Modulators of complement activity

Abstract

The present invention relates to a complement activity regulator, in particular, to a polypeptide regulator of complement activity, including a cyclic polypeptide regulator, and to a method of using such a regulator as a therapeutic agent.

Description

[0001] This application is a divisional application of the Chinese patent application with application number 201680081854.4, application date December 7, 2016, and invention name “Modulator of complement activity”.

[0002] CROSS-REFERENCE TO RELATED APPLICATIONS

[0003] This application claims priority to U.S. Provisional Application No. 62 / 268,360, entitled Modulators of Complement Activity, filed on December 16, 2015, U.S. Provisional Application No. 62 / 331,320, entitled Modulators of Complement Activity, filed on May 3, 2016, and U.S. Provisional Application No. 62 / 347,486, entitled Modulators of Complement Activity, filed on June 8, 2016, the contents of each of which are incorporated herein by reference in their entirety.

[0004] Sequence Listing

[0005] This application contains a sequence listing that has been submitted electronically in ASCII format and is hereby incorporated by reference in its entirety. The ASCII copy (created on December 7, 2016) is named 2011_1009PCT_SL.txt and is 1,099 bytes in size. Technical Field

[0006] The present invention relates to compounds, including polypeptides, that are useful as modulators of complement activity. Methods of using these modulators as therapeutic agents are also provided. Background Art

[0007] The vertebrate immune response consists of adaptive and innate immune components. The adaptive immune response is selective for specific pathogens and responds slowly, while components of the innate immune response recognize a wide range of pathogens and respond rapidly following infection. One such component of the innate immune response is the complement system.

[0008] The complement system includes about 20 kinds of circulating complement component proteins synthesized mainly by the liver. Due to the observation that they supplement antibody responses in the destruction of bacteria, the components of this specific immune response were first referred to as "complement". Before activation in response to infection, these proteins remain in an inactive form. Activation occurs by means of a proteolytic cleavage pathway that is triggered by pathogen recognition and causes pathogen destruction. Three such pathways are known in the complement system and are referred to as the classical pathway, the lectin pathway, and the alternative pathway. When IgG or IgM molecules are bound to the surface of the pathogen, the classical pathway is activated. The lectin pathway is triggered by the lectin protein binding mannan of the sugar residues of the bacterial cell wall. In the absence of any specific stimulation, the alternative pathway remains active at a low level. Although all three pathways are different about the initiation event, all three pathways converge on the cutting of complement component C3. C3 is cut into two products called C3a and C3b. Among these, C3b becomes covalently attached to the pathogen surface, and C3a acts as a diffusible signal to promote inflammation and recruit circulating immune cells. Surface-bound C3b forms complexes with other components to initiate a cascade of reactions in subsequent components of the complement system. Due to the requirement for surface attachment, complement activity remains localized and minimizes damage to non-target cells.

[0009] Pathogen-associated C3b promotes pathogen destruction in two ways. In one approach, C3b is directly recognized by phagocytes and leads to the ingestion of pathogens. In the second approach, pathogen-associated C3b triggers the formation of a membrane attack complex (MAC). In the first step, C3b is complexed with other complement components to form a C5-convertase complex. Depending on the initial complement activation pathway, the components of this complex can be different. In addition to C3b, the C5 convertase formed by the classical complement pathway also contains C4b and C2a. When formed by the alternative pathway, the C5 convertase contains two subunits of C3b and a Bb component.

[0010] Complement component C5 is cleaved into C5a and C5b by either C5 convertase complex. C5a, much like C3a, diffuses into the circulation and promotes inflammation, thereby acting as a chemoattractant for inflammatory cells. C5b remains attached to the cell surface, where it triggers the formation of MACs through interactions with C6, C7, C8, and C9. MACs are hydrophilic pores across the membrane and promote the free flow of fluids into and out of the cell, thereby destroying the cell.

[0011] An important component of all immune activity is the ability of the immune system to distinguish between self cells and non-self cells. When the immune system cannot make this distinction, pathology occurs. With respect to the complement system, vertebrate cells express proteins that protect them from the effects of the complement cascade. This ensures that the targets of the complement system are confined to pathogenic cells. Many complement-related disorders and diseases are related to the abnormal destruction of self cells by the complement cascade. In one embodiment, subjects suffering from paroxysmal nocturnal hemoglobinuria (PNH) cannot synthesize functional forms of complement regulatory proteins CD55 and CD59 on hematopoietic stem cells. This leads to complement-mediated hemolysis and a variety of downstream complications. Other complement-related disorders and diseases include, but are not limited to, autoimmune diseases and disorders, neurological diseases and disorders, blood diseases and disorders, and infectious diseases and disorders. Experimental evidence shows that many complement-related disorders are alleviated by the inhibition of complement activity. Therefore, there is a need for compositions and methods for selectively blocking complement-mediated cell destruction to treat related indications. The present invention meets this need by providing relevant compositions and methods. Summary of the invention

[0012] In certain embodiments, the present disclosure provides a pharmaceutical composition comprising R5000 and a pharmaceutically acceptable excipient, wherein the pharmaceutically acceptable excipient comprises sodium chloride at a concentration of about 25 mM to about 100 mM and sodium phosphate at a concentration of about 10 mM to about 100 mM. R5000 may be present at a concentration of about 1 mg / mL to about 400 mg / mL. The pharmaceutical composition may comprise a pH of about 6.5 to about 7.5. R5000 may be present at an equilibrium dissociation constant (K) of about 0.1 nM to about 1 nM. D ) binds to C5. R5000 can block the generation of C5a after activation of the alternative pathway of complement activation. R5000 can block the formation of the membrane attack complex (MAC) after activation of the classical pathway, alternative pathway or lectin pathway of complement activation.

[0013] In certain embodiments, the present disclosure provides a method of inhibiting hemolysis in a subject, the method comprising administering a pharmaceutical composition comprising R5000 and a pharmaceutically acceptable excipient, wherein the pharmaceutically acceptable excipient comprises sodium chloride at a concentration of about 25mM to about 100mM and sodium phosphate at a concentration of about 10mM to about 100mM. The pharmaceutical composition may be administered at a dose sufficient to achieve a plasma level of R5000 of about 0.1μg / mL to about 20μg / mL. After administration, hemolysis may be inhibited by about 25% to 100%. The pharmaceutical composition may be administered daily for at least 2 days. The pharmaceutical composition may be administered daily for 7 days. The pharmaceutical composition may be administered daily for at least 100 days. According to some methods, no adverse cardiovascular, respiratory, and / or central nervous system (CNS) effects are observed for at least 1 month after administration. According to some methods, no changes in heart rate and / or arterial blood pressure are observed for at least 1 month after administration. According to some methods, no changes in respiratory rate, tidal volume, and / or minute volume are observed for at least 1 month following administration.

