 60 120 1 180 1 1 240 W0 Analysis day 1 360 1 420 1 4B0 1 $40 — Cerebrospinal fluid••A,,…CSF+gray matter total brain volume (CSF+gray matter+white matter) ---brain Spinal fluid.........Grey matter. White matter 【Figure 8K】 800000- 600000- 4WW0- 200000- 0_ M0 analysis day Group: SDO, Instance: 1323-1019 «00000- 600000- 400000- 200000- 0- i 1 -28 1 1 1 60 120 1 180 ill 240 500 )60 420 Analysis day 1 4A0 540 ——cerebrospinal fluid---cerebrospinal fluid A CSF+transformation........ gray matter Brain volume (CSF+gray matter+white matter) ------white matter C232142DA.pdf Page 40H^67 in total (invention diagram) 0-1 JJ Dai Bairan 0 2 4 6 8 10 12 14 number of individuals [Figure 9B] 12- 11- 10- 8- 4- 3- 1- 0- 60 120 180 240 300 360 420 4B0 54008 1 60 120 180 240 300 360 420 480 540 analysis day 12- n- 10- 8- 7- 6- 5- 4- 3- 2- 1- -28 1 60 120 180 240 300 360 420 W 540-28 I 60 120 240 300 360 420 4«0 540 analysis day - sum - in the first 3. On or before 0 mg infusion —•—summation—after first 300 mg® infusion -O—movement / gait --A—language X—…seizure / myoclonus -9…vision / feeding 【Figure 10A】 Cl: 1244W3 Complete Hamburger Sachets C!: 1244-1003 Weill Cornell Scale Sum - on or before one 300 mg infusion - - Sum - after first 300 mg infusion ... £3 ....Motor stance -f—.Language X Seizures / myoclonus Vision / feeding 【Figure 10B】 60 120 180 240 300 360 420 480 540-28 1 60 120 180 240 300 360 420 430 540 analysis day 12-j 11- 10- 9- B- 7- 6- 2« 1 60 120 24D 300 420 MO-2» 1 60 120 240 300 360 420 4») 540 analysis day & • Sum - on or before first 300 mg infusion - • - Sum - after first 300 mg infusion .... £3 ....Motor state - - A - - language ... X ... Seizures / myoclonus vision / eating [Figure IOC] 11- 10- 9- 8- 7- 4- 60 120 180 240 300 360 420 480 540 -28 1 60 12Q 180 240 300 360 420 4«0 540-28 1 analysis day 12- 11- 10- 9- 8« 7- 6・ 5- 4- 3- 2- 1 - 0- -28 1 60 120 180 240 300 360 420 4B0 540-28 1 60 120 180 240 300 560 420 480 540 analysis day • - -©• •• Sum - at or before first 300 mg infusion - • ~ Sum - after first 300 mg infusion ....£3. …Motor stance --A --Language X •• …seizure / myoclonus S-vision / feeding 【Figure 10D】 C3: 1244-1010 C3: 1244 1010 Complete Burger Scale Weill Cornell Scale X' \ ..X' X C3: 1287-1007 C3: 1287-1007 Complete Burger Scale Wilannon Chiner Scale O O X 00-0 Know x to X □ 12- 11- 10- 9- 8_ 7- 6_ 5- 4- 3_ 2- 1- G- -2S 1 60 120 180 240 W0 360 420 4^0 540-28 1 60 120 180 240 300 3^0 420 4^0 540 analysis day • --sum - on or before the first 300 mg infusion -•—summary -after the first 300 m infusion....8...Movement / gait—-A— ,language...X••… Seizures / myoclonus--O--vision / feeding [Figure 10E] 12- 11 - 10- 9- 7- 6 - 5- 4- 3- 2- SDO: 0119*1020 SDO: 0119-1020 Complete Burger Scale Weill Cornell Circle Scale Q-QQI----& —----《>----Lao-----g — - — O - — - -0 —— -Ql — — - -•,-•-0---O- • — - -0 A-#-—A--S--S--« — TI-- w- — -a- —— ..…x... ----a--•« X X-.......X.......X 60 120 180 240 500 360 420 480 540 -28 1 60 120 180 240 50« 360 420 4S0 540-28 1 analysis day 12- 11- 10- 9- 8- 7- 6 - 3- 0- -28 1 60 120 180 240 MX) 360 420 4^0 540-28 1 60 120 1B0 240 300 360 420 4SO 540 analysis day --©•* -total:sum-at or before the first 300 mg infusion-•-sum-after the first 300 mg infusion-€3•…motor status--A-language X Seizures / myoclonus...Vision / eating 【Figure 10F】 12- 11- W- 9- 8- 7- 4- 3- -2S 1 60 120 180 240 300 360 420 480 540-2U 1 60 120 180 240 300 560 420 480 MO analysis day - Sum - On or before first 300 mg infusion - • - Sum - After first 300 mg infusion - O - Movement / gait - 6 - .Language X - •… Seizures / Myoclonus-4 - Vision / Eating 【Figure 10G】 analysis day SDO: 1244-1012 SDO: 1244-1012 Complete Burger Scale Weill Cornell Scale ・.