Methods for reversing ticagrelor activity

Abstract

The present disclosure provides methods for reversing ticagrelor-related bleeding in a patient by administering an antibody or fragment thereof that binds to ticagrelor.

Description

[0001] Cross - reference to related applications

[0002] This application claims the benefit of U.S. Provisional Application No. 62 / 733,892, filed on September 20, 2018, U.S. Provisional Application No. 62 / 806,225, filed on February 15, 2019, and U.S. Provisional Application No. 62 / 836,373, filed on April 19, 2019, the entire contents of each of which are incorporated herein by reference for all purposes.

[0003] Description of electronically - submitted text file

[0004] The entire contents of the electronically - submitted text file are incorporated herein by reference: a computer - readable format copy of the sequence listing (filename: PHAS_037_01WO_SeqList_ST25.txt, date of record: September 20, 2019, file size 44 kilobytes). Background of the Invention

[0005] Acute coronary syndrome (ACS) describes a series of conditions related to a sudden reduction in blood flow to the heart, including unstable angina and myocardial infarction or heart attack. ACS is caused by inappropriate clot formation in the coronary arteries. These blood clots are mainly composed of platelets, which are small lens - shaped cells found in the blood and which normally aggregate at the site of injury to help stop bleeding. According to the Centers for Disease Control and Prevention, approximately 790,000 Americans have a heart attack each year, and heart attack is the leading cause of death in developed countries.

[0006] The primary treatment for ACS is the use of anti - platelet drugs to prevent the worsening of existing clots or reduce the formation of additional clots. These clots can occur in the heart or in stents, which are placed in blocked coronary arteries to keep the blood vessels open, or in other parts of the body. Without anti - platelet drugs, patients are at a significantly increased risk of recurrent heart attack, stroke, and death. The standard of care for ACS patients is dual anti - platelet therapy or DAPT, which is a combination of aspirin and an inhibitor of a specific receptor called P2Y 12 receptor found on platelets. This combination, initiated after a patient experiences a heart attack or other manifestation of ACS, has been shown to significantly reduce platelet aggregation and clot formation, and reduce the frequency of recurrent heart attack, stroke, and death.

[0007] Although the antiplatelet drugs used in DAPT therapy have proven effective in improving overall outcomes in ACS patients, their suppression of blood clotting increases the risk of major bleeding in patients. Bleeding events in patients under antiplatelet therapy that occur spontaneously or due to injury or surgery are classified as mild or severe. In the Platelet Inhibition and Patient Outcomes (PLATO) clinical trial of 18,000 patients conducted by AstraZeneca, ticagrelor was shown to be superior to the antiplatelet drug clopidogrel, sold under the trade name Plavix, in reducing recurrent heart attacks, strokes, and death in ACS patients (Wallentin et al. 2009). However, in both treatment groups, 11% to 12% of the patients in the trial experienced major bleeding events, and in 5.8% of the patients, these major bleeding events were fatal or life-threatening. The causes of bleeding varied in the trial population. In approximately 3% of the patients treated with ticagrelor, the major bleeding events were spontaneous and unrelated to any medical procedure, while approximately 9% of the patients treated with ticagrelor developed major bleeding that was related to procedures such as coronary artery bypass grafting or CABG (Wallentin et al. 2009). Although the trial protocol recommended that patients who needed CABG stop taking ticagrelor one to three days before surgery, nearly half of all ticagrelor patients needed emergency surgery and could not wait up to three days for the effects of ticagrelor to dissipate so that normal blood clotting could resume. Overall, up to 80% of CABG patients in this trial experienced major or life-threatening bleeding events related to surgery, and for patients who needed emergency surgery and could not wait three days for ticagrelor washout, approximately 50% experienced fatal or life-threatening bleeding events (Held et al., 2011). While some of this risk is likely related to the patient's underlying condition, the overall bleeding risk is significantly increased by antiplatelet drugs, and the current prescribing information for ticagrelor in the United States recommends suspending ticagrelor treatment five days before surgery.

[0008] Despite the increased bleeding risk, antiplatelet drugs, along with anticoagulant drugs used to prevent clots in veins, represent some of the most widely prescribed drugs in the United States due to their life-saving effects. Although both classes of drugs increase the risk of bleeding, reversal agents have been developed for anticoagulant drugs, but to date, no reversal agent exists for antiplatelet drugs. In the absence of a reversal agent, physicians have limited treatment options and sometimes administer platelet transfusions that are unproven in this context. In cases of major bleeding and in situations where urgent surgery or other medical interventions related to bleeding are needed, the ability to rapidly reverse ticagrelor's antiplatelet activity and restore normal clotting will increase its safety.

[0009] The three oral antiplatelet P2Y 12 receptor antagonist drugs prescribed in DAPT therapy are clopidogrel, marketed under the trade name Plavix, prasugrel, marketed under the trade name Effient, and ticagrelor, marketed under the trade names Brilinta and Brilique. Unlike clopidogrel and prasugrel, which bind permanently and inhibit the target receptor on platelets, ticagrelor binds to the P2Y 12 receptor in a transient manner, rapidly cycling on and off the receptor. This transient binding of ticagrelor presents a unique opportunity to develop a specific reversal agent for ticagrelor, while the permanent binding of other drugs to the receptor has hampered the development of reversal agents.

[0010] Ticagrelor is regarded as the best-in-class P2Y 12 antiplatelet agent because it has demonstrated superior efficacy compared to clopidogrel. However, the side effects of ticagrelor treatment may cause spontaneous bleeding. Further, due to its antiplatelet activity, ticagrelor treatment may be dangerous in patients requiring emergency surgery and result in increased blood loss.

[0011] Ticagrelor can also be used in patients with unstable angina, stable ischemic heart disease, sickle cell disease including pediatric patients, atrial fibrillation, coronary artery disease, peripheral artery disease, ischemic stroke, patients with one or more coronary stents, patients with carotid stents, patients with stents after intracranial aneurysms, patients with arteriovenous fistulas created for hemodialysis. Ticagrelor can also be used in patients with type 2 diabetes. SUMMARY OF THE INVENTION

[0012] The present disclosure provides a method of using a human Fab fragment to reverse ticagrelor activity, the human Fab fragment binding to ticagrelor with high affinity and specificity to reverse ticagrelor's antiplatelet activity.

[0013] In some aspects, the present disclosure provides a method of reversing ticagrelor-related bleeding or the risk of such bleeding in a patient in need thereof, comprising administering to the patient a composition comprising a pharmaceutically effective amount of a pharmaceutical composition comprising an antibody or fragment thereof that binds to ticagrelor ((1 S ,2 S ,3 R ,5 S )-3-[7-{[(1 R ,2 S )-2-(3,4-difluorophenyl)cyclopropyl]amino}-5-(propylthio)-3 H -[1,2,3]triazolo[4,5- d pyrimidin-3-yl]-5-(2-hydroxyethoxy)cyclopent-1,2-diol), or a metabolite or derivative thereof.

[0014] In some embodiments, the antibody or fragment thereof comprises a combination of complementarity determining regions (CDRs) selected from:

[0015] a) SEQ ID NO:53 (VH CDR1), SEQ ID NO:54 (VH CDR2), SEQ ID NO:55 (VHCDR3), SEQ ID NO:58 (VL CDR1), SEQ ID NO:59 (VL CDR2), and SEQ ID NO:60 (VL CDR3);

[0016] b) SEQ ID NO:63 (VH CDR1), SEQ ID NO:64 (VH CDR2), SEQ ID NO:65 (VHCDR3), SEQ ID NO:68 (VL CDR1), SEQ ID NO:69 (VL CDR2), and SEQ ID NO:70 (VL CDR3); and

[0017] c) SEQ ID NO:73 (VH CDR1), SEQ ID NO:74 (VH CDR2), SEQ ID NO:75 (VHCDR3), SEQ ID NO:78 (VL CDR1), SEQ ID NO:79 (VL CDR2), and SEQ ID NO:80 (VL CDR3).

[0018] In some embodiments, the antibody or fragment thereof comprises a combination of heavy chain variable region (VH) and light chain variable region (VL) sequences selected from SEQ ID NO:52 and SEQ ID NO:57; SEQ ID NO:62 and SEQ ID NO:67; and SEQ ID NO:72 and SEQ ID NO:77.

[0019] In some embodiments, ticagrelor has been administered to a patient prior to administration of the anti-ticagrelor antibody or fragment thereof.

[0020] In some embodiments, the antibody or fragment thereof is a Fab, and a dose of about 1 g to about 48 g is administered to the patient. In some embodiments, the dose is about 9 g to about 18 g of Fab. In some embodiments, a dose of about 1 g, about 3 g, about 9 g, about 18 g, about 24 g, about 30 g, about 36 g or about 48 g of Fab is administered to the patient.

[0021] In some embodiments, the pharmaceutical composition is administered intravenously to the patient. In some embodiments, the pharmaceutical composition is administered intravenously over about 15 minutes to about 36 hours.

[0022] In some embodiments, the pharmaceutical composition is administered in two or more segments. In some embodiments, the first segment is a bolus injection. In some embodiments, the administration rate of each segment is different. In some embodiments, for successive infusion segments, the administration rate of each segment is different. In some embodiments, the pharmaceutical composition is administered in three or more segments, wherein for successive infusion segments, the administration rate of each segment is different. In some embodiments, the pharmaceutical composition is administered according to the following schedule: 12 g is infused over 10 minutes, followed by 12 g infused over 6 hours, followed by 12 g infused over 18 hours.

[0023] In some embodiments, the pharmaceutical composition comprises about 50 mg / mL to about 200 mg / mL of anti-ticagrelor antibody or fragment thereof, about 5 mM to about 50 mM histidine / histidine hydrochloride buffer, about 100 mM to about 300 mM sucrose, and about 0.01% (w / v) to about 1.0% (w / v) polysorbate 80, pH 5.5 to 6.5. In some embodiments, the pharmaceutical formulation comprises 100 mg / mL of anti-ticagrelor antibody or fragment thereof, 25 mM histidine / histidine hydrochloride buffer, 290 mM sucrose, and 0.05% (w / v) polysorbate 80, pH 6.0. In some embodiments, the pharmaceutical formulation is diluted in isotonic saline for administration.

[0024] In some embodiments, ticagrelor-related bleeding is major bleeding. In some embodiments, major bleeding is characterized as life-threatening, likely to result in clinically significant disability, requiring surgery to control bleeding, requiring treatment with blood products, or acute bleeding associated with a clinically important decline in hemoglobin. In some embodiments, the patient requires surgery or intervention. In some embodiments, the patient requires urgent surgery or intervention. In some embodiments, urgent surgery or intervention is known to be associated with a significant bleeding risk such as coronary artery bypass surgery, which has adverse surgical outcomes in neurosurgery, ophthalmology, or joint replacement surgery if bleeding is not carefully controlled, is associated with the risk of experiencing perioperative events; or in patients who are at high risk of thrombosis if dual antiplatelet therapy is discontinued preoperatively. In some embodiments, the patient requires elective surgery or intervention known to be associated with a significant bleeding risk. In some embodiments, the patient is at risk of developing acute coronary syndrome (ACS) or has been diagnosed with acute coronary syndrome (ACS). In some embodiments, the patient is at risk of developing a disease selected from the following or has been diagnosed with a disease selected from the following: myocardial infarction (MI), unstable angina, stable ischemic heart disease, sickle cell disease including pediatric patients, atrial fibrillation, coronary artery disease, peripheral artery disease, ischemic stroke, one or more coronary stents, carotid stents, stents after intracranial aneurysms, and arteriovenous fistulas created for hemodialysis.

[0025] In some embodiments, the patient is a pediatric patient. In some embodiments, the pediatric patient is less than 18 years old. In some embodiments, the pediatric patient is less than 2 years old.

[0026] In some embodiments, the patient is an adult patient. In some embodiments, the adult patient is 18 to 64 years old, inclusive. In some embodiments, the patient is over 64 years old. In some embodiments, the patient is 65 to 80 years old, inclusive.

[0027] In some embodiments, aspirin (acetylsalicylic acid) has been administered to the patient.

[0028] In some embodiments, administration of an antibody or fragment thereof reverses ticagrelor activity. In some embodiments, administration of an antibody or fragment thereof restores platelet function. In some embodiments, administration of an antibody or fragment thereof restores platelet aggregation. In some embodiments, administration of an antibody or fragment thereof restores platelet aggregation to at least 80% of baseline. In some embodiments, administration of an antibody or fragment thereof restores platelet aggregation within 1 minute to 60 minutes of administration. In some embodiments, administration of an antibody or fragment thereof restores platelet aggregation within 5 minutes of administration. In some embodiments, administration of an antibody or fragment thereof provides a sustained restoration of platelet aggregation. In some embodiments, the restoration of platelet aggregation persists for at least 12 hours after administration. In some embodiments, the restoration of platelet aggregation persists for at least 16 hours after administration. In some embodiments, the restoration of platelet aggregation persists for at least 24 hours after administration.

[0029] In some embodiments, ticagrelor has been administered to a patient along with one or more additional drugs that affect ticagrelor exposure in the patient. In some embodiments, ticagrelor and one or more additional drugs have been administered to a patient, the drugs inhibiting cytochrome P450 isoform 3A (CYP3A) activity, resulting in increased exposure to ticagrelor. In some embodiments, ticagrelor and one or more additional drugs have been administered to a patient, the drugs inducing CYP3A activity, resulting in decreased exposure to ticagrelor.

[0030] In some embodiments, a patient has taken an overdose of ticagrelor. BRIEF DESCRIPTION OF THE DRAWINGS

[0031] Figure 1 The structures of ticagrelor and metabolites of ticagrelor are shown.

[0032] Figure 2 Mean platelet aggregation inhibition (IPA) in Group 4 is shown. Intravenous administration of 1 g of PB2452 does not reverse the effect of ticagrelor.

[0033] Figure 3 Mean platelet aggregation inhibition (IPA) in Groups 4 and 6 is shown. Intravenous administration of 3 g or 9 g of PB2452 over 30 minutes results in complete restoration of platelet function up to 30 minutes.

[0034] Figure 4 Platelet aggregation inhibition (IPA) in Group 7 is shown. Administration of PB2452 results in 16-hour ticagrelor reversal.

[0035] Figure 5Shows platelet aggregation inhibition (IPA) in groups 8, 9, and 10. Administration of PB2452 caused reversal of ticagrelor for approximately 24 hours.

[0036] Figure 6A -Panel B shows an exemplary enrollment and study flow chart. Healthy subjects were screened and randomized according to the shown flow chart. To ensure randomization of all groups for each dose group, an excess number of subjects were screened prior to enrollment in each group (Panel A). The subject admission, randomization, and discharge schedule is shown in Panel B.

[0037] Figure 7A -Panel B shows the onset and duration of ticagrelor reversal. Shown is the increase in platelet aggregation measured by LT245 observed in the PB2452 and placebo groups (groups 4 - 6) following intravenous administration of escalating doses of PB2452 for 30 minutes (Panel A). A fixed 18 g dose of PB2452 was administered to subjects in groups 7 - 10, with infusion durations of 8, 12, and 16 hours in groups 7, 8, and 9 / 10, respectively (Panel B). The -48 hour time point shows platelet aggregation prior to ticagrelor administration.

[0038] Figure 8A -Panel B shows the onset and duration of ticagrelor reversal by VerifyNow and VASP ELISA. Shown is the mean platelet function analysis for subjects in groups 7 - 10 treated with PB2452 (open markers) or placebo (solid circles) measured at multiple time points before and after PB2452 (or placebo) infusion. Time 0 represents the mean platelet function 48 hours after pretreatment with ticagrelor but before PB2452 infusion. The mean platelet aggregation (PRU) measured by VerifyNow is shown in Panel A. The mean VASP ELISA PRI is shown in Panel B.

[0039] Figure 9A -Panel C shows correlation analysis between platelet function assays measured by LTA, VerifyNow, and VASP ELISA. Pearson and Spearman correlation analyses were performed between aggregation measured by LTA and VerifyNow PRU (Panel A), between aggregation measured by LTA and VASP ELISA PRI (Panel B), and between VerifyNow PRU and VASP ELISA PRI (Panel C). All time points were included. The r value represents the correlation coefficient. For all analyses, P < 0.0001.

[0040] Figure 10A-C shows the normalization of normal platelet function after PB2452 administration. The degree of reversal delivered by PB2452 was evaluated by comparing platelet function at multiple time points after PB2452 with the baseline platelet function evaluated in all subjects before ticagrelor pre-treatment (-48 hours). For platelet aggregation evaluated by LTA, normal platelet function after reversal was considered as ≥80% of the baseline platelet aggregation, as shown by the dashed line (A). For VerifyNow platelet reactivity units (PRU), normal platelet function after reversal was considered as ≥180 PRU, as shown by the dashed line (B). For P2Y12 receptor signaling measured by VASP platelet reactivity index (PRI), normal platelet function after reversal was considered as ≥80% of the baseline PRI, as shown by the dashed line (C).

[0041] Figure 11A -D shows the pharmacokinetics of PB2452 and ticagrelor. Shown are the circulating drug concentrations of escalating doses of PB2452 over time in groups 4, 5, and 6 (A), the circulating drug concentrations of total ticagrelor over time in groups 4, 5, and 6 (B), the circulating drug concentrations of a fixed 18 g dose of PB2452 with extended infusion times over time in groups 7 - 10 (C), and the circulating drug concentrations of total ticagrelor over time in groups 7 - 10 (D).

[0042] Figure 12A -B shows platelet aggregation with low-dose ADP. Shown are the mean platelet aggregation data of groups 7 - 10 measured by LTA using 5 µM ADP as the P2Y 12 agonist (A), and the mean platelet aggregation data of groups 7 - 10 using 20 µM ADP as the P2Y 12 agonist (B). Detailed Description

[0043] Ticagrelor acts by binding to the P2Y 12 receptor on platelets, thereby preventing adenosine diphosphate or ADP from causing platelet aggregation. Ticagrelor binds transiently to the P2Y 12 receptor, cycling on and off, allowing an anti-ticagrelor agent such as PB2452 (a human Fab fragment that binds to ticagrelor) to bind to free ticagrelor, thereby preventing receptor activation of ticagrelor and removing ticagrelor from the circulation. With ticagrelor bound to PB2452 or removed, ADP can once again bind to the P2Y 12 receptor and induce platelet aggregation.