[0014] In certain embodiments, the present disclosure provides a method of inhibiting hemolysis in a subject, the method comprising administering a pharmaceutical composition comprising R5000 and a pharmaceutically acceptable excipient, wherein the pharmaceutically acceptable excipient comprises sodium chloride at a concentration of about 25 mM to about 100 mM and sodium phosphate at a concentration of about 10 mM to about 100 mM, wherein the pharmaceutical composition can be administered subcutaneously (SC) or intravenously (IV). The half-life (t 1 / 2 ) may be at least 4 hours. The level of R5000 in the subject's plasma 1 / 2 The steady-state distribution volume of R5000 in the subject's plasma may be about 10 mL / kg to about 200 mL / kg. The steady-state distribution volume of R5000 in the subject's plasma may be equal to at least 50% of the total blood volume. The total clearance rate of R5000 in the subject's plasma may be about 0.04 mL / hr / kg to about 4 mL / hr / kg. The T of R5000 in the subject's plasma may be about 10 mL / kg to about 200 mL / kg. maxIt can be about 1 hour to about 48 hours. The presence of a measurable amount of R5000 can be substantially limited to the plasma compartment. The pharmaceutical composition can be administered at a dose sufficient to deliver about 0.01 mg to about 2 mg R5000 / kg of subject weight. About 50% to about 99% C5 activation in a subject can be inhibited. The pharmaceutical composition can be administered at a dose sufficient to deliver about 0.1 mg to about 0.4 mg R5000 / kg of subject weight. The pharmaceutical composition can be administered subcutaneously or intravenously. The pharmaceutical composition can be administered once or more per day. The pharmaceutical composition can be administered for a period of 7 days. The percentage inhibition of hemolysis can reach at least 90% to about 95% or more 3 hours after the first administration. The percentage inhibition of hemolysis can be at least 90% to about 95% or more, as measured at least 7 days after administration. At least 4 days after administration, the percentage inhibition of hemolysis can be at least 90% to about 95% or more. Maximum inhibition of hemolysis and / or maximum inhibition of complement activity may be achieved from about 2 hours after administration to about 4 hours after administration.

[0015] In certain embodiments, the present disclosure provides a method of inhibiting hemolysis in a subject, the method comprising administering a pharmaceutical composition comprising R5000 and a pharmaceutically acceptable excipient, wherein the pharmaceutically acceptable excipient comprises sodium chloride at a concentration of about 25mM to about 100mM and sodium phosphate at a concentration of about 10mM to about 100mM, wherein R5000 is administered at a dose of 0.2mg / kg. Hemolysis may be ≤3% 24 hours after the last administration. Complement activity may be reduced to about 1% to about 10% over a 7-day period. Complement activity may be ≤5% 24 hours after the last administration. The pharmaceutical composition may be administered subcutaneously or intravenously daily at a dose sufficient to deliver about 0.1mg / day to about 60mg / day of R5000 / kg of subject weight. The maximum serum concentration (C max ) can be about 0.1 μg / mL to about 1000 μg / mL. The area under the curve (AUC) can be about 200 μg*hr / mL to about 10,000 μg*hr / mL.

[0016] In certain embodiments, the present disclosure provides a method of treating paroxysmal nocturnal hemoglobinuria (PNH) in a subject in need thereof, the method comprising administering subcutaneously or intravenously a pharmaceutical composition comprising R5000 and a pharmaceutically acceptable excipient, wherein the pharmaceutically acceptable excipient comprises sodium chloride at a concentration of about 25 mM to about 100 mM and sodium phosphate at a concentration of about 10 mM to about 100 mM. The subject may have been previously treated with an antibody-based therapeutic agent. PNH in the subject may be resistant or unresponsive to treatment with an antibody-based therapeutic agent. The antibody-based therapeutic agent may be eculizumab.

[0017] In certain embodiments, the present disclosure provides a kit comprising a pharmaceutical composition comprising R5000 and a pharmaceutically acceptable excipient, wherein the pharmaceutically acceptable excipient comprises sodium chloride at a concentration of about 25 mM to about 100 mM and sodium phosphate at a concentration of about 10 mM to about 100 mM.

[0018] In certain embodiments, the present disclosure provides an automatic injector device comprising a pharmaceutically acceptable excipient, wherein the pharmaceutically acceptable excipient comprises sodium chloride at a concentration of about 25 mM to about 100 mM and sodium phosphate at a concentration of about 10 mM to about 100 mM. BRIEF DESCRIPTION OF THE DRAWINGS

[0019] The foregoing and other objects, features and advantages will be apparent from the following description of specific embodiments of the present invention and the accompanying drawings that explain the principles of the various embodiments of the present invention.

[0020] Figure 1 is a scatter plot showing the inhibition of R5000 produced by C5a.

[0021] Figure 2 is a scatter plot showing R5000 inhibition of membrane attack complex formation.

[0022] Figure 3 is a scatter plot showing the inhibitory activity of R5000 in the Cynomolgus monkey model.

[0023] Figure 4A is a scatter plot showing the pharmacokinetic and pharmacodynamic correlation of R5000 in male cynomolgus monkeys following multiple subcutaneous administration at 0.21 mg / kg.

[0024] Figure 4B is a scatter plot showing the pharmacokinetic and pharmacodynamic correlation of R5000 in male cynomolgus monkeys following multiple subcutaneous administration at 4.2 mg / kg.

[0025] Figure 5A The graph shows R5000 levels over time following subcutaneous administration in rats and monkeys.

[0026] Figure 5B The graph shows plasma concentrations over time following multiple subcutaneous dose administration at 0.21 and 4.2 mg / kg in monkeys.

[0027] Figure 6 The graph shows predicted plasma concentrations of R5000 in men administered R5000 daily.

[0028] Figure 7 The line graph shows the concentration of R5000 in cynomolgus monkeys after the first dose in a repeated dose toxicology study.

[0029] Figure 8 The line graph shows the concentration of R5000 in cynomolgus monkeys after the last dose in the repeated dose toxicology study.

[0030] Fig. 9A The graph shows the change in percent hemolysis as a function of R5000 concentration in the multiple dose human study.

[0031] Fig. 9B The graph shows the plasma concentration of R5000 over time in a multiple dose human study.

[0032] Fig. 10A The graph shows the change in complement activity over time for R5000 treatment in a multiple dose human study.

[0033] Fig. 10B The graph shows the changes in complement activity over a prolonged period of time for R5000 treatment in a multiple dose human study.

[0034] Fig.11A The graph shows the maximum plasma concentration levels of R5000 in a single ascending dose clinical study in humans in a dose-dependent manner.

[0035] Fig. 11B The graph shows the plasma concentration over time after a single dose of R5000.

[0036] Fig. 12A The graph shows the percentage of hemolysis over time following a single dose administration of R5000 over a 4-day sustained period in humans.

[0037] Fig. 12B The graph shows the CH changes over time after a single dose of R5000 in humans. 50 percentage.

