Blood coagulation factor FXI / fxia inhibitor for treating pulmonary hypertension and / or hypertension

Abstract

The present disclosure provides a blood coagulation factor FXI / FXIa inhibitor for treating pulmonary hypertension and / or hypertension. Specifically, provided is a method for treating and / or preventing pulmonary hypertension in a patient receiving a conventional treatment by means of administering the FXI / FXIa inhibitor; and a method for treating and / or preventing hypertension in a patient with essential hypertension by means of administering the FXI / FXIa inhibitor.

Description

Coagulation factor FXI / FXIa inhibitors for treating pulmonary hypertension and / or hypertension

[0001] This application claims priority to Chinese patent application 2024105983760 with a filing date of 2024 / 5 / 14 and Chinese patent application 2024117152005 with a filing date of 2024 / 11 / 27. This application incorporates the entire text of the above-mentioned Chinese patent applications. TECHNICAL FIELD

[0002] The present disclosure relates to the field of biological medicine, in particular to the use of coagulation factor FXI / FXIa inhibitors in the treatment and / or prevention of pulmonary hypertension and / or hypertension. BACKGROUND

[0003] Pulmonary hypertension (PH) is a pathophysiological disorder that can involve multiple clinical conditions and can be associated with multiple cardiovascular and respiratory diseases. Pulmonary hypertension (PH) generally refers to the mean pulmonary arterial pressure (mPAP) ≥ 25 mmHg (1 mmHg = 0.133 kPa) measured by right heart catheterization (RHC) at sea level in a resting state. With increasing clinical evidence, the 2022 ESC / ERS guidelines adopted new standards and recommended the hemodynamic definition of PH as mPAP > 20 mmHg at rest.

[0004] The clinical symptoms of pulmonary hypertension lack specificity, mainly showing symptoms related to progressive right heart dysfunction, often induced by exertion, and showing fatigue, dyspnea, chest tightness, chest pain, and syncope. Some patients may also show dry cough and exercise-induced nausea and vomiting. In advanced patients, symptoms may occur at rest. With the aggravation of right heart dysfunction, edema may occur in the ankles, lower extremities, even the abdomen, and the whole body. The underlying disease or accompanying disease leading to PH will also have corresponding clinical manifestations. The clinical manifestations of some patients are related to the complications of PH and abnormal distribution of pulmonary blood flow, including hemoptysis, hoarseness, chest pain, etc. Severe pulmonary artery dilatation can cause pulmonary artery rupture or dissection.

[0005] At present, the general measures of PH treatment in China include rehabilitation exercise under the guidance of professional physicians, contraception for women of childbearing age, vaccination, social psychological support, and avoidance of high-altitude areas, etc. Basic treatment includes oxygen inhalation, anticoagulation, diuresis, and cardiotonic, etc. Specific treatment includes calcium channel blockers and targeted therapy. Targeted drugs mainly include drugs acting on the prostacyclin pathway, endothelin pathway, and nitric oxide (NO) pathway. Currently, marketed targeted therapy drugs include prostacyclin analogues, endothelin receptor antagonists (ERA), type 5 phosphodiesterase inhibitors (PDE5i), and soluble guanylate cyclase (sGC) stimulators, etc.

[0006] Primary hypertension is a syndrome with elevated blood pressure as the main clinical manifestation, usually referred to as hypertension. It is caused by the interaction of factors including genetics, environmental factors, and body fluids. The harm of hypertension depends on the elevation of blood pressure itself, as well as the patient's combined other cardiovascular risk factors, target organ damage, and / or heart, brain, kidney and vascular complications, etc. Although there are currently more treatment methods, the blood pressure of some patients is still difficult to control. A meta-analysis of 91 global studies from 1991 to 2017 involving 3207911 treated hypertensive patients showed that among the treated hypertensive patients, the true refractory hypertension patients could reach 10.3%. There is still an unmet treatment need.

[0007] Coagulation factor XI (FXI) is a dimer composed of identical 80KDa subunits, and each subunit consists of four Apple domains (A1, A2, A3, and A4) and a catalytic domain starting from the N terminus. FXI is a circulating zymogen complexed with high molecular weight kininogen (HK). HK binds to the A2 domain in FXI and is a physiological cofactor for FXIIa activation of FXI to FXIa.

[0008] Coagulation factor XI (FXI) is a bridge between the tissue factor (TF)-initiated coagulation process and the kinin-kallikrein system (KKS), and can also assist in thrombin formation independently of the KKS, as a zymogen or substrate in the KKS, or as a bidirectional factor linking the two systems, playing an auxiliary role in the hemostatic process after bleeding, rather than a core substance initiating the coagulation pathway. In vitro studies have found that the loss of function of FXI or targeting FXI can interfere with the coagulation process and play an anticoagulant role, which is a new direction for the development of antithrombotic drugs. Related research results of FXI-deficient population in Israel show that patients with severe FXI deficiency have a lower incidence of deep venous thrombosis (DVT) in the lower extremities. Animal in vivo data and clinical data show that FXI is closely related to thrombosis, but has little effect on the hemostatic process, so FXI is an ideal target for antithrombotic therapy. However, there is no report on the use of FXI / FXIa inhibitors for the treatment or prevention of pulmonary arterial hypertension. SUMMARY

[0009] The present disclosure relates to the use of FXI / FXIa inhibitors in the treatment and / or prevention of pulmonary arterial hypertension. Specifically, the present disclosure discloses the positive effects of various FXI / FXIa inhibitors on a model animal of pulmonary arterial hypertension, demonstrating the clinical potential of the FXI / FXIa inhibitors in the treatment of pulmonary arterial hypertension.

[0010] In a first aspect, the present disclosure relates to a method for treating and / or preventing pulmonary arterial hypertension, comprising administering to a subject in need thereof an effective amount of a FXI / FXIa inhibitor. The pharmaceutical form of the inhibitor is not limited as long as it can effectively inhibit the biological activity of FXI / FXIa. For example, the FXI / FXIa inhibitor can be a small molecule drug, an antibody or an antigen-binding fragment thereof, an antisense nucleotide, and an siRNA.

[0011] In a second aspect, the present disclosure also relates to a class of FXI / FXIa inhibitors for use in the treatment and / or prevention of pulmonary arterial hypertension.

[0012] In a third aspect, the present disclosure also relates to the use of a FXI / FXIa inhibitor in the preparation of a medicament for the treatment and / or prevention of pulmonary arterial hypertension.

[0013] In a fourth aspect, the present disclosure also relates to a method for treating and / or preventing pulmonary arterial hypertension, comprising administering to a subject in need thereof an effective amount of a FXI / FXIa inhibitor. The pharmaceutical form of the inhibitor is not limited as long as it can effectively inhibit the biological activity of FXI / FXIa. For example, the FXI / FXIa inhibitor can be a small molecule drug, an antibody or an antigen-binding fragment thereof, an antisense nucleotide, and an siRNA.

[0014] In the present disclosure, the hypertension is essential hypertension or secondary hypertension.

[0015] In a fifth aspect, the present disclosure also relates to a class of FXI / FXIa inhibitors for use in the treatment and / or prevention of hypertension.

[0016] In a sixth aspect, the present disclosure also relates to the use of a FXI / FXIa inhibitor for the manufacture of a medicament for the treatment and / or prevention of hypertension. BRIEF DESCRIPTION OF DRAWINGS

[0017] Figure 1 is the mean right ventricular systolic pressure (RVSP) of animals in each group; wherein ***p<0.001, ***p<0.01, vs G2-Model.

[0018] Figure 2 is the mean right ventricular hypertrophy index (RVHI%) of animals in each group.

[0019] Figure 3 is the mean relative media thickness (PAWT%) of animals in each group.

[0020] Figure 4 is the systolic pressure change of animals in each group; wherein ***p<0.001, vs G2.

[0021] Figure 5 is the diastolic pressure change of animals in each group; wherein ***p<0.001, *p<0.05 vs G2.

[0022] Figure 6 is the mean blood pressure change of animals in each group; wherein ***p<0.001, **p<0.01 vs G2. DETAILED DESCRIPTION

[0023] TERMS DEFINITION

[0024] Unless otherwise indicated or defined, all terms used have the usual meaning in the art, which will be understood by those skilled in the art. Reference is made to, for example, standard manuals, such as Sambrook et al., "Molecular Cloning: A Laboratory Manual" (2nded.), Vols. 1-3, Cold Spring Harbor Laboratory Press (1989); Lewin, "Genes IV", Oxford University Press, New York, (1990); and Roitt et al., "Immunology" (2nded.), Gower Medical Publishing, London, New York (1989), as well as the general prior art cited herein; and furthermore, all methods, procedures, techniques and manipulations not specifically detailed are performed and known in the art per se, unless otherwise stated, which will be understood by those skilled in the art. Reference is also made to, for example, standard manuals, the above general prior art, and other references cited therein.

[0025] As used herein, the term "pulmonary hypertension (PH)" is defined based on hemodynamic evaluation by right heart catheterization (RHC). While hemodynamics are the core elements to characterize PH, the final diagnosis and classification should reflect the overall clinical context and consider the results of all investigations. Pulmonary arterial hypertension is defined as mean pulmonary arterial pressure (mPAP) > 20 mmHg at rest.

[0026] Pulmonary arterial wedge pressure (PAWP) is the blood pressure measured distal to the site of obstruction after a balloon-tipped catheter is inserted into a branch of the pulmonary artery and the balloon is inflated to block blood flow. PH is further divided into pre-capillary PH (PAWP < 15 mmHg) and post-capillary PH (PAWP > 15 mmHg) based on the PAWP of 15 mmHg. To better distinguish the types of post-capillary PH, pulmonary vascular resistance (PVR) is added to the PAWP. Specifically, PAWP > 15 mmHg and PVR < 3 WU are defined as pure post-capillary PH, and PAWP > 15 mmHg and PVR > 3 WU are defined as mixed post-capillary PH, on the premise that mPAP exceeds the threshold value.

[0027] According to the pathophysiological mechanism, clinical manifestations, hemodynamic characteristics and treatment management, pulmonary arterial hypertension is generally divided into five categories in clinical practice: (1) Pulmonary arterial hypertension (PAH); (2) Pulmonary arterial hypertension caused by left heart disease; (3) Pulmonary arterial hypertension caused by pulmonary diseases and / or hypoxia; (4) Pulmonary arterial hypertension caused by chronic thromboembolic pulmonary hypertension (CTEPH) and / or other pulmonary arterial obstructive diseases; (5) Pulmonary arterial hypertension caused by unknown and / or multiple factors.

[0028] Among them, PAH (Pulmonary Arterial Hypertension) refers to the increase of pulmonary vascular resistance and pulmonary arterial pressure caused by pulmonary arterial (mainly pulmonary arteriole) disease, while PAWP is normal, and its hemodynamic definition is mPAP≥25mmHg, PAWP≤15mmHg and PVR>3WU (1WU=80dyn·s·cm-5), mainly including idiopathic pulmonary arterial hypertension (IPAH), hereditary pulmonary arterial hypertension (HPAH), drug and toxicant related pulmonary arterial hypertension, disease related pulmonary arterial hypertension, pulmonary arterial hypertension with long-term effectiveness of calcium channel blockers, pulmonary arterial hypertension with obvious pulmonary vein / pulmonary capillary involvement (pulmonary vein occlusion disease / pulmonary capillary hemangioma disease) and persistent pulmonary arterial hypertension (PPHN) in newborns.

[0029] Pulmonary arterial hypertension caused by left heart disease can be mainly caused by the following factors: heart failure with preserved ejection fraction, heart failure with reduced ejection fraction, valvular heart disease and congenital / acquired cardiovascular disease leading to post-capillary pulmonary arterial hypertension.

[0030] Pulmonary arterial hypertension caused by pulmonary diseases and / or hypoxia can be mainly caused by the following diseases: obstructive pulmonary disease, restrictive pulmonary disease, other obstructive and restrictive coexisting pulmonary disease, hypoxemia caused by non-pulmonary diseases and pulmonary dysplasia disease.

[0031] Pulmonary arterial hypertension caused by unknown and / or multiple factors mainly includes pulmonary arterial hypertension caused by hematological diseases (such as chronic hemolytic anemia, myeloproliferative disease), systemic and metabolic diseases (such as sarcoidosis, Gaucher's disease, glycogen storage disease), complex congenital heart disease or other diseases (such as fibrous mediastinitis).