[0044] Anti - ticagrelor agent

[0045] In some aspects, the present disclosure provides an agent that binds to ticagrelor ((1 S ,2 S ,3 R ,5 S )-3-[7-{[(1 R ,2 S )-2-(3,4-difluorophenyl)cyclopropyl]amino}-5-(propylthio)-3 H -[1,2,3]-triazolo[4,5- d pyrimidin-3-yl]-5-(2-hydroxyethoxy)cyclopentane-1,2-diol), or a metabolite or derivative thereof.

[0046] In some embodiments, ticagrelor and / or its metabolite is depicted in Figure 1 . In some embodiments, the ticagrelor metabolite is an active metabolite.

[0047] In some aspects, the agent that binds to ticagrelor and / or its metabolite is an antibody or a fragment thereof. In some embodiments, the antibody or fragment thereof is selected from, but not limited to, polyclonal antibodies, monoclonal antibodies, humanized antibodies, human antibodies, single-chain Fv (scFv), single-domain antibodies, Fab, F(ab')2, single-chain diabodies, antibody mimetics, antibody variable domains, camel antibodies (also referred to as V HH or nanobodies). In some embodiments, the antibody comprises an scFv. In some embodiments, the antibody or fragment thereof comprises a Fab. In some embodiments, the antibody mimetic is an adnectin molecule, an affibody molecule, an affilin molecule, an affimer molecule, an affitin molecule, an alphabody molecule, an anticalin molecule, an aptamer molecule, an armadillo repeat protein molecule, an atrimer molecule, an avimer molecule, a designed ankyrin repeat protein (DARPin) molecule, a fynomer molecule, a knottin molecule, a Kunitz domain inhibitor molecule, a monomer, a nanoCLAMP molecule or a nanofitin molecule.

[0048] In a further embodiment of the above aspects and embodiments, the antibody or fragment thereof comprises a heavy chain variable region (VH) sequence selected from SEQ ID NO:2, SEQ ID NO:12, SEQ ID NO:22, SEQ ID NO:32, SEQ ID NO:42, SEQ ID NO:52, SEQ ID NO:62, and SEQ ID NO:72; and a light chain variable region (VL) sequence selected from SEQ ID NO:7, SEQ ID NO:17, SEQ ID NO:27, SEQ ID NO:37, SEQ ID NO:47, SEQ ID NO:57, SEQ ID NO:67, and SEQ ID NO:77. In some embodiments, the antibody comprises a combination of VH and VL sequences selected from: SEQ ID NO:2 and SEQ ID NO:7; SEQ ID NO:12 and SEQ ID NO:17; SEQ ID NO:22 and SEQ ID NO:27; SEQ ID NO:32 and SEQ ID NO:37; SEQ ID NO:42 and SEQ ID NO:47; SEQ ID NO:52 and SEQ ID NO:57; SEQ ID NO:62 and SEQ ID NO:67; and SEQ ID NO:72 and SEQ ID NO:77. In a further embodiment, the antibody comprises a combination of VH and VL selected from SEQ ID NO:52 and SEQ ID NO:57; SEQ ID NO:62 and SEQ ID NO:67; and SEQ ID NO:72 and SEQ ID NO:77.

[0049] In a further embodiment of the above aspects and embodiments, the antibody or fragment thereof comprises framework regions (FRs) of the heavy chain variable region and the light chain variable region, and complementarity determining regions (CDRs) 1, 2, and 3, wherein the CDR1, CDR2, and CDR3 sequences of the heavy chain variable region comprise SEQ ID NO:3 (CDR1), SEQ ID NO:4 (CDR2), and SEQ ID NO:5 (CDR3); SEQ ID NO:13 (CDR1), SEQ ID NO:14 (CDR2), and SEQ ID NO:15 (CDR3); SEQ ID NO:23 (CDR1), SEQ ID NO:24 (CDR2), and SEQ ID NO:25 (CDR3); SEQ ID NO:33 (CDR1), SEQ ID NO:34 (CDR2), and SEQ ID NO:35 (CDR3); SEQ ID NO:43 (CDR1), SEQ ID NO:44 (CDR2), and SEQ ID NO:45 (CDR3); SEQ ID NO:53 (CDR1), SEQ ID NO:54 (CDR2), and SEQ ID NO:55 (CDR3); SEQ ID NO:63 (CDR1), SEQ ID NO:64 (CDR2), and SEQ ID NO:65 (CDR3); or SEQ ID NO:73 (CDR1), SEQ ID NO:74 (CDR2), and SEQ ID NO:75 (CDR3); and wherein the CDR1, CDR2, and CDR3 sequences of the light chain variable region comprise SEQ ID NO:8 (CDR1), SEQ ID NO:9 (CDR2), and SEQ ID NO:10 (CDR3); SEQ ID NO:18 (CDR1), SEQ ID NO:19 (CDR2), and SEQ ID NO:20 (CDR3); SEQ ID NO:28 (CDR1), SEQ ID NO:29 (CDR2), and SEQ ID NO:30 (CDR3); SEQ ID NO:38 (CDR1), SEQ ID NO:39 (CDR2), and SEQ ID NO:40 (CDR3); SEQ ID NO:48 (CDR1), SEQ ID NO:49 (CDR2), and SEQ ID NO:50 (CDR3); SEQ ID NO:58 (CDR1), SEQ ID NO:59 (CDR2), and SEQ ID NO:60 (CDR3);SEQ ID NO:68 (CDR1), SEQ ID NO:69 (CDR2), and SEQ ID NO:70 (CDR3); or SEQ ID NO:78 (CDR1), SEQ ID NO:79 (CDR2), and SEQ ID NO:80 (CDR3). In a further embodiment, the antibody comprises a combination of CDR regions selected from: SEQ ID NO:53 (VH CDR1), SEQ ID NO:54 (VH CDR2), SEQ ID NO:55 (VH CDR3), SEQ ID NO:58 (VL CDR1), SEQ ID NO:59 (VL CDR2), and SEQ ID NO:60 (VL CDR3); SEQ ID NO:63 (VH CDR1), SEQ ID NO:64 (VH CDR2), SEQ ID NO:65 (VH CDR3), SEQ ID NO:68 (VL CDR1), SEQ ID NO:69 (VL CDR2), and SEQ ID NO:70 (VL CDR3); and SEQ ID NO:73 (VH CDR1), SEQ ID NO:74 (VH CDR2), SEQ ID NO:75 (VH CDR3), SEQ ID NO:78 (VL CDR1), SEQ ID NO:79 (VL CDR2), and SEQ ID NO:80 (VL CDR3).;

[0050] In some embodiments, the antibody or fragment thereof comprises the amino acid sequences of SEQ ID NO:73 (VH CDR1), SEQ ID NO:74 (VH CDR2), SEQ ID NO:75 (VH CDR3), SEQ ID NO:78 (VL CDR1), SEQ ID NO:79 (VL CDR2), and SEQ ID NO:80 (VL CDR3). In some embodiments, the antibody or fragment thereof comprises the amino acid sequences of SEQ ID NO:72 and SEQ ID NO:77. In some embodiments, the antibody or fragment thereof comprising the amino acid sequences of SEQ ID NO:72 and SEQ ID NO:77 is PB2452 (MEDI2452). In some embodiments, the antibody or fragment thereof comprises SEQ ID NO:81. In some embodiments, the antibody or fragment thereof comprises the amino acid sequences of the VH region and the CH region. In some embodiments, the antibody or fragment thereof comprises the amino acid sequences of the VH region and the CH1 region. In some embodiments, the antibody or fragment thereof comprises the amino acid sequence of SEQ ID NO:72 and the CH1 region. In some embodiments, the antibody or fragment thereof comprises the amino acid sequence of SEQ ID NO:83. In some embodiments, the antibody or fragment thereof comprises the amino acid sequence encoded by the nucleic acid sequence of SEQ ID NO:84. In some embodiments, the antibody or fragment thereof comprises the amino acid sequences of the VL region and the CL region. In some embodiments, the antibody or fragment thereof comprises the amino acid sequence of SEQ ID NO:77 and the CL region. In some embodiments, the antibody or fragment thereof comprises the amino acid sequence of SEQ ID NO:85. In some embodiments, the antibody or fragment thereof comprises the amino acid sequence encoded by the nucleic acid sequence of SEQ ID NO:86. In some embodiments, the antibody or fragment thereof comprising the amino acid sequences of SEQ ID NO:83 and SEQ ID NO:85 is PB2452 (MEDI2452).

[0051] In some embodiments, the antibodies or fragments thereof of the present disclosure include one or more amino acid substitutions, deletions, or additions from natural mutations or artificial manipulations. As indicated, the changes preferably have a minor nature, such as conservative amino acid substitutions that do not significantly affect the folding or activity of the antibody or fragment thereof.

[0052] The present disclosure provides an antibody or fragment thereof that comprises, alternatively consists of, variants (including derivatives) of the VH domain, VH CDRs, VL domain, and VL CDRs described herein, and that immunospecifically binds ticagrelor or a derivative or metabolite thereof. Standard techniques known to those of skill in the art can be used to introduce mutations in the nucleotide sequences encoding the molecules of the invention, including, for example, site-directed mutagenesis and PCR-mediated mutagenesis that result in amino acid substitutions. Preferably, the variant (including derivative) encodes fewer than 50 amino acid substitutions, fewer than 40 amino acid substitutions, fewer than 30 amino acid substitutions, fewer than 25 amino acid substitutions, fewer than 20 amino acid substitutions, fewer than 15 amino acid substitutions, fewer than 10 amino acid substitutions, fewer than 5 amino acid substitutions, fewer than 4 amino acid substitutions, fewer than 3 amino acid substitutions, or fewer than 2 amino acid substitutions relative to a reference VH domain, VH CDR1, VH CDR2, VH CDR3, VL domain, VL CDR1, VL CDR2, or VL CDR3. In a specific embodiment, the variant encodes a substitution in VH CDR3. In a preferred embodiment, the variant has conservative amino acid substitutions at one or more predicted non-essential amino acid residues. A "conservative amino acid substitution" is an amino acid substitution in which an amino acid residue is replaced with an amino acid residue having a side chain with a similar charge. Families of amino acid residues having side chains with similar charges have been defined in the art. These families include amino acids having basic side chains (e.g., lysine, arginine, histidine), acidic side chains (e.g., aspartic acid, glutamic acid), uncharged polar side chains (e.g., glycine, asparagine, glutamine, serine, threonine, tyrosine, cysteine), nonpolar side chains (e.g., alanine, valine, leucine, isoleucine, proline, phenylalanine, methionine, tryptophan), β-branched side chains (e.g., threonine, valine, isoleucine), and aromatic side chains (e.g., tyrosine, phenylalanine, tryptophan, histidine). Alternatively, mutations can be introduced randomly, for example, by saturation mutagenesis, along all or part of the coding sequence, and the biological activity of the resulting mutants can be screened to identify mutants that retain activity (e.g., the ability to bind ticagrelor or a derivative or metabolite thereof). After mutagenesis, the encoded protein can be expressed routinely, and the function and / or biological activity of the encoded protein (e.g., the ability to immunospecifically bind ticagrelor or a derivative or metabolite thereof) can be determined using the techniques described herein or by conventional modification techniques known in the art.

[0053] In another embodiment, the antibody or fragment thereof of the present disclosure that immunospecifically binds to ticagrelor, its derivatives or metabolites comprises or alternatively consists of a polypeptide having an amino acid sequence that is at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95% or at least 99% identical to any one VL domain. In another embodiment, the antibody of the present disclosure that immunospecifically binds to ticagrelor, its derivatives or metabolites comprises or alternatively consists of a polypeptide having an amino acid sequence that is at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95% or at least 99% identical to any one VL CDR. In another embodiment, the antibody of the present disclosure that immunospecifically binds to ticagrelor, its derivatives or metabolites comprises or alternatively consists of a polypeptide having an amino acid sequence that is at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95% or at least 99% identical to any one VL CDR3. Nucleic acid molecules encoding these antibodies are also encompassed by the present disclosure.

[0054] In another embodiment, an antibody or fragment thereof of the present disclosure that immunospecifically binds to ticagrelor, its derivatives, or metabolites comprises or alternatively consists of a polypeptide having an amino acid sequence that is at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, or at least 99% identical to any one VH domain. In another embodiment, an antibody of the present disclosure that immunospecifically binds to ticagrelor, its derivatives, or metabolites comprises or alternatively consists of a polypeptide having an amino acid sequence that is at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, or at least 99% identical to any one VH CDR. In another embodiment, an antibody of the present disclosure that immunospecifically binds to ticagrelor, its derivatives, or metabolites comprises or alternatively consists of a polypeptide having an amino acid sequence that is at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, or at least 99% identical to any one VH CDR3. Nucleic acid molecules encoding these antibodies are also encompassed by the present disclosure.

[0055] PB2452 is a recombinant human IgG1λ monoclonal Fab antibody fragment that specifically binds to ticagrelor and TAM. PB2452 was obtained from a library by optimizing a human anti-ticagrelor antibody using phage display, the library being generated by randomizing the amino acids in the variable heavy or variable light chain complementarity determining region 3, followed by affinity selection and screening. See US 2016 / 0130366, which is incorporated herein by reference in its entirety for all purposes. PB2452 is produced in Escherichia coli ( E. coli ) cells and purified using a 4-step chromatography method.

[0056] In some embodiments, the antibody or fragment thereof binds to ticagrelor and neutralizes the antiplatelet aggregation activity of ticagrelor and TAM, thus restoring ADP-induced platelet aggregation in the presence of ticagrelor and TAM.

[0057] In some embodiments, the terminal half-life of the antibody or fragment thereof in a subject is substantially the same as the terminal half-lives of ticagrelor and TAM. In some embodiments, the antibody terminal half-life is about 4 - 24 hours (e.g., 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 hours). In some embodiments, the terminal half-life is about 4 - 12 hours (e.g., 4, 5, 6, 7, 8, 9, 10, 11, or 12 hours). In some embodiments, the terminal half-life in a subject is about 6 - 9 hours. In some embodiments, the terminal half-life in a subject is about 6 - 7 hours. In some embodiments, the terminal half-life is about 6.9 hours.

[0058] In some embodiments, the distribution half-life of the antibody or fragment thereof in a subject is substantially the same as the distribution half-lives of ticagrelor and TAM. In some embodiments, the distribution half-life is about 0.1 to 2 hours (e.g., 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, 1.0, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, or 2 hours). In some embodiments, the distribution half-life is about 0.1 to 1 hour (e.g., 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9, or 1.0 hours). In some embodiments, the distribution half-life is about 0.89 hours.

[0059] In some embodiments, the antibody or fragment thereof provides a rapid onset of activity. For example, in an embodiment, the onset time of the antibody or the time to neutralize ticagrelor and TAM-mediated platelet inhibition is about 5 - 120 minutes or about 5 - 60 minutes. In some embodiments, the onset time is less than 60 minutes. In some embodiments, the onset time is about 30 minutes. In some embodiments, the onset time is less than about 30 minutes. In some embodiments, the onset time is less than about 10 minutes. In some embodiments, the onset time is less than about 5 minutes.

[0060] In some embodiments, the antibody or fragment thereof provides sustained inhibition of ticagrelor and TAM activity. In some embodiments, the inhibition of ticagrelor and TAM activity by the antibody or fragment thereof persists for about 2 to about 48 hours (e.g., 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, or 48 hours). In some embodiments, the sustained inhibition of ticagrelor and TAM activity is dose-dependent. In some embodiments, the sustained inhibition of ticagrelor and TAM activity depends on the dose administered as a bolus prior to IV infusion. In some embodiments, the sustained inhibition of ticagrelor and TAM activity depends on the dose administered via IV infusion.

[0061] In some embodiments, the antibody or fragment thereof of the present disclosure exhibits both rapid (e.g., within 5 minutes of administration) and sustained (e.g., up to 24 or 48 hours) inhibition of ticagrelor and TAM activity.

[0062] In some embodiments, the antibody or fragment thereof is administered to a subject in need thereof immediately after the last ticagrelor administration. In some embodiments, the antibody or fragment thereof is administered to a subject in need thereof within about 1 hour to 120 hours after the last ticagrelor administration. In some embodiments, the antibody or fragment thereof is administered to a subject in need thereof within about 1 hour to 72 hours after the last ticagrelor administration. In some embodiments, the antibody or fragment thereof is administered to a subject in need thereof within about 1 hour to 24 hours (e.g., about 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 hours).

[0063] In some embodiments, the antibody or fragment thereof has a PK / PD profile that provides a rapid offset of activity such that, for example, a subject to whom the antibody has been administered can resume a prescribed ticagrelor therapy. In some embodiments, a subject who has received an antibody disclosed herein (e.g., by i.v. infusion) can receive or re-initiate ticagrelor therapy within six hours after antibody administration. In some embodiments, a subject who has received an antibody or fragment thereof disclosed herein (e.g., by i.v. infusion) can receive or re-initiate ticagrelor therapy within twelve hours after antibody administration. In some embodiments, a subject who has received an antibody disclosed herein (e.g., by i.v. infusion) can receive or re-initiate ticagrelor therapy within twenty-four hours after antibody administration.

[0064] PB2452 activity

[0065] Without being bound by theory, PB2452 binds to ticagrelor with an affinity that is 100-fold that of ticagrelor for the P2Y 12 receptor. This high affinity enables PB2452 to bind to free ticagrelor, resulting in a rapid reversal of the effects of ticagrelor and restoration of platelet activity.

[0066] The chemical starting point for ticagrelor development was adenosine triphosphate (ATP), and ticagrelor retains an adenosine-like core. To confirm the specificity of PB2452 for ticagrelor and the ticagrelor active metabolite (TAM), its binding to ATP, ADP, and adenosine was evaluated. To further confirm the specificity of PB2452, a search of the structural database of marketed drugs was performed for molecules with any structural similarity to ticagrelor. Based on this in silico ( in silico ) analysis, a group of 12 compounds (fenofibrate, nilvadipine, cilostazol, bucladesine, regadenoson, cyclothiazide, cyfluthrin, lovastatin, linezolid, simvastatin, canagrelor, and pantoprazole) was selected. The selectivity of PB2452 was determined by competitive binding of PB2452 to biotinylated ticagrelor. No inhibition of the binding of PB2452 to biotinylated ticagrelor was found for ATP, ADP, adenosine, or the 12 structurally related compounds. Thus, PB2452 binds to ticagrelor and TAM with high affinity and selectivity.