[0038] Fig. 12C The graph shows the percentage of hemolysis for different doses over a duration of 28 days in humans.

[0039] Fig.13 The graph shows the percent complement activity over time following a single dose administration of R5000 in humans. DETAILED DESCRIPTION

[0040] I. Compounds and Compositions

[0041] According to the present invention, compounds and compositions that act to regulate complement activity are provided. Such compounds and compositions of the present invention may include inhibitors that block complement activation. "Complement activity" as used herein includes activation of the complement cascade, formation of cleavage products from complement components (such as C3 or C5), assembly of downstream complexes after a cleavage event, or any process or event associated with the cleavage of complement components (e.g., C3 or C5) or caused by the cleavage. Complement inhibitors may include C5 inhibitors that block complement activation at the level of complement component C5. C5 inhibitors may bind C5 and prevent C5 convertase from cleaving it into cleavage products C5a and C5b. "Complement component C5" or "C5" as used herein is defined as a complex that is cleaved into at least cleavage products C5a and C5b by the C5 convertase. "C5 inhibitors" according to the present invention include any compound or composition that inhibits the processing or cleavage of the cleavage products of the complement component C5 complex before cleavage or the complement component C5.

[0042] It is understood that inhibition of C5 cleavage will prevent the assembly and activity of the cell lytic membrane attack complex (MAC) on glycosylphosphatidylinositol (GPI)-attached protein-deficient erythrocytes. Thus, in some cases, the C5 inhibitors of the present invention may also bind to C5b, thereby preventing C6 binding and subsequent assembly of the C5b-9 MAC.

[0043] Peptide-based compounds

[0044] In certain embodiments, the C5 inhibitors of the present invention are polypeptides. According to the present invention, any amino acid-based molecule (natural or non-natural) may be referred to as a "polypeptide", and the term includes "peptides", "peptide mimetics" and "proteins". "Peptides" are traditionally considered to be in the size range of about 4 to about 50 amino acids. Polypeptides greater than about 50 amino acids are generally referred to as "proteins".

[0045] C5 inhibitor polypeptides can be linear or cyclic. Cyclic polypeptides include any polypeptides having one or more cyclic features (such as rings and / or internal connections) as part of their structure. In certain embodiments, when a molecule acts as a bridging moiety to connect two or more regions of a polypeptide, a cyclic polypeptide is formed. The term "bridging moiety" used herein refers to one or more components of a bridge formed between two adjacent or non-adjacent amino acids, non-natural amino acids or non-amino acids in a polypeptide. The bridging moiety can have any size or composition. In certain embodiments, the bridging moiety may be included in one or more chemical bonds between two adjacent or non-adjacent amino acids, non-natural amino acids, non-amino acid residues or a combination thereof. In certain embodiments, such a chemical bond may be between one or more functional groups on adjacent or non-adjacent amino acids, non-natural amino acids, non-amino acid residues or a combination thereof. The bridging moiety may include one or more of an amide bond (lactam), a disulfide bond, a thioether bond, an aromatic ring, a triazole ring and a hydrocarbon chain. In certain embodiments, the bridging moiety includes an amide bond between an amine functional group and a carboxylate functional group, each present in an amino acid, a non-natural amino acid or a non-amino acid residue side chain. In certain embodiments, the amine or carboxylate functional group is part of a non-amino acid residue or a non-natural amino acid residue.

[0046] The C5 inhibitor polypeptide can be cyclized as follows: through the carboxyl terminus, the amino terminus, or through any other convenient point of attachment, such as, for example, through the sulfur of cysteine ​​(e.g., through the formation of a disulfide bond between two cysteine ​​residues in the sequence) or any side chain of an amino acid residue. Other bonds forming the cyclic ring may include, but are not limited to, maleimide bonds, amide bonds, ester bonds, ether bonds, thioether bonds, hydrazone bonds, or acetamide bonds.

[0047] In certain embodiments, a lactam moiety is used to form a cyclic C5 inhibitor polypeptide of the invention. For example, such a cyclic polypeptide can be formed by synthesis on a solid support Wang resin using standard Fmoc chemistry. In some cases, Fmoc-ASP(allyl)-OH and Fmoc-LYS(allyloxycarbonyl)-OH (Fmoc-LYS(alloc)-OH) are incorporated into the polypeptide to serve as precursor monomers for lactam bridge formation.

[0048] The C5 inhibitor polypeptide of the present invention can be a peptide mimetic. A "peptide mimetic" or "peptide mimetic" is a polypeptide in which the molecule contains structural elements that are not present in a natural polypeptide (i.e., a polypeptide consisting of only 20 protein-forming amino acids). In certain embodiments, a peptide mimetic can recapitulate or mimic the biological effects of a natural peptide. A peptide mimetic can differ from a natural polypeptide in many ways, such as changes in the backbone structure or the percentage of amino acids that do not exist in nature. In some cases, a peptide mimetic can include: amino acids having side chains that do not exist in the known 20 protein-forming amino acids; non-polypeptide-based bridging moieties that are used to achieve cyclization between the ends or internal parts of the molecule; substitution of methyl (N-methylation) or other alkyl groups for the hydrogen moieties of the amide bonds; replacement of peptide bonds with chemical groups or bonds that are resistant to chemical or enzymatic treatment; N- and C-terminal modifications; and / or conjugation to non-peptide extensions (such as polyethylene glycol, lipids, carbohydrates, nucleosides, nucleotides, nucleoside bases, various small molecules, or phosphate or sulfate groups).

[0049] The term "amino acid" as used herein includes residues of natural amino acids and non-natural amino acids. 20 kinds of natural protein-forming amino acids have been identified and are represented herein by the following single-letter or three-letter nomenclature: aspartic acid (Asp:D), isoleucine (Ile:I), threonine (Thr:T), leucine (Leu:L), serine (Ser:S), tyrosine (Tyr:Y), glutamic acid (Glu:E), phenylalanine (Phe:F), proline (Pro:P), histidine (His:H), glycine (Gly:G), lysine (Lys:K), alanine (Ala:A), arginine (Arg:R), cysteine ​​(Cys:C), tryptophan (Trp:W), valine (Val:V), glutamine (Gln:Q), methionine (Met:M), asparagine (Asn:N). Naturally occurring amino acids exist in their left-handed (L) stereoisomer forms. Unless otherwise noted, the amino acids mentioned in this article are L-stereoisomers. The term "amino acid" also includes amino acids with conventional amino protecting groups (e.g., acetyl or benzyloxycarbonyl), as well as natural and non-natural amino acids protected at the carboxyl terminus (e.g., as (C1-C6) alkyl, phenyl or benzyl esters or amides; or as α-methylbenzylamide). Other suitable amino and carboxyl protecting groups are known to those skilled in the art (see, e.g., Greene, TW; Wutz, PGM, Protecting Groups In Organic Synthesis; 2nd Edition, 1991, New York, John Wiley & sons, Inc., and documents cited therein, the contents of each of which are incorporated herein by reference in their entirety). The polypeptides and / or polypeptide compositions of the present invention may also include modified amino acids.