[0032] As used herein, the term "hypertension" refers to a sustained elevation of systolic or (and) diastolic blood pressure in a resting state (systolic blood pressure ≥ 140 mmHg, diastolic blood pressure ≥ 90 mmHg). According to the level of blood pressure elevation, hypertension can be classified into grade 1, grade 2 and grade 3. According to the blood pressure level, cardiovascular risk factors, target organ damage, clinical complications and diabetes, cardiovascular stratification can be divided into 4 levels, i.e. low risk, medium risk, high risk and very high risk. According to the pathogenic cause, it can be divided into primary hypertension and secondary hypertension, among which primary hypertension is more common. Secondary hypertension is usually caused by primary aldosterone hyperplasia. Sleep apnea, chronic kidney disease, obesity or renal artery stenosis are other causes of secondary hypertension.

[0033] The treatment of hypertension usually includes lifestyle changes and the use of drugs. The fundamental goal of hypertension treatment is to reduce the overall risk of cardiovascular, cerebrovascular, renal and vascular complications and death. The benefit of antihypertensive treatment mainly comes from blood pressure reduction itself. On the basis of improving lifestyle, antihypertensive drugs should be given according to the overall risk level of hypertensive patients, while intervening in correctable risk factors, target organ damage and coexisting clinical diseases. In conditions permitting, intensive antihypertensive treatment strategies should be adopted to achieve the maximum cardiovascular benefit.

[0034] Common antihypertensive drugs include calcium channel blockers (CCB) (dihydropyridines: nifedipine, amlodipine, levamlodipine, felodipine, lacidipine, nicardipine, nitrendipine, benidipine, lercanidipine, manidipine, cinaldipine, barnidipine, etc.; non-dihydropyridines: verapamil, diltiazem , etc.), angiotensin-converting enzyme inhibitors (ACEI) (such as captopril, enalapril, benazepril, lisinopril, ramipril, fosinopril, cilazapril, perindopril, imidapril, etc.), angiotensin receptor blockers (ARB) (such as losartan, valsartan, irbesartan, telmisartan, candesartan, olmesartan, aliskiren, etc.), diuretics (thiazide diuretics: hydrochlorothiazide, chlorthalidone, indapamide; loop diuretics: furosemide, torsemide; potassium-sparing diuretics: amiloride, triamterene) and beta blockers (such as bisoprolol, metoprolol, atenolol, propranolol, betaxolol, labetalol, carvedilol, arrotolol, etc.).

[0035] As used herein, the term "FXI / FXIa inhibitor" refers to a substance that can specifically bind to FXI and / or FXIa, preventing FXI and / or FXIa from exerting its biological efficacy.

[0036] The terms "antibody" or "immunoglobulin" are used interchangeably throughout the present application and refer to either a heavy chain antibody or a conventional 4-chain antibody, unless otherwise indicated, as a general term to include full-length antibodies, individual chains thereof, and all portions, domains or fragments thereof, including but not limited to antigen binding domains or fragments, such as VHH domains or VH / VL domains, respectively. Furthermore, the term "sequence" as used throughout the present application, such as in the terms "immunoglobulin sequence", "antibody sequence", "single variable domain sequence", "VHH sequence" or "protein sequence", is to be understood as encompassing both the relevant amino acid sequence as well as the nucleic acid sequence or nucleotide sequence encoding said sequence, unless the present application requires a more defined interpretation.

[0037] The term "domain" (of a polypeptide or protein) as used throughout the present application refers to a folded protein structure which is able to maintain its tertiary structure independently from the rest of the protein. Generally, a domain is responsible for a single functional property of a protein and in many cases can be added, removed or transferred to other proteins without loss of function of the rest of the protein and / or the domain.

[0038] The term "immunoglobulin domain" as used throughout the present application refers to a globular region of an antibody chain, such as a chain of a conventional 4-chain antibody or a chain of a heavy chain antibody, or to a polypeptide consisting essentially of such a globular region. An immunoglobulin domain is characterized by the fact that it maintains the immunoglobulin fold characteristic of antibody molecules.

[0039] The term "immunoglobulin variable domain" as used throughout the present application refers to an immunoglobulin domain consisting essentially of four "framework regions" referred to in the art and hereinafter as "framework region 1" or "FR1", "framework region 2" or "FR2", "framework region 3" or "FR3", and "framework region 4" or "FR4", respectively, which are interrupted by three "complementarity determining regions" or "CDRs" referred to in the art and hereinafter as "complementarity determining region 1" or "CDR1", "complementarity determining region 2" or "CDR2", and "complementarity determining region 3" or "CDR3", respectively. Thus, the general structure or sequence of an immunoglobulin variable domain can be represented as follows: FR1-CDR1-FR2-CDR2-FR3-CDR3-FR4. An immunoglobulin variable domain confers specificity to an antibody for an antigen due to the presence of the antigen binding site.

[0040] The term "immunoglobulin single variable domain" as used in the present application refers to an immunoglobulin variable domain that is capable of specifically binding to an epitope of an antigen without pairing with another immunoglobulin variable domain. An example of an immunoglobulin single variable domain within the meaning of the present application is a "domain antibody", such as an immunoglobulin single variable domain VH and VL (VH domain and VL domain). Another example of an immunoglobulin single variable domain is a "VHH domain" (or simply "VHH") of Camelidae as defined below.

[0041] A "VHH domain", also known as heavy chain single domain antibody, VHH, VHH domain, VHH antibody fragment and VHH antibody, is the variable domain of an antigen binding immunoglobulin termed "heavy chain antibody" (i.e. "antibody devoid of light chain") (Hamers-Casterman C, Atarhouch T, Muyldermans S, Robinson G, Hamers C, Songa EB, Bendahman N, Hamers R.: "Naturally occurring antibodies devoid of light chains"; Nature 363, 446-448 (1993)). The term "VHH domain" is used to distinguish the variable domain from the heavy chain variable domain present in a conventional 4-chain antibody (which is referred to as "VH domain" in the present application) and from the light chain variable domain present in a conventional 4-chain antibody (which is referred to as "VL domain" in the present application). A VHH domain specifically binds to an epitope without the need of another antigen binding domain (in contrast to a VH or VL domain in a conventional 4-chain antibody, in which case the epitope is recognized by the VL domain together with the VH domain). A VHH domain is a small, stable and highly efficient antigen recognition unit formed by a single immunoglobulin domain.

[0042] In the context of the present application, the terms "heavy chain single domain antibody", "VHH domain", "VHH", "VHH antibody fragment", and "VHH antibody" are used interchangeably.

[0043] For example, the amino acid residues applied for VHH domains of Camelidae can be numbered according to the general numbering scheme for VH domains given by Kabat et al. (Kabat et al., Sequences of Proteins of Immunological Interest, 5th Ed. Public Health Service, National Institutes of Health, Bethesda, Md. (1991)), as shown in Figure 2 of Riechmann and Muyldermans, J. Immunol. Methods 231, 25-38 (1999).

[0044] Alternative methods of numbering and defining amino acid residues of VH domains are known in the art and can similarly be applied to VHH domains. For example, Chothia CDRs refer to the locations of structural loops (Chothia and Lesk, J. Mol. Biol. 196:901-917 (1987)). AbM CDRs represent a compromise between the Kabat hypervariable regions and Chothia structural loops, and are used in Oxford Molecular's AbM antibody modeling software. "Contact" CDRs are based on an analysis of available complex crystal structures. The residues from the CDRs from each method are described below:

[0045] It should be noted, however, that the total number of amino acid residues in each CDR can vary, and can not correspond to the total number of amino acid residues indicated by the Kabat numbering (i.e. one or more positions according to the Kabat numbering can not be occupied in the actual sequence, or the actual sequence can contain more amino acid residues than allowed by the Kabat numbering), as is well known in the art for VH and VHH domains. This means that in general, the numbering according to Kabat can or can not correspond to the actual numbering of the amino acid residues in the actual sequence. Unless specifically indicated otherwise, the CDRs in the present disclosure are defined according to the Kabat rules.

[0046] For example, the CDRs can include "extended CDRs", for example: 24-36 or 24-34 (LCDR1), 46-56 or 50-56 (LCDR2) and 89-97 or 89-96 (LDR3) in VL; 26-35 (HCDR1), 50-65 or 49-65 (HCDR2) and 93-102, 94-102 or 95-102 (HCDR3) in VH.

[0047] The total number of amino acid residues in a VHH domain will generally range from 110 to 120, often between 112 and 115. It is noted, however, that smaller and longer sequences can also be suitable for the purposes described herein. Methods for obtaining VHHs that bind to a particular antigen or epitope have been previously disclosed in R. van der Linden et al., Journal of Immunological Methods, 240 (2000) 185-195; Li et al., J Biol Chem., 287 (2012) 13713-13721; Deffar et al., African Journal of Biotechnology Vol. 8(12), pp. 2645-2652, 17 June, 2009 and WO94 / 04678.

[0048] As used herein, the term "specificity" refers to the number of different types of antigens or epitopes to which a particular antigen-binding molecule or antigen-binding protein can bind. The specificity of an antigen-binding protein can be determined based on its affinity and / or avidity. Affinity, as represented by the dissociation equilibrium constant (KD) of an antigen for an antigen-binding protein, is a measure of the strength of binding between an epitope and an antigen-binding site on an antigen-binding protein: the smaller the KD value, the stronger the binding strength between the epitope and the antigen-binding protein (or, affinity can also be expressed as the association constant (KA), which is 1 / KD). As will be appreciated by those skilled in the art, affinity can be determined in known ways, depending on the particular antigen of interest. Avidity is a measure of the strength of binding between an antigen-binding protein (e.g., an immunoglobulin, an antibody, an immunoglobulin single variable domain, or a polypeptide containing the same) and the relevant antigen. Avidity is related to both the affinity between the antigen-binding site on its antigen-binding protein and the number of relevant binding sites present on the antigen-binding protein.

[0049] As used herein, "identity" refers to sequence similarity between two polynucleotide sequences or between two polypeptides. When a position in both of the compared sequences is occupied by the same base or amino acid monomer subunit, e.g., if a position in each of two DNA molecules is occupied by adenine, then the molecules are homologous at that position. The percent identity between two sequences is a function of the number of matching or homologous positions shared by the sequences divided by the number of positions compared x 100. For example, if 6 of 10 positions in two sequences are matched or homologous when the two sequences are optimally aligned, the two sequences are 60% homologous. In general, the comparison is made at the nucleotide or amino acid level, when two sequences are optimally aligned.

[0050] As used herein, the term "and / or" means either or both of the items.

[0051] As used herein the term "comprising" or "including", or any variation thereof, is intended to reference the compositions, integers and steps described herein but does not preclude the addition of further compositions, integers or steps. Where used herein the term "comprising" or "including" or any variation thereof, does not preclude the presence of unspecified further compositions, integers or steps.

[0052] As used herein, the term "treatment" refers to slowing, interrupting, arresting, stopping, reducing, or reversing the progression or severity of an existing symptom, disorder, condition, or disease. The term "prevention" includes inhibition of the onset or development of a disease or disorder or symptoms of a particular disease or disorder. Generally, the term "prevention" refers to the administration of a drug prior to the onset of a sign or symptom, particularly in an individual at risk.

[0053] As used herein, the term "prevention" includes inhibition of the onset or development of a disease or disorder or symptoms of a particular disease or disorder. Generally, the term "prevention" refers to the administration of a drug prior to the onset of a sign or symptom, particularly in an individual at risk.

[0054] The term "administration" generally refers to methods of delivering a dose of a compound or pharmaceutical composition to a subject (e.g., a patient). Administration can be performed by any suitable means, including parenterally, intrapulmonary, and intranasally, as well as intralesionally, if local treatment is desired. Parenteral infusions include, e.g., intramuscular, intravenous, intraarterial, intraperitoneal, or subcutaneous administration.

[0055] In this application, the term "about" is used to indicate that a value includes the inherent variation of error for the device, the method being employed to determine the value, or the variation that exists among the study subjects and / or within the normal limits included in the study design. When no particular value is specified, the value is assumed to be "about 5%" unless expressly specified otherwise. If there is a question as to whether a value is "about," the value is assumed to be "about" unless otherwise expressly indicated. "About" means ±5% of the value of the term it precedes, unless otherwise indicated.