[0067] In some embodiments, the anti-ticagrelor antibody or fragment thereof reverses, blocks, inhibits, or reduces ticagrelor or TAM activity. In some embodiments, such ticagrelor or TAM activity is selected from, but not limited to, reducing ADP-induced platelet aggregation and / or binding to P2Y 12Binding of the receptor. In some embodiments, administration of an anti - ticagrelor antibody or fragment thereof restores ADP - induced platelet aggregation and / or binding to the P2Y 12 receptor. In some embodiments, an anti - ticagrelor antibody that restores ADP - induced platelet aggregation and / or binding to the P2Y 12 receptor is PB2452. See US 2016 / 0130366, which is incorporated herein by reference in its entirety for all purposes.

[0068] Treatment method

[0069] In some aspects, the present disclosure provides methods of reversing, inhibiting, reducing, or preventing ticagrelor or TAM activity, which include administering to a subject in need thereof a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof. Reversal, inhibition, reduction, or prevention of ticagrelor or TAM activity can be measured by any means known in the art, including, for example, by measuring free or total ticagrelor in a blood sample.

[0070] In some embodiments, administration of a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof restores platelet aggregation. In some embodiments, administration of a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof inhibits binding of ticagrelor or TAM to the P2Y 12 receptor. In some embodiments, the anti - ticagrelor antibody or fragment thereof is PB2452.

[0071] In some aspects, the present disclosure provides methods of restoring platelet aggregation, which include administering to a subject in need thereof a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof. In some aspects, the present disclosure provides methods of reducing blood loss in patients receiving ticagrelor, which include administering to a subject in need thereof a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof. In some embodiments, administration of the pharmaceutical composition of the present disclosure inhibits ticagrelor - related bleeding in a patient.

[0072] In some embodiments, a pharmaceutical composition comprising an anti - ticagrelor antibody or a fragment thereof is administered to a subject in need thereof to clear ticagrelor and / or TAM from the subject's body. In some embodiments, a pharmaceutical composition comprising an anti - ticagrelor antibody or a fragment thereof is administered to a subject in need thereof to reduce the amount of ticagrelor and / or TAM in the patient's blood. In some embodiments, compared to the baseline amount of ticagrelor and / or TAM, administration of a pharmaceutical composition comprising an anti - ticagrelor antibody or a fragment thereof to a subject in need thereof reduces the amount of ticagrelor in the patient's blood by about 100% to about 5%. In some embodiments, compared to the baseline amount of ticagrelor and / or TAM, administration of a pharmaceutical composition comprising an anti - ticagrelor antibody or a fragment thereof to a subject in need thereof reduces the amount of ticagrelor in the patient's serum by about 90%, about 80%, about 70%, about 60%, about 50%, about 40%, about 30%, about 20%, about 10% or about 5%.

[0073] In some embodiments, administering a pharmaceutical composition comprising an anti - ticagrelor antibody or a fragment thereof to a subject reduces the amount of free ticagrelor and / or TAM in the subject's body. In some embodiments, administering a pharmaceutical composition comprising an anti - ticagrelor antibody or a fragment thereof to a subject in need reduces the amount of free ticagrelor and / or TAM in the subject's blood. In some embodiments, compared to the baseline amount of ticagrelor and / or TAM, administering a pharmaceutical composition comprising an anti - ticagrelor antibody or a fragment thereof to a subject in need reduces the amount of free ticagrelor and / or TAM in the subject's blood by about 100% to about 15%. In some embodiments, compared to the baseline amount of ticagrelor and / or TAM, administering a pharmaceutical composition comprising an anti - ticagrelor antibody or a fragment thereof to a subject in need reduces the amount of free ticagrelor and / or TAM in the subject's blood by about 99.9%, about 99.8%, about 99.7%, about 99.6%, about 99.5%, about 99.4%, about 99.3%, about 99.2%, about 99.1%, about 99%, about 98%, about 97%, about 96%, about 95%, about 94%, about 93%, about 92%, about 91%, about 90%, about 80%, about 70%, about 60%, about 50%, about 40%, about 30%, about 20%, about 10% or about 5%. In some embodiments, ticagrelor or TAM activity is reversed, inhibited, reduced or blocked for about 1 hour to about 2 days. In some embodiments, ticagrelor or TAM activity is reversed, inhibited, reduced or blocked for about 1 hour, about 2 hours, about 3 hours, about 4 hours, about 5 hours, about 6 hours, about 7 hours, about 8 hours, about 9 hours, about 10 hours, about 11 hours, about 12 hours, about 13 hours, about 14 hours, about 15 hours, about 16 hours, about 17 hours, about 18 hours, about 19 hours, about 20 hours, about 21 hours, about 22 hours, about 23 hours, about 24 hours, about 36 hours or about 48 hours. In some embodiments, this reversal, inhibition, reduction or block is observed at the time points disclosed herein.

[0074] In some embodiments, compared to an untreated subject, administration of the pharmaceutical compositions disclosed herein reverses, inhibits, reduces or blocks ticagrelor or TAM activity in the subject. In some embodiments, compared to the activity of an untreated subject, ticagrelor or TAM activity is reversed, inhibited, reduced or blocked by about 1%, about 5%, about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, or about 90% or about 100%. In some embodiments, this reversal, inhibition, reduction or block is observed at the time points disclosed herein.

[0075] In some embodiments, administration of the pharmaceutical compositions disclosed herein reverses platelet aggregation inhibition in a subject as compared to a subject not treated with ticagrelor. In some embodiments, the inhibition of platelet aggregation is reversed by about 1%, about 5%, about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, or about 90% or about 100% as compared to platelet aggregation inhibition in a subject not treated with ticagrelor. In some embodiments, this reversal of platelet aggregation inhibition is observed at the time points disclosed herein.

[0076] In some embodiments, administration of a pharmaceutical composition comprising an anti-ticagrelor antibody or fragment thereof to a subject restores platelet aggregation in the patient's blood. In some embodiments, administration of a pharmaceutical composition comprising an anti-ticagrelor antibody or fragment thereof to a subject in need restores platelet aggregation in the patient's blood to from about 100% to about 15% as compared to the baseline level of normal platelet aggregation. In some embodiments, administration of a pharmaceutical composition comprising an anti-ticagrelor antibody or fragment thereof to a subject in need restores platelet aggregation in the patient's blood to about 100%, about 90%, about 80%, about 70%, about 60%, about 50%, about 40%, about 30%, about 20%, about 10%, or about 5% of the baseline level of normal platelet aggregation. In some embodiments, administration of a pharmaceutical composition comprising an anti-ticagrelor antibody or fragment thereof to a subject in need restores platelet aggregation in the patient's blood to about 80% or higher of the baseline level of normal platelet aggregation. In some embodiments, within about 1 hour to about 2 days after administration, platelet aggregation is restored to at least 80% of the baseline level of normal platelet aggregation. In some embodiments, platelet aggregation is restored at about 5 minutes, about 10 minutes, about 20 minutes, about 30 minutes, about 40 minutes, about 50 minutes, about 1 hour, about 2 hours, about 3 hours, about 4 hours, about 5 hours, about 6 hours, about 7 hours, about 8 hours, about 9 hours, about 10 hours, about 11 hours, about 12 hours, about 13 hours, about 14 hours, about 15 hours, about 16 hours, about 17 hours, about 18 hours, about 19 hours, about 20 hours, about 21 hours, about 22 hours, about 23 hours, about 24 hours, about 36 hours, or about 48 hours. In some embodiments, this restoration is observed at the time points disclosed herein.

[0077] In some embodiments, as measured by VerifyNow P2Y 12Measured by the (also known as VerifyNow PRUTest) assay method (Accriva / Instrumentation Laboratory, San Diego CA), a pharmaceutical composition comprising an anti-ticagrelor antibody or a fragment thereof is administered to a subject to restore platelet aggregation in the patient's blood. In some embodiments, as measured by VerifyNow, a pharmaceutical composition comprising an anti-ticagrelor antibody or a fragment thereof is administered to a subject in need thereof to restore platelet aggregation in the patient's blood to from about 50 to about 250 platelet reactivity units (PRU). In some embodiments, as measured by VerifyNow, a pharmaceutical composition comprising an anti-ticagrelor antibody or a fragment thereof is administered to a subject in need thereof to restore platelet aggregation in the patient's blood to about 250 platelet reactivity units (PRU), about 240 PRU, about 230 PRU, about 220 PRU, about 210 PRU, about 200 PRU, about 190 PRU, about 180 PRU, about 170 PRU, about 160 PRU, about 150 PRU, about 140 PUR, about 130 PRU, about 120 PRU, about 110 PRU, about 100 PRU, about 90 PRU, about 80 PRU, about 70 PRU, about 60 PRU, about 50 PRU. In some embodiments, a pharmaceutical composition comprising an anti-ticagrelor antibody or a fragment thereof is administered to a subject in need thereof to restore platelet aggregation in the patient's blood to at least 180 PRU. In some embodiments, within about 1 hour to about 2 days after administration, platelet aggregation is restored to at least 180 PRU. In some embodiments, at about 5 minutes, about 10 minutes, about 20 minutes, about 30 minutes, about 40 minutes, about 50 minutes, about 1 hour, about 2 hours, about 3 hours, about 4 hours, about 5 hours, about 6 hours, about 7 hours, about 8 hours, about 9 hours, about 10 hours, about 11 hours, about 12 hours, about 13 hours, about 14 hours, about 15 hours, about 16 hours, about 17 hours, about 18 hours, about 19 hours, about 20 hours, about 21 hours, about 22 hours, about 23 hours, about 24 hours, about 36 hours or about 48 hours, platelet aggregation is restored to at least 180 PRU. In some embodiments, such restoration is observed at the time points disclosed herein.

[0078] In some embodiments, administration of a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof to a subject restores platelet aggregation in the patient's blood, as measured by the vasodilator - stimulated phosphoprotein (VASP) assay. In some embodiments, administration of a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof to a subject in need restores platelet aggregation in the patient's blood to from about 50% to about 150% of the baseline platelet reactivity index (PRI). In some embodiments, administration of a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof to a subject in need restores platelet aggregation in the patient's blood to about 150% of the baseline PRI, about 140% of the baseline PRI, about 130% of the baseline PRI, about 120% of the baseline PRI, about 110% of the baseline PRI, about 100% of the baseline PRI, about 90% of the baseline PRI, about 80% of the baseline PRI, about 70% of the baseline PRI, about 60% of the baseline PRI, about 50% of the baseline PRI. In some embodiments, administration of a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof to a subject in need restores platelet aggregation in the patient's blood to at least 100% of the baseline PRI. In some embodiments, platelet aggregation is restored to at least 100% of the baseline PRI within about 1 hour to about 2 days after administration. In some embodiments, platelet aggregation is restored to at least 100% of the baseline PRI at about 5 minutes, about 10 minutes, about 20 minutes, about 30 minutes, about 40 minutes, about 50 minutes, about 1 hour, about 2 hours, about 3 hours, about 4 hours, about 5 hours, about 6 hours, about 7 hours, about 8 hours, about 9 hours, about 10 hours, about 11 hours, about 12 hours, about 13 hours, about 14 hours, about 15 hours, about 16 hours, about 17 hours, about 18 hours, about 19 hours, about 20 hours, about 21 hours, about 22 hours, about 23 hours, about 24 hours, about 36 hours, or about 48 hours. In some embodiments, such restoration is observed at the time points disclosed herein.

[0079] Patient population

[0080] The anti - ticagrelor antibody or fragment thereof of the present disclosure can be administered to any patient in need. In some embodiments, the patient is at risk of acute coronary syndrome (ACS) or has been diagnosed with acute coronary syndrome (ACS). In some embodiments, the patient is at risk of myocardial infarction (MI) or has been diagnosed with myocardial infarction (MI). In some embodiments, the patient has a history of MI. In some embodiments, the patient is receiving or has received ticagrelor. In some embodiments, the patient is receiving or has received ticagrelor, in combination with another anti - platelet therapy such as aspirin.

[0081] In some embodiments, the patient has unstable angina, stable ischemic heart disease, sickle cell disease including pediatric patients, atrial fibrillation, coronary artery disease, peripheral artery disease, ischemic stroke, one or more coronary stents, carotid stents, stents after intracranial aneurysms, or arteriovenous fistulas created for hemodialysis.

[0082] In some embodiments, the patient has type 2 diabetes. In some embodiments, the patient has type 2 diabetes and coronary heart disease. In some embodiments, the patient has type 2 diabetes with a history of percutaneous coronary intervention.

[0083] In some embodiments, the patient is at a higher risk of bleeding associated with ticagrelor treatment, or has an increased bleeding rate associated with ticagrelor treatment. In some embodiments, this ticagrelor-related bleeding is gastrointestinal bleeding. In some embodiments, this ticagrelor-related bleeding is intracranial bleeding or intracranial hemorrhage (ICH). In some embodiments, this ticagrelor-related bleeding is the result of a traumatic injury such as a road traffic accident. In some embodiments, ticagrelor-related bleeding is classified as major bleeding. Major bleeding includes any bleeding event that is judged by the treating physician to require reversal. This includes but is not limited to bleeding events that are life-threatening, have the potential to cause clinically significant disability, require surgery to control bleeding, require treatment with blood products, or are acute bleeding associated with a clinically important decrease in hemoglobin level.

[0084] In some embodiments, the patient requires urgent surgery or intervention. Urgent surgery or intervention is defined as a surgical procedure or medical procedure associated with the risk of perioperative bleeding in a situation where it is not medically advisable to discontinue ticagrelor for 5 days. The need for urgent surgery may include, but is not limited to, patients in any of the following clinical situations: undergoing a surgery or procedure known to be associated with a significant risk of bleeding (such as coronary artery bypass surgery); undergoing a surgery or procedure that may have an adverse surgical outcome if bleeding is not carefully controlled (such as neurosurgical, ophthalmic, or joint replacement surgery); being at risk of experiencing perioperative events such as shock, myocardial infarction, or stroke if significant perioperative bleeding occurs (especially in elderly patients or patients with comorbidities); being at high risk of thrombosis if dual antiplatelet therapy is discontinued preoperatively (such as patients with recent coronary stent placement).

[0085] In some embodiments, the patient has started to experience bleeding prior to administration of the anti - ticagrelor antibody or fragment thereof. In some embodiments, the patient has not started to experience bleeding prior to administration of the anti - ticagrelor antibody or fragment thereof. In some embodiments, the patient requires surgery and thus has an increased risk of bleeding due to ticagrelor treatment. In some embodiments, the surgery is an urgent surgery. In some embodiments, the surgery is an emergency surgery.

[0086] In some embodiments, the patient is an adult. In some embodiments, the adult patient is 30 to 100 years old or older. In some embodiments, the adult patient is over 40 years old, over 50 years old, over 60 years old, over 70 years old, over 80 years old, or over 90 years old. In some embodiments, the adult patient is 50 - 64 years old. In some embodiments, the adult patient is 65 - 75 years old. In some embodiments, the patient is defined as elderly (e.g., 50 to 64 years old, including the endpoints). In some embodiments, the patient is defined as old (e.g., over 65 years old or 65 to 80 years old, including the endpoints). In some embodiments, the elderly or old patient has been pretreated with ticagrelor and aspirin. In some embodiments, compared to younger subjects, the elderly or old patient experiences higher exposure to ticagrelor and / or lower response to ticagrelor.

[0087] In some embodiments, the patient is a young adult. In some embodiments, the young adult patient is 18 to 30 years old or older. In some embodiments, the patient is a pediatric patient less than 18 years old. In some embodiments, the patient is a pediatric patient less than 2 years old. In some embodiments, the pediatric patient or young adult patient has sickle cell disease.

[0088] Pharmaceutical composition and administration

[0089] The present disclosure provides a pharmaceutical composition comprising an anti - ticagrelor antibody or fragment thereof and one or more pharmaceutically acceptable excipients and / or diluents. In some embodiments, the anti - ticagrelor antibody or fragment thereof is PB2452.

[0090] The formulations of the present disclosure may include any suitable excipients known in the art. Exemplary excipients include, but are not limited to, amino acids such as histidine, glycine, or arginine; glycerol; sugars such as sucrose; surface - active agents such as polysorbate 20 and polysorbate 80; citric acid; sodium citrate; antioxidants; salts including alkaline earth metal salts such as sodium, potassium, and calcium; counterions such as chloride and phosphate; sugar alcohols (e.g., mannitol); preservatives; sugar alcohols (e.g., mannitol, sorbitol); and buffering agents. Exemplary salts include sodium chloride, potassium chloride, magnesium chloride, calcium chloride, disodium hydrogen phosphate, sodium dihydrogen phosphate, sodium phosphate, and potassium phosphate.

[0091] In certain embodiments, the formulation may include from about 5 mM histidine / histidine hydrochloride buffer to about 100 mM histidine / histidine hydrochloride buffer. In some embodiments, the formulation includes about 50 mM histidine / histidine hydrochloride buffer, about 40 mM histidine / histidine hydrochloride buffer, about 30 mM histidine / histidine hydrochloride buffer, about 25 mM histidine / histidine hydrochloride buffer, about 20 mM histidine / histidine hydrochloride buffer, or about 15 mM histidine / histidine hydrochloride buffer.

[0092] In certain embodiments, the formulation may include from about 100 mM sucrose to about 1 M sucrose. In some embodiments, the formulation may include about 150 mM sucrose, about 200 mM sucrose, about 250 mM sucrose, about 290 mM sucrose, about 300 mM sucrose, about 350 mM sucrose, about 400 mM sucrose or about 500 mM sucrose.