[0050] "Unnatural" amino acids have side chains or other moieties not found in the 20 naturally occurring amino acids listed above, and include, but are not limited to, N-methyl amino acids, N-alkyl amino acids, α,α substituted amino acids, β-amino acids, α-hydroxy amino acids, D-amino acids, and other unnatural amino acids known in the art (see, e.g., Josephson et al., (2005) J. Am. Chem. Soc. 127: 11727-11735; Forster, AC et al. (2003) Proc. Natl. Acad. Sci. USA 100: 6353-6357; Subtelny et al., (2008) J. Am. Chem. Soc. 130: 6131-6136; Hartman, MCT et al. (2007) PLoS ONE 2: e972; and Hartman et al., (2006) Proc. Natl. Acad. Sci. USA 101: 6353-6357). 103:4356-4361). Other unnatural amino acids that can be used to optimize the polypeptides and / or polypeptide compositions of the present invention include, but are not limited to: 1,2,3,4-tetrahydroisoquinoline-1-carboxylic acid, 1-amino-2,3-hydro-1H-indene-1-carboxylic acid, homolysine, homoarginine, homoserine, 2-aminoadipic acid, 3-aminoadipic acid, β-alanine, aminopropionic acid, 2-aminobutyric acid, 4-aminobutyric acid, 5-aminopentanoic acid, 5-aminohexanoic acid, 6-aminohexanoic acid, 2-aminoheptanoic acid, 2-aminoisobutyric acid, 3-aminoisobutyric acid, 2-aminopimelic acid, desmosine, 2,3-diaminopropionic acid, N-ethylglycine, N-ethylasparagine, homoproline, hydroxylysine, allohydroxylysine, 3-hydroxyproline, 4-hydroxyproline, isodesmosine, alloisoleucine, N-methylpentylglycine, naphthylalanine, ornithine, pentylglycine, thioproline, norvaline, tert-butylglycine, phenylglycine, azatryptophan, 5-azatryptophan, 7-Azatryptophan, 4-fluorophenylalanine, penicillamine, sarcosine, homocysteine, 1-aminocyclopropanecarboxylic acid, 1-aminocyclobutanecarboxylic acid, 1-aminocyclopentanecarboxylic acid, 1-aminocyclohexanecarboxylic acid, 4-aminotetrahydro-2H-pyran-4-carboxylic acid, (S)-2-amino-3-(1H-tetrazol-5-yl)propionic acid, cyclopentylglycine, cyclohexylglycine, cyclopropylglycine, η-ω-methyl-arginine, 4-chlorophenylalanine, 3-chlorotyrosine, 3-fluorotyrosine, 5-fluorotryptophan, 5-chlorotryptophan, citrulline, 4-chloro-homophenylalanine, homophenylalanine, 4-aminomethyl-phenylalanine, 3-aminomethyl-phenylalanine, octylglycine, norleucine, tranexamic acid, 2-aminopentanoic acid, 2-aminohexanoic acid, 2-aminoheptanoic acid, 2-aminooctanoic acid, 2-aminononanoic acid, 2-aminodecanoic acid, 2-aminoundecanoic acid, 2-aminododecanoic acid, aminovaleric acid, and 2-(2-aminoethoxy)acetic acid,2-piperidinic acid, 2-carboxyazetidine, hexafluoroleucine, 3-fluorovaline, 2-amino-4,4-difluoro-3-methylbutyric acid, 3-fluoro-isoleucine, 4-fluoroisoleucine, 5-fluoroisoleucine, 4-methyl-phenylglycine, 4-ethyl-phenylglycine, 4-isopropyl-phenylglycine, (S)-2-amino-5-azidopentanoic acid (also referred to herein as "X02"), (S)-2-aminohept-6-enoic acid (also referred to herein as "X30"), (S)-2-aminopent-4-ynoic acid (also referred to herein as "X31") ”), (S)-2-aminopent-4-enoic acid (also referred to herein as “X12”), (S)-2-amino-5-(3-methylguanidino)pentanoic acid, (S)-2-amino-3-(4-(aminomethyl)phenyl)propanoic acid, (S)-2-amino-3-(3-(aminomethyl)phenyl)propanoic acid, (S)-2-amino-4-(2-aminobenzo[d]oxazol-5-yl)butanoic acid, (S)-leucinol, (S)-valinol, (S)-tert-leucinol, (R)-3-methylbutan-2-amine, (S)-2-methyl-1-phenylpropan-1-amine, and (S)-N,2-dimethyl-1-(pyridin-2-yl)propane-1-amine, (S)-2-amino-3-(oxazol-2-yl)propanoic acid, (S)-2-amino-3-(oxazol-5-yl)propanoic acid, (S)-2-amino-3-(1,3,4-oxadiazol-2-yl)propanoic acid, (S)-2-amino-3-(1,2,4-oxadiazol-3-yl)propanoic acid, (S)-2-amino-3-(5-fluoro-1H-indazol-3-yl)propanoic acid, and (S)-2-amino-3-(1H-indazol-3-yl)propanoic acid, (S)-2-amino-3 -(oxazol-2-yl)butyric acid, (S)-2-amino-3-(oxazol-5-yl)butyric acid, (S)-2-amino-3-(1,3,4-oxadiazol-2-yl)butyric acid, (S)-2-amino-3-(1,2,4-oxadiazol-3-yl)butyric acid, (S)-2-amino-3-(5-fluoro-1H-indazol-3-yl)butyric acid, and (S)-2-amino-3-(1H-indazol-3-yl)butyric acid, 2-(2'MeOphenyl)-2-aminoacetic acid, tetrahydro-3-isoquinolinecarboxylic acid and stereoisomers thereof (including, but not limited to, D and L isomers). ,

[0051] Additional non-natural amino acids that can be used to optimize the polypeptides or polypeptide compositions of the present invention include, but are not limited to, fluorinated amino acids in which one or more carbon-bound hydrogen atoms are replaced with fluorine. The number of fluorine atoms included can range from 1 up to (and including) all hydrogen atoms. Examples of such amino acids include, but are not limited to: 3-fluoroproline, 3,3-difluoroproline, 4-fluoroproline, 4,4-difluoroproline, 3,4-difluoroproline, 3,3,4,4-tetrafluoroproline, 4-fluorotryptophan, 5-fluorotryptophan, 6-fluorotryptophan, 7-fluorotryptophan, and stereoisomers thereof.