[0056] DETAILED DESCRIPTION

[0057] Methods of treating and uses of treating pulmonary arterial hypertension

[0058] In a first aspect, the disclosure relates to a method of treating and / or preventing pulmonary arterial hypertension, comprising administering to a subject in need thereof an effective amount of a FXI / FXIa inhibitor.

[0059] In a second aspect, the disclosure also relates to a class of FXI / FXIa inhibitors for use in the treatment and / or prevention of pulmonary arterial hypertension.

[0060] In some embodiments, the FXI / FXIa inhibitor can be selected from a small molecule drug, an antibody or antigen-binding fragment thereof, an antisense nucleotide, and an siRNA.

[0061] In some embodiments, the FXI / FXIa inhibitor is a small molecule drug. For example, the FXI / FXIa inhibitor can be selected from Asundexian, Milvexian, BMS-962212, Frunexian, SHR-2285, NIP003, SAL-0104, EP-7327, ONO-5450598, BMS-262084, DSR-130787, ONO-7269, ONO-7684, and pharmaceutically acceptable salts thereof.

[0062] In some embodiments, the FXI / FXIa inhibitor is Asundexian, or a pharmaceutically acceptable salt thereof. The Asundexian is also known as BAY-2433334, CAS No. 2064121-65-7, having the chemical structure of:

[0063] In some embodiments, the FXI / FXIa inhibitor is an antibody or antigen-binding fragment thereof. Preferably, the antibody specifically binds to the A2 domain of FXI and / or FXIa, or, the antibody specifically binds to the A3 domain of FXI and / or FXIa, or, the antibody specifically binds to the catalytic domain of FXI and / or FXIa. More preferably, the antibody specifically binds to the A2 and A3 domains of FXI and / or FXIa.

[0064] In some embodiments, the FXI / FXIa inhibitor is an antibody or antigen-binding fragment thereof, the antibody is selected from Abelacimab, KN060, MK-2060, Osocimab, REGN-7508, REGN-9933, SHR-2004, Xisomab 3G3, AB-012, SKB-336, and BEM-015.

[0065] In some embodiments, the FXI / FXIa inhibitor comprises an immunoglobulin single variable domain comprising CDR1, CDR2, and CDR3 in a VHH as set forth in SEQ ID NO: 1.

[0066] In some embodiments, the immunoglobulin single variable domain comprises a CDR1 as set forth in SEQ ID NO: 2, a CDR2 as set forth in SEQ ID NO: 3, and a CDR3 as set forth in SEQ ID NO: 4.

[0067] In some embodiments, the immunoglobulin single variable domain comprises (1) SEQ ID NO: 1; (2) a sequence having at least 85%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99% identity to SEQ ID NO: 1; or (3) a sequence comprising one or more amino acid substitutions, preferably conservative amino acid substitutions, compared to SEQ ID NO: 1, e.g., a sequence comprising 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 conservative amino acid substitutions, or consists of thereof. In some embodiments, the immunoglobulin single variable domain comprises or consists of the amino acid sequence set forth in SEQ ID NO: 1.

[0068] In other embodiments, the FXI / FXIa inhibitor comprises an immunoglobulin single variable domain comprising a CDR1, a CDR2, and a CDR3 in a VHH as set forth in SEQ ID NO: 5.

[0069] In some embodiments, the immunoglobulin single variable domain comprises a CDR1 as set forth in SEQ ID NO: 6, a CDR2 as set forth in SEQ ID NO: 7, and a CDR3 as set forth in SEQ ID NO: 8.

[0070] In some embodiments, the immunoglobulin single variable domain comprises (1) SEQ ID NO: 5; (2) a sequence having at least 85%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99% identity to SEQ ID NO: 5; or (3) a sequence comprising one or more amino acid substitutions, preferably conservative amino acid substitutions, compared to SEQ ID NO: 5, e.g., a sequence comprising 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 conservative amino acid substitutions, or consists of thereof. In some embodiments, the immunoglobulin single variable domain comprises or consists of the amino acid sequence set forth in SEQ ID NO: 5.

[0071] In some embodiments, the FXI / FXIa inhibitor comprises a first immunoglobulin single variable domain and a second immunoglobulin single variable domain, wherein the first immunoglobulin single variable domain can bind to the Apple2 binding domain of FXI and / or the second immunoglobulin single variable domain can bind to the Apple3 binding domain of FXI.

[0072] In some embodiments, the FXI / FXIa inhibitor comprises a first immunoglobulin single variable domain and a second immunoglobulin single variable domain, wherein the first immunoglobulin single variable domain comprises CDR1, CDR2 and CDR3 in a VHH as set forth in SEQ ID NO: 1, and the second immunoglobulin single variable domain comprises CDR1, CDR2 and CDR3 in a VHH as set forth in SEQ ID NO: 5.

[0073] In some embodiments, the first immunoglobulin single variable domain comprises CDR1 as set forth in SEQ ID NO: 2, CDR2 as set forth in SEQ ID NO: 3, and CDR3 as set forth in SEQ ID NO: 4.

[0074] In some embodiments, the first immunoglobulin single variable domain comprises (1) SEQ ID NO: 1; (2) a sequence having at least 85%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99% identity to SEQ ID NO: 1; or (3) a sequence comprising one or more amino acid substitutions, preferably conservative amino acid substitutions, as compared to SEQ ID NO: 1, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 conservative amino acid substitutions, or consists of thereof. In some embodiments, the first immunoglobulin single variable domain comprises or consists of the amino acid sequence set forth in SEQ ID NO: 1.

[0075] In some embodiments, the second immunoglobulin single variable domain comprises CDR1 as set forth in SEQ ID NO: 6, CDR2 as set forth in SEQ ID NO: 7, and CDR3 as set forth in SEQ ID NO: 8.

[0076] In some embodiments, the second immunoglobulin single variable domain comprises (1) SEQ ID NO: 5; (2) a sequence having at least 85%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99% identity to SEQ ID NO: 5; or (3) a sequence comprising one or more amino acid substitutions, preferably conservative amino acid substitutions, compared to SEQ ID NO: 5, for example, an amino acid sequence of 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 conservative amino acid substitutions, or consists thereof. In some embodiments, the second immunoglobulin single variable domain comprises or consists of the amino acid sequence set forth in SEQ ID NO: 5.

[0077] In some embodiments, the FXI / FXIa inhibitor comprises a first immunoglobulin single variable domain and a second immunoglobulin single variable domain, wherein the first immunoglobulin single variable domain comprises the amino acid sequence set forth in SEQ ID NO: 1 and the second immunoglobulin single variable domain comprises the amino acid sequence set forth in SEQ ID NO: 5.

[0078] In some embodiments, the FXI / FXIa inhibitor comprises a first immunoglobulin single variable domain and a second immunoglobulin single variable domain, wherein the first immunoglobulin single variable domain consists of the amino acid sequence set forth in SEQ ID NO: 1 and the second immunoglobulin single variable domain consists of the amino acid sequence set forth in SEQ ID NO: 5.

[0079] In some embodiments, the first and second immunoglobulin single variable domains are directly linked to each other.

[0080] In other embodiments, the first and second immunoglobulin single variable domains are linked to each other by a linker. The linker can be a long 1-20 or more amino acids, a non-functional amino acid sequence without secondary structure above. For example, the linker is a flexible linker, such as GGGGS (SEQ ID NO: 12), GS, GAP, (GGGGS)3(SEQ ID NO: 13), and the like.

[0081] In some embodiments, the first immunoglobulin single variable domain is located at the N-terminus of the second immunoglobulin single variable domain. In other embodiments, wherein the second immunoglobulin single variable domain is located at the N-terminus of the first immunoglobulin single variable domain.

[0082] In some embodiments, the aforementioned FXI / FXIa inhibitors comprising an immunoglobulin single variable domain can further comprise an immunoglobulin Fc region. The Fc region useful in the present disclosure can be from different subtypes of immunoglobulins, for example, IgG (e.g., IgG1, IgG2, IgG3, or IgG4 subtypes), IgA1, IgA2, IgD, IgE, or IgM.

[0083] In some embodiments, the immunoglobulin Fc region can be a human immunoglobulin Fc region, can be an Fc region of human IgG1. In this context, the amino acid sequence of the immunoglobulin Fc region is shown in SEQ ID NO: 9.

[0084] In some embodiments, the FXI / FXIa inhibitor of the present disclosure comprises or consists of the amino acid sequence shown in SEQ ID NO: 10.

[0085] In some embodiments, the FXI / FXIa inhibitor is an antisense nucleotide; preferably, the FXI / FXIa inhibitor is selected from the group consisting of Fesomersen, IONIS-FXIRX, ION-957943, and SR-059.

[0086] In some embodiments, the FXI / FXIa inhibitor is an siRNA; preferably, the FXI / FXIa inhibitor is selected from the group consisting of SRSD-107 and STP-122G.

[0087] In some embodiments, the pulmonary arterial hypertension is selected from the group consisting of: (1) pulmonary arterial hypertension (PAH); (2) pulmonary arterial hypertension due to left heart disease; (3) pulmonary arterial hypertension due to lung disease and / or hypoxia; (4) pulmonary arterial hypertension due to chronic thromboembolic pulmonary arterial hypertension (CTEPH) and / or other pulmonary arterial obstructive disorders; and (5) pulmonary arterial hypertension of unclear and / or multifactorial origin.

[0088] In some embodiments, the pulmonary arterial hypertension is pulmonary arterial hypertension (PAH).

[0089] In some embodiments, the FXI / FXIa inhibitor is administered on the basis of conventional treatment. The conventional treatment refers to the treatment measures generally accepted for patients with confirmed pulmonary arterial hypertension before the filing date.

[0090] According to the definition in the “Guidelines for the Diagnosis and Treatment of Pulmonary Arterial Hypertension (2021 Edition)”, the conventional treatment mainly includes two categories: basic treatment and specific treatment.

[0091] Among them, the basic treatment mainly includes anticoagulant therapy (such as warfarin), diuretics (including loop diuretics, such as furosemide, torsemide; aldosterone receptor inhibitors, such as spironolactone; vasopressin V2 receptor antagonists, such as tolvaptan, etc.), oxygen therapy, digoxin and other cardiovascular drugs, and the treatment of anemia (such as intravenous iron supplement).

[0092] The specific treatment mainly includes the administration of calcium channel blockers (such as nifedipine, amlodipine, diltiazem , etc.), and endothelin receptor antagonists (such as bosentan, ambrisentan, macitentan, etc.), PDE5 inhibitors (such as sildenafil, tadalafil, vardenafil, etc.), soluble guanylate cyclase agonists (such as riociguat, etc.), prostacyclin analogs and prostacyclin receptor agonists (such as epoprostenol, iloprost, treprostinil, seletipag, etc.) and other targeted drugs.

[0093] In some embodiments, the FXI / FXIa inhibitor is administered on the basis of receiving the aforementioned targeted drug treatment.

[0094] In some embodiments, the FXI / FXIa inhibitor is administered once daily, every two days, every three days, every week, every two weeks, every three weeks, every four weeks, every five weeks, every six weeks, every seven weeks, every eight weeks, every month, every two months, every three months, every four months, every five months, or every six months.

[0095] In some embodiments, the FXI / FXIa inhibitor can be administered orally, intravenously or subcutaneously; preferably, the FXI / FXIa inhibitor can be administered intravenously.