[0093] In certain embodiments, the formulation may include a surfactant. In some embodiments, the surfactant is a nonionic surfactant. In some embodiments, the nonionic surfactant is polysorbate 80. In some embodiments, the formulation may include from about 0.01% w / v polysorbate 80 to about 1.00% w / v polysorbate 80. In some embodiments, the formulation may include about 0.01% w / v, about 0.02% w / v, about 0.03% w / v, about 0.05% w / v, about 0.06% w / v, about 0.07% w / v, about 0.08% w / v, about 0.09% w / v, or about 0.1% w / v polysorbate 80.

[0094] In certain embodiments, the formulation may include from about 10 mg / mL anti - ticagrelor antibody or fragment thereof to about 200 mg / mL anti - ticagrelor antibody or fragment thereof. In some embodiments, the formulation may include about 10 mg / mL, about 20 mg / mL, about 30 mg / mL, about 40 mg / mL, about 50 mg / mL, about 60 mg / mL, about 70 mg / mL, about 80 mg / mL, about 90 mg / mL, about 100 mg / mL, about 110 mg / mL, about 120 mg / mL, about 130 mg / mL, about 140 mg / mL, or about 150 mg / mL anti - ticagrelor antibody or fragment thereof.

[0095] In some embodiments, the formulation comprises 100 mg / mL anti - ticagrelor antibody or a fragment thereof, 25 mM histidine / histidine hydrochloride buffer, 290 mM sucrose, and 0.05% (w / v) polysorbate 80, pH 6.0.

[0096] The formulation can be stored frozen, refrigerated, or at room temperature. The storage conditions may be below the freezing point, such as below about - 10°C, or below about - 20°C, or below about - 40°C, or below about - 70°C. The storage conditions are generally less than room temperature, such as less than about 32°C, or less than about 30°C, or less than about 27°C, or less than about 25°C, or less than about 20°C, or less than about 15°C. In some embodiments, the formulation is stored at 2°C - 8°C. For example, the formulation can be isotonic with blood or have an ionic strength simulating physiological conditions.

[0097] In some embodiments, the formulation is formulated at physiological pH. In some embodiments, the formulation is formulated at a pH in the range of about 5.5 to about 8.5. In some embodiments, the formulation is formulated at a pH in the range of about 6.0 to about 8.0. In some embodiments, the formulation is formulated at a pH in the range of about 6.5 to about 7.5. In some embodiments, the formulation is formulated at a pH of 7.5. In some embodiments, formulations with a lower pH demonstrate improved formulation stability compared to formulations at a higher pH. In some embodiments, formulations with a higher pH demonstrate improved formulation stability compared to formulations at a lower pH.

[0098] In some embodiments, the formulation is stable under the storage conditions. Any suitable means in the art can be used to measure stability. Generally, a stable formulation is one that shows less than a 5% increase in degradation products or impurities. In some embodiments, the formulation is stable under the storage conditions for at least about 1 month, at least about 2 months, at least about 3 months, at least about 4 months, at least about 5 months, at least about 6 months, at least about one year, or at least about 2 years or longer. In some embodiments, the formulation is stable at 25°C for at least about 1 month, at least about 2 months, at least about 3 months, at least about 4 months, at least about 5 months, at least about 6 months, or at least about one year or longer.

[0099] In some aspects, the formulation is a lyophilized product. In some embodiments, the formulation is a lyophilized product that contains from about 1 g to about 36 g of anti - ticagrelor antibody or a fragment thereof. In some embodiments, the formulation is a lyophilized product that contains about 6 g of anti - ticagrelor antibody or a fragment thereof. In some aspects, after reconstitution with water for injection, the product can further be diluted into 0.9% saline for intravenous (iv) infusion. In some embodiments, the product is not lyophilized and is further diluted into 0.9% saline for intravenous (iv) infusion.

[0100] In one aspect, the formulations of the present disclosure are pyrogen-free formulations that are substantially free of endotoxins and / or related pyrogenic substances. Endotoxins include toxins that are bound within microorganisms and are released only upon decomposition or death of the microorganisms. Pyrogenic substances also include heat-stable substances (glycoproteins) from the outer membranes of bacteria and other microorganisms that induce fever. If administered to humans, both substances can cause fever, hypotension, and shock. Due to the potential harmful effects, even small amounts of endotoxins must be removed from pharmaceutical drug solutions administered intravenously. The United States Food and Drug Administration (“FDA”) has set an upper limit of 5 endotoxin units (EU) / dose / kg body weight over a one-hour period for intravenous drug applications (The United States Pharmacopeial Convention, Pharmacopeial Forum 26 (1):223 (2000)). In certain specific aspects, the endotoxin and pyrogen levels in the composition are less than about 1 EU / mg, or less than about 0.1 EU / mg, or less than about 0.01 EU / mg, or less than about 0.001 EU / mg. In some embodiments, the endotoxin and pyrogen levels in the composition are 0.0138 EU / mg or less.

[0101] When used for in vivo administration, the formulations of the present disclosure should be sterile. The formulations of the present disclosure can be sterilized by various sterilization methods including sterile filtration, radiation, etc. In one aspect, the formulation is filter sterilized using a pre-sterilized 0.22 micron filter. Sterile compositions for injection can be formulated according to conventional pharmaceutical practice, as described in “Remington: The Science & Practice of Pharmacy”, 21st Edition, Lippincott Williams & Wilkins, (2005).

[0102] In some embodiments, the pharmaceutical composition is formulated for intravenous administration. In some embodiments, the formulation is administered intravenously within about 5 minutes to 48 hours. In some embodiments, the formulation is administered in any suitable volume. In some embodiments, the formulation is administered in a total volume of about 30 mL to about 2 L. In some embodiments, the formulation is administered in a total volume of about 30 mL, about 40 mL, about 50 mL, about 100 mL, about 125 mL, about 150 mL, about 175 mL, about 200 mL, about 225 mL, about 250 mL, about 275 mL, about 300 mL, about 400 mL, about 500 mL, about 1 L, about 1.5 L, or about 2 L. In some embodiments, the formulation is administered intravenously in a total volume of about 250 mL over about 30 minutes. In some embodiments, the formulation is administered first as a bolus, followed by a longer infusion. In some embodiments, the longer infusion following the bolus is about 4 hours. In some embodiments, the longer infusion following the bolus is about 8 hours. In some embodiments, the longer infusion following the bolus is about 12 hours. In some embodiments, the longer infusion following the bolus is about 18 hours. In some embodiments, the longer infusion following the bolus is about 24 hours. In some embodiments, the longer infusion following the bolus is about 36 hours.

[0103] In some embodiments, the concentration of the anti - ticagrelor antibody or fragment thereof in the formulation varies between 0.4 mg / mL and 72 mg / mL in a single IV infusion, to deliver 250 mL over 30 minutes to 12 hours, at a dose of 0.1 g, 0.3 g, 1.0 g, 3 g, 9 g, 180 g, 24 g, 30 g, 36 g, or 48 g or an intermediate dose between 9 g and 48 g. In some cases, a portion (up to about 12 g) of the therapeutic composition is infused at a faster rate (equivalent to a bolus) for the first 5 - 20 minutes of the infusion.

[0104] In some embodiments, the anti - ticagrelor antibody or fragment thereof is stored in one or more glass vials and then transferred to an infusion bag for administration. In some embodiments, the anti - ticagrelor antibody or fragment thereof is stored in one or more glass vials and then transferred to a syringe for administration using an infusion pump. In some embodiments, the anti - ticagrelor antibody or fragment thereof is stored in a pre - filled syringe for administration using an infusion pump. In some embodiments, the anti - ticagrelor antibody or fragment thereof is stored in an IV container, such as a Baxter Galaxy Liquid Premix System or a Baxter Galaxy Frozen Premix System.

[0105] In some embodiments, an antibody or fragment thereof is administered to achieve rapid and extended reversal of ticagrelor activity. In some embodiments, the infusion rate is kept constant throughout the infusion. In some embodiments, the infusion rate varies over the course of the infusion. In some embodiments, a larger amount of the pharmaceutical composition is administered first in the infusion, and the amount gradually decreases over the remainder of the infusion.

[0106] In some embodiments, the infusion duration lasts from about 5 minutes to about 36 hours. In some embodiments, the infusion regimens are selected from (but not limited to) infusing about 3 g to about 36 g at a constant infusion rate over about 1 hour to about 24 hours, infusing about 3 g over about 5 minutes followed by infusing about 15 grams over about 8 hours, infusing about 6 g over about 15 minutes followed by infusing about 6 g over about 3 hours, followed by infusing about 6 g over about 8.75 hours, infusing about 6 g over about 15 minutes followed by infusing about 6 g over about 4 hours, followed by infusing about 6 g over about 12 hours, infusing about 6 g over about 10 minutes followed by infusing about 6 g over about 3 hours, followed by infusing about 6 g over about 13 hours, infusing about 12 g over about 10 minutes followed by infusing about 12 g over about 6 hours, followed by infusing about 12 g over about 18 hours.

[0107] In some embodiments, if rapid reversal of ticagrelor activity is needed (e.g., during active bleeding in a patient), the antibody or fragment thereof of the present disclosure may be administered as follows:

[0108] 1. Infusing about 3 g to about 6 g over about 5 to about 15 minutes, followed by infusing about 3 g to about 6 g over about 1 to about 3 hours, followed by infusing about 3 g to about 6 g over about 3 to about 8 hours.

[0109] 2. Infusing about 3 g to about 6 g over about 5 to about 15 minutes, followed by infusing about 6 g to about 12 g over about 1 to about 3 hours, followed by infusing about 6 g to about 12 g over about 3 to 8 hours.

[0110] 3. Infusing about 3 g to about 6 g over about 5 to about 15 minutes, followed by infusing about 6 g to about 12 g over about 1 to about 3 hours, followed by infusing at about 1 g / hour for up to about 24 to about 48 hours.

[0111] 4. Infusing about 9 g over about 5 to about 30 minutes, followed by infusing at about 1 g / hour to about 3 g / hour over about 3 to about 8 hours.

[0112] 5. Infusing about 9 g to about 24 g over about 1 to about 4 hours.

[0113] In some embodiments, if a patient is going to undergo surgery, the antibodies or fragments thereof of the present disclosure can be administered as follows:

[0114] 1. Infuse about 3 to about 6 g over about 5 to about 30 minutes, followed by infusing about 3 to about 6 g over about 3 to about 6 hours, and then followed by infusing about 1 g / hour over up to about 12 to about 24 hours;

[0115] 2. Infuse about 3 to about 6 g over about 5 to about 15 minutes, followed by infusing about 3 to about 6 g over about 1 to about 3 hours, and then followed by infusing about 1 g / hour over about 12 to about 24 hours.

[0116] 3. Infuse about 9 g to about 24 g over about 1 to about 4 hours.

[0117] In some embodiments, if a patient is taking one or more additional drugs that affect ticagrelor exposure, such as drugs that inhibit cytochrome P450 isoform 3A (CYP3A) activity, resulting in increased exposure to ticagrelor, or if a patient has taken an overdose of ticagrelor, the antibodies or fragments thereof of the present disclosure can be administered as follows:

[0118] 1. Infuse about 6 to about 12 g over about 5 to about 30 minutes, followed by infusing about 6 to about 12 g over about 3 to about 6 hours, and then followed by infusing about 6 to about 12 g over up to about 12 to about 24 hours;

[0119] 2. Infuse about 6 to about 12 g over about 5 to about 15 minutes, followed by infusing about 6 to about 12 g over about 1 to about 3 hours, and then followed by infusing about 0.5 – 1 g / hour over about 12 to about 24 hours.

[0120] 3. Infuse about 18 g to about 36 g over about 3 to about 6 hours.

[0121] The formulations can conveniently be presented in unit dosage form and can be prepared by any method well known in the pharmaceutical art. The actual dosage levels of the active ingredient in the pharmaceutical compositions of the present disclosure can be varied so as to obtain an amount of the active ingredient that is effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration, and that is non-toxic to the patient (e.g., a “therapeutically effective amount”). The selected dosage level depends on various pharmacokinetic factors, including the activity of the particular composition employed, the route of administration, the time of administration, the rate of excretion of the particular compound to be employed, the duration of the treatment, other drugs, compounds, and / or materials used in combination with the particular composition employed, the age, sex, weight, condition, general health, and prior medical history of the patient to be treated, and similar factors well known in the medical arts.

[0122] Suitable dosage ranges can be from about 1000 mg to about 36 g, or from about 9 g to about 24 g, or from about 9 g to about 15 g, or from about 1 g to about 3 g. In some embodiments, the dosage can be about 1000 mg, about 3 g, about 9 g, about 18 g, about 24 g, about 30 g, about 36 g or about 48 g. In some embodiments, the amount of anti - ticagrelor antibody or fragment thereof administered to a patient depends on the amount of ticagrelor the patient has received. In some embodiments, the amount of anti - ticagrelor antibody or fragment thereof administered to a patient depends on the patient's body weight.

[0123] The dosage of the anti - ticagrelor antibody or fragment thereof administered will be the dosage that causes reversal of ticagrelor - induced platelet disaggregation in 95% of a simulated patient population, where reversal is considered platelet disaggregation reversed to less than 10% of baseline.

[0124] In some embodiments, at least 180 mg of ticagrelor has been administered to the patient. In some embodiments, a loading dose of at least 180 mg of ticagrelor has been administered to the patient, followed by 90 mg of ticagrelor administered twice daily. In some embodiments, ticagrelor has been administered to the patient at least three days prior to the administration of the anti - ticagrelor antibody or fragment thereof. In some embodiments, ticagrelor is administered to the patient concurrently with the administration of the anti - ticagrelor antibody or fragment thereof. In some embodiments, an excessive amount of ticagrelor has been administered to the patient.

[0125] It should be noted that the present disclosure similarly contemplates that formulations suitable for diagnostic and research use can also be prepared. The concentration of the active agent in such formulations, as well as the presence or absence of excipients and / or pyrogens, can be selected based on the specific application and intended use.

[0126] It should be understood that, for convenience, the singular forms, such as "a", "an", and "the", are used throughout this application. However, the singular forms are intended to include the plural unless the context or an explicit statement indicates otherwise. All numerical ranges should be understood to include each and every numerical point within the numerical range and should be interpreted as individually reciting each and every numerical point. The endpoints of all ranges referring to the same component or property are included and are expected to be combinable independently.

[0127] When used in conjunction with a reference numeral indication, the term "about" means the reference numeral indication plus or minus up to 10% of the reference numeral indication. For example, the language "about 50" covers the range from 45 to 55.

[0128] As used herein, the term "comprising" and variations thereof are intended to be non-limiting, such that recitation of items in a list does not exclude other similar items that may be useful in the materials, compositions, devices, and methods of this technology. Similarly, the terms "may" and "might" and variations thereof are intended to be non-limiting, such that a statement that an embodiment may or might include certain elements or features does not exclude other embodiments of this technology that do not contain those elements or features. Although the open-ended term "comprising", which is a synonym for terms such as including, containing, or having, is used herein to describe and claim the present disclosure, the technology or its embodiments may alternatively be described using more restrictive terms such as "consisting of the ingredients" or "consisting essentially of the ingredients".

[0129] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this disclosure pertains. Although preferred methods and materials are described herein, any methods and materials similar to or equivalent to those described herein can be used in the practice or testing of this disclosure.

[0130] Examples of non-limiting embodiments of the present disclosure

[0131] The embodiments of the subject matter disclosed herein may be beneficial alone or in combination with one or more other embodiments. Without limiting the foregoing description, certain non-limiting embodiments of the present disclosure numbered 1-42 are provided below. As will be apparent to those skilled in the art upon reading this disclosure, each individually numbered embodiment can be used in combination with any preceding or subsequent individually numbered embodiment. This is intended to support all such combinations of embodiments and is not limited to the combinations of embodiments explicitly provided below.

[0132] Embodiment 1. A method of reversing ticagrelor-related bleeding or the risk of such bleeding in a patient in need thereof, comprising administering to the patient a composition comprising a pharmaceutically effective amount of a pharmaceutical composition comprising an antibody or a fragment thereof that binds to ticagrelor ((1 S ,2 S ,3 R ,5 S )-3-[7-{[(1 R ,2 S )-2-(3,4-difluorophenyl)cyclopropyl]amino}-5-(propylthio)-3 H -[1,2,3]triazolo[4,5- d pyrimidin-3-yl]-5-(2-hydroxyethoxy)cyclopent-1,2-diol), or a metabolite or derivative thereof.

[0133] Embodiment 2. The method of Embodiment 1, wherein the antibody or fragment thereof comprises a combination of complementarity determining regions (CDRs) selected from:

[0134] a) SEQ ID NO:53 (VH CDR1), SEQ ID NO:54 (VH CDR2), SEQ ID NO:55 (VH CDR3), SEQ ID NO:58 (VL CDR1), SEQ ID NO:59 (VL CDR2), and SEQ ID NO:60 (VL CDR3);

[0135] b) SEQ ID NO:63 (VH CDR1), SEQ ID NO:64 (VH CDR2), SEQ ID NO:65 (VH CDR3), SEQ ID NO:68 (VL CDR1), SEQ ID NO:69 (VL CDR2), and SEQ ID NO:70 (VL CDR3); and

[0136] c) SEQ ID NO:73 (VH CDR1), SEQ ID NO:74 (VH CDR2), SEQ ID NO:75 (VH CDR3), SEQ ID NO:78 (VL CDR1), SEQ ID NO:79 (VL CDR2), and SEQ ID NO:80 (VL CDR3).

[0137] Embodiment 3. The method of Embodiment 1 or 2, wherein the antibody or fragment thereof comprises a combination of heavy chain variable region (VH) and light chain variable region (VL) sequences selected from SEQ ID NO:52 and SEQ ID NO:57; SEQ ID NO:62 and SEQ ID NO:67; and SEQ ID NO:72 and SEQ ID NO:77.

[0138] Embodiment 4. The method of any one of Embodiments 1-4, wherein ticagrelor has been administered to the patient prior to administration of the anti-ticagrelor antibody or fragment thereof.

[0139] Embodiment 5. The method of any one of Embodiments 1-5, wherein the antibody or fragment thereof is a Fab, and a dose of about 1 g to about 48 g is administered to the patient.

[0140] Embodiment 6. The method of Embodiment 5, wherein the dose is about 9 g to about 18 g of Fab.