[0052] Other non-natural amino acids that can be used to optimize the polypeptides of the present invention include, but are not limited to, those that are disubstituted at the α-carbon. These include: wherein the two substituents on the α-carbon are the same amino acid, such as α-aminoisobutyric acid and 2-amino-2-ethylbutyric acid, and wherein the substituents are different amino acids, such as α-methylphenylglycine and α-methylproline. Further, the substituents on the α-carbon can form a ring together, such as 1-aminocyclopentanecarboxylic acid, 1-aminocyclobutanecarboxylic acid, 1-aminocyclohexanecarboxylic acid, 3-aminotetrahydrofuran-3-carboxylic acid, 3-aminotetrahydropyran-3-carboxylic acid, 4-aminotetrahydropyran-4-carboxylic acid, 3-aminopyrrolidine-3-carboxylic acid, 3-aminopiperidine-3-carboxylic acid, 4-aminopiperidine-4-carboxylic acid, and stereoisomers thereof.

[0053] Other non-natural amino acids that can be used to optimize the polypeptide or polypeptide composition of the present invention include, but are not limited to, analogs of tryptophan, wherein the indole ring system is replaced by another 9 or 10-membered bicyclic ring system containing 0, 1, 2, 3 or 4 heteroatoms, and the heteroatoms are independently selected from N, O or S. Each ring system can be saturated, partially unsaturated or completely unsaturated. The ring system can be substituted by 0, 1, 2, 3 or 4 substituents at any substitutable atom. Each substituent can be independently selected from H, F, Cl, Br, CN, COOR, CONRR', oxo, OR, NRR'. Each R and R' can be independently selected from H, C1-C20 alkyl, or C1-C20 alkyl-O-C1-20 alkyl.

[0054] In certain embodiments, analogs of tryptophan (also referred to herein as "tryptophan analogs") may be used in the optimization of the polypeptides or polypeptide compositions of the present invention. Tryptophan analogs may include, but are not limited to: 5-fluorotryptophan [(5-F)W], 5-methyl-O-tryptophan [(5-MeO)W], 1-methyltryptophan [(1-Me-W) or (1-Me)W], D-tryptophan (D-Trp), azatryptophans (including, but not limited to, 4-azatryptophan, 7-azatryptophan and 5-azatryptophan), 5-chlorotryptophan, 4-fluorotryptophan, 6-fluorotryptophan, 7-fluorotryptophan, and stereoisomers thereof. Unless otherwise indicated, the term "azatryptophan" and its abbreviation "azaTrp" as used herein refer to 7-azatryptophan.

[0055] Modified amino acid residues that can be used to optimize the polypeptides and / or polypeptide compositions of the present invention include, but are not limited to: those that are chemically blocked (reversibly or irreversibly); those that are chemically modified at their N-terminal amino groups or their side chain groups; those that are chemically modified in the amide backbone, such as, for example, N-methylated, D (non-natural amino acid) and L (natural amino acid) stereoisomers; or residues in which the side chain functional group is chemically modified to another functional group. In certain embodiments, modified amino acids include, but are not limited to, methionine sulfoxide; methionine sulfone; aspartic acid-(β-methyl ester), a modified amino acid of aspartic acid; N-ethylglycine, a modified amino acid of glycine; alanine carboxamide; and / or a modified amino acid of alanine. Non-natural amino acids can be purchased from Sigma-Aldrich (St. Louis, MO), Bachem (Torrance, CA) or other suppliers. Unnatural amino acids may also include any of those listed in Table 2 of U.S. Patent Publication No. US 2011 / 0172126, the contents of which are incorporated herein by reference in their entirety.

[0056] The present invention contemplates variants and derivatives of the polypeptides presented herein. These include substitutions, insertions, deletions, and covalent variants and derivatives. As used herein, the term "derivative" is used synonymously with the term "variant" and refers to a molecule that has been modified or altered in any way relative to a reference molecule or a starting molecule.

[0057] The polypeptides of the present invention may include any of the following components, features or moieties, the abbreviations of which used herein include: "Ac" and "NH2" indicate an acetyl group and an amidated terminus, respectively; "Nvl" represents norvaline; "Phg" represents phenylglycine; "Tbg" represents tert-butylglycine; "Chg" represents cyclohexylglycine; "(N-Me)X" represents an N-methylated form of an amino acid indicated by a letter or three-letter amino acid code in place of the variable "X" written as N-methyl-X [e.g., (N-Me)D or (N-Me)Asp represent an N-methylated form of aspartic acid or N-methyl-aspartic acid]; "azaTrp" represents azatryptophan; "(4-F)" represents amino acid residues; "(4-F)" represents amino acid residues; "(4-F)" represents amino acid residues. ")Phe" represents 4-fluorophenylalanine; "Tyr(OMe)" represents O-methyltyrosine, "Aib" represents aminoisobutyric acid; "(homo)F" or "(homo)Phe" represents homophenylalanine; "(2-OMe)Phg" represents 2-O-methylphenylglycine; "(5-F)W" represents 5-fluorotryptophan; "DX" represents the D-stereoisomer of a given amino acid "X" [e.g., (D-Chg) represents D-cyclohexylglycine]; "(5-MeO)W" represents 5-methyl-O-tryptophan; "homoC" represents homocysteine; "(1-Me-W)" or "(1-Me)W" represents 1-methyltryptophan; "Nle" represents norleucine; "Tiq ... " represents a tetrahydroisoquinoline residue; "Asp(T)" represents (S)-2-amino-3-(1H-tetrazol-5-yl)propionic acid; "(3-Cl-Phe)" represents 3-chlorophenylalanine; "[(N-Me-4-F)Phe]" or "(N-Me-4-F)Phe" represents N-methyl-4-fluorophenylalanine; "(m-Cl-homo)Phe" represents meta-chlorohomophenylalanine; "(des-amino)C" represents 3-thiopropionic acid; "(α-methyl)D" represents α-methyl L-aspartic acid; "2Nal" represents 2-naphthylalanine; "(3-aminomethyl)Phe" represents 3-aminomethyl-L-phenylalanine; "Cle" represents cycloleucine; "Ac-pyridine" represents cycloleucine; "(Lys-C16)" means 4-amino-tetrahydro-pyran-4-carboxylic acid; "(Lys-C12)" means N-ε-lauryl lysine; "(Lys-C10)" means N-ε-octyl (capryl) lysine; "(Lys-C8)" means N-ε-caprylic lysine; "[x-xylyl (y,z)]" means a xylyl bridging moiety between two sulfhydryl-containing amino acids, wherein x can be m, p or o to indicate the use of m-, p- or o-dibromoxylene (respectively) to create the bridging moiety, and the numerical identifiers y and z identify the amino acid positions within the polypeptide of the amino acids involved in the cyclization;"[Cyclo(y,z)]" indicates bond formation between two amino acid residues, wherein the numerical identifiers y and z determine the positions of the residues participating in the bond; "[Cyclo-alkene(y,z)]" indicates bond formation between two amino acid residues by olefin metathesis, wherein the numerical identifiers y and z determine the positions of the residues participating in the bond; "[Cyclo-thioalkyl(y,z)]" indicates the formation of a thioether bond between two amino acid residues, wherein the numerical identifiers y and z determine the positions of the residues participating in the bond; "[Cyclo-triazolyl(y,z)]" indicates the formation of a triazole ring between two amino acid residues, wherein the numerical identifiers y and z determine the positions of the residues participating in the bond. "B20" means N-ε-(PEG2-γ-glutamic acid-N-α-octadecandioic acid)lysine [also known as (1S,28S)-1-amino-7,16,25,30-tetraoxo-9,12,18,21-tetraoxa-6,15,24,29-tetraazahexadecane-1,28,46-tricarboxylic acid]. ;

[0058] B20

[0059]

[0060] "B28" represents N-ε-(PEG24-γ-glutamic acid-N-α-hexadecanoyl)lysine.

[0061] B28

[0062]

[0063] "K14" represents N-ε-1-(4,4-dimethyl-2,6-dioxocyclohex-1-ylidene)-3-methylbutyl-L-lysine. All other symbols represent the standard single letter amino acid code.

[0064] Some C5 inhibitor polypeptides comprise from about 5 amino acids to about 10 amino acids, from about 6 amino acids to about 12 amino acids, from about 7 amino acids to about 14 amino acids, from about 8 amino acids to about 16 amino acids, from about 10 amino acids to about 18 amino acids, from about 12 amino acids to about 24 amino acids, or from about 15 amino acids to about 30 amino acids. In some cases, the C5 inhibitor polypeptide comprises at least 30 amino acids.

[0065] Some C5 inhibitors of the present invention include a C-terminal lipid portion. Such a lipid portion may include a fatty acyl group (e.g., a saturated or unsaturated fatty acyl group). In some cases, the fatty acyl group may be a palmitoyl group.

[0066] The C5 inhibitor with a fatty acyl group may include one or more molecular linkers that connect the fatty acid to the peptide. Such a molecular linker may include an amino acid residue. In some cases, L-gamma glutamic acid residues may be used as a molecular linker. In some cases, the molecular linker may include one or more polyethylene glycol (PEG) linkers. The PEG linker of the present invention may include about 1 to about 5, about 2 to about 10, about 4 to about 20, about 6 to about 24, about 8 to about 32, or at least 32 PEG units.

[0067] The C5 inhibitor of the present invention can have a molecular weight of about 200 g / mol to about 600 g / mol, about 500 g / mol to about 2000 g / mol, about 1000 g / mol to about 5000 g / mol, about 3000 g / mol to about 4000 g / mol, about 2500 g / mol to about 7500 g / mol, about 5000 g / mol to about 10000 g / mol, or at least 10000 g / mol.

[0068] In certain embodiments, the C5 inhibitor polypeptide of the present invention includes R5000. The core amino acid sequence of R5000 (SEQ ID NO: 1) comprises: 15 amino acids (all L-amino acids), including 4 unnatural amino acids (N-methyl-aspartic acid, tert-butylglycine, 7-azatryptophan and cyclohexylglycine); a lactam bridge between K1 and D6 of the polypeptide sequence; and a C-terminal lysine residue with a modified side chain to form an N-ε-(PEG24-γ-glutamic acid-N-α-hexadecanoyl) lysine residue (also referred to herein as "B28"). The C-terminal lysine side chain modification includes a polyethylene glycol (PEG) spacer (PEG24), wherein PEG24 is linked to an L-γ glutamic acid residue derivatized with a palmitoyl group.

[0069] In certain embodiments, the present invention includes variants of R5000. In some R5000 variants, the C-terminal lysine side chain moiety can be changed. In some cases, the PEG24 spacer (having 24 PEG subunits) of the C-terminal lysine side chain moiety can include less or other PEG subunits. In other cases, the palmitoyl group of the C-terminal lysine side chain moiety can be replaced by another saturated or unsaturated fatty acid. In other cases, the L-gamma glutamic acid linker (between PEG and acyl group) of the C-terminal lysine side chain moiety can be replaced by alternative amino acid or non-amino acid linker.

[0070] In certain embodiments, R5000 variants may include modifications to the core polypeptide sequence in R5000, which may be used in combination with one or more cyclic or C-terminal lysine side chain moieties of R5000. Such variants may have at least 50%, at least 55%, at least 65%, at least 70%, at least 80%, at least 85%, at least 90%, or at least 95% sequence identity with the core polypeptide sequence of SEQ ID NO: 1. In some cases, R5000 variants may be cyclized by forming lactam bridges between amino acids other than those used in R5000.

[0071] The C5 inhibitors of the present invention can be developed or modified to achieve specific binding characteristics. Inhibitor binding can be evaluated by determining the binding and / or dissociation rate to a specific target. In some cases, the compound exhibits strong and rapid binding to the target and a slow dissociation rate. In certain embodiments, the C5 inhibitors of the present invention exhibit strong and rapid binding to C5. Such inhibitors may further exhibit a slow dissociation rate to C5.

[0072] The C5 inhibitors of the invention that bind to the C5 complement protein can have an equilibrium dissociation constant (K) of about 0.001 nM to about 0.01 nM, about 0.005 nM to about 0.05 nM, about 0.01 nM to about 0.1 nM, about 0.05 nM to about 0.5 nM, about 0.1 nM to about 1.0 nM, about 0.5 nM to about 5.0 nM, about 2 nM to about 10 nM, about 8 nM to about 20 nM, about 15 nM to about 45 nM, about 30 nM to about 60 nM, about 40 nM to about 80 nM, about 50 nM to about 100 nM, about 75 nM to about 150 nM, about 100 nM to about 500 nM, about 200 nM to about 800 nM, about 400 nM to about 1,000 nM, or at least 1,000 nM. D ) binds to C5 complement protein.

[0073] In certain embodiments, the C5 inhibitor of the present invention blocks the formation or generation of C5a from C5. In some cases, after activation of the alternative pathway of complement activation, the formation or generation of C5a is blocked. In some cases, the C5 inhibitor of the present invention blocks the formation of the membrane attack complex (MAC). Such MAC formation inhibition can be attributed to the binding of the C5 inhibitor to the C5b subunit. The binding of the C5 inhibitor to the C5b subunit can prevent C6 from binding, thereby resulting in the blocking of MAC formation. In certain embodiments, the MAC formation inhibition occurs after activation of the classical pathway, the alternative pathway, or the lectin pathway.

[0074] The C5 inhibitors of the present invention can be synthesized using chemical methods. In some cases, such synthesis eliminates the risks associated with preparing biological products in mammalian cell lines. In some cases, chemical synthesis can be simpler and more cost-effective than biological production methods.