[0096] In some embodiments, the dose of a single administration of the foregoing FXI / FXIa inhibitor is 0.1 mg / kg to 50.0 mg / kg of the subject's body weight, preferably 0.5 mg / kg to 30 mg / kg of the subject's body weight, more preferably 1 mg / kg to 20 mg / kg of the subject's body weight, even more preferably 5 mg / kg to 15 mg / kg of the subject's body weight; for example, 0.1 mg / kg, 0.2 mg / kg, 0.3 mg / kg, 0.4 mg / kg, 0.5 mg / kg, 0.6 mg / kg, 0.7 mg / kg, 0.8 mg / kg, 0.9 mg / kg, 1.0 mg / kg, 1.1 mg / kg, 1.2 mg / kg, 1.3 mg / kg, 1.4 mg / kg, 1.5 mg / kg, 1.6 mg / kg, 1.7 mg / kg, 1.8 mg / kg, 1.9 mg / kg, 2.0 mg / kg, 2.1 mg / kg, 2.2 mg / kg, 2.3 mg / kg, 2.4 mg / kg, 2.5 mg / kg, 2.6 mg / kg, 2.7 mg / kg, 2.8 mg / kg, 2.9 mg / kg, 3.0 mg / kg, 3.1 mg / kg, 3.2 mg / kg, 3.3 mg / kg, 3.4 mg / kg, 3.5 mg / kg, 3.6 mg / kg, 3.7 mg / kg, 3.8 mg / kg, 3.9 mg / kg, 4.0 mg / kg, 4.1 mg / kg, 4.2 mg / kg, 4.3 mg / kg, 4.4 mg / kg, 4.5 mg / kg, 4.6 mg / kg, 4.7 mg / kg, 4.8 mg / kg, 4.9 mg / kg, 5.0 mg / kg, 5.1 mg / kg, 5.2 mg / kg, 5.3 mg / kg, 5.4 mg / kg, 5.5 mg / kg, 5.6 mg / kg, 5.7 mg / kg, 5.8 mg / kg, 5.9 mg / kg, 6.0 mg / kg, 6.1 mg / kg, 6.2 mg / kg, 6.3 mg / kg, 6.4 mg / kg, 6.5 mg / kg, 6.6 mg / kg, 6.7 mg / kg, 6.8 mg / kg, 6.9 mg / kg, 7.0 mg / kg, 7.1 mg / kg, 7.2 mg / kg, 7.3 mg / kg, 7.4 mg / kg, 7.5 mg / kg, 7.6 mg / kg, 7.7 mg / kg, 7.8 mg / kg, 7.9 mg / kg, 8.0 mg / kg, 8.1 mg / kg, 8.2 mg / kg, 8.3 mg / kg, 8.4 mg / kg, 8.5 mg / kg, 8.6 mg / kg, 8.7 mg / kg, 8.8 mg / kg, 8.9 mg / kg, 9.0 mg / kg, 9.1 mg / kg, 9.2 mg / kg, 9.3 mg / kg, 9.4 mg / kg, 9.5 mg / kg, 9.6 mg / kg, 9.7 mg / kg, 9.8 mg / kg, 9.9 mg / kg, 10.0 mg / kg, 10.1 mg / kg, 10.2 mg / kg, 10.3 mg / kg, 10.4 mg / kg, 10.5 mg / kg, 10.6 mg / kg, 10.7 mg / kg, 10.8 mg / kg, 10.9 mg / kg, 11.0 mg / kg, 11.1 mg / kg, 11.2 mg / kg, 11.3 mg / kg, 11.4 mg / kg, 11.5 mg / kg, 11.6 mg / kg, 11.7 mg / kg, 11.8 mg / kg, 11.9 mg / kg, 12.0 mg / kg, 12.1 mg / kg, 12.2 mg / kg, 12.3 mg / kg, 12.4 mg / kg, 12.5 mg / kg, 12.6 mg / kg, 12.7 mg / kg, 12.8 mg / kg, 12.9 mg / kg, 13.0 mg / kg, 13.1 mg / kg, 13.2 mg / kg, 13.3 mg / kg, 13.4 mg / kg, 13.5 mg / kg, 13.6 mg / kg, 13.7 mg / kg, 13.8 mg / kg, 13.9 mg / kg, 14.0 mg / kg, 14.1 mg / kg, 14.2 mg / kg, 14.3 mg / kg, 14.4 mg / kg, 14.5 mg / kg, 14.6 mg / kg, 14.7 mg / kg, 14.8 mg / kg, 14.9 mg / kg, 15.0 mg / kg, 15.1 mg / kg, 15.2 mg / kg, 15.3 mg / kg, 15.4 mg / kg, 15.5 mg / kg, 15.6 mg / kg, 15.7 mg / kg, 15.8 mg / kg, 15.9 mg / kg, 16.0 mg / kg, 16.1 mg / kg, 16.2 mg / kg, 16.3 mg / kg, 16.4 mg / kg, 16.5 mg / kg, 16.6 mg / kg, 16.7 mg / kg, 16.8 mg / kg, 16.9 mg / kg, 17.0 mg / kg, 17.1 mg / kg, 17.2 mg / kg, 17.3 mg / kg, 17.4 mg / kg, 17.5 mg / kg, 17.6 mg / kg, 17.7 mg / kg, 17.8 mg / kg, 17.9 mg / kg, 18.0 mg / kg, 18.1 mg / kg, 18.2 mg / kg, 18.3 mg / kg, 18.4 mg / kg, 18.5 mg / kg, 18.6 mg / kg, 18.7 mg / kg, 18.8 mg / kg, 18.9 mg / kg, 19.0 mg / kg, 19.1 mg / kg, 19.2 mg / kg, 19.3 mg / kg, 19.4 mg / kg, 19.5 mg / kg, 19.6 mg / kg, 19.7 mg / kg, 19.8 mg / kg, 19.9 mg / kg, 20.0 mg / kg, 20.1 mg / kg, 20.2 mg / kg, 20.3 mg / kg, 20.4 mg / kg, 20.5 mg / kg, 20.6 mg / kg, 20.7 mg / kg, 20.8 mg / kg, 20.9 mg / kg, 21.0 mg / kg, 21.1 mg / kg, 21.2 mg / kg, 21.3 mg / kg, 21.4 mg / kg, 21.5 mg / kg, 21.6 mg / kg, 21.7 mg / kg, 21.8 mg / kg, 21.9 mg / kg, 22.0 mg / kg, 22.1 mg / kg, 22.2 mg / kg, 22.3 mg / kg, 22.4 mg / kg, 22.5 mg / kg, 22.6 mg / kg, 22.7 mg / kg, 22.8 mg / kg, 22.9 mg / kg, 23.0 mg / kg, 23.1 mg / kg, 23.2 mg / kg, 23.3 mg / kg, 23.4 mg / kg, 23.5 mg / kg, 23.6 mg / kg, 23.7 mg / kg, 23.8 mg / kg, 23.9 mg / kg, 24.0 mg / kg, 24.1 mg / kg, 24.2 mg / kg, 24.3 mg / kg, 24.4 mg / kg, 24.5 mg / kg, 24.6 mg / kg, 24.7 mg / kg, 24.8 mg / kg, 24.9 mg / kg, 25.0 mg / kg, 25.1 mg / kg, 25.2 mg / kg, 25.3 mg / kg, 25.4 mg / kg, 25.5 mg / kg, 25.6 mg / kg, 25.7 mg / kg, 25.8 mg / kg, 25.9 mg / kg, 26.0 mg / kg, 26.1 mg / kg, 26.2 mg / kg, 26.3 mg / kg, 26.4 mg / kg, 26.5 mg / kg, 26.6 mg / kg, 26.7 mg / kg, 26.8 mg / kg, 26.9 mg / kg, 27.0 mg / kg, 27.1 mg / kg, 27.2 mg / kg, 27.3 mg / kg, 27.4 mg / kg, 27.5 mg / kg, 27.6 mg / kg, 27.7 mg / kg, 27.8 mg / kg, 27.7 mg / kg, 9.8 mg / kg, 9.9 mg / kg, 10.0 mg / kg, 10.5 mg / kg, 11.0 mg / kg, 11.5 mg / kg, 12.0 mg / kg, 12.5 mg / kg, 13.0 mg / kg, 13.5 mg / kg, 14.0 mg / kg, 14.5 mg / kg, 15.0 mg / kg, 15.5 mg / kg, 16.0 mg / kg, 16.5 mg / kg, 17.0 mg / kg, 17.5 mg / kg, 18.0 mg / kg, 18.5 mg / kg, 19.0 mg / kg, 19.5 mg / kg, 20.0 mg / kg subject body weight.

[0097] In some embodiments, the subject is administered 10 mg / kg subject body weight of a FXI / FXIa inhibitor comprising the amino acid sequence of SEQ ID NO: 10 once every 4 weeks. Preferably, the FXI / FXIa inhibitor is administered on top of conventional therapy. More preferably, the FXI / FXIa inhibitor is administered on top of conventional therapy and the FXI / FXIa inhibitor is KN060.

[0098] In some embodiments, the aforementioned methods, after administration of the FXI / FXIa inhibitor, the subject has a significant decrease in pulmonary vascular resistance (PVR) as measured by right heart catheterization (RHC) compared to baseline. In some embodiments, the PVR is significantly decreased compared to baseline after 12 weeks of treatment with the FXI / FXIa inhibitor on top of conventional therapy. In some embodiments, the PVR is significantly decreased compared to baseline after 24 weeks of treatment with the FXI / FXIa inhibitor on top of conventional therapy. For example, the PVR is decreased by at least 10%, preferably by at least 15%, more preferably by at least 20%, even more preferably by at least 25% or more compared to baseline.

[0099] In some embodiments, the aforementioned methods, after administration of the FXI / FXIa inhibitor, the subject has a significant increase in 6 minute walk distance (6MWD) compared to baseline. In some embodiments, the 6MWD is significantly increased compared to baseline after 12 weeks of treatment with the FXI / FXIa inhibitor on top of conventional therapy. In some embodiments, the 6MWD is significantly increased compared to baseline after 24 weeks of treatment with the FXI / FXIa inhibitor on top of conventional therapy. For example, the 6MWD is increased by at least 2%, preferably by at least 5%, more preferably by at least 8%, even more preferably by at least 10% or more compared to baseline.

[0100] In some embodiments, following administration of the FXI / FXIa inhibitor, the subject has a significant decrease in N-terminal pro-B-type natriuretic peptide (NT-proBNP) from baseline. In some embodiments, following administration of the FXI / FXIa inhibitor for 12 weeks on top of standard of care, there is a significant decrease in NT-proBNP from baseline. In some embodiments, following administration of the FXI / FXIa inhibitor for 24 weeks on top of standard of care, there is a significant decrease in NT-proBNP from baseline. For example, there is a decrease in NT-proBNP of at least 10%, preferably at least 15%, more preferably at least 20%, even more preferably at least 25% or more from baseline.

[0101] In some embodiments, following administration of the FXI / FXIa inhibitor, the subject has an improved WHO functional class. In some embodiments, following administration of the FXI / FXIa inhibitor for 12 weeks on top of standard of care, the subject has an improved WHO functional class. In some embodiments, following administration of the FXI / FXIa inhibitor for 24 weeks on top of standard of care, the subject has an improved WHO functional class. For example, at least 15%, preferably at least 20%, more preferably at least 25%, even more preferably at least 30% or more of the subjects have an improved WHO functional class.

[0102] In some embodiments, following administration of the FXI / FXIa inhibitor, the subject has a significant decrease in mean pulmonary arterial pressure (mPAP) from baseline. In some embodiments, following administration of the FXI / FXIa inhibitor for 12 weeks on top of standard of care, there is a significant decrease in mPAP from baseline. In some embodiments, following administration of the FXI / FXIa inhibitor for 24 weeks on top of standard of care, there is a significant decrease in mPAP from baseline. For example, there is a decrease in mPAP of at least 10%, preferably at least 20%, more preferably at least 30%, even more preferably at least 40% or more from baseline.

[0103] In other embodiments, the method further comprises administering to the subject an activin pathway inhibitor on top of the administration of the FXI / FXIa inhibitor. Preferably, the further comprises administering to the subject Sotatercept on top of the administration of the FXI / FXIa inhibitor.

[0104] In other embodiments, the FXI / FXIa inhibitor of the present disclosure, in combination with an activin pathway inhibitor, is used for the treatment and / or prevention of pulmonary arterial hypertension. Preferably, the FXI / FXIa inhibitor of the present disclosure, in combination with Sotatercept, is used for the treatment and / or prevention of pulmonary arterial hypertension.

[0105] Medicament for the preparation of a medicament for the treatment and / or prevention of pulmonary arterial hypertension

[0106] In a third aspect, the disclosure also relates to the use of a FXI / FXIa inhibitor for the manufacture of a medicament for the treatment and / or prevention of pulmonary arterial hypertension. For the definition of the FXI / FXIa inhibitor and pulmonary arterial hypertension, reference is made to the preceding first and second aspects. It is understood that the technical features described in the preceding methods of treatment and uses of treatment also apply to this pharmaceutical use.

[0107] In some embodiments, the disclosure also relates to the use of a FXI / FXIa inhibitor in combination with an activin pathway inhibitor for the manufacture of a medicament for the treatment and / or prevention of pulmonary arterial hypertension. Preferably, the activin pathway inhibitor is Sotatercept.