[0141] Embodiment 7. The method of Embodiment 5 or 6, wherein a dose of about 1 g, about 3 g, about 9 g, about 18 g, about 24 g, about 30 g, about 36 g or about 48 g of Fab is administered to the patient.

[0142] Embodiment 8. The method of any one of Embodiments 1-7, wherein the pharmaceutical composition is administered intravenously to the patient.

[0143] Embodiment 9. The method of Embodiment 8, wherein the pharmaceutical composition is administered intravenously over about 15 minutes to about 36 hours.

[0144] Embodiment 10. The method of any one of Embodiments 1-9, wherein the pharmaceutical composition is administered in two or more segments.

[0145] Embodiment 11. The method of Embodiment 10, wherein the first segment is a bolus injection.

[0146] Embodiment 12. The method of Embodiment 10 or 11, wherein the administration rate of each segment is different.

[0147] Embodiment 13. The method of any one of Embodiments 10-12, wherein for successive infusion segments, the administration rate of each segment is different.

[0148] Embodiment 14. The method of any one of Embodiments 10-13, wherein the pharmaceutical composition is administered in three or more segments, wherein for successive infusion segments, the administration rate of each segment is different.

[0149] Embodiment 15. The method of any one of Embodiments 5-14, wherein the pharmaceutical composition is administered according to the following schedule: 12 g is infused over 10 minutes, followed by 12 g infused over 6 hours, followed by 12 g infused over 18 hours.

[0150] Embodiment 16. The method of any one of Embodiments 1-15, wherein the pharmaceutical composition comprises about 50 mg / mL to about 200 mg / mL of an anti-ticagrelor antibody or fragment thereof, about 5 mM to about 50 mM histidine / histidine hydrochloride buffer, about 100 mM to about 300 mM sucrose, and about 0.01% (w / v) to about 1.0% (w / v) polysorbate 80, pH 5.5 to 6.5.

[0151] Embodiment 17. The method of Embodiment 16, wherein the pharmaceutical formulation comprises 100 mg / mL of an anti-ticagrelor antibody or fragment thereof, 25 mM histidine / histidine hydrochloride buffer, 290 mM sucrose, and 0.05% (w / v) polysorbate 80, pH 6.0.

[0152] Embodiment 18. The method of embodiment 16 or 17, wherein the pharmaceutical formulation is diluted in saline for administration.

[0153] Embodiment 19. The method of any one of embodiments 1-18, wherein the ticagrelor-related bleeding is major bleeding.

[0154] Embodiment 20. The method of embodiment 19, wherein the major bleeding is characterized by being life-threatening, having the potential to cause clinically significant disability, requiring surgery to control bleeding, requiring treatment with blood products, or being acute bleeding associated with a clinically important hemoglobin drop.

[0155] Embodiment 21. The method of any one of embodiments 1-20, wherein the patient requires emergency surgery or intervention.

[0156] Embodiment 22. The method of embodiment 21, wherein the emergency surgery or intervention is known to be associated with a significant bleeding risk such as coronary artery bypass surgery, having adverse surgical outcomes in nerve, ophthalmic, or joint replacement surgery if bleeding is not carefully controlled, being associated with the risk of experiencing perioperative events; or in patients who are at high risk of thrombosis if dual antiplatelet therapy is discontinued preoperatively.

[0157] Embodiment 23. The method of any one of embodiments 1-22, wherein the patient is at risk of developing acute coronary syndrome (ACS) or has been diagnosed with acute coronary syndrome (ACS).

[0158] Embodiment 24. The method of any one of embodiments 1-23, wherein the patient is at risk of developing a disease selected from the following or has been diagnosed with a disease selected from the following: myocardial infarction (MI), unstable angina, stable ischemic heart disease, sickle cell disease including pediatric patients, atrial fibrillation, coronary artery disease, peripheral artery disease, ischemic stroke, one or more coronary stents, carotid stents, stents after intracranial aneurysms, and arteriovenous fistulas created for hemodialysis.

[0159] Embodiment 25. The method of any one of embodiments 1-24, wherein the patient is a pediatric patient.

[0160] Embodiment 26. The method of embodiment 25, wherein the pediatric patient is less than 18 years old.

[0161] Embodiment 27. The method of embodiment 26, wherein the pediatric patient is less than 2 years old.

[0162] Embodiment 28. The method of any one of embodiments 1-24, wherein the patient is an adult patient.

[0163] Embodiment 29. The method of embodiment 28, wherein the adult patient is 18 to 64 years old, inclusive.

[0164] Embodiment 30. The method of embodiment 28, wherein the patient is over 65 years old.

[0165] Embodiment 31. The method of embodiment 30, wherein the patient is 65 to 80 years old, inclusive.

[0166] Embodiment 32. The method of any one of embodiments 1-31, wherein aspirin (acetylsalicylic acid) has been administered to the patient.

[0167] Embodiment 33. The method of any one of embodiments 1-32, wherein the administration of the antibody or fragment thereof reverses ticagrelor activity.

[0168] Embodiment 34. The method of embodiment 33, wherein the administration of the antibody or fragment thereof restores platelet function.

[0169] Embodiment 35. The method of embodiment 34, wherein the administration of the antibody or fragment thereof restores platelet aggregation.

[0170] Embodiment 36. The method of embodiment 35, wherein the administration of the antibody or fragment thereof restores platelet aggregation to at least 80% of baseline.

[0171] Embodiment 37. The method of embodiment 35 or 36, wherein the administration of the antibody or fragment thereof restores platelet aggregation within 1 minute to 60 minutes of administration.

[0172] Embodiment 38. The method of embodiment 37, wherein the administration of the antibody or fragment thereof restores platelet aggregation within 5 minutes of administration.

[0173] Embodiment 39. The method of any one of embodiments 35 to 38, wherein the administration of the antibody or fragment thereof provides a sustained restoration of platelet aggregation.

[0174] Embodiment 40. The method of embodiment 39, wherein the restoration of platelet aggregation persists for at least 12 hours after administration.

[0175] Embodiment 41. The method of embodiment 40, wherein the restoration of platelet aggregation persists for at least 16 hours after administration.

[0176] Embodiment 42. The method of embodiment 41, wherein the restoration of platelet aggregation persists for at least 24 hours after administration.

[0177] The present disclosure is further illustrated by the following non-limiting examples. Example

[0178] Example 1 - A Phase 1, randomized, double - blind, placebo - controlled, single - ascending - dose study to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics of PB2452 with and without ticagrelor pretreatment in healthy volunteers Example 2

[0179] Primary objectives: 1) To evaluate the safety and tolerability of a single escalating intravenous (IV) dose of PB2452 with or without oral ticagrelor; 2) To evaluate the effect of a single escalating dose of PB2452 on the antiplatelet activity of ticagrelor using light transmission aggregometry (LTA).

[0180] Secondary objectives: 1) To determine the pharmacokinetics of escalating doses of IV PB2452 in the presence and absence of ticagrelor; 2) To determine the pharmacokinetics of ticagrelor and its active metabolite TAM in the presence and absence of PB2452; 3) To evaluate the effectiveness of a single IV PB2452 dose in reversing ticagrelor antiplatelet activity by measuring the P2Y 12 reaction units (PRU) with the VerifyNow™ P2Y 12 assay and by measuring the platelet reactivity index (PRI) with vasodilator-stimulated phosphoprotein (VASP) phosphorylation assay by enzyme-linked immunosorbent assay (ELISA); 3) If the 6th dose of ticagrelor is administered, to evaluate the pharmacokinetics and pharmacodynamics of reinitiating a single oral dose of ticagrelor 24 hours after IV PB2452 administration; 4) To evaluate the immunogenic potential of PB2452.

[0181] Exploratory objective: To evaluate the effect of PB2452 on the pharmacokinetic (PK) profile of the plasma concentrations of unbound ticagrelor and unbound TAM.

[0182] Study design and methods: This is a Phase 1, first-in-human, randomized, double-blind, placebo-controlled, single escalating dose, sequential group study to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics of PB2452 with or without ticagrelor pretreatment when administered to healthy male and female subjects. All references to the study drug within the protocol apply to PB2452 or the matching placebo.

[0183] This study has up to 10 groups and a total of approximately 80 subjects in total. The starting dose of PB2452 is 100 mg, and the planned doses for subsequent groups are 300, 1000, 3,000, 9,000, and 18,000 mg. Other doses may also be tested and may exceed 18,000 mg.

[0184] The study consisted of a screening period (days –45 to –4), an inpatient / pre-treatment period (days –3 to –1), an in-treatment period (days 1 to 3), and follow-up visits (days 4, 7, and 28 [+2 days]). Subjects received an IV dose of the study drug on day 1. On day 1, subjects who met all inclusion criteria and none of the exclusion criteria were randomly assigned in a 3:1 ratio to receive PB2452 or placebo in all treatment groups:

[0185] Groups 1 to 3: For the initial group (Group 1), 4 healthy subjects were randomly assigned in a 3:1 ratio of active treatment / placebo (3A:1P) to receive a single 100 mg IV dose of the study drug over 30 minutes. For the second group (Group 2), 4 healthy subjects were randomly assigned (3A:1P) to receive a single 300 mg IV dose of the study drug over 30 minutes. For the third group (Group 3), 4 healthy subjects were randomly assigned (3A:1P) to receive a 1,000 mg IV dose of the study drug over 30 minutes.

[0186] Groups 4 to 6: If there were no safety concerns in the previously dosed group, 8 subjects in each of Groups 4 to 6 were randomly assigned in a 3:1 ratio (6A:2P) to receive a single IV dose of the study drug approximately 2 hours after pre-treatment with the 5th dose of ticagrelor. For ticagrelor pre-treatment, subjects received an oral loading dose of 180 mg ticagrelor in the morning (day –2), followed by 90 mg ticagrelor orally every 12 hours for a total of 4 additional doses, and then a single IV dose of the study drug approximately 2 hours after the 5th ticagrelor dose (day 1). Subjects in each of Groups 4 to 6 would receive ticagrelor pre-treatment as described above and, over 30 minutes, a single IV dose of 1,000, 3,000, or 9,000, or 18,000 mg of the study drug, respectively. After safety and dose escalation evaluations in each previous dose group, Groups 4 to 6 would be dosed sequentially.

[0187] Groups 7 to 10: For Group 7, after ticagrelor pre-treatment, subjects were randomly assigned in a 3:1 ratio (6A:2P) to receive a single IV dose of the study drug. The intravenous infusion was initiated 2 hours after the 5th ticagrelor dose and PB2452 would be administered continuously but at the following different rates during the infusion period: 3,000 mg over 5 minutes, followed by 15,000 mg over 7 hours 55 minutes.

[0188] For Group 8, the infusion rate during the infusion period was as follows: 6,000 mg was infused over 15 minutes, followed by 6,000 mg over 3 hours, and then 6,000 mg over 8.75 hours. For Group 9, the infusion rate during the infusion period was as follows: 6,000 mg was infused over 15 minutes, followed by 6,000 mg over 4 hours, and then 6,000 mg over 12 hours. For Group 10, the infusion rate during the infusion period was as follows: 6,000 mg was infused over 10 minutes, followed by 6,000 mg over 3 hours, and then 6,000 mg over 13 hours.

[0189] Subjects in Groups 1 to 3 were admitted to the clinical site on Day - 1. On Day 1, the subjects received a single IV dose of the study drug in the morning. The subjects were discharged from the clinical site on Day 3 and returned for follow - up visits on Days 4, 7, and 28 (+2 days).

[0190] Subjects in Groups 4 to 10 were admitted to the clinical site on Day - 3. In the morning of Day - 2, the subjects started pre - treatment with ticagrelor. On Day 1, the subjects received a single IV dose of the study drug in the morning. Subjects in Groups 4 to 8 (and Group 9 if Group 9 did not receive the 6th dose of ticagrelor) were discharged from the clinical site on Day 3 and returned for follow - up visits on Days 4, 7, and 28 (+2 days). Group 10 was discharged from the clinical site on Day 7 and returned for its final follow - up visit on Day 28 (+2 days).

[0191] On Day 2, in the morning 24 hours after the start of the study drug infusion, subjects in Group 9 may receive an additional dose of ticagrelor. In this case, the subjects were discharged from the clinical site on Day 4 and returned for follow - up visits on Days 7 and 28 (+2 days). If the 6th ticagrelor dose was not given, they were discharged from the unit ward on Day 3 and returned for follow - up visits on Days 4, 7, and 28. The decision on whether to administer the 6th dose of ticagrelor was made based on the review of data from the previous groups.

[0192] Plasma samples were collected at specified intervals up to 28 days after dosing for PK and pharmacodynamic (PD) analysis of PB2452, ticagrelor, and its active metabolite TAM, and urine samples were collected for PK analysis of ticagrelor and TAM. 0 hours was the start of the study drug infusion for all groups.

[0193] Safety and tolerability were carefully monitored throughout the study. Immunogenicity was determined in all subjects at baseline and up to 28 days after the administration of the study drug.

[0194] Sentinel Dosing: Dosing for Group 1 (the first exposure of PB2452 in humans) was conducted with two sentinel subjects who initially received a single IV dose randomly assigned to receive the study drug. Up to 24 hours after the study drug infusion, blinded safety data from the sentinel subjects were reviewed by the investigator and then dosing was administered to the remaining 2 subjects in Group 1. At least 24 hours after the sentinel subjects, dosing was administered to the remaining subjects. Additionally, dosing for Group 4 (the first exposure of PB2452 in combination with ticagrelor in humans) was conducted with 2 sentinel subjects pre-treated with ticagrelor and then received a single IV dose of PB2452 or placebo randomized in a 1:1 ratio of active agent / placebo. Up to 24 hours after ticagrelor and the study drug administration, blinded safety data from the sentinel subjects were reviewed by the investigator and then dosing was administered to the remaining 6 subjects in Group 4. At least 24 hours after the sentinel subjects, dosing was administered to the remaining subjects.

[0195] Dose Escalation: A Safety Review Committee (SRC) will be established for blinded review of safety (e.g., clinical laboratory results, adverse events [AE], 12-lead electrocardiogram [ECG], vital signs) through Day 4 and available PK data for each dose group. Dose escalation to subsequent groups will be based on the safety of the previous group. The investigator makes recommendations regarding whether to proceed to the next predetermined dose level, suspend dosing for review of additional safety and / or PK data, or adjust the dose for the next dose group. Decisions to adjust or suspend the dose or proceed to the next group are made by the SRC. Safety data are reviewed in a blinded manner and must be considered acceptable by the SRC prior to dosing of the next higher dose group.

[0196] Based on review of safety and PK data (if available), the SRC may choose to repeat a dose level, administer a dose less than the previous dose, or escalate to a dose lower than the next planned dose. The SRC has the authority to make a decision to escalate the dose after reviewing available safety data regarding any DLT.

[0197] Stopping Criteria: After completion of Day 4 for each dose group, the SRC reviews and evaluates all available safety (e.g., clinical laboratory results, AE, ECG, vital signs), tolerability, and available PK data to make a decision regarding dose escalation for the next dose group. Dose escalation is suspended if any of the following occur after confirmation of receipt of PB2452 and review by the SRC:

[0198] Any preclinical or clinical event that, in the opinion of the SRC, prohibits further dosing of additional subjects with PB2452;

[0199] Any serious adverse event (SAE) in the dose group;

[0200] Data from a previous dose group indicate a safety issue for the next group to be dosed at a higher level, such as an unexpected response (e.g., clinically significant changes in clinical laboratory data, ECG, cardiac telemetry, vital signs, or physical examination);

[0201] Two or more subjects in a dose group experienced any DLT, or 1 subject experienced a grade 2 or higher AE (DLT), which in the opinion of the SRC is a justifiable reason to suspend dose escalation.

[0202] Two or more subjects had alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 3 × upper limit of normal (ULN), or bilirubin or alkaline phosphatase > 2 × ULN, for which no other cause could be identified to explain the increase; or

[0203] One or more subjects experienced a grade 2 or higher infusion-related reaction despite premedication for infusion-related reactions.

[0204] Dose escalation may also be suspended if, in the opinion of the SRC or the sponsor, any other significant safety or tolerability issues are identified in a comprehensive review of the available data, which are a justifiable reason for further evaluation prior to dosing additional subjects. This may include emerging non-clinical data, clinically relevant AEs, or relevant data from other sources indicating safety concerns, even if the event itself does not meet the protocol-defined dose-limiting toxicity definition. After reviewing the available safety data regarding SAEs and other stopping criteria, the SRC has the authority to make a decision regarding dose escalation.

[0205] Inclusion criteria:

[0206] 1) For male or female subjects in groups 1 - 10, the subject is a male or female 18 to 50 years of age, inclusive.

[0207] 2) The subject has a body mass index of 18 to 35 kg / m 2 and a weight of ≥ 50 kg but ≤ 120 kg, inclusive, at screening.

[0208] 3) As determined by medical history, clinical laboratory test results, vital sign measurements, 12-lead ECG results, and physical examination findings at screening, the subject is considered by the investigator to be in good general health.

[0209] 4) Female subjects with childbearing potential must not become pregnant, breastfeed, or plan to become pregnant within 3 months after the last dose of the investigational drug and must have a negative serum pregnancy test at screening and at the time of enrollment. From 30 days before the administration of the investigational drug until the end of the study, female subjects with childbearing potential must use two effective methods of birth control (i.e., oral, implantable, patch, or injectable contraceptives in combination with a condom, a hormonal intrauterine contraceptive device in combination with a condom [which has been in place for at least 2 months before screening], a double-barrier method [i.e., condom, contraceptive sponge, diaphragm, or cervical cap with spermicidal gel or cream], or vasectomy for male subjects or male partners of female subjects). If a female has met one of the following conditions, she is considered to have no childbearing potential: documentation of irreversible surgical sterilization (i.e., hysterectomy or bilateral oophorectomy [not tubal ligation]), or postmenopause (defined as 12 consecutive months of amenorrhea after discontinuation of all exogenous hormone therapy, with a documented plasma follicle-stimulating hormone level > 40 IU / mL, or 24 consecutive months of amenorrhea). Male subjects with female partners of childbearing potential must agree to use appropriate and effective contraceptive measures (e.g., condom plus diaphragm with spermicide; condom plus spermicide) during the study and for 30 days after the last dose of the investigational drug, and must avoid donating sperm for at least 7 days before the dose of the investigational drug and until at least 90 days after the last dose of the investigational drug.