・ / Dish--"--・One--9---- "One O—-C -28 1 60 120 180 240 300 360 420 430 540-28 1 60 120 180 240 300 360 420 480 540 analysis day …。 • One • Sum - at or before the first 300 mg infusion — • - Sum - at the first 30. After mg infusion ...Day...Movement / gait - A - Speech • X...Seizures / myoclonus - Vision / feeding [Figure 10H] )2-n- 10- 9- 8- 7- 6- 5- 4- 3- 2- 1- 0- -28 1 60 120 W) 240 300 360 420 Marriage) 540-28 1 60 120 180 240 300 Portuguese 0 420 480 540 analysis day 12- 11 - 10- 9- 8- 7- 5- 4- 60 120 180 240 300 360 420 480 540-28 1 60 120 180 240 300 360 420 480 540 analysis day •- 9--.Sum--at or before the first 300 mg infusion—•--Sum-after the first 300 mg infusion*—O--Motion / Git--A--Language X• •…seizures / myoclonus vision / feeding 【Figure 101】 analysis day Sum - at or before the first 300 mg infusion - • - sum - at the first 30. m After Injection - Mortar...Movement / Gait -A-Language X ...Seizure / Myoclonus - 9-Vision / Feeding 【Figure 10J】 360 42) 4W0 540-28 1 analysis day 12- n- 10- 9- 8 - 7- 6- 5- 4- 3. 2- 1 . 0- *28 1 60 120 180 240 300 560 420 480 540-28 1 60 120 180 240 500 %0 420 480 540 analysis day •・. • Sum - at or before first 300 mg infusion - Sum - after first 300 mg infusion * —-O--Motion / Gait --A language •…X••…seizure / myoclonus vision / feeding 【Figure 10K】 wmwis 60 120 180 240 500 360 420 480 S40-28 1 60 120 180 240 300 360 420 480 540 analysis day -©・・• Sum - at or before the first 300 mg infusion - • - sum - after the _ first 300 mgigj infusion....•-Movement / gait language•…X•…Celax / myoclonus-e-vision / eating 12- 11 - 10- 9- 8- 7- 6 - 5- 4- 3- •2» 1 60 120 180 240 300 360 429 "0 540-28 1 60 120 1«0 240 300 360 420 480 540 analysis day Sum - On or before first 300 mg infusion - - Total - After first 300 mg infusion*, 5 - Movement / gait - A - Speech X - ... Seizures / muscles Convulsion・y…Vision / eating 【Figure 10L】 Assessment and Event Screening - Baseline Injury One Infusion Treatment Period Week 1 to Week 96 Study Completion / Early Termination Device Safety Follow-up NOTE Visits (Days 1-6) Visits every 2 weeks (±3 days) Approximately at time of last dose (+3 days) 4 weeks after device removal (±3 days) 6 months after last dose± 1 week informed consent / consent* x CLN2 genotypeb x h TPP1 activity <dried blood spot)>> CLN2 disease rating scale with video. X X Q12W X Validation criteria for study entry X ECG, 12-lead X Q24W X EEG, standard wake-up. X Q24W Cranial MRF X X Q24W X CSF (cell number, white matter, grapevine)' D1,D6 Q2W X Device open / infectedh Dl t D6 Q2W Administer study drug DI Q2W Telephone follow-up | Inpatients within hours after discharge £-per visit CSF / 'blood for biomarkers D1 Q24W X for immunogenicity-deficient CSF / serum X Q12W X (gold only clear) (but only) Vital Signs" DI* D2 Q2W X X X Complete Physical Examination1 X X Q24W X X Simple Physical Examination DLD6 ​​Q2W X Neurological Examination' X Q12W X X Blood / Fluid for Clinical Laboratory Tests°* X D2 Q4W X X X Modified Unified 22 Batten Rating Scale Involuntary Movement Scale X Q12W Modified Unified Batten Rating Scale Seizures Scale X Q12W Optical Coherence Tomography X QI 2W Infant Quality of Life Questionnairen X Q12W PedsQL n X Q12W EQ-5D-5L X Q12W Denver II Developmental Scale. X Q12W X CLN2-specific QoL questionnaire X X Q12W X Ophthalmological evaluation X Q48W X Pregnancy test X Adverse event, including 7E prior to onset History of seizuresp X Continuous monitoring Concomitant medication X Continuous monitoring Baseline values ​​will be recorded no more than two days before the first infusion which will be given at least 14 days and no more than 28 days after surgery. Thereafter, starting from the first time, research visits were conducted every two weeks ± 3 weeks. If the individual discontinues the study prematurely, an early termination visit should be scheduled within 3 days. 3 Written informed consent must be obtained prior to the start of the study procedure. All screening procedures should be completed immediately prior to ICV implantation surgery* "Diagnosis of CLN2 disease by CLN2 enzyme activity assay should be obtained at Screening. Regardless of whether genotype information is available, blood will be collected at Screening for CLN2 genetic analysis. "All CLN2 disease scale assessments will be videotaped. CLN2 scale assessments should be performed prior to MRI and blood and CSF sampling should be performed prior to conditioning for BMN 190 infusions. 11 A standard 12-lead liCG will be recorded, including heart rate, rhythm, interval, axis, • conduction defects and anatomical abnormalities. An ECG will be taken 15 (±5) minutes after the end of the infusion. 。 At each time point, a standard wake-up electroencephalogram (EEG) will be recorded within 48 hours prior to the infusion. , a screening cranial MRI will be performed prior to surgery to ensure proper planning and placement of the ICV access device. MRI should be performed before blood and CSF sampling. This assessment allows a ±4-week window, and scans can be performed concurrently with scheduled infusions. gCSF (for differential cell counts, protein, and glucose) will be collected within 30 (±5) minutes prior to each infusion (or within one pass of the Early Termination Visit). During the 'first infusion, CSF (for cell counts, protein, and glucose) will be collected 30 (±5): minutes prior to the infusion (Day 1). 11 The device and the surgical site of the device should be observed prior to each infusion for any signs of swelling or infection in the scalp or surrounding area. 【Figure 11】 "Before first infusion (baseline or week 1 prior to infusion)," 12 weeks thereafter and at the completion of the visit, samples of blood (serum) will be collected for TAb testing and CSF will be collected The samples are used for TAb and NAb tests. Blood (serum) samples will be collected for TAb testing at the Device Safety Follow-up and Safety Follow-up Visits. Collection must be done prior to infusion. NAb will be tested in CSF at baseline, and at subsequent time points, TAb will be tested only if field in CSF. Hypersensitivity reaction requiring additional laboratory work if subsequent (as outlined in note q below)' the baseline total IgE content and drug-transferred IgE content will be obtained using the baseline sample. *For the first dose, it will be given within 30 (±5) minutes before the initial (or restarted) infusion, 30 (±5) minutes after the infusion, 0.5 and 1 hour after the end of the infusion (±5 minutes) and every 4 hours (±15; minutes) until discharge to measure vital signs (SBP, DBP, age, beat rate, breath rate and body temperature). Pairs • Each hindbend infusion' will measure vitals within 30 (±5) minutes before the start of the infusion, every 60 (±5) minutes during the infusion, and 1 and 4 hours (±5 minutes) after the end of the infusion signs. 1 Details of a full and brief physical examination and neurological examination are provided in Section 9.7.3 -m Collection of samples for clinical laboratory evaluation should be done prior to inflow. Assessment of QOL should be performed prior to MRI-infusion and other procedures. PedsQL parent reports for age-appropriate individuals. 5 Evaluation of the Denver II scale should be performed prior to MRI and resampling. From the signing of the ICE on day P to the first administration of the study drug, the SAEs related to the designated procedures of the study were revised and reported. w Since the implantation of the AICV device, all device-related events were reported. All AEs and SAEs will be recorded from the first dose of study drug in Studies 190-203 until 6 months after the last dose of study drug or the early termination visit. A safety follow-up visit will also be conducted within 6 months after the last dose of study drug or early discontinuation. The 6-month safety follow-up visit will be forfeited for individuals who begin receiving another BioMarin-sponsored study or a registered study drug within this 6-month time period. qIn the event of a suspected anaphylaxis, severe allergic event, or severe allergic event (defined as a grade 3 or higher allergic event), a blood sample will be collected within 1 hour of the event to assess C4, serum pancreatoid Protease and total IgE: To assess drug-specific IgE, blood samples should be collected no more than 8 hours after the event (or the next transfusion). Upon discharge following ICV placement, the individual and their caregiver will be provided with written information on signs and symptoms of potential device complications and instructions on when to return to the study site for device review. , after the study completion visit (week 97) or early termination visit, preparations should be made for removal of the ICV access device. If the individual intends to receive BMN190 after enrollment in this study (for example, via a "marketed product" registration or another BMN 190 study), there is no need to remove the device. It should be no more than 4 weeks after the last dose of study drug Perform Device Removal - The device removal safety visit will be performed within 4 weeks (± 3 days) of removal of the ICV access device. [Figure 11] (continued) s3M42DA.Pdf Hamburg LINCL scale (Dyke, 2012b. AJNR "American Journal of Neuroradiology (Am. J Neuroradiol.)") Weill Cornell LINCL scale (Stcinfcld.2002. "American Journal of Medical Genetics (Am.J.Mcd) .Genet.)") Movement 3 Generally king gait Gait 3 Generally normal gait 2 Abnormal gait: non-dependent 21. walking, frequent falls, apparent clumsiness.........._J 2 Abnormal gait: non-dependent N 10 steps, frequent falls, marked clumsiness 1 unable to walk without assistance or only able to crawl 1 Unable to walk or crawl without assistance 0 Immobile, mostly bedridden o Immobile, mostly bedridden Speech 3 Generally normal Speech 3 Body normal 2 Becoming identifiably abnormal (worse than individual maxima) 2 Becoming identifiably abnormal Is identifiably abnormal (especially worse for individual maxima) 1 Barely intelligible 1 Barely intelligible 0 Incomprehensible speech or no speech 0 Difficult to understand speech or no speech Vision 3 Apparently normal, myoclonus grasping desired objects 3 No myoclonus, movement, Yen's sign 2 Uncoordinated grasping of pet 2 One sign (myoclonus / movement / Pap sign) 1 Response to light1 Two symptoms (myoclonus / movement / 0 No response to visual stimuli 0 Both seizures (grand mal) 3 Seizure-free eating over a 12-week period 3 No significant swallowing dysfunction 2 1 to 2 seizures over a 12-week period 2 Mild Swallowing dysfunction1 3 seizures within 12 weeks 1 Moderate swallowing 0 > 3 seizures within 12 weeks 0 1-inch gastric tube shell dependence 3S AO2O2 【Figure 12】 s3M42DA.Pdf Median (range) PK parameters of cellular liponazyme spheres following single administration of 30, X0 and mg by ICV infusion Parameter 30 mg 100 mg 300 mg CSF N 3 a 3 17 c Tmax 5 hr 4.50 (4.33, 8.08 b ) 4.50 (4.42, 4.50) 4.50 (4.25, 5.75 d ) Cmax, Pg / mL 208(186, 269) 665 (646, 5640) 1420(359, 4380) AUCo-t, pg-hr / mL 1660 (1180, 1950) 5740 (3620, 62700) 9210(3660, 19000 ) AUCo-qo, ng-hr / mL 1810(1660, 1950) a 5740 (3630, 62700) 9290(3660, 19000) CL, mL / hr 16,7(15.4, 18.0) a 17.4(1.59, 27,6) 32,3(15.8, 81.9) Vz, mL 286(151, 420) a 296(11.0, 409) 311 (159, 1920) ti / 2, hr 11.5(6.81, 16.2) a 10.3 (4.79, 11.8) 6.13 (4.13, 16.3) Plasma N of l r 13 tg Tmax, hr NA 24.0 12.0 (4.25,24.5) Cmax, ie g / mL NA 0357 0,944 (0.176,3,87) AUCo-t, ig-hr / mL e NA 11,4 11.4(1.12, 69.9) AUCq-co, |ig-hr / mL NA NA 14.3 e CL, mL / hr NA NA 21000 g V z ,mL NA NA 356000g ti / 2, hr NA NA 118 8 3S AO2O2 NA=not available a CSFt is reported for N=2 in the 30 mg cohort due to insufficient quantifiable samples for the end-stage period in 1 patient 1 / 2 、AUC 0 -», CL and V,. The CSFTmax for this patient was 8.08 hours, collected 4 hours post-dose, instead of the planned 0.25-hour post-dose assessment. ° In the 300 mg cohort > 1 / 18 patients had no CSF ​​sample collected on Day 1. d This patient's CSF Tmax was 5.75 hours, collected at 1.5 hours post-dose, instead of the planned 0.25-hour post-dose assessment. *Plasma AUCoa was sometimes estimated using fewer than three quantifiable concentration-time points. Plasma samples were not properly stored for 3 / 3 patients in the ten 30 mg cohort, 2 / 3 patients in the 100 mg cohort and 5 / 18 patients in the 300 mg cohort. & Plasma, AUCok, CL and Vz were not estimated for almost all patients in the 300 mg cohort 'due to insufficient quantifiable samples during the end-stage period' except 1 patient. s3M42DA.Pdf 3S AO2O2 Median (range) PK parameters of cellular liponase a following administration of 300 mg as W by ICV infusion Parameters Day 1, Week 5, Week 13 CSF N 13 ' 14 13 a Tmax hr 4.50 (4.25, 5.75) 4.25 (3.83,4.50) 4.25 (4.00, 4,50) Cmax, ie g / mL 1260 (359, 4380) 1630(376, 4670) 1390(1110, 2340) AUCo.t, ng-hr / mL 9290 (3660, 19000) 12400 (4620, 26200) 10500 (7000, 18200) AUCo-oo, ie g-hr / mL mL 9290 (3660, 19000) 12400(4620, 26200) 10500 (7000, 18200) CL, mL / hr 32.3 (15.8, 81.9) 24.2(11.4, 64.9) 28.7(16.

5. 42.9) Vss, mL 245 (78.4, 909 ) 196 (85.4, 665) 186 (131,257) Vz,mL 316 (178, 1920) 254 (148, 573) 263 (160, 443) ti / 2, hr blood 6.15 (5.49, 16.3) 7.35 (3.33, 9.53 ) 7.65 (5.05, 9.43) N 12 d 12 d 9 e TMAX, HR 12.0 (4.25, 24.5) 12.0 (7,50, 24,2) 12.3 (4.25, 75.9) CMAX, | LG / ML 1.28 (0.176, 3.87) 1.92 (0.222, 4.27) 0.962 (0.0295, 2.57) Auco Auco .t, ie g-hr / mL c 16.2 (1.12, 69.9) 40.1 (11.1, 78.9) 9.50 (0.239, 51.6) AUCo-oo, i.e. g-hr / mL 14.3 b NA NA CL, mL / hr 21000 b NA NA Vz, mL 356000 b NA NA ti / 2, hr 11.8 b NA NA NA=not available a CSF samples were not collected from 1 / 14 patients on day 1 and week 13. "Plasma &, AUCoz, CL, and Vz were not estimated for almost all patients except 1 patient on day 1 'due to insufficient quantifiable samples during the end-phase period'. cSometimes less than three quantifiable concentration-time point estimates were used Plasma AUCo-t. Plasma samples from 2 / 4 patients were not properly stored on Day 1 and Week 5. e At week 13, plasma samples from 5 / 14 patients were hemolyzed or not collected. CSF • plasma SD week 13 10000- 1000- Day 1—SD Week 5 (Xuanyu, Banju) Quying (as+) is buying back 100- 10- 1 - 0.1 - 0.01- time (hours) 【Figure 15】 CP O O 。0 oo O O © O (9 Q 0 ° O o o o o°. 0 1000 2000 3000 4000 5000 CSF Cmax (µg / ml) 000.

9. Inch 0<N £»Special ""Fake Show" USDV萱 【Figure 16】 o° O 渉 0D 8 g <d° °O 15000 25000 CSF AUC°_t (microgram-hour μl) Don't cctfo ccc^ CGtf ccc-' t c sex £ Yingxian sound J n-wo (Ykw original 騒n saddle W baseline age 4 5 6 8 Baseline age (years) - - - - -0000-. . . already . . . 00 (L>w embedded) Monv feu 3 4 5 6 8 Baseline age (years) 4 5 8 . 9 . inch 0Z 0 Mofw Final Eye 3 4 5 8 Baseline age (years) [Figure 17b] Baseline age (years) baseline weight Baseline body weight (kg) 0009T - .

0. establish . . . 00 ("Ou Shan"" Banner Og) 09. Inch 0Z 0 (Food W Disgrace W Embedded Stove)-.0MV Toy g m — o O - 18 20 22 24 26 Baseline body weight (kg) io 18 20 22 24 io cd Baseline body weight (kg) [Figure 17c] (Ichihara Sao) ioLLS. LO o 1 2 3 4 5 6 Baseline CLN2 score Baseline CLN2 score . . . 9|- . . . pregnant. . . 00 (water will help w embedded wgv set . 9 . Inch 0Z 0 (Zhilang should be embedded with W) JQV boots 1 2 3 4 5 Baseline CLN2 score s.cogcxis” s.o & good card) calamus. chopsticks Baseline CLN2 score [Figure 17dJ in CSF . Negative ADA • Positive ADA 5000- 4000- 3000- 2000- 1000- 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 patient ID 25000- 20000- 15000- 10000- 5000- 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 patient ID 【Figure 18a】 in plasma / serum . Negative ADA • Positive ADA O . O O O O O • . 8 Q O W o • o 0 • O o O ° 0 O O O o O • O 0 . 4- 3- 2- 1- 0- 7 12 13 14 15 16 17 18 19 20 21 22 23 24 patient ID O O O O o . 8 O . O • o o . O • o O 0 a o o o C • . o o o s 80- 60- 40- 20- 0- 7 12 13 14 15 16 17 18 19 20 21 22 23 24 patient ID 【Figure 18b】 Increase by 1 point No change Decrease by 1 point Decrease by 2 points Changes in CLN2 score 0009L 00. Inch L 0.0 0000-00000 (*» / Your second to flag stove) yoQV dso WWWT entry SO Increase by 1 point No change Decrease by 1 point Decrease by 2 points Changes in CLN2 score 【Figure 19】