[0108] Methods and uses for the treatment of hypertension

[0109] In a fourth aspect, the disclosure provides a method for the prevention and / or treatment of hypertension, comprising administering to a subject in need thereof an effective amount of a FXI / FXIa inhibitor.

[0110] In a fifth aspect, the disclosure also relates to a class of FXI / FXIa inhibitors for use in the treatment and / or prevention of hypertension.

[0111] In a sixth aspect, the disclosure also relates to the use of a FXI / FXIa inhibitor for the manufacture of a medicament for the treatment and / or prevention of hypertension.

[0112] For the specific definition of the FXI / FXIa inhibitor, reference is made to the preceding first and second aspects.

[0113] Preferably, the FXI / FXIa inhibitor comprises a first and a second immunoglobulin single variable domain, wherein the first immunoglobulin single variable domain comprises CDR1, CDR2 and CDR3 of a VHH as set forth in SEQ ID NO: 1 (e.g. CDR1 as set forth in SEQ ID NO: 2, CDR2 as set forth in SEQ ID NO: 3 and CDR3 as set forth in SEQ ID NO: 4) and the second immunoglobulin single variable domain comprises CDR1, CDR2 and CDR3 of a VHH as set forth in SEQ ID NO: 5 (e.g. CDR1 as set forth in SEQ ID NO: 6, CDR2 as set forth in SEQ ID NO: 7 and CDR3 as set forth in SEQ ID NO: 8). More preferably, the FXI / FXIa inhibitor comprises a first and a second immunoglobulin single variable domain, wherein the first immunoglobulin single variable domain comprises the amino acid sequence as set forth in SEQ ID NO: 1 and the second immunoglobulin single variable domain comprises the amino acid sequence as set forth in SEQ ID NO: 5.

[0114] In some embodiments, the FXI / FXIa inhibitor comprises a first and a second immunoglobulin single variable domain, wherein the first immunoglobulin single variable domain consists of the amino acid sequence as set forth in SEQ ID NO: 1 and the second immunoglobulin single variable domain consists of the amino acid sequence as set forth in SEQ ID NO: 5.

[0115] In some embodiments, the first and the second immunoglobulin single variable domain are directly linked to each other.

[0116] In other embodiments, the first and the second immunoglobulin single variable domain are linked to each other via a linker. The linker can be a long 1-20 or more amino acids, a non-functional amino acid sequence without secondary structure above. For example, the linker is a flexible linker, such as GGGGS (SEQ ID NO: 12), GS, GAP, (GGGGS)3(SEQ ID NO: 13), etc.

[0117] In some embodiments, the first immunoglobulin single variable domain is located N-terminal to the second immunoglobulin single variable domain. In other embodiments, wherein the second immunoglobulin single variable domain is located N-terminal to the first immunoglobulin single variable domain.

[0118] In some embodiments, the aforementioned FXI / FXIa inhibitor comprising an immunoglobulin single variable domain can further comprise an immunoglobulin Fc region. In some embodiments, the immunoglobulin Fc region can be a human immunoglobulin Fc region, which can be an Fc region of human IgGl. For example, the immunoglobulin Fc region can comprise or consist of the amino acid sequence set forth in SEQ ID NO: 9.

[0119] In some embodiments, the FXI / FXIa inhibitor of the present disclosure comprises or consists of the amino acid sequence set forth in SEQ ID NO: 10.

[0120] Further, in some embodiments, the hypertension can be essential hypertension or secondary hypertension.

[0121] In some embodiments, the FXI / FXIa inhibitor is used or administered alone in the method for preventing and / or treating hypertension. Alternatively, the FXI / FXIa inhibitor can be used alone for treating and / or preventing hypertension. Alternatively, the FXI / FXIa inhibitor can be used alone for preparing a medicament for treating and / or preventing hypertension.

[0122] In other embodiments, the FXI / FXIa inhibitor is used or administered in combination with other anti-hypertensive drugs in the method for preventing and / or treating hypertension. Alternatively, the FXI / FXIa inhibitor can be combined with other anti-hypertensive drugs for treating and / or preventing hypertension. Alternatively, the FXI / FXIa inhibitor can be combined with other anti-hypertensive drugs for preparing a medicament for treating and / or preventing hypertension.

[0123] In some embodiments, the other anti-hypertensive drugs are selected from the group consisting of calcium channel blockers (CCB), angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), diuretics, and beta receptor blockers.

[0124] The calcium channel blockers (CCB) can be selected from the group consisting of nifedipine, amlodipine, levamlodipine, felodipine, lacidipine, nicardipine, nitrendipine, benidipine, lercanidipine, manidipine, cinaldipine, barnidipine, verapamil, and diltiazem and the like. The angiotensin converting enzyme inhibitors (ACEI) can be selected from the group consisting of captopril, enalapril, benazepril, lisinopril, ramipril, fosinopril, cilazapril, perindopril and imidapril, and the like. The angiotensin receptor blockers (ARB) can be selected from the group consisting of losartan, valsartan, irbesartan, telmisartan, candesartan, olmesartan and azilsartan medoxomil, and the like. The diuretics can be selected from the group consisting of hydrochlorothiazide, chlorthalidone, indapamide, furosemide, torsemide, amiloride and triamterene, and the like. The beta blockers can be selected from the group consisting of bisoprolol, metoprolol, atenolol, propranolol, betaxolol, labetalol, carvedilol and acebutolol, and the like.

[0125] In some embodiments, the subject is a primary hypertensive patient newly diagnosed and not yet treated; for example, the subject has improved lifestyle without taking anti-hypertensive drugs.

[0126] In other embodiments, the subject is a primary hypertensive patient who is not adequately controlled by stable monotherapy with ACEI / ARB / CCB.

[0127] In some embodiments, the subject is a male or female human being of >18 and <75 years of age.

[0128] In some embodiments, the subject has an ambulatory office blood pressure measurement (AOBP) mean sitting systolic blood pressure (SBP) of >140 and <180 mmHg, and / or a 24h ambulatory blood pressure monitoring (ABPM) mean SBP of >130 and <170 mmHg.

[0129] In some embodiments, for the foregoing methods of preventing and / or treating hypertension or uses, the FXI / FXIa inhibitor is administered once daily, once every two days, once every three days, once weekly, once every two weeks, once every three weeks, once every four weeks, once every five weeks, once every six weeks, once every seven weeks, once every eight weeks, once a month, once every two months, once every three months, once every four months, once every five months, or once every six months. For example, the FXI / FXIa inhibitor can be administered once every two weeks.

[0130] In some embodiments, the FXI / FXIa inhibitor can be administered orally, by intravenous drip or by subcutaneous injection; preferably, the FXI / FXIa inhibitor can be administered by intravenous drip.

[0131] In some embodiments, the dose of a single administration of the foregoing FXI / FXIa inhibitor is 0.1 mg / kg to 50.0 mg / kg of the subject's body weight, preferably 0.5 mg / kg to 30 mg / kg of the subject's body weight, more preferably 1 mg / kg to 20 mg / kg of the subject's body weight, even more preferably 2 mg / kg to 10 mg / kg of the subject's body weight; for example, 0.1 mg / kg, 0.2 mg / kg, 0.3 mg / kg, 0.4 mg / kg, 0.5 mg / kg, 0.6 mg / kg, 0.7 mg / kg, 0.8 mg / kg, 0.9 mg / kg, 1.0 mg / kg, 1.1 mg / kg, 1.2 mg / kg, 1.3 mg / kg, 1.4 mg / kg, 1.5 mg / kg, 1.6 mg / kg, 1.7 mg / kg, 1.8 mg / kg, 1.9 mg / kg, 2.0 mg / kg, 2.1 mg / kg, 2.2 mg / kg, 2.3 mg / kg, 2.4 mg / kg, 2.5 mg / kg, 2.6 mg / kg, 2.7 mg / kg, 2.8 mg / kg, 2.9 mg / kg, 3.0 mg / kg, 3.1 mg / kg, 3.2 mg / kg, 3.3 mg / kg, 3.4 mg / kg, 3.5 mg / kg, 3.6 mg / kg, 3.7 mg / kg, 3.8 mg / kg, 3.9 mg / kg, 4.0 mg / kg, 4.1 mg / kg, 4.2 mg / kg, 4.3 mg / kg, 4.4 mg / kg, 4.5 mg / kg, 4.6 mg / kg, 4.7 mg / kg, 4.8 mg / kg, 4.9 mg / kg, 5.0 mg / kg, 5.1 mg / kg, 5.2 mg / kg, 5.3 mg / kg, 5.4 mg / kg, 5.5 mg / kg, 5.6 mg / kg, 5.7 mg / kg, 5.8 mg / kg, 5.9 mg / kg, 6.0 mg / kg, 6.1 mg / kg, 6.2 mg / kg, 6.3 mg / kg, 6.4 mg / kg, 6.5 mg / kg, 6.6 mg / kg, 6.7 mg / kg, 6.8 mg / kg, 6.9 mg / kg, 7.0 mg / kg, 7.1 mg / kg, 7.2 mg / kg, 7.3 mg / kg, 7.4 mg / kg, 7.5 mg / kg, 7.6 mg / kg, 7.7 mg / kg, 7.8 mg / kg, 7.9 mg / kg, 8.0 mg / kg, 8.1 mg / kg, 8.2 mg / kg, 8.3 mg / kg, 8.4 mg / kg, 8.5 mg / kg, 8.6 mg / kg, 8.7 mg / kg, 8.8 mg / kg, 8.9 mg / kg, 9.0 mg / kg, 9.1 mg / kg, 9.2 mg / kg, 9.3 mg / kg, 9.4 mg / kg, 9.5 mg / kg, 9.6 mg / kg, 9.7 mg / kg, 9.8 mg / kg, 9.9 mg / kg, 10.0 mg / kg, 10.1 mg / kg, 10.2 mg / kg, 10.3 mg / kg, 10.4 mg / kg, 10.5 mg / kg, 10.6 mg / kg, 10.7 mg / kg, 10.8 mg / kg, 10.9 mg / kg, 11.0 mg / kg, 11.1 mg / kg, 11.2 mg / kg, 11.3 mg / kg, 11.4 mg / kg, 11.5 mg / kg, 11.6 mg / kg, 11.7 mg / kg, 11.8 mg / kg, 11.9 mg / kg, 12.0 mg / kg, 12.1 mg / kg, 12.2 mg / kg, 12.3 mg / kg, 12.4 mg / kg, 12.5 mg / kg, 12.6 mg / kg, 12.7 mg / kg, 12.8 mg / kg, 12.9 mg / kg, 13.0 mg / kg, 13.1 mg / kg, 13.2 mg / kg, 13.3 mg / kg, 13.4 mg / kg, 13.5 mg / kg, 13.6 mg / kg, 13.7 mg / kg, 13.8 mg / kg, 13.9 mg / kg, 14.0 mg / kg, 14.1 mg / kg, 14.2 mg / kg, 14.3 mg / kg, 14.4 mg / kg, 14.5 mg / kg, 14.6 mg / kg, 14.7 mg / kg, 14.8 mg / kg, 14.9 mg / kg, 15.0 mg / kg, 15.1 mg / kg, 15.2 mg / kg, 15.3 mg / kg, 15.4 mg / kg, 15.5 mg / kg, 15.6 mg / kg, 15.7 mg / kg, 15.8 mg / kg, 15.9 mg / kg, 16.0 mg / kg, 16.1 mg / kg, 16.2 mg / kg, 16.3 mg / kg, 16.4 mg / kg, 16.5 mg / kg, 16.6 mg / kg, 16.7 mg / kg, 16.8 mg / kg, 16.9 mg / kg, 17.0 mg / kg, 17.1 mg / kg, 17.2 mg / kg, 17.3 mg / kg, 17.4 mg / kg, 17.5 mg / kg, 17.6 mg / kg, 17.7 mg / kg, 17.8 mg / kg, 17.9 mg / kg, 18.0 mg / kg, 18.1 mg / kg, 18.2 mg / kg, 18.3 mg / kg, 18.4 mg / kg, 18.5 mg / kg, 18.6 mg / kg, 18.7 mg / kg, 18.8 mg / kg, 18.9 mg / kg, 19.0 mg / kg, 19.1 mg / kg, 19.2 mg / kg, 19.3 mg / kg, 19.4 mg / kg, 19.5 mg / kg, 19.6 mg / kg, 19.7 mg / kg, 19.8 mg / kg, 19.9 mg / kg, 20.0 mg / kg, 20.1 mg / kg, 20.2 mg / kg, 20.3 mg / kg, 20.4 mg / kg, 20.5 mg / kg, 20.6 mg / kg, 20.7 mg / kg, 20.8 mg / kg, 20.9 mg / kg, 21.0 mg / kg, 21.1 mg / kg, 21.2 mg / kg, 21.3 mg / kg, 21.4 mg / kg, 21.5 mg / kg, 21.6 mg / kg, 21.7 mg / kg, 21.8 mg / kg, 21.9 mg / kg, 22.0 mg / kg, 22.1 mg / kg, 22.2 mg / kg, 22.3 mg / kg, 22.4 mg / kg, 22.5 mg / kg, 22.6 mg / kg, 22.7 mg / kg, 22.8 mg / kg, 22.9 mg / kg, 23.0 mg / kg, 23.1 mg / kg, 23.2 mg / kg, 23.3 mg / kg, 23.4 mg / kg, 23.5 mg / kg, 23.6 mg / kg, 23.7 mg / kg, 23.8 mg / kg, 23.9 mg / kg, 24.0 mg / kg, 24.1 mg / kg, 24.2 mg / kg, 24.3 mg / kg, 24.4 mg / kg, 24.5 mg / kg, 24.6 mg / kg, 24.7 mg / kg, 24.8 mg / kg, 24.9 mg / kg, 25.0 mg / kg, 25.1 mg / kg, 25.2 mg / kg, 25.3 mg / kg, 25.4 mg / kg, 25.5 mg / kg, 25.6 mg / kg, 25.7 mg / kg, 25.8 mg / kg, 25.9 mg / kg, 26.0 mg / kg, 26.1 mg / kg, 26.2 mg / kg, 26.3 mg / kg, 26.4 mg / kg, 26.5 mg / kg, 26.6 mg / kg, 26.7 mg / kg, 26.8 mg / kg, 26.9 mg / kg, 27.0 mg / kg, 27.1 mg / kg, 27.2 mg / kg, 27.3 mg / kg, 27.4 mg / kg, 27.5 mg / kg, 27.6 mg / kg, 27.7 mg / kg, 27.8 mg / kg, 27.7 mg / kg, 9.8 mg / kg, 9.9 mg / kg, 10.0 mg / kg, 10.5 mg / kg, 11.0 mg / kg, 11.5 mg / kg, 12.0 mg / kg, 12.5 mg / kg, 13.0 mg / kg, 13.5 mg / kg, 14.0 mg / kg, 14.5 mg / kg, 15.0 mg / kg, 15.5 mg / kg, 16.0 mg / kg, 16.5 mg / kg, 17.0 mg / kg, 17.5 mg / kg, 18.0 mg / kg, 18.5 mg / kg, 19.0 mg / kg, 19.5 mg / kg, 20.0 mg / kg of the subject's body weight.

[0132] In some embodiments, the FXI / FXIa inhibitor is administered once every two weeks at 2 mg / kg to 10 mg / kg of the subject's body weight, the FXI / FXIa inhibitor comprising a first immunoglobulin single variable domain as set forth in SEQ ID NO: 1 and a second immunoglobulin single variable domain as set forth in SEQ ID NO: 5.

[0133] In some embodiments, the FXI / FXIa inhibitor is administered once every two weeks at 5 mg / kg of the subject's body weight, the FXI / FXIa inhibitor comprising an amino acid sequence as set forth in SEQ ID NO: 10.

[0134] In some embodiments of the foregoing methods, the mean systolic blood pressure (SBP) of the subject as measured by 24-hour ambulatory blood pressure monitoring (ABPM) is significantly decreased from baseline after administration of the FXI / FXIa inhibitor. In some embodiments, the mean systolic blood pressure (SBP) of the subject as measured by 24-hour ambulatory blood pressure monitoring (ABPM) is significantly decreased from baseline after 12 weeks of treatment with the FXI / FXIa inhibitor. For example, the mean systolic blood pressure (SBP) as measured by 24-hour ambulatory blood pressure monitoring (ABPM) is decreased by at least 5 mmHg, preferably at least 10 mmHg, more preferably at least 15 mmHg, even more preferably at least 20 mmHg or more, from baseline. For another example, the mean systolic blood pressure (SBP) as measured by 24-hour ambulatory blood pressure monitoring (ABPM) is decreased by at least 5%, preferably at least 10%, more preferably at least 15%, even more preferably at least 20% or more, from baseline.

[0135] In some embodiments, the mean diastolic blood pressure (DBP) of the subjects 24h ABMP is significantly decreased from baseline after administration of the FXI / FXIa inhibitor. In some embodiments, the mean diastolic blood pressure (DBP) of the subjects 24h ABMP is significantly decreased from baseline after 12 weeks of treatment with the FXI / FXIa inhibitor. For example, the mean diastolic blood pressure (DBP) of the 24h ABMP is decreased by at least 5 mmHg, preferably by at least 10 mmHg, more preferably by at least 15 mmHg, even more preferably by at least 20 mmHg or more, from baseline. Also for example, the mean diastolic blood pressure (DBP) of the 24h ABMP is decreased by at least 5%, preferably by at least 10%, more preferably by at least 15%, even more preferably by at least 20% or more, from baseline.

[0136] In some embodiments, at least 30% or more, for example 40% or more, 50% or more, 60% or more, 70% or more, 80% or more, or 90% or more of the subjects have a decrease in ABMP nighttime mean SBP / daytime mean SBP from baseline after administration of the FXI / FXIa inhibitor. In some embodiments, at least 30% or more, for example 40% or more, 50% or more, 60% or more, 70% or more, 80% or more, or 90% or more of the subjects have a decrease in ABMP nighttime mean SBP / daytime mean SBP from baseline after 12 weeks of treatment with the FXI / FXIa inhibitor.

[0137] In some embodiments, at least 30% or more, for example 40% or more, 50% or more, 60% or more, 70% or more, 80% or more, or 90% or more of the subjects have a blood pressure goal of the ABMP after administration of the FXI / FXIa inhibitor. In some embodiments, at least 30% or more, for example 40% or more, 50% or more, 60% or more, 70% or more, 80% or more, or 90% or more of the subjects have a blood pressure goal of the ABMP after 12 weeks of treatment with the FXI / FXIa inhibitor. The blood pressure goal of the ABMP means that the 24h mean blood pressure is < 130 / 80 mmHg, the daytime (06:00-21 :30) mean blood pressure is < 135 / 85 mmHg, and the nighttime (21 :30-06:00) mean blood pressure is < 120 / 70 mmHg.

[0138] In some embodiments, following administration of the FXI / FXIa inhibitor, the subject has a significant decrease in ambulatory office blood pressure measurement (AOBP) mean sitting SBP and / or DBP from baseline. In some embodiments, following administration of the FXI / FXIa inhibitor for 12 weeks, the subject has a significant decrease in ambulatory office blood pressure measurement (AOBP) mean sitting SBP and / or DBP from baseline. For example, the ambulatory office blood pressure measurement (AOBP) mean sitting SBP and / or DBP is decreased by at least 5 mmHg, preferably by at least 10 mmHg, more preferably by at least 15 mmHg, even more preferably by at least 20 mmHg or more, from baseline. Also for example, the ambulatory office blood pressure measurement (AOBP) mean sitting SBP and / or DBP is decreased by at least 5%, preferably by at least 10%, more preferably by at least 15%, even more preferably by at least 20% or more, from baseline.

[0139] In some embodiments, following administration of the FXI / FXIa inhibitor, at least 30% or more, for example 40% or more, 50% or more, 60% or more, 70% or more, 80% or more, or 90% or more of the subjects achieve target ambulatory office blood pressure measurement (AOBP) mean sitting blood pressure. In some embodiments, following administration of the FXI / FXIa inhibitor for 12 weeks, at least 30% or more, for example 40% or more, 50% or more, 60% or more, 70% or more, 80% or more, or 90% or more of the subjects achieve target ambulatory office blood pressure measurement (AOBP) mean sitting blood pressure. The target ambulatory office blood pressure measurement (AOBP) mean sitting blood pressure means < 140 / 90 mmHg, and can further be < 130 / 80 mmHg to further reduce the rate of cardiovascular events.

[0140] Examples

[0141] I. Preparation of the test molecule

[0142] KN060 is an anti-FXI bispecific single-domain antibody fusion protein selected from a camelid immunization library, which is a homodimer formed by two identical peptide chains, wherein the amino acid sequence of the peptide chain is as follows:

[0143] Sotatercept (ACE-011) is a fusion protein composed of a type IIA activin receptor and the Fc region of human IgG1, the amino acid sequence of which is published in WHO Drug Information, Vol. 24, No. 3, 2010 Recommended INN: List 64, as follows:

[0144] RAP-011 is a murine molecule of Sotatercept, which replaces the human IgG1 Fc in Sotatercept with murine IgG2a Fc, published in Am J Hematol. 2015 Jan; 90(1): 8-14.

[0145] The above molecular sequence is genetically synthesized and cloned into a conventional mammalian expression vector to obtain a recombinant plasmid of a fusion protein for expression in mammals. The constructed plasmid is transfected into HEK293 cells for transient expression, and the target protein is purified by Protein A affinity chromatography.

[0146] Asundexian was purchased from MedChemExpress, item number HY-137431; losartan was purchased from Macklin, item number L873675.

[0147] II. Pharmacodynamic study of KN060 in a rat PAH model induced by monocrotaline

[0148] 1. Experimental grouping and drug administration design

[0149] 29 male SD rats (6-8 weeks old, purchased from Beijing Vital River Laboratory Animal Technology Co., Ltd.) were randomly divided into 6 groups (G1-sham group without modeling, n=4; G2-PAH modeling group-PBS control group, n=5; G3-PAH modeling group-KN060 3mpk group, n=5; G4-PAH modeling group-KN060 15mpk group, n=5; G5-PAH modeling group-RAP-011 1mpk positive control group, n=5; G6-PAH modeling group-asundexian 5mpk group, n=5). The specific grouping and drug administration scheme are shown in Table 1.

[0150] Table 1

[0151] 2. Animal administration and modeling

[0152] All animals except those in group 1 were subjected to PAH modeling. Modeling and first administration were performed on the same day. One hour before modeling, the first administration was performed. Group G1 and G2 animals were injected intraperitoneally with PBS as controls, group G3 and G4 animals were given KN060 at 3mpk / kg and 15mg / kg intravenously, respectively, group G5 animals were injected intraperitoneally with RAP-011 at 1mg / kg, and group G6 animals were injected intraperitoneally with Asundexian at 5mg / kg. One hour after administration, the sham group animals were injected subcutaneously with PBS control on the back of the neck, and the remaining 5 PAH modeling groups were injected subcutaneously with monocrotaline MCT (60mg / kg) in a single dose. The administration volume was 2ml / kg, which induced the PAH model in SD rats.

[0153] 3. Test endpoint detection

[0154] 1) Right ventricular catheterization for detecting right ventricular systolic pressure (RVSP): rats were anesthetized with 10% chloral hydrate (3 ml / kg, ip), fixed in supine position on the operation board, the neck hair was removed, the skin was incised, the subcutaneous tissue and muscle layer were bluntly separated, and the right jugular vein was dissected and separated. A PE catheter (outer diameter about 1.5 mm, small arc in the front segment) connected with a pressure transducer and filled with 0.3% heparin sodium solution was inserted into the right jugular vein of the rat, and whether it reached the heart position was judged according to the pressure waveform. The catheter was rotated to the left and pushed forward into the right ventricle to detect RVSP.

[0155] 2) Right ventricular hypertrophy index (RVHI) detection: after the animals were euthanized, the heart was dissected and removed, the atrium and large vessels were removed, the water was absorbed with filter paper, the right ventricle was stripped and weighed, and the RVHI was calculated as RVHI = right ventricular weight / (left ventricular weight + interventricular septum weight) * 100%.

[0156] 3) The middle lobe of the left lung of the rat was dissected and the tissue at the hilar site was fixed with 10% formalin, routinely embedded in paraffin, HE stained, and the percentage of pulmonary arteriole vascular wall thickness (PAWT%) = (vessel outer diameter - inner diameter) ÷ 2 ÷ vessel outer diameter * 100% was analyzed.

[0157] 4. Experimental results

[0158] 1) After MCT modeling, the RVSP of the model group animals was significantly higher than that of the non-model animals (G2: 83.4 ± 0.8 mmHg vs G1: 37.2 ± 0.9 mmHg), and after treatment with KN060, RAP-011 and Asundexian, the RVSP was reduced compared with G2 group, and there was statistical significance, among which the average RVSP of G3, G4, G5 and G6 groups was 65.4 ± 3.1 mmHg, 56.0 ± 3.7 mmHg, 51.6 ± 4.2 mmHg and 52.8 ± 3.3 mmHg, respectively.

[0159] 2) In terms of RVHI, after MCT modeling, the RVHI of the model group animals was significantly higher than that of the non-model animals (G2: 69.3 ± 2.3% vs G1: 23.5 ± 2.4%), and after treatment with KN060, RAP-011 and Asundexian, the RVHI was reduced compared with G2 group, and there was statistical significance among G4, G5 and G6 groups, among which the average RVHI of G3, G4, G5 and G6 groups was 61.7 ± 2.9%, 54.7 ± 1.4%, 47.4 ± 3.1% and 53.4 ± 2.3%, respectively.

[0160] 3) PAWT% results showed that the model group animals had significant thickening of the pulmonary arteriole media after MCT modeling than the non-model animals, PAWT% G2: 23.9 ± 1.1% vs G1: 13.6 ± 1.3%, after KN060, RAP-011 and Asundexian treatment, PAWT% was reduced compared with G2 group, G5 group had significant statistical significance, as shown in Figure 3, KN060 had a dose-dependent trend to reduce the thickness of the pulmonary arteriole media. The average PAWT% of G3, G4, G5, G6 groups of animals were 21.6 ± 2.2%, 20.4 ± 1.0%, 16.6 ± 1.2%, 20.0 ± 1.0%, respectively.

[0161] III. Clinical study of KN060 in the treatment of pulmonary arterial hypertension

[0162] Purpose of the study

[0163] 1. Primary objective: To evaluate the change in pulmonary vascular resistance (PVR) by right heart catheterization (RHC) after 24 weeks of treatment with KN060 in combination with standard of care in patients with pulmonary arterial hypertension.

[0164] 2. Secondary objectives: (a) To evaluate the change in PVR by RHC after 12 weeks of treatment with KN060 in combination with standard of care in patients with pulmonary arterial hypertension compared to baseline; (b) To evaluate the change in the following parameters after 12 and 24 weeks of treatment with KN060 in combination with standard of care in patients with pulmonary arterial hypertension compared to baseline: 6-minute walk distance (6MWD), N-terminal pro-B-type natriuretic peptide (NT-proBNP), WHO functional class, mean pulmonary arterial pressure (mPAP), St. George's Respiratory Questionnaire (SGRQ); (c) To evaluate the occurrence of adverse events during treatment with KN060 in combination with standard of care; (d) To evaluate the PK / PD characteristics of KN060 in patients with PH.

[0165] Dosing regimen

[0166] PH subjects received 10 mg / kg KN060 intravenous infusion on the basis of standard of care, KN060 was given once every 4 weeks, a total of 6 times of administration.

[0167] Endpoints of the trial

[0168] 1. Primary endpoint: Change in PVR from baseline after 24 weeks of treatment with KN060 in combination with standard of care.

[0169] 2. Secondary endpoints: (a) Change from baseline in PVR at Week 12 of combination therapy with KN060; (b) Change from baseline in 6MWD, NT-proBNP, WHO functional class, mean pulmonary arterial pressure (mPAP), and SGRQ at Week 12 and Week 24 of combination therapy with KN060; (c) Incidence of adverse events during combination therapy with KN060 and follow-up period; (d) Pharmacokinetics and PD trends after multiple dosing of KN060.

[0170] Inclusion criteria

[0171] 1. Age ≥ 18.

[0172] 2. PH of confirmed diagnosis.

[0173] 3. WHO functional class II or III.

[0174] 4. Oxygen partial pressure ≥ 60 mmHg and arterial blood carbon dioxide partial pressure < 55 mmHg under 1-4 L / min oxygen flow.

[0175] 5. Mean pulmonary arterial pressure (mPAP) ≥ 50 mmHg and pulmonary vascular resistance (PVR) ≥ 5 Wood units as shown by RHC during the screening period.

[0176] 6. 6-minute walk distance (6MWD) ≥ 100 meters and ≤ 550 meters (measured twice with an interval of ≥ 4 hours but not more than 1 week, and the error between the two values is within 15%) during the screening period.

[0177] 7. Having received stable dose levels of conventional PH treatment for at least 3 months.

[0178] 8. Male subjects: agreeing to take effective contraceptive measures from the time of signing the informed consent form until 3 months after the last follow-up; effective contraceptive measures include: consistently using condoms or having undergone vasoligation and avoiding sperm donation during this period, or the partner having undergone tubal ligation or hysterectomy, having implanted an intrauterine device, etc.

[0179] 9. Women who are infertile and have no plan to have children (surgical infertility: such as hysterectomy, bilateral salpingectomy, bilateral ovariectomy; or natural menopause: amenorrhea ≥ 12 months and serum follicle-stimulating hormone (FSH) > 40 U / L).

[0180] 8. Being able to comply with the study visit schedule, understand and comply with all protocol requirements; being able to understand and provide a written informed consent form.

[0181] Four, Pharmacodynamic study of KN060 in spontaneously hypertensive rats

[0182] 1. Experimental grouping and drug administration design

[0183] The animals enrolled in the study were monitored for blood pressure for 3 consecutive days before drug administration as baseline data. The animals were purchased from Beijing Vital River Laboratory Animal Technology Co., Ltd. According to the baseline blood pressure results of the animals, 25 spontaneously hypertensive rats (SHR) aged 12-14 weeks were randomly divided into 5 groups, and the number of animals in each group is shown in the table below. In addition, 5 WKY rats were used as a blank control group, and the specific grouping and drug administration scheme are shown in Table 2.

[0184] Table 2

[0185] 2. Animal drug administration and blood pressure detection

[0186] All animals were tested for baseline blood pressure on D-3, D-2, and D-1. After grouping the animals on DO, drug administration was performed according to the above drug administration scheme, and the drug amount was calculated based on the latest body weight. The animals in groups G1-G4 were administered intravenously twice a week, and the appropriate amount of drug was accurately drawn. The needle was inserted into the vein at the distal segment of the tail vein, and all the drugs were injected at a constant speed within 1 minute. The animals in group G5 were administered orally once a day, and the drug amount was accurately drawn. The gavage needle was inserted into the animal's mouth, and the presence of negative pressure or gastric contents in the syringe confirmed that it was in the stomach. All the drugs were injected quickly. During the entire drug administration period, all animals were tested for blood pressure twice a week. Before each blood pressure test, the animals were allowed to adapt to the test environment for at least 5 minutes, and the environment was kept quiet and stable during the entire test process without disturbing the animals. The animals' systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded while the animals were in a calm state, and the mean pressure (MBP) was calculated. Blood pressure was tested 6 times at each time point, and the average value was taken as the blood pressure data at that time point.

[0187] The blood pressure index calculation formula is as follows:

[0188] Mean arterial pressure (MBP) = 1 / 3 systolic blood pressure (SBP) + 2 / 3 diastolic blood pressure (DBP);

[0189] Blood pressure change rate (%) = Dn blood pressure / D0 blood pressure * 100%;

[0190] Blood pressure reduction level (%) = 1 - blood pressure change rate (%);

[0191] Dn represents the nth day after grouping and drug administration, and D0 represents the average value of the baseline blood pressure measured 3 times before grouping and drug administration;

[0192] All data will be entered into an EXCEL document and represented as MEAN ± SEM. Experimental data were analyzed and compared using ANOVA or T-TEST two-tailed test. Statistical analysis results P<0.05 were considered statistically significant.

[0193] 3. Experimental results

[0194] The blood pressure detection results show that the blood pressure indicators of the SHR rats are obviously increased compared with the WKY rats, indicating that the SHR rat hypertension model is established. After 27 days of continuous observation, the blood pressure of the WKY rats is relatively stable, and therefore the observation and blood pressure measurement are terminated at D27.

[0195] After the losartan administration is started, the blood pressure of the SHR rats starts to show a significant downward trend, and basically reaches the maximum efficacy platform at D6. After that, the maximum efficacy platform is maintained until the 27th day of continuous administration, and therefore the administration and blood pressure monitoring are stopped at D27. At the administration endpoint of D27, the systolic pressure, diastolic pressure and mean arterial pressure of the SHR control rats in the G2 group are 205.7, 142.4 and 163.6 mmHg respectively, and the systolic pressure, diastolic pressure and mean arterial pressure of the SHR rats in the G5 losartan treatment group are 164.8, 109.5 and 129.8 mmHg respectively. The decrease of all the blood pressure indicators has statistical significance. Based on the pre-drug blood pressure as the baseline, the blood pressure change rate at different time points is calculated, and the results show that at the endpoint of D27, the systolic pressure, diastolic pressure and mean arterial pressure change rates of the SHR control rats in the G2 group are 102%, 107% and 105% respectively, and the systolic pressure, diastolic pressure and mean arterial pressure change rates of the SHR rats in the G5 losartan treatment group are 81%, 84% and 84% respectively.

[0196] After 6 weeks of treatment with 3 mg / kg and 15 mg / kg KN060 twice a week, the blood pressure of SHR rats decreased to different degrees, and the effect of 15 mg / kg KN060 was more obvious. The systolic pressure of the low-dose KN060 treatment group did not decrease significantly during the entire treatment process, and the diastolic pressure and mean arterial pressure showed a slow downward trend from the beginning of treatment D10. On test days D27 and D41, the diastolic pressure and mean arterial pressure of the G2 control group were statistically significantly lower than those of the G2 control group. In the high-dose KN060 treatment group, the blood pressure indicators showed a significant downward trend around D20. By the end of the test on D41, the systolic pressure, diastolic pressure, and mean arterial pressure of the G2 group of SHR control rats were 208.7, 146.5, and 167.3 mmHg, respectively, and the systolic pressure, diastolic pressure, and mean arterial pressure of the G4 group of KN060 15 mg / kg treatment rats were 172.5, 121.3, and 138.4 mmHg, respectively. The decrease in all blood pressure indicators was statistically significant. The blood pressure change rate at different time points was calculated based on the pre-treatment blood pressure as the baseline. The results showed that on D41, the systolic pressure, diastolic pressure, and mean arterial pressure change rates of the G2 group of SHR control rats were 103%, 110%, and 107%, respectively, and the systolic pressure, diastolic pressure, and mean arterial pressure change rates of the G4 group of KN060 15 mg / kg treatment rats were 84%, 87%, and 86%, respectively. The changes in blood pressure indicators over time for all animals are shown in Figures 4, 5, and 6.

[0197] It can be seen that the antihypertensive effect of KN060 in spontaneously hypertensive rats is dose-dependent, although the maximum antihypertensive effect of the high-dose KN060 group is similar to that of losartan, KN060 takes longer to take effect than losartan, suggesting that the antihypertensive mechanism of KN060 may differ from that of losartan, and that KN060 has clinical development value for refractory hypertension.

[0198] Five. Randomized, single-blind, placebo-controlled exploratory clinical trial to evaluate the antihypertensive efficacy and safety of KN060 in patients with essential hypertension

[0199] This study is a randomized, single-blind, placebo-controlled study to evaluate the antihypertensive efficacy and safety of KN060 in patients with essential hypertension. Sixty patients with newly diagnosed, untreated (with improved lifestyle without antihypertensive drugs) or substandard single-drug treatment with stable ACEI / ARB / CCB for essential hypertension are planned to be included in the KN060 and placebo groups, with 30 subjects in each group, to evaluate the change in blood pressure from baseline after KN060 treatment and compare it with the addition of placebo.

[0200] Purpose of the study

[0201] 1. Primary objective: In patients with essential hypertension: to compare the change from baseline in systolic blood pressure after 12 weeks of treatment with KN060 versus placebo.

[0202] 2. Secondary objectives: In patients with essential hypertension: (a) to evaluate the blood pressure control with KN060; (b) to evaluate the night blood pressure control with KN060; (c) to evaluate the safety and tolerability of KN060; (d) to evaluate the pharmacokinetic and pharmacodynamic characteristics of KN060; (e) to evaluate the immunogenicity of KN060.

[0203] Dosing regimen

[0204] Table 3

[0205] Trial endpoints

[0206] 1. Primary endpoint: Change from baseline in mean systolic blood pressure (SBP) at 24-hour ambulatory blood pressure monitoring (ABPM) after 12 weeks of treatment with KN060 or placebo.

[0207] 2. Secondary endpoints: (a) Change from baseline in mean diastolic blood pressure (DBP) at 24-hour ABPM after 12 weeks of treatment with KN060 or placebo; (b) Proportion of patients with a reduction in mean SBP at night / mean SBP during the day at ABPM after 12 weeks of treatment with KN060 or placebo; (c) Proportion of patients achieving blood pressure goal (24-hour mean blood pressure < 130 / 80 mmHg, mean blood pressure during the day (06:00-21:30) < 135 / 85 mmHg, mean blood pressure at night (21:30-06:00) < 120 / 70 mmHg) at ABPM after 12 weeks of treatment with KN060 or placebo; (d) Change from baseline in mean sitting SBP, DBP at automated office blood pressure measurement (AOBP) after 12 weeks of treatment with KN060 or placebo; (e) Proportion of patients achieving blood pressure goal (< 140 / 90 mmHg, < 130 / 80 mmHg) at AOBP after 12 weeks of treatment with KN060 or placebo; (f) Incidence of adverse events (TEAEs), serious adverse events (SAEs), treatment-related adverse events (TRAEs), etc. during the trial (treatment period and follow-up period) in each group; (g) Pharmacokinetic and pharmacodynamic characteristics of KN060 in patients with essential hypertension; (h) Immunogenicity of KN060 in patients with essential hypertension.

[0208] Inclusion criteria

[0209] 1. Male or female, aged > 18 and < 75 years;

[0210] 2. Untreated hypertensive (improved lifestyle without taking antihypertensive drugs) or receiving stable monotherapy of ACEI / ARB / CCB (stable treatment: no change in antihypertensive drugs and dose within 30 days before screening);

[0211] 3. AOBP average sitting SBP≥140 and≤180 mmHg (rest for at least 5 min before measurement, measure 3 times with an average value, interval 30-60 s), and 24h ABPM average SBP≥130 and≤170 mmHg;

[0212] 4. Male subjects: agree to take effective contraception from the time of signing the informed consent until 3 months after the last dose of KN060; effective contraception methods include: insist on the scientific use of condoms, or have vasoligation, and avoid donating sperm during this period. Or the partner has undergone tubal ligation or hysterectomy, has implanted an intrauterine device, etc.

[0213] 5. Infertile women 〔surgical infertility: such as hysterectomy, bilateral salpingectomy, bilateral oophorectomy; or natural menopause: amenorrhea≥12 months and serum follicle-stimulating hormone (FSH)>40 U / L〕;

[0214] 6. Voluntarily participate in this study and sign a written informed consent form.

[0215] Although the specific embodiments of the present disclosure are described above, those skilled in the art should understand that these are only illustrative, and various changes or modifications can be made to these embodiments without departing from the principles and essence of the present disclosure. Therefore, the protection scope of the present disclosure is defined by the appended claims.

[0216] Some sequences used in the present disclosure:

[0217] SEQ ID NO: 1 (KN060 VHH1)

[0218] SEQ ID NO: 2 (KN060 VHH1 CDR1 Kabat)

[0219] SEQ ID NO: 3 (KN060 VHH1 CDR2 Kabat)

[0220] SEQ ID NO: 4 (KN060 VHH1 CDR3 Kabat)

[0221] SEQ ID NO: 5 (KN060 VHH2)

[0222] SEQ ID NO:6 (KN060 VHH2 CDR1 Kabat)

[0223] SEQ ID NO:7 (KN060 VHH2 CDR2 Kabat)

[0224] SEQ ID NO:8 (KN060 VHH2 CDR3 Kabat)

[0225] SEQ ID NO:9 (IgG1 Fc)

[0226] SEQ ID NO:10 (KN060)

[0227] SEQ ID NO:11 (Sotatercept)

[0228] SEQ ID NO:12

[0229] SEQ ID NO:13

Claims

1. A method of treating and / or preventing pulmonary arterial hypertension, comprising administering to a subject in need thereof an effective amount of a FXI / FXIa inhibitor.

2. The method of claim 1, wherein, The FXI / FXIa inhibitor is selected from the group consisting of a small molecule drug, an antibody or an antigen-binding fragment thereof, an antisense nucleotide, and an siRNA.

3. The method of claim 1 or 2, wherein, The FXI / FXIa inhibitor is a small molecule drug; preferably, the FXI / FXIa inhibitor is selected from the group consisting of Asundexian, Milvexian, BMS-962212, Frunexian, SHR-2285, NIP003, SAL-0104, EP-7327, ONO-5450598, BMS-262084, DSR-130787, ONO-7269, ONO-7684, and pharmaceutically acceptable salts thereof.

4. The method of claim 1 or 2, wherein the FXI / FXIa inhibitor is an antibody or an antigen-binding fragment thereof; preferably, the antibody or the antigen-binding fragment thereof specifically binds to the A2 domain of FXI and / or FXIa, or the antibody or the antigen-binding fragment thereof specifically binds to the A3 domain of FXI and / or FXIa, or the antibody or the antigen-binding fragment thereof specifically binds to the catalytic domain of FXI and / or FXIa; more preferably, the antibody or the antigen-binding fragment thereof specifically binds to the A2 and A3 domains of FXI and / or FXIa.

5. The method of claim 4, wherein the FXI / FXIa inhibitor is an antibody or an antigen-binding fragment thereof selected from the group consisting of Abelacimab, KN060, MK-2060, Osocimab, REGN-7508, REGN-9933, SHR-2004, Xisomab 3G3, AB-012, SKB-336, and BEM-015, and antigen-binding fragments thereof.

6. The method of claim 1 or 2, wherein, The FXI / FXIa inhibitor comprises a first immunoglobulin single variable domain and a second immunoglobulin single variable domain, wherein the first immunoglobulin single variable domain can bind to the Apple2 binding domain of FXI, and / or the second immunoglobulin single variable domain can bind to the Apple3 binding domain of FXI.

7. The method of claim 1 or 2, the inhibitor of FXI / FXIa comprising a first immunoglobulin single variable domain and a second immunoglobulin single variable domain, wherein, The first immunoglobulin single variable domain comprises CDR1, CDR2, and CDR3 in a VHH as set forth in SEQ ID NO: 1, and the second immunoglobulin single variable domain comprises CDR1, CDR2, and CDR3 in a VHH as set forth in SEQ ID NO:

5.

8. The method of claim 7, wherein the first immunoglobulin single variable domain comprises CDR1 as set forth in SEQ ID NO: 2, CDR2 as set forth in SEQ ID NO: 3, and CDR3 as set forth in SEQ ID NO: 4; preferably, the first immunoglobulin single variable domain comprises an amino acid sequence as set forth in SEQ ID NO:

1.

9. The method of claim 7, wherein the second immunoglobulin single variable domain comprises a CDR1 as set forth in SEQ ID NO: 6, a CDR2 as set forth in SEQ ID NO: 7, and a CDR3 as set forth in SEQ ID NO: 8; preferably, the second immunoglobulin single variable domain comprises an amino acid sequence as set forth in SEQ ID NO:

5.

10. The method of any one of claims 1-2, 6-9, wherein, The FXI / FXIa inhibitor comprises a first immunoglobulin single variable domain and a second immunoglobulin single variable domain, wherein the first immunoglobulin single variable domain comprises an amino acid sequence as set forth in SEQ ID NO: 1, and the second immunoglobulin single variable domain comprises an amino acid sequence as set forth in SEQ ID NO:

5.

11. The method according to any one of claims 6-10, wherein, The FXI / FXIa inhibitor further comprises an immunoglobulin Fc region; preferably, the immunoglobulin Fc region is a human immunoglobulin Fc region; more preferably, the immunoglobulin Fc region is a human IgG1 Fc region; for example, the immunoglobulin Fc region comprises an amino acid sequence as set forth in SEQ ID NO:

9.

12. The method of any one of claims 1-2, 6-11, wherein, The FXI / FXIa inhibitor comprises an amino acid sequence as set forth in SEQ ID NO:

10.

13. The method of any one of claims 1-12, wherein, The pulmonary arterial hypertension is a pulmonary arterial hypertension (PAH).

14. The method of any one of claims 1-13, wherein the FXI / FXIa inhibitor is administered on top of a conventional treatment.

15. The method of any one of claims 1-14, wherein the FXI / FXIa inhibitor is administered once daily, once every two days, once every three days, once a week, once every two weeks, once every three weeks, once every four weeks, once every five weeks, once every six weeks, once every seven weeks, once every eight weeks, once a month, once every two months, once every three months, once every four months, once every five months, or once every six months.

16. The method of any one of claims 1-15, wherein the FXI / FXIa inhibitor is administered at a dose of 0.1 mg / kg to 50.0 mg / kg of the subject’s body weight, preferably 0.5 mg / kg to 30 mg / kg of the subject’s body weight, more preferably 1 mg / kg to 20 mg / kg of the subject’s body weight, and even more preferably 5 mg / kg to 15 mg / kg of the subject’s body weight.

17. The method of any one of claims 1-16, further comprising administering to the subject an activin pathway inhibitor; preferably, the activin pathway inhibitor is Sotatercept.

18. A FXI / FXIa inhibitor for use in the treatment and / or prevention of pulmonary arterial hypertension. Preferably, the FXI / FXIa inhibitor is as described in any one of claims 2-12; and / or, the pulmonary arterial hypertension is a pulmonary arterial hypertension (PAH).

19. Use of a FXI / FXIa inhibitor for the manufacture of a medicament for the treatment and / or prevention of pulmonary arterial hypertension. Preferably, the FXI / FXIa inhibitor is as described in any one of claims 2-12; and / or, the pulmonary arterial hypertension is a pulmonary arterial hypertension (PAH).

20. Use of a FXI / FXIa inhibitor in combination with an activin pathway inhibitor for the manufacture of a medicament for the treatment and / or prevention of pulmonary arterial hypertension; preferably, the FXI / FXIa inhibitor is as described in any one of claims 2-12; and / or, the pulmonary arterial hypertension is a pulmonary arterial hypertension; and / or, the activin pathway inhibitor is Sotatercept.

21. A method for the treatment and / or prevention of hypertension, comprising administering to a subject in need thereof an effective amount of a FXI / FXIa inhibitor; preferably, the FXI / FXIa inhibitor is as described in any one of claims 2-12.

22. The method of claim 21, wherein the hypertension is essential hypertension or secondary hypertension.

23. The method of claim 21 or 22, wherein the FXI / FXIa inhibitor is used alone; or, the FXI / FXIa inhibitor is administered concurrently with other anti-hypertensive drugs.

24. The method of any one of claims 21-23, wherein, the subject is a newly diagnosed and treatment-naive essential hypertension patient; or, the subject is a treatment-inadequate essential hypertension patient who is receiving stable monotherapy of ACEI / ARB / CCB.

25. The method of any one of claims 21-24, wherein the FXI / FXIa inhibitor is administered once daily, once every two days, once every three days, once weekly, once every two weeks, once every three weeks, once every four weeks, once every five weeks, once every six weeks, once every seven weeks, once every eight weeks, once monthly, once every two months, once every three months, once every four months, once every five months, or once every six months.

26. The method of any one of claims 21-25, wherein the FXI / FXIa inhibitor is administered at a dose of 0.1 mg / kg to 50.0 mg / kg of the subject’s body weight, preferably 0.5 mg / kg to 30 mg / kg of the subject’s body weight, more preferably 1 mg / kg to 20 mg / kg of the subject’s body weight, and even more preferably 2 mg / kg to 10 mg / kg of the subject’s body weight, in a single administration.

27. The method of any one of claims 21-26, wherein the FXI / FXIa inhibitor is administered at 2 mg / kg to 10 mg / kg of the subject’s body weight once every two weeks.

28. A FXI / FXIa inhibitor for use in the treatment and / or prevention of hypertension; preferably, the FXI / FXIa inhibitor is as described in any one of claims 2-12; and / or, the hypertension is essential hypertension or secondary hypertension.

29. Use of a FXI / FXIa inhibitor for the manufacture of a medicament for the treatment and / or prevention of hypertension; preferably, the FXI / FXIa inhibitor is as described in any one of claims 2-12; and / or, the hypertension is essential hypertension or secondary hypertension.

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