[0210] 5) The subject agrees to comply with all protocol requirements.

[0211] 6) The subject is able to provide written informed consent.

[0212] Exclusion Criteria

[0213] 1. Any history of clinically significant acute or chronic disease or medical condition.

[0214] 2. Gastrointestinal, hepatic (except Gilbert syndrome), or renal disease or renal insufficiency (i.e., estimated glomerular filtration rate < 60 ml / min / 1.73 m 2 ), or history or presence of any other condition known to interfere with the absorption, distribution, metabolism, or excretion of the drug.

[0215] 3. Any clinically significant illness, medical / surgical procedure, or trauma within 4 weeks of the administration of the investigational drug, or any planned surgical procedure that will occur during the study (from screening to the 28-day follow-up visit).

[0216] 4. Any clinically significant abnormal findings in physical examination, vital signs, laboratory evaluations, and ECG parameters identified during screening or enrollment. Note: Abnormal test results may be repeated once for confirmation.

[0217] The specific vital sign exclusion criteria that occur after 10 minutes of supine rest are any of the following:

[0218] Systolic blood pressure > 150 mmHg;

[0219] Diastolic blood pressure > 90 mmHg; or

[0220] Heart rate < 50 or > 100 beats per minute.

[0221] The specific exclusion criteria for ECG parameters at screening or admission are any of the following:

[0222] Prolonged QT interval corrected by Fridericia (QTcF) > 450 milliseconds (msec), shortened QTcF < 340 ms or pause > 3 seconds, or family history of long QT syndrome;

[0223] Prolonged PR (PQ) interval > 240 msec, intermittent second-degree or third-degree atrioventricular (AV) block or AV dissociation, or shortened PR interval < 120 msec;

[0224] Incomplete, complete or intermittent bundle branch block (QRS < 110 msec, with normal QRS and T wave morphology) is acceptable if there is no evidence of left ventricular hypertrophy;

[0225] 5. Any history of arterial or venous thrombosis, including any of the following:

[0226] History of transient ischemic attack, cardiovascular accident, stroke (ischemic or hemorrhagic), unstable angina, myocardial infarction or peripheral arterial disease; or

[0227] History of deep vein thrombosis, pulmonary embolism, thrombophlebitis or cavernous malformation.

[0228] 6. Any increased bleeding risk, including the following:

[0229] History of recent gastrointestinal bleeding (within 30 days before the first dose of the study drug);

[0230] Any history of severe head trauma, intracranial hemorrhage, intracranial neoplasm, arteriovenous malformation, aneurysm or proliferative retinopathy;

[0231] Any history of intracranial, intraocular, retroperitoneal or spinal hemorrhage;

[0232] Any recent (within 30 days before the first dose of the study drug) major trauma;

[0233] History of bleeding disorders (e.g., hemophilia, von Willebrand disease) that may increase the bleeding risk;

[0234] Receiving long-term treatment with non-steroidal anti-inflammatory drugs (including aspirin [more than 100 mg per day]), anticoagulants, or other antiplatelet agents that cannot be discontinued (including clopidogrel, prasugrel, ticlopidine, dipyridamole, or cilostazol).

[0235] Having taken any oral or parenteral anticoagulant within 30 days of screening, including low molecular weight heparin;

[0236] Having taken non-steroidal anti-inflammatory drugs, including aspirin, within 14 days of screening;

[0237] 7. The subject has a positive test result for hepatitis B surface antigen, hepatitis C virus antibody, or human immunodeficiency virus type 1 or 2 antibody at the time of screening.

[0238] 8. Any ongoing or recent (i.e., during the screening period) minor medical complaints that, in the judgment of the investigator, may interfere with the interpretation of study data or are considered unlikely to comply with the study procedures, restrictions, and requirements.

[0239] 9. Any risk of bradycardia events (e.g., known sick sinus syndrome, atrial fibrillation, or second- or third-degree AV block).

[0240] 10. Concomitant oral or IV therapy with a strong CYP3A inhibitor, a CYP3A substrate with a narrow therapeutic index, or a strong CYP3A inducer that cannot be discontinued at least 5 half-lives but not less than 10 days before randomization (a list of examples can be found in section 6.2).

[0241] 11. Any prescription drugs (excluding hormonal contraceptives) or over-the-counter drugs (excluding acetaminophen [up to 2 g per day] treatment, including herbal or nutritional supplements) within 14 days before the first dose of the study drug.

[0242] 12. The subject has consumed grapefruit or grapefruit juice, Seville oranges or products containing Seville oranges (e.g., marmalade), or products containing alcohol or xanthine within 48 hours before dosing with the study drug.

[0243] 13. The subject is participating in any other study or non-drug study that, in the opinion of the investigator, will interfere with the results of this study.

[0244] 14. The subject has received another new chemical entity (defined as a compound not yet approved for marketing) or any marketed or investigational biologic within 30 days of the administration of the study drug in this study. The exclusion period begins 30 days (whichever is longer) after the last dose of the investigational drug or 5 half-lives have passed.

[0245] 15. The subject has a relationship with any sponsor or study site employee or their next of kin (e.g., spouse, parent, sibling, or child, whether biological or legally adopted).

[0246] 16. The subject has previously received PB2452 or has been randomized in an earlier group of this study to receive the study drug.

[0247] 17. The subject is a smoker or has used nicotine or nicotine-containing products (e.g., snuff, nicotine patches, nicotine gum, nicotine cigarettes, or inhalers) within 3 months prior to the infusion of the study drug.

[0248] 18. The subject has a known or suspected history of substance abuse (including alcohol) at screening or at the time of enrollment, or has a positive test result for substance abuse, alcohol, or cotinine (nicotine level > 300 ng / mL).

[0249] 19. The subject has engaged in strenuous activity or contact sports within 24 hours prior to the infusion of the study drug and while confined to the clinical site.

[0250] 20. The subject has donated blood or plasma within 1 month prior to screening or has had more than 500 mL of any blood donation / bleeding during the 3 months prior to the infusion of the study drug.

[0251] 21. The subject has a history of severe allergic / hypersensitivity reactions or ongoing allergy / hypersensitivity, as judged by the investigator, or a history of hypersensitivity to drugs with a chemical structure or class similar to ticagrelor, any biologic agent, or any severe food allergy that may interfere with the standard diet at the clinical site.

[0252] 22. Concerns regarding the subject's inability to comply with study procedures and / or follow-up, or in the investigator's opinion, the subject is not suitable for entry into the study.

[0253] Evaluation Criteria:

[0254] Safety Evaluation: Safety and tolerability will be evaluated by monitoring and recording AEs, clinical laboratory test results (hematology, coagulation, serum chemistry, and urinalysis), vital sign measurements (systolic and diastolic blood pressure, oral temperature, respiratory rate, and heart rate), 12-lead ECG results, cardiac telemetry monitoring, immunogenicity, and physical examination findings.

[0255] Pharmacokinetic Evaluation

[0256] Plasma collection: Blood samples were collected from all subjects at the following time points for PK analysis of PB2452 in plasma: before dosing (within 10 minutes before the start of the study drug infusion), and up to 28 days after the start of the study drug infusion. The specific collection times for each group are listed in the following table:

[0257]

[0258] Plasma samples were collected from subjects in groups 4 to 10 before dosing (within 10 minutes before the start of the study drug infusion [time 0]) and up to 48 hours after the start of the study drug infusion to determine the total concentration of ticagrelor and its active metabolite TAM (or ARC-124910XX). The specific collection times for each group are listed in the following table:

[0259]

[0260] If, in group 9, the 6th dose of ticagrelor is administered 24 hours after the study drug infusion, additional PK samples were collected up to 24 hours after the 6th ticagrelor dose, as noted in the following table:

[0261]

[0262] Plasma samples were collected from subjects in groups 4 to 10 before dosing (within 10 minutes before the start of the study drug infusion [time 0]) and up to 48 hours after the start of the study drug infusion to determine the unbound concentrations of ticagrelor and TAM. The specific collection times for each group are listed in the following table:

[0263]

[0264] The following plasma PK parameters for PB2452 were calculated:

[0265] Area under the plasma concentration-time curve (AUC) from time 0 to the time of the last quantifiable concentration (AUC0-t);

[0266] Observed maximum plasma concentration (Cmax);

[0267] Time to reach the observed maximum plasma concentration (Tmax);

[0268] AUC extrapolated from time 0 to infinity (AUC0-inf) (if data permit);

[0269] Terminal elimination half-life (t½) (if data permit);

[0270] Apparent clearance (CL) (if data permit);

[0271] Calculate the following plasma PK parameters for ticagrelor and TAM:

[0272] Cmax;

[0273] Tmax;

[0274] AUC from time 0 to 12 hours post-dose (AUC0-12);

[0275] AUC from time 0 to 24 hours post-dose (AUC0-24);

[0276] AUC from time 0 to 48 hours post-dose (AUC0-48);

[0277] AUC from time 0 to the time of the last quantifiable concentration (Clast) (AUC0-t);

[0278] AUC0-inf (if data permit);

[0279] t½ (if data permit);

[0280] For the group receiving the 6th dose of ticagrelor 24 hours after the investigational drug, calculate only the PK parameters AUC0-24 and AUC 0-inf (if data permit). Additional PK parameters may be included.

[0281] Pharmacodynamic evaluation:

[0282]

[0283] The following PD data and parameters are generated by LTA, P2Y 12 response units (pRU) and platelet reactivity index (PRI) assays.

[0284] Record, at each evaluation point, the maximum, final aggregation extent, and area under the curve for up to four platelet agonists [(20 μM adenosine diphosphate (ADP), 5 μM adenosine diphosphate (ADP), 1.6 mM arachidonic acid (AA), and 15 μM thrombin receptor-activating peptide (TRAP)].

[0285] Percentage of baseline platelet aggregation;

[0286] Maximum platelet aggregation;

[0287] Time to maximum platelet aggregation;

[0288] Time to 60%, 80%, 90% of baseline platelet aggregation.

[0289] VerifyNow™ P2Y 12 : 1) PRU at each evaluation point; 2) percentage of baseline in PRU; 3) maximum PRU; 4) time to maximum PRU; 5) time to 60%, 80%, 90% of baseline PRU

[0290] VASP by ELISA: 1) PRU at each evaluation point; 2) percentage of baseline in PRU; 3) maximum PRU; 4) time to maximum PRU; 5) time to 60%, 80%, 90% of baseline PRU

[0291] Investigational drug, dose, and route of administration:

[0292] PB2452:

[0293] All groups: Single IV infusion of PB2452 (concentration ranging from 0.4 mg / mL to 72 mg / mL), delivering 250 mL over 30 minutes to 12 hours, at increasing doses of 100, 300, 1,000, 3,000, 9,000, 18,000 mg, 24,000 or 36,000 mg, or intermediate doses of 9,000 to 36,000 mg. In some cases, the sponsor may choose to infuse a portion of the investigational drug (up to 6 g) at a faster rate (equivalent to a bolus) for the first 5 - 20 minutes of the infusion.

[0294] Matched placebo:

[0295] All groups: Single IV infusion of 0.9% sodium chloride, delivering 250 mL at a rate matching the defined active infusion duration.

[0296] Ticagrelor:

[0297] Groups 4 to 10: Ticagrelor 90 mg oral tablets (immediate release); administered as a 180 mg (2 × 90 mg tablets) loading dose plus an additional 4 times 90 mg every 12 hours

[0298] Group 9: 24 hours after the start of the investigational drug infusion, may have an additional dose administered as a 180 mg ([2 × 90 mg) oral tablet (immediate release)].

[0299] Background - Human clinical trial data – PB2452 reverses ticagrelor activity

[0300] Ticagrelor is an oral P2Y used in combination with aspirin 12Inhibitors to reduce the risk of ischemic events in patients with acute coronary syndrome. As with other antiplatelet drugs, spontaneous major bleeding and bleeding associated with urgent invasive procedures are also of concern. The antiplatelet effect of ticagrelor cannot be reversed by platelet transfusion. A rapid-acting reversal agent would be useful.

[0301] In the first randomized, double-blind, placebo-controlled study in humans in healthy volunteers, intravenous (IV) PB2452 (a monoclonal antibody fragment that binds to ticagrelor with high affinity) was evaluated as a ticagrelor reversal agent. Before and 48 hours after ticagrelor administration, light transmission aggregometry (LTA), VerifyNow, and vasodilator-stimulated phosphoprotein (VASP) assays were used to evaluate platelet function.

[0302] Among the 64 randomized subjects, 48 received PB2452 and 16 received placebo. At 48 hours after ticagrelor, platelet aggregation was suppressed by ~80%. Compared with placebo, PB2452 was administered as a 10-minute intravenous bolus followed by a 16-hour infusion, with significant restoration of platelet function measured by multiple assays. Reversal onset occurred within 5 minutes and lasted for more than 20 hours (Bonferroni-corrected P < 0.0001 for all assays across all time points). There was no evidence of platelet activity rebound after drug discontinuation. There were no drug-related adverse events.

[0303] PB2452 is a specific reversal agent for ticagrelor, providing safe and effective immediate and sustained reversal of the antiplatelet effect of ticagrelor (using multiple assays). PB2452 may represent a useful approach for treating or preventing ticagrelor-related bleeding complications.

[0304] Trial design

[0305] Antiplatelet therapy is a necessary part of secondary prevention of cardiovascular events. (Bhatt (2014)). In particular, dual antiplatelet therapy - the combination of aspirin and an oral P2Y12 antagonist - is the dominant approach in patients with acute coronary syndrome, coronary stenting, and previous myocardial infarction. (Yusuf 92001); Mehta (2001); Bhatt (2006); Bhatt (2007); Chen (2005); Wiviott (2007); Prasugrel (2012); Wiviott(2013). The three oral P2Y12 receptor antagonists used are clopidogrel, prasugrel, and ticagrelor. (Koski(2018)). Randomized trials have found that ticagrelor is superior to clopidogrel across the entire spectrum of acute coronary syndromes (Wallentin (2009); Cannon (2010); James (2011).

[0306] All three oral P2Y 12 antagonists have the limitation that they increase the risk of bleeding, which persists for several days after discontinuation. (Plavix prescribing information; Brilinta prescribing information; Effient prescribing information). This poses a challenge in patients with major bleeding such as intracranial or gastrointestinal bleeding. (Ducrocq (2013); Bhatt (2007)). Additionally, patients who require urgent and especially urgent invasive procedures are also at increased risk of perioperative bleeding complications. If an urgent procedure is needed, the proceduralist must accept the increased risk of bleeding often associated with empirically administered platelet transfusions. If urgent, the operator either proceeds and anticipates the risk of increased bleeding, or delays the procedure for several days, with the attendant risk of delaying clinically indicated procedures. Society guidelines recommend discontinuing oral P2Y 12 receptor antagonists at least five days before surgery. (Capodanno (2013); Douketis (2012)).

[0307] Currently, there is no reversal agent for P2Y 12 receptor antagonists. Unlike other P2Y 12 antagonists, ticagrelor is a reversible inhibitor. Thus, ticagrelor binds to P2Y 12 on infused platelets, rendering them ineffective. Therefore, a specific reversal agent for ticagrelor would be desirable.

[0308] Results

[0309] This study was a single-center, randomized, double-blind, placebo-controlled, single ascending dose study to evaluate the safety, efficacy, and pharmacokinetics of PB2452 in healthy subjects aged 18 to 50 years with or without ticagrelor pretreatment. As shown in Table 1, ten sequential dose groups were evaluated.

[0310] Table 1 – Final Study Design

[0311]

[0312] Abbreviation: BID, twice daily

[0313] Groups 1 - 3 each enrolled 4 subjects, and intravenous doses of 0.1, 0.3, and 1.0 grams of PB2452 were evaluated over a 30-minute infusion in the absence of ticagrelor pretreatment.

[0314] Subjects in Groups 4 to 10 were pretreated with a 180 mg oral ticagrelor loading dose, followed by 90 mg twice daily for 48 hours, and then PB2452 was evaluated at doses of 1.0 to 18 grams. Groups 4, 5, and 6 each consisted of 8 subjects who were randomly assigned to receive 1.0, 3.0, and 9.0 grams of PB2452 or placebo after ticagrelor pretreatment. Groups 7 to 10 received a fixed 18-gram dose of PB2452 or placebo via various infusion regimens. The PB2452 infusion in these groups was initiated 2 hours after the last ticagrelor pretreatment dose to coincide with the peak concentration of ticagrelor. (Gurbel (2009). Subjects in all groups were randomized at a 3:1 ratio to receive PB2452 or placebo.

[0315] Subject Eligibility: Eligible subjects were healthy men and women aged 18 to 50 years with a body mass index of 18 to 35 kg / m 2 and a weight of ≥50 kg to ≤120 kg. Subjects with any contraindications to ticagrelor, a medical history suggestive of an increased bleeding risk, or an estimated glomerular filtration rate of less than 60 mL / min / 1.73m 2 were excluded. Written informed consent was obtained from all subjects.

[0316] Statistical analysis

[0317] The primary efficacy outcome was the effectiveness of PB2452 in reversing ticagrelor's antiplatelet effect by analyzing platelet aggregation using light transmission aggregometry at multiple time points before and after PB2452 or placebo administration in ticagrelor-pretreated subjects. The secondary efficacy outcome was the effectiveness of ticagrelor reversal as evaluated using VerifyNow and vasodilator-stimulated phosphoprotein phosphorylation immunoassay (VASP).

[0318] The primary safety outcome was the frequency and severity of treatment-emergent adverse events (AEs) associated with PB2452, with or without oral ticagrelor pretreatment. Clinical laboratory test results, vital sign measurements, 12-lead ECG and continuous telemetry results, and physical examination findings were also evaluated at multiple time points from screening through the end of the 28-day safety follow-up period. Immunogenicity was evaluated before PB2452 administration and on Days 7 and 28 after PB2452 administration.

[0319] Other secondary outcomes included evaluating the pharmacokinetic profiles of PB2452 and ticagrelor and assessing the immunogenicity of PB2452 on Days 7 and 28 after infusion.

[0320] Results

[0321] The sample size of 64 was based on clinical and practical considerations rather than on formal statistical power calculations. This sample size was considered sufficient to adequately evaluate the safety, efficacy, and pharmacokinetic profile of PB2452, as well as the pharmacokinetic and pharmacodynamic profiles of ticagrelor. The reversal of the antiplatelet effect was evaluated by comparing the mean percentage of baseline platelet aggregation between PB2452 and placebo using the Wilcoxon rank sum test. Multiplicity was adjusted using the Bonferroni method. Pearson correlation and Spearman rank correlation coefficients were used to evaluate the correlation between each pair of platelet function tests. For all presentations, the mean data of subjects who received placebo in each group were pooled. Categorical variables were summarized by their frequency and percentage, and continuous variables were presented with the number of subjects with no missing data, mean, standard deviation, median, minimum, and maximum. Descriptive statistics for each group, as well as pooled placebo and PB2452 data, were presented. For pharmacodynamic data, platelet aggregation results were compared between each group and the pooled placebo data (pooling groups 4 to 6 and groups 7 to 10, respectively). All analyses were performed using SAS software, version 9.4 (SAS Institute).

[0322] Reversal of ticagrelor

[0323] Study population: A total of 64 subjects were randomized. Of these, 48 received PB2452 and 16 received placebo. Of the 48 who received PB2452, 21 received the highest dose of 18 grams and 39 received ticagrelor pretreatment. The final study design and subject flow diagram are shown in Table 1 and Figure 6, respectively. Baseline characteristics of the subjects are provided in Table 2.

[0324] Table 2 – Baseline characteristics

[0325]

[0326] Safety: Overall, PB2452 was considered safe and well tolerated. A total of 30 treatment-emergent adverse events were reported in 19 (29.7%) of the 64 subjects. Among the 48 subjects who received PB2452, 17 (35.4%) reported 27 adverse events, while 2 (12.5%) of the 16 subjects who received placebo reported 3 adverse events (Table 3). None of the adverse events were considered related to the study drug. There were no study drug-related serious adverse events, dose-limiting toxicities, or infusion-related reactions. There were no deaths or adverse events leading to discontinuation of the study drug. One subject experienced 2 serious adverse events (alcohol intoxication and acute respiratory failure) after discharge from the clinical site, both of which were considered unrelated to the study drug. All subjects with adverse events had received ticagrelor pretreatment, except for 1 subject in Group 3. Changes in mean clinical laboratory results, vital sign measurements, and ECG values were similar across treatment groups and when compared to placebo.

[0327] Table 3 – Treatment-emergent adverse events, safety population

[0328]

[0329] Note: Treatment-emergent AE (TEAE) is defined as any event that was not present before exposure to the study drug or any existing event that worsened in intensity or frequency after exposure. For analysis purposes, TEAE is an event that started at or after initiation of the study drug. At each level of subject summary, if a subject reported 1 or more events, the subject was counted once. Percentages are based on the number of subjects in each treatment group and the overall safety population. Adverse events were coded using MedDRA version 21.0.

[0330] Figure 3 - 5

[0331] The reversal of ticagrelor was evaluated in Groups 4 to 10. Prior to receiving PB2452 or placebo, subjects were pretreated with ticagrelor for 48 hours. In subjects receiving placebo, platelet aggregation was suppressed by 80 - 85% 48 hours after ticagrelor pretreatment and remained suppressed for an additional 24 hours after ticagrelor discontinuation. Platelet function gradually increased between 24 and 48 hours ( Figure 7A ; Figure 2 and 7B ), and no reversal was observed for the administration of 1 g of PB2452 ( Figure 7A ). For PB2452, in Groups 5 and 6, the first significant reversal of ticagrelor was observed at dose levels of 3.0 and 9.0 grams, respectively ( Figure 7A and 7B ). A significant but transient increase in mean platelet aggregation was observed at the first time point of 30 minutes immediately following completion of the 30 - minute infusion. The duration of reversal was dose - dependent and lasted 1 to 3 hours ( Figure 7B ).

[0332] To achieve a more rapid and sustained reversal, the total PB2452 dose was increased to 18 grams in Groups 7 to 10 to accommodate an initial bolus of PB2452 and a longer infusion of 8, 12, or 16 hours. In Group 7, a 3.0 - gram bolus of PB2452 followed by an 8 - hour infusion resulted in a significant increase in mean platelet aggregation for 2 hours, with a duration of approximately 12 hours ( Figure 7B ). In Groups 8 to 10, the bolus was increased to 6.0 grams, followed by an infusion of 12 or 16 hours. With the larger bolus, reversal was achieved within 5 minutes of infusion initiation and lasted 16 to 24 hours ( Figure 8A ).

[0333] Statistically significant immediate and sustained reversal, as measured by the primary efficacy assessment using the aggregation assay, was confirmed with VerifyNow and VASP ( Figure 10A and 8B ). Correlation analysis between the results of the three platelet function tests confirmed a highly significant correlation for all comparisons, with r - values for Pearson and Spearman analyses of ≥0.81 and ≥0.91, respectively (P < 0.0001 for all comparisons, Figure 9).

[0334] To evaluate the extent of normal platelet function recovery, platelet function after PB2452 was compared to baseline platelet function before ticagrelor using all three assays. At all post - treatment time points up to 20 hours, PB2452 restored mean platelet aggregation within 80% of baseline ( Figure 10B)。The mean VerifyNow platelet reactivity revealed a rapid and sustained normalization of platelet function for PRU ≥ 180 at 24 hours ( Figure 10C )。When assessing the recovery of P2Y12 receptor signaling with VASP, the PRI recovered to nearly 100% of baseline within 5 minutes and persisted for 20 - 24 hours ( Figure 12A )。

[0335] To determine whether acute ticagrelor reversal causes an increase in potential pro - thrombotic rebound in platelet aggregation, platelet aggregation in response to low - concentration ADP (5 µM instead of the usual 20 µM) was determined. Additionally, platelet aggregation in response to other agonists including arachidonic acid and thrombin receptor - activating peptide was also tested. As expected, the response elicited by 5 µM ADP was lower than that of 20 µM ADP ( Pharmacokinetics and 12B ), and the responses to arachidonic acid and thrombin receptor - activating peptide after reversal were similar to the baseline before ticagrelor or PB2425 administration (data not shown).

[0336] Figure 11A

[0337] Pharmacokinetic analysis of PB2425 confirmed a dose - linear increase in mean exposure across a dose range of 0.1 to 9.0 grams ( Figure 11B )。The estimated distribution half - life and terminal half - life were 0.86 hours and 6.9 hours, respectively, with an estimated clearance rate of 1.88 L / minute and a distribution volume of approximately 2.9 L, suggesting that PB2452 is confined to the vascular compartment. In subjects receiving ticagrelor alone, the total ticagrelor concentration reached a peak of 900 ng / mL at approximately 2 hours after the oral dose. In the presence of PB2452, the mean concentration of circulating ticagrelor increased to approximately 2 - 5.6 - fold ( Figure 11C )。At the 18 - gram dose level with an 8 - to 16 - hour infusion, PB2452 exposure was prolonged by 12 - 24 hours ( Figure 11D ), and the mean ticagrelor concentration increased to 5.6 - fold compared to subjects given ticagrelor alone ( Immunogenicity )。These increases in ticagrelor exposure appear to depend on the PB2452 dose and most likely reflect the tight binding between PB2452 and ticagrelor, as well as the subsequent redistribution of extravascular ticagrelor into the vascular compartment.

[0338] Discussion

[0339] Of the 48 subjects given PB2452, 21 (43.8%) had detectable antidrug antibodies, of which 15 (31.3%) had pre - existing (predose) antibodies and 6 (12.5%) became positive post - dose, although at low titers of 40 (n = 5) or 160 (n = 1). Of the subjects assigned to placebo, 3 of 16 (18.8%) tested positive, of which 2 had pre - existing antibodies. All antibody titers were low and no observed effect on the safety or efficacy of PB2452 was seen.

[0340] Conclusion

[0341] This study demonstrated that intravenous infusion of the monoclonal antibody fragment PB2452 significantly reversed the antiplatelet effect of ticagrelor, as measured using a multiplex sensitive assay of platelet function. Within the healthy cohort of the study, no serious adverse events or infusion reactions related to PB2452 were present. Thus, PB2452 represents an effective means to reverse the antiplatelet effect of ticagrelor in patients with bleeding or urgent need for hemostasis during invasive procedures.

[0342] The ability to reverse the action of novel oral anticoagulants is a major advance in antithrombotic therapy. Currently, other than stopping the drug and waiting 3 to 5 days for its effect to dissipate, there is no effective method to reverse the antiplatelet effect of oral P2Y 12 antagonists such as ticagrelor, which is problematic in patients with life - threatening bleeding or at high risk of thrombosis. Treatment guidelines and the prescribing information for ticagrelor state to wait at least 5 days before a surgical procedure. Waiting this long is not possible in patients requiring urgent surgery and may be undesirable in patients requiring urgent surgery. Unfortunately, platelet transfusion is not useful for patients taking ticagrelor because the drug binds to fresh platelets. (Godier (2015); Teng (2016)). Thus, there is a need for a ticagrelor reversal agent.

[0343] PB2452 is a recombinant human IgG1 monoclonal antibody antigen - binding fragment that binds with high specificity to ticagrelor or its active metabolite AR - C124910XX. (Buchanan (2015)). By virtue of its high affinity, PB2452 can neutralize free ticagrelor as well as the drug bound to the P2Y12 receptor, without being bound by theory, which explains the rapid reversal observed with PB2452. The mechanism of action is specific only for ticagrelor and not applicable to clopidogrel or prasugrel, which are irreversible P2Y 12 receptor antagonists, nor is any other off - target binding anticipated.

[0344] Example 3 - A study to evaluate the safety, tolerability, PK, and PD of PB2452 in older and elderly subjects pre - dosed with ticagrelor and acetylsalicylic acid

[0345] Intravenous PB2452 reverses the antiplatelet effect of ticagrelor. In patients with severe bleeding or in need of urgent surgery or other invasive procedures, administration of PB2452 can be a useful strategy for ticagrelor reversal.

[0346] Example 4 - A study to evaluate the safety, tolerability, pharmacokinetics, and pharmacodynamics of PB2452 with high - dose ticagrelor pretreatment in healthy subjects Introduced for reference

[0347] In a Phase 2A, randomized, double-blind, placebo-controlled, single-dose, sequential-group study, the safety, tolerability, pharmacokinetics, and pharmacodynamics of PB2452 were compared with a matched placebo in older and elderly patients pretreated with ticagrelor and acetylsalicylic acid (ASA). Various dose levels and administration regimens were administered to older (50 to 64 years) and elderly (65 to 80 years) male and female subjects.

[0348] Up to 5 dose levels and / or administration regimens were evaluated in up to 5 groups. Each group included 8 to 12 subjects randomized in a 3:1 ratio (PB2452:placebo).

[0349] The initial group (Group 1) included approximately 8 subjects aged 50 to 64 years pretreated with ASA + ticagrelor, randomized to receive 18 grams (g) of PB2452 or a matched placebo, administered as an initial 6 g bolus over 10 minutes, followed by 12 g over the next 15 hours 50 minutes of infusion to complete a 16-hour protocol. In a previous Phase 1 study, this initial protocol was shown to be safe and well tolerated in healthy young adults (18 to 50 years) and provided immediate and sustained reversal of the antiplatelet effect of ticagrelor.

[0350] After completion of Group 1, subsequent groups could test the same, higher, or lower dose levels and / or different infusion regimens of PB2452 or a matched placebo in the same population as Group 1 or a different population such as elderly subjects (65 to 80 years).

[0351] The study consisted of a screening period (Days –45 to –4), an admission day (Day –3) and a pre-treatment period, a site randomization / treatment day (Day 1), 3 days of on-site treatment and safety monitoring, a follow-up visit (Day 7) and a final follow-up visit (Day 28 [±2 days]). For 7 days prior to randomization (Day –7), 81 mg of ASA was administered orally once daily (QD) to the subjects until the final dose on the morning of Day 1 prior to receiving the study drug. A 180 mg oral loading dose of ticagrelor was administered on the morning of Day –2, followed by 90 mg every 12 hours until the 5th dose had been administered on the morning of Day 1. The 6th dose of ticagrelor could be administered 24 hours after the start of the study drug in the subsequent groups.

[0352] On the morning of Day –2, the subjects started pre-treatment with ticagrelor as described in the previous paragraph. On Day 1, the subjects were randomized at a ratio of 3:1 (PB2452: placebo) to receive an IV dose of PB2452 or placebo 2 hours after the 5th ticagrelor dose. The subjects could be discharged from the clinical site between Days 3 and 7 (inclusive of the endpoints), and if discharged, returned for follow-up visits on Days 7 and 28 (±2 days).

[0353] Study drugs, doses and routes of administration:

[0354] PB2452: The PB2452 IV infusion was administered on Day 1 for up to 48 hours. The total dose for each subject did not exceed 30 g. The infusion rate did not exceed 18 g over 30 minutes, and the concentration did not exceed 24 g in 250 mL. The subjects did not receive more than 250 mL of the study drug infusion in any 1-hour period.

[0355] Matched placebo: A single IV infusion of 0.9% sodium chloride, to be delivered at a rate and volume matching the active infusion.

[0356] Ticagrelor: Ticagrelor 90 mg oral tablets (immediate release) were administered as a 180 mg (2 × 90 m tablets) loading dose plus 90 mg every 12 hours for an additional 4 doses. In one or more subsequent groups after Group 1, the subjects could also receive an additional single oral dose of 90 mg ticagrelor 24 hours after the start of the study drug infusion (the 6th ticagrelor dose).

[0357] Aspirin (acetylsalicylic acid; ASA): An 81 mg oral tablet (enteric-coated) of aspirin (ASA) was administered daily between -7 days and the morning before receiving the study drug on Day 1. Subjects could restart ASA after discharge from the study. Subjects entering the study who were already taking ASA daily had to be willing to record the 81 mg dose daily between -7 days and Day 1 and had to suspend further ASA doses until discharge from the clinical facility.

[0358] Evaluation criteria:

[0359] Safety evaluation: Safety and tolerability will be evaluated by monitoring and recording AEs, clinical laboratory test results (hematology, coagulation, serum chemistry, and urinalysis), vital sign measurements (SBP and DBP, oral temperature, respiratory rate [RR], and HR), 12-lead ECG, immunogenicity, biomarkers, and physical examination findings.

[0360] Immunogenicity: The presence of bound anti-drug antibodies (ADA) was screened for in blood / serum samples at the time of admission and on Days 1, 7, and 28 (±2 days).

[0361] Pharmacodynamic evaluation:

[0362] PD data and parameters were generated by the VerifyNow® P2Y, PRU, LTA, and PRI assays:

[0363] VerifyNow® P2Y 12 :

[0364] • PRU at each evaluation point

[0365] • Percentage reversal of ticagrelor antiplatelet activity based on PRU at each evaluation point

[0366] • Maximum PRU

[0367] • Time to maximum PRU

[0368] • Maximum PRU within 4 hours

[0369] • Time to ≥180 PRU

[0370] • Time to ≥200 PRU

[0371] • Time to ≥220 PRU

[0372] • Time to 60%, 80%, and 90% reversal of PRU within 30 minutes or 4 hours

[0373] LTA:

[0374] • At each evaluation point, record the maximum and final aggregation levels with respect to up to 4 platelet agonists (20 μM adenosine diphosphate [ADP], 5 μM ADP, 1.6 mM arachidonic acid [AA], and 15 μM thrombin receptor activating peptide [TRAP]).

[0375] • To be recorded at each evaluation point.

[0376] • Percentage of reversal of ticagrelor antiplatelet aggregation

[0377] • Maximum platelet aggregation

[0378] • Time to maximum platelet aggregation

[0379] • Maximum platelet aggregation within 4 hours

[0380] • Time to 60%, 80%, and 90% reversal of platelet aggregation

[0381] • Number and percentage of subjects achieving 60%, 80%, and 90% reversal of platelet aggregation within 30 minutes or 4 hours.

[0382] VASP by ELISA:

[0383] • PRI at each evaluation point;

[0384] • Percentage of reversal of PRI at each evaluation point;

[0385] • Maximum PRI;

[0386] • Time to maximum PRI;

[0387] • Maximum PRI within 4 hours;

[0388] • Time to 60%, 80%, and 90% reversal of PRI;

[0389] • Number and percentage of subjects achieving 60%, 80%, and 90% reversal of PRI within 30 minutes or 4 hours.

[0390] For the group receiving the 6th dose of ticagrelor 24 hours after the study drug, calculate the PD parameters separately for Day 1 and Day 2.

[0391] Pharmacokinetic evaluation:

[0392] Blood collection for plasma: Blood samples are drawn at appropriate time points, and the plasma concentration of PB2452 is evaluated at each sampling time point. Calculate the following PK parameters:

[0393] • Time from time zero to the time of the last quantifiable concentration (AUC 0-τ ) Area under the plasma concentration-time curve (AUC)

[0394] • Observed maximum plasma concentration (C max )

[0395] • Time to reach the observed maximum plasma concentration (T max )

[0396] • AUC from time zero to 24 hours after dosing (AUC 0-24 )

[0397] • AUC from time zero to 48 hours after dosing (AUC 0-48 )

[0398] • AUC extrapolated from time zero to infinity (AUC 0-∞ ; if data permit)

[0399] • Terminal elimination half-life (t ½ ; if data permit)

[0400] • Clearance (CL; if data permit)

[0401] At each sampling time point, plasma PK concentrations for ticagrelor and metabolite TAM were evaluated. The following PK parameters were calculated:

[0402] • C max

[0403] • T max

[0404] • AUC 0-τ

[0405] • AUC from time zero to 12 hours after dosing (AUC 0-12 )

[0406] • AUC 0-24

[0407] • AUC 0-48

[0408] • AUC 0-∞ ; if data permit

[0409] • t ½ ; if data permit

[0410] For the group receiving the 6th dose of ticagrelor 24 hours after the start of the investigational drug, AUC is not calculated for either plasma PB2452 or ticagrelor / TAM. 0-48 The remaining PK parameters can be calculated separately for Day 1 and Day 2.

[0411] Urine collection: Pooled urine samples are collected at the following intervals to evaluate the urinary concentrations of PB2452, ticagrelor, and TAM: before dosing (within 60 minutes before the first ticagrelor dose on Day -2), and at 0 to 6, 6 to 12, and 12 to 24 hours. In patients receiving the 6th dose of ticagrelor, starting from the 6th ticagrelor dose, pooled urine samples are collected at the following intervals to evaluate the urinary concentrations of ticagrelor and TAM: 0 to 6, 6 to 12, 12 to 24 hours.

[0412] For all subjects in the PK population, the pharmacokinetic parameters for the concentrations of PB2452, ticagrelor, and TAM in urine to be calculated are:

[0413] • Total amount of drug excreted in urine at 24 hours (Ae 24 ) and 48 hours (Ae 48 ) after dosing

[0414] • Total amount of drug excreted in urine from time t1 to t2 (Ae t1-t2 ) hours when the value of t1 to t2 is 0 to 6, 6 to 12, 12 to 24, and 24 to 48 hours

[0415] • Fraction excreted in urine at 1 to 24 hours (Fe 24 ) and 1 to 48 hours (Fe 48 ) after dosing

[0416] • Renal clearance (CLr) at 24 hours after dosing

[0417] For the group receiving the 6th dose of ticagrelor 24 hours after the start of the investigational drug, Fe 48 and Ae 24-48 are not calculated. Other urinary PK parameters can be calculated separately for Day 1 and Day 2.

[0418] References Circulation

[0419] A group of healthy subjects pretreated orally with 180 mg ticagrelor twice daily for 48 hours was randomized at a 3:1 ratio (PB2452: placebo) to the dose and regimen of PB2452 or placebo. The dose regimen of PB2452 was an infusion of 12 g over 10 minutes, followed by an infusion of 12 g over 6 hours, followed by an infusion of 12 g over 18 hours. Platelet function was determined as described above.

[0420] ​

[0421] All publications, patents, and patent publications cited are hereby incorporated by reference in their entirety for all purposes.

[0422] This application incorporates by reference in their entirety the following publication: US 2016 / 0130366.

[0423] ​

[0424] Bhatt DL, Hulot JS, Moliterno DJ, Harrington RA. Antiplatelet and anticoagulation therapy for acute coronary syndromes. Circ Res. 2014;114:1929 - 43.

[0425] Yusuf S, Zhao F, Mehta SR et al.: Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST - segment elevation. N Engl J Med. 2001;345(23):1716.

[0426] Mehta SR, Yusuf S, Peters RJ et al.: Effects of pretreatment with clopidogrel and aspirin followed by long - term therapy in patients undergoing percutaneous coronary intervention: the PCI - CURE study. Lancet. 2001;358(9281):527 - 33.

[0427] Bhatt DL, Fox KA, Hacke W et al.: Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354(16):1706-17.

[0428] Bhatt DL, Flather MD, Hacke W et al.: Patients with prior myocardial infarction, stroke, or symptomatic peripheral arterial disease in the CHARISMA trial. J Am Coll Cardiol. 2007;49(19):1982-8.

[0429] Chen ZM, Jiang LX, Chen YP et al.: Addition of clopidogrel to aspirin in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005;366(9497):1607-21.

[0430] Wiviott SD, Braunwald E, McCabe CH et al.: Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001-15.

[0431] Prasugrel versus clopidogrel for acute coronary syndromes without revascularization. N Engl J Med. 2012;367(14):1297-309.

[0432] Wiviott SD, White HD, Ohman EM et al: Prasugrel versus clopidogrel for patients with unstable angina or non-ST-segment elevation myocardial infarction with or without angiography: a secondary, prespecified analysis of the TRILOGY ACS trial. Lancet. 2013;382(9892):605-13.

[0433] Koski R, Kennedy B. Comparative Review of Oral P2Y12 Inhibitors. P T. 2018;43(6):352-357.

[0434] Wallentin L, Becker RC, Budaj A et al: Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045-57.

[0435] Cannon CP, Harrington RA, James S et al: Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study. Lancet. 2010;375(9711):283-93.

[0436] James SK, Roe MT, Cannon CP, Cornel JH, Horrow J, Husted S et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient outcomes (PLATO) trial. BMJ. 2011;342:d3527.

[0437] Plavix [prescribing information] (clopidogrel bisulfate). Bridgewater, NJ: Bristol-Myers Squibb / Sanofi Pharmaceuticals Partnership; 2017.

[0438] Brilinta [prescribing information] (ticagrelor). Wilmington, DE: Astra Zeneca LP; 2016

[0439] Effient [prescribing information] (prasugrel). Eli Lilly and Company, Indianapolis, IN, 46285, 2018

[0440] Ducrocq G, Amarenco P, Labreuche J et al.: A history of stroke / transient ischemic attack indicates high risks of cardiovascular event and hemorrhagic stroke in patients with coronary artery disease. Circulation. 2013 Feb 12;127(6):730-8.

[0441] Bhatt DL Intensifying Platelet Inhibition — Navigating between Scylla and Charybdis. N Engl J Med. 2007;357:2078-2081.

[0442] Capodanno D, Angiolillo D.Management of Antiplatelet Therapy in Patients With Coronary Artery Disease Requiring Cardiac and Noncardiac Surgery. ​ . 2013;128:2785-2798.

[0443] Douketis JD, Spyropoulos AC, Spencer FA et al., Perioperative Management of Antithrombotic Therapy. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e326S-e350S.

[0444] Buchanan A, Newton P, Pehrsson S et al: Structural and functional characterization of a specific antidote for ticagrelor. Blood. 2015;125(22):3484-90.

[0445] Gurbel PA, Bliden KP, Butler K et al., Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: the ONSET / OFFSET study. Circulation. 2009;120(25):2577-85.

[0446] Godier A, Taylor G, Gaussem P. Inefficacy of platelet transfusion to reverse ticagrelor. N Engl J Med. 2015;372 (2):196-7.

[0447] Teng R, Carlson GF, Nylander S, Andersson TL. Effects of autologous platelet transfusion on platelet inhibition in ticagrelor - and clopidogrel-treated subjects. J Thromb Haemost. 2016;14:2342-52.

[0448] Jin L, Yu H, Dong T, Zhang B, Yan H, Liao H, Zou X. The Prognostic Value of ADP-Induced Platelet Aggregation for Bleeding Complications in Low - Intermediate Risk Patients with Acute Coronary Syndrome Taking Clopidogrel After Percutaneous Coronary Intervention. Heart Lung Circ. 2017 Jan;26(1):49-57

[0449] Reed GW, Kumar A, Guo J et al: Point-of-care platelet function testing predicts bleeding in patients exposed to clopidogrel undergoing coronary artery bypass grafting: Verify pre-op TIMI 45--a pilot study. Clin Cardiol. 2015;38(2):92-8.

[0450] Mangiacapra F, Ricottini E, Barbato E et al: Incremental Value of Platelet Reactivity Over a Risk Score of Clinical and Procedural Variables in Predicting Bleeding After Percutaneous Coronary Intervention via the Femoral Approach: Development and Validation of a New Bleeding Risk Score. Circ Cardiovasc Interv. 2015;8(5). pii: e002106.

[0451] Tantry US, Bonello L, Aradi D et al: Consensus and update on the definition of on-treatment platelet reactivity to adenosine diphosphate associated with ischemia and bleeding. J Am Coll Cardiol. 2013;62 (24):2261-73.

[0452] Aradi D, Kirtane A, Bonello L et al.: Bleeding and stent thrombosis on P2Y12-inhibitors: collaborative analysis on the role of platelet reactivity for risk stratification after percutaneous coronary intervention. Eur Heart J. 2015;36(27):1762-71。

Claims

1. A pharmaceutical composition for a method of reversing ticagrelor-related bleeding or reducing the risk of said bleeding in a patient to whom ticagrelor has been administered, said pharmaceutical composition comprising an antibody or a fragment thereof that binds to ticagrelor or its metabolite or derivative, wherein ticagrelor is (1S,2S,3R,5S)-3-[7-{[(1R,2S)-2-(3,4-difluorophenyl)cyclopropyl]amino}-5-(propylthio)-3H-[1,2,3]triazolo[4,5-d]pyrimidin-3-yl]-5-(2-hydroxyethoxy)cyclopentane-1,2-diol, wherein said antibody or fragment thereof comprises a combination of complementarity-determining regions (CDRs) selected from: a) SEQ ID NO:53 (VH CDR1), SEQ ID NO:54 (VH CDR2), SEQ ID NO:55 (VH CDR3), SEQ ID NO:58 (VL CDR1), SEQ ID NO:59 (VL CDR2), and SEQ ID NO:60 (VL CDR3); b) SEQ ID NO:63 (VH CDR1), SEQ ID NO:64 (VH CDR2), SEQ ID NO:65 (VH CDR3), SEQ ID NO:68 (VL CDR1), SEQ ID NO:69 (VL CDR2), and SEQ ID NO:70 (VL CDR3); and c) SEQ ID NO:73 (VH CDR1), SEQ ID NO:74 (VH CDR2), SEQ ID NO:75 (VH CDR3), SEQ ID NO:78 (VL CDR1), SEQ ID NO:79 (VL CDR2), and SEQ ID NO:80 (VL CDR3), wherein said pharmaceutical composition comprises a pharmaceutical formulation containing: 50 mg / mL to 200 mg / mL of said antibody or fragment thereof, 5 mM to 50 mM histidine / histidine hydrochloride buffer, 100 mM to 300 mM sucrose, and 0.01% (w / v) to 1.0% (w / v) polysorbate 80, at pH 5.5 to 6.5, and wherein said antibody or fragment thereof is formulated for administration at a dose of 9 g to 48 g of said antibody or fragment thereof.

2. The pharmaceutical composition of claim 1, wherein said antibody or fragment thereof comprises a CDR combination containing: SEQ ID NO:73 (VH CDR1), SEQ ID NO:74 (VH CDR2), SEQ ID NO:75 (VH CDR3), SEQ ID NO:78 (VL CDR1), SEQ ID NO:79 (VL CDR2), and SEQ ID NO:80 (VL CDR3).

3. The pharmaceutical composition of claim 1, wherein the antibody or fragment thereof comprises a combination of heavy chain variable region (VH) and light chain variable region (VL) sequences selected from SEQ ID NO:52 and SEQ ID NO:57; SEQ ID NO:62 and SEQ ID NO:67; and SEQ ID NO:72 and SEQ ID NO:

77.

4. The pharmaceutical composition of claim 3, wherein the antibody or fragment thereof comprises a combination of heavy chain variable region (VH) and light chain variable region (VL) of SEQ ID NO:72 and SEQ ID NO:

77.

5. The pharmaceutical composition of claim 1, wherein the antibody or fragment thereof is an antibody fragment, and the antibody fragment is Fab.

6. The pharmaceutical composition of claim 5, wherein the dose is 9 g to 36 g of the Fab.

7. The pharmaceutical composition of claim 5, wherein the dose is 9 g to 18 g of the Fab.

8. The pharmaceutical composition of claim 5, wherein the antibody or fragment thereof is formulated for administration at a dose of 9 g, 18 g, 24 g, 30 g, 36 g or 48 g of the Fab.

9. The pharmaceutical composition of claim 5, wherein the dose is 18 g of the Fab.

10. The pharmaceutical composition of claim 5, wherein the dose is 24 g of the Fab.

11. The pharmaceutical composition of claim 5, wherein the dose is 36 g of the Fab.

12. The pharmaceutical composition of any one of claims 1-11, wherein the pharmaceutical composition is formulated for intravenous administration.

13. The pharmaceutical composition of claim 12, wherein the pharmaceutical composition is formulated for intravenous administration over 15 minutes to 36 hours.

14. The pharmaceutical composition of claim 12, wherein the pharmaceutical composition is administered in three or more segments, and the first segment is a bolus injection.

15. The pharmaceutical composition of claim 14, wherein the administration rate of each segment is different.

16. The pharmaceutical composition of claim 12, wherein the pharmaceutical composition is administered in three or more segments, and the administration rate of each segment is different.

17. The pharmaceutical composition of claim 14, wherein the first segment comprises administration of 6 g of the antibody or fragment thereof over 5-20 minutes.

18. The pharmaceutical composition of claim 14, wherein the segment after the first segment comprises infusion of the antibody or fragment thereof over 4 hours.

19. The pharmaceutical composition of claim 14, wherein the segment after the first segment comprises infusion of the antibody or fragment thereof over 12 hours.

20. The pharmaceutical composition of claim 12, wherein the pharmaceutical composition is formulated for administration according to the following schedule: a bolus injection of 12 g of the antibody or fragment thereof over 10 minutes, followed by an infusion of 12 g of the antibody or fragment thereof over 6 hours, and then an infusion of 12 g of the antibody or fragment thereof over 18 hours.

21. The pharmaceutical composition of claim 1, wherein the pharmaceutical composition comprises: 100 mg / mL of said antibody or fragment thereof, 25 mM histidine / histidine hydrochloride buffer, 290 mM sucrose, and 0.05% (w / v) polysorbate 80, at pH 6.

0.

22. The pharmaceutical composition of any one of claims 1-11, wherein the antibody or fragment thereof binds to ticagrelor active metabolite (TAM).

23. A pharmaceutical composition for a method of reversing ticagrelor-related bleeding or reducing the risk of such bleeding in a patient to whom ticagrelor has been administered, the pharmaceutical composition comprising an antibody Fab that binds to ticagrelor or ticagrelor active metabolite (TAM), wherein ticagrelor is (1S,2S,3R,5S)-3-[7-{[(1R,2S)-2-(3,4-difluorophenyl)cyclopropyl]amino}-5-(propylthio)-3H-[1,2,3]triazolo[4,5-d]pyrimidin-3-yl]-5-(2-hydroxyethoxy)cyclopentane-1,2-diol, wherein the Fab comprises a combination of complementarity-determining regions (CDRs) of SEQ ID NO:73 (VH CDR1), SEQ ID NO:74 (VH CDR2), SEQ ID NO:75 (VH CDR3), SEQ ID NO:78 (VL CDR1), SEQ ID NO:79 (VL CDR2), and SEQ ID NO:80 (VL CDR3), wherein the pharmaceutical composition comprises a pharmaceutical formulation containing: 50 mg / mL to 200 mg / mL of said Fab, 5 mM to 50 mM histidine / histidine hydrochloride buffer, 100 mM to 300 mM sucrose, and 0.01% (w / v) to 1.0% (w / v) polysorbate 80, at pH 5.5 to 6.5, the pharmaceutical composition being formulated for administration according to the following schedule: a bolus of 12 g of said Fab administered over 10 minutes, followed by an infusion of 12 g of said Fab over 6 hours, followed by an infusion of 12 g of said Fab over 18 hours, and wherein the Fab is formulated for administration at a dose of 36 g of said Fab.

24. The pharmaceutical composition of claim 23, wherein the Fab comprises a combination of a heavy chain variable region (VH) containing the amino acid sequence of SEQ ID NO:72 and a light chain variable region (VL) containing the amino acid sequence of SEQ ID NO:

77.

25. The pharmaceutical composition of claim 23, wherein the pharmaceutical formulation comprises 100 mg / Ml of said Fab, 25 mM histidine / histidine hydrochloride buffer, 290 mM sucrose, and 0.05% (w / v) polysorbate 80, at pH 6.

0.

26. The pharmaceutical composition of claim 21 or 25, wherein the pharmaceutical formulation is diluted in saline for administration.

27. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the Fab is a human IgG1 monoclonal Fab.

28. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the ticagrelor-related bleeding is major bleeding.

29. The pharmaceutical composition of claim 28, wherein the major bleeding is characterized by being life-threatening, having the potential to cause clinically significant disability, requiring surgery to control bleeding or treatment with blood products; being gastrointestinal bleeding, intracranial bleeding, intracranial hemorrhage (ICH) or the result of a traumatic injury; or being acute bleeding associated with a clinically important decline in hemoglobin.

30. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the patient requires urgent surgery or intervention.

31. The pharmaceutical composition of claim 30, wherein the urgent surgery or intervention is known to be associated with a significant risk of bleeding; has adverse surgical outcomes if bleeding is not carefully controlled; is a neurological, ophthalmic or joint replacement surgery; is associated with the risk of experiencing perioperative events; or is in a patient who is at high risk of thrombosis if dual antiplatelet therapy is discontinued preoperatively.

32. The pharmaceutical composition of claim 30, wherein the urgent surgery or intervention is coronary artery bypass graft surgery (CABG).

33. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the patient is at risk of developing a disease selected from the following, or has been diagnosed with a disease selected from the following: myocardial infarction (MI); unstable angina; stable ischemic heart disease; sickle cell disease; atrial fibrillation; coronary artery disease; peripheral artery disease; hemorrhagic stroke; ischemic stroke; in need of one or more coronary stents or carotid stents; in need of a stent after an intracranial aneurysm; and in need of an arteriovenous fistula created for hemodialysis.

34. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the patient is at risk of developing acute coronary syndrome (ACS), or has been diagnosed with acute coronary syndrome (ACS).

35. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the patient has a history of percutaneous coronary intervention.

36. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the patient is over 65 years old.

37. The pharmaceutical composition of claim 36, wherein the patient is 65 to 80 years old, including the endpoints.

38. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein aspirin (acetylsalicylic acid) has been administered to the patient.

39. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the administration of the pharmaceutical composition restores platelet aggregation within 5 minutes - 10 minutes of the start of administration.

40. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the administration of the pharmaceutical composition provides a sustained restoration of platelet aggregation, wherein the restoration of platelet aggregation persists for at least 12 hours after the start of administration.

41. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein ticagrelor and one or more additional drugs have been administered to the patient, and the drugs inhibit the activity of cytochrome P450 isoform 3A (CYP3A).

42. The pharmaceutical composition according to any one of claims 1-11 or 23-25, wherein the patient is receiving concomitant oral or intravenous therapy with a strong CYP3A inhibitor.

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