[0075] Isotopic variants

[0076] The polypeptides of the present invention may contain one or more atoms that are isotopes. The term "isotope" as used herein refers to a chemical element with one or more additional neutrons. In one embodiment, the polypeptides of the present invention may be deuterated. The term "deuterated" as used herein refers to a substance that has one or more hydrogen atoms replaced by deuterium isotopes. Deuterium isotopes are isotopes of hydrogen. The nucleus of hydrogen contains one proton, while the nucleus of deuterium contains one proton and one neutron. The compounds and pharmaceutical compositions of the present invention may be deuterated in order to change physical properties, such as stability, or to allow them to be used in diagnostic and experimental applications.

[0077] II. How to use

[0078] Provided herein are methods of modulating complement activity using the compounds and / or compositions of the invention.

[0079] Treatment Indications

[0080] An important component of all immune activity (innate and adaptive) is the ability of the immune system to distinguish between self and non-self cells. When the immune system cannot make this distinction, pathology occurs. With respect to the complement system, vertebrate cells express proteins that protect them from the effects of the complement cascade, and this ensures that the complement system is directed against microbial pathogens. Many complement-related disorders and diseases are associated with abnormal destruction of self cells by the complement cascade.

[0081] The methods of the invention include methods of treating complement-associated disorders with the compounds and compositions of the invention. "Complement-associated disorders" referred to herein can include any condition associated with a malfunction of the complement system (e.g., cleavage or processing of complement components such as C5).

[0082] In certain embodiments, the methods of the present invention include methods for inhibiting complement activity in a subject. In some cases, the percentage of complement activity inhibited in a subject can be at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 85%, at least 90%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99%, at least 99.5% or at least 99.9%. In some cases, this level of inhibition and / or maximum inhibition of complement activity can be achieved at about 1 hour after administration to about 3 hours after administration, about 2 hours after administration to about 4 hours after administration, about 3 hours after administration to about 10 hours after administration, about 5 hours after administration to about 20 hours after administration, or about 12 hours after administration to about 24 hours after administration. Inhibition of complement activity can be sustained over a period of at least 1 day, at least 2 days, at least 3 days, at least 4 days, at least 5 days, at least 6 days, at least 7 days, at least 2 weeks, at least 3 weeks, or at least 4 weeks. In some cases, this level of inhibition can be achieved by daily administration. Such daily administration can include administration of at least 2 days, at least 3 days, at least 4 days, at least 5 days, at least 6 days, at least 7 days, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 2 months, at least 4 months, at least 6 months, at least 1 year, or at least 5 years. In some cases, a compound or composition of the disclosure can be administered to a subject throughout the life of such a subject.

[0083] In certain embodiments, the methods of the present invention include methods of inhibiting C5 activity in a subject. As used herein, "C5-dependent complement activity" or "C5 activity" refers to the following activation of the complement cascade: cleavage of C5, assembly of downstream cleavage products of C5, or any other method or event accompanying or caused by the cleavage of C5. In some cases, the percentage of C5 activity inhibited in a subject can be at least 10%, at least 20%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80%, at least 85%, at least 90%, at least 95%, at least 96%, at least 97%, at least 98%, at least 99%, at least 99.5% or at least 99.9%.

[0084] In certain embodiments, the method of the present invention may include a method of suppressing hemolysis by administering one or more compounds of the present invention or compositions to a subject or patient in need thereof. According to some such methods, hemolysis can be reduced by about 25% to about 99%. In other embodiments, hemolysis is reduced by about 10% to about 40%, about 25% to about 75%, about 30% to about 60%, about 50% to about 90%, about 75% to about 95%, about 90% to about 99%, or about 97% to about 99.5%. In some cases, hemolysis is reduced by at least 50%, 60%, 70%, 80%, 90% or 95%.

[0085] According to some methods, the inhibition percentage of hemolysis is about ≥90% to about ≥99% (e.g., ≥91%, ≥92%, ≥93%, ≥94%, ≥95%, ≥96%, ≥97%, ≥98%). In some cases, the inhibition level and / or maximum inhibition of hemolysis can be achieved at about 1 hour after administration to about 3 hours after administration, about 2 hours after administration to about 4 hours after administration, about 3 hours after administration to about 10 hours after administration, about 5 hours after administration to about 20 hours after administration, or about 12 hours after administration to about 24 hours after administration. The inhibition of the level of hemolytic activity can be sustained in a time period of at least 1 day, at least 2 days, at least 3 days, at least 4 days, at least 5 days, at least 6 days, at least 7 days, at least 2 weeks, at least 3 weeks, or at least 4 weeks. In some cases, the inhibition level can be achieved by daily administration. Such daily administration can include administration for at least 2 days, at least 3 days, at least 4 days, at least 5 days, at least 6 days, at least 7 days, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 2 months, at least 4 months, at least 6 months, at least 1 year, or at least 5 years. In some cases, a compound or composition of the disclosure can be administered to a subject throughout the life of such a subject.

[0086] The C5 inhibitors of the present invention can be used to treat one or more indications, wherein little or no adverse effects occur as a result of treatment with the C5 inhibitor. In some cases, adverse cardiovascular, respiratory and / or central nervous system (CNS) effects do not occur. In some cases, changes in heart rate and / or arterial blood pressure do not occur. In some cases, changes in respiratory rate, tidal volume and / or volume per minute do not occur.

[0087] In the context of a disease marker or symptom, "reduction" or "reduction" refers to a significant decrease in such levels, often statistically significant. The decrease can be, for example, at least 10%, at least 20%, at least 30%, at least 40% or more, and is preferably as low as a level that is accepted as being within the normal range for individuals without such a disorder.

[0088] In the context of a disease marker or symptom, "increase" or "elevation" refers to a significant increase in such levels, often statistically significant. The increase can be, for example, at least 10%, at least 20%, at least 30%, at least 40% or more, and preferably up to a level that is accepted as being within the normal range for individuals without such a disorder.

[0089] The therapeutic or preventive effect is evident when there is a marked improvement (often statistically significant) in one or more parameters of the disease state, or when failure occurs exacerbation or symptoms occur (where they would otherwise be expected). As an example, a favorable change of at least 10%, and preferably at least 20%, 30%, 40%, 50% or more in a measurable parameter of the disease may indicate an effective treatment. The efficacy of a given compound or composition may also be judged using experimental animal models of a given disease known in the art. When an experimental animal model is used, the efficacy of the treatment is confirmed when a statistically significant modulation of a marker or symptom is observed.

[0090] Paroxysmal nocturnal hemoglobinuria

[0091] In certain embodiments, provided herein is a method for treating paroxysmal nocturnal hemoglobinuria (PNH) with a compound or composition of the present invention (e.g., a pharmaceutical composition). PNH is a rare complement-related disorder caused by an acquired mutation in the phosphatidylinositol glycan anchor biosynthesis class A (PIG-A) gene derived from pluripotent hematopoietic stem cells (Pu, JJ et al., Clin Transl Sci. 2011 Jun; 4 (3): 219-24). PNH is characterized by bone marrow disorders, hemolytic anemia, and thrombosis. The PIG-A gene product is necessary for the production of glycolipid anchor glycosylphosphatidylinositol (GPI) used to connect proteins to the plasma membrane. Two complement regulatory proteins CD55 (decay accelerating factor) and CD59 (membrane inhibitor of reactive lysis) responsible for protecting cells from the lytic activity of the terminal complement complex become non-functional in the absence of GPI. This leads to the accumulation of C5 activation and specific complement proteins on the surface of red blood cells (RBCs), thereby leading to the destruction of these cells mediated by complement.

[0092] Patients with PNH initially present with hemoglobinuria, abdominal pain, smooth muscle dystonia, and fatigue, for example, symptoms or disorders associated with PNH. PNH is also characterized by intravascular hemolysis (the main clinical manifestation of the disease) and venous thrombosis. Venous thrombosis can occur in rare sites, including, but not limited to, hepatic veins, mesenteric veins, cerebral veins, and dermal veins (Parker, C. et al., 2005. Blood. 106: 3699-709 and Parker, CJ, 2007. Exp Hematol. 35: 523-33). Currently, eculizumab ( Alexion Pharmaceuticals, Cheshire, CT) (a C5 inhibitor monoclonal antibody) is the only approved PNH treatment.

[0093] Treatment with eculizumab results in adequate control of intravascular hemolysis in most PNH patients (Schrezenmeier, H. et al., 2014. Haematologica. 99:922-9). However, Nishimura and colleagues have described 11 patients in Japan (3.2% of PNH patients) who had mutations in the C5 gene that prevented eculizumab from binding to C5 and did not respond to treatment with the antibody (Nishimura, JI. et al., 2014. N Engl J Med. 370:632-9). In addition, eculizumab is administered every 2 weeks as an intravenous infusion under the supervision of a health care professional, which is inconvenient and burdensome to the patient.

[0094] Long-term intravenous administration has the potential to lead to serious complications such as infection, local thrombosis, hematoma, and diminished venous access. In addition, eculizumab is a large protein and is associated with the risk of immunogenicity and hypersensitivity reactions. Finally, although eculizumab binds to C5 and prevents C5b production, any C5b produced by incomplete inhibition can trigger MAC formation and cause hemolysis.

[0095] The peripheral blood of PNH patients can vary in the proportion of normal and abnormal cells. According to the International PNH Interest Group, the disease is divided into subclasses based on clinical features, bone marrow characteristics, and the percentage of GPI-AP-deficient polymorphonuclear leukocytes (PMNs). Since GPI-AP-deficient red blood cells are more sensitive to destruction in PNH patients, flow cytometric analysis of PMNs is considered to provide more information (Parker, CJ, 2012. Curr Opin Hematol. 19: 141-8). Flow cytometric analysis in classic PNH shows 50-100% GPI-AP-deficient PMNs.

[0096] The hemolytic anemia of PNH is independent of autoantibodies (Coombs-negative) and results from uncontrolled activation of the alternative pathway (AP) of complement.

[0097] In certain embodiments, the compounds and compositions (e.g., pharmaceutical compositions) of the present invention are particularly useful in the treatment of PNH. Such compounds and compositions may include C5 inhibitors (e.g., R5000). In some cases, the C5 inhibitors of the present invention that can be used to treat PNH can block C5 from being cut into C5a and C5b. In some cases, the C5 inhibitors of the present invention can be used as a substitute for the eculizumab therapy of PNH. Unlike eculizumab, the C5 inhibitors of the present invention can bind to C5b, preventing C6 from binding and the subsequent assembly of C5b-9MAC.

[0098] In some cases, R5000 and compositions thereof can be used to treat PNH in a subject. Such subjects can include subjects who already have adverse effects, who have resistance to other treatments (e.g., using eculizumab), who are unresponsive to other treatments, who show reduced responsiveness to other treatments, or who show resistance to other treatments. In certain embodiments, treatment using the compounds and compositions of the present disclosure can inhibit hemolysis of PNH erythrocytes in a dose-dependent manner.

[0099] In certain embodiments, R5000 is administered in combination with eculizumab in a regimen that may involve parallel or sequential treatment.

[0100] Based on sequence and structural data, R5000 may be particularly useful for the treatment of PNH in a limited number of patients with mutations in the C5 gene that prevent eculizumab from binding to C5. An example of such a patient is one with a single missense C5 heterozygous mutation c.2654G->A, which predicts the polymorphism p.Arg885His (for a description of this polymorphism, see Nishimura, J. et al., N Engl J Med. 2014. 370 (7): 632-9, the contents of which are incorporated herein by reference in their entirety). Like eculizumab, R5000 blocks the proteolytic cleavage of C5 into C5a and C5b. Unlike eculizumab, R5000 can also bind to C5b and block binding to C6, thereby preventing the subsequent assembly of MAC. Therefore, advantageously, any C5b produced by incomplete inhibition of R5000 is prevented from binding to C6 and completing the assembly of MAC.

[0101] In some cases, for patients with PNH, R5000 is used as a therapeutic alternative to eculizumab, which can provide additional efficacy without the inconvenience and disadvantage of intravenous administration and the risk of immunogenicity and hypersensitivity reactions known to be associated with monoclonal antibodies. In addition, R5000 administered by subcutaneous (SC) injection can overcome the serious complications of long-term intravenous administration, such as infection, loss of venous access, local thrombosis and hematoma.

[0102] Inflammatory Indications

[0103] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat subjects with diseases, disorders, and / or conditions associated with inflammation. During the proteolytic cascade of the complement system, inflammation can be upregulated. Although inflammation can have beneficial effects, excessive inflammation can lead to various pathologies (Markiewski et al. 2007. Am J Pathol. 17: 715-27). Therefore, the compounds and compositions of the present invention can be used to reduce or eliminate inflammation associated with complement activation.

[0104] Sterile inflammation

[0105] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat, prevent, or delay the development of sterile inflammation. Sterile inflammation is inflammation that occurs in response to stimuli other than infection. Sterile inflammation can be a common response to stress (such as genomic stress, hypoxic stress, nutritional stress, or endoplasmic reticulum stress caused by physical, chemical, or metabolic harmful stimuli). Sterile inflammation can promote the pathogenesis of many diseases, for example, but not limited to, ischemia-induced damage, rheumatoid arthritis, acute lung injury, drug-induced liver damage, inflammatory bowel disease, and / or other diseases, disorders, or conditions. Mechanisms of sterile inflammation and methods and compositions for treating, preventing and / or delaying symptoms of sterile inflammation may include any of those taught by Rubartelli et al., Frontiers in Immunology, 2013, 4:398-99, Rock et al., Annu Rev Immunol. 2010, 28:321-342, or in U.S. Pat. No. 8,101,586 (the contents of each of which are incorporated herein by reference in their entirety).

[0106] Systemic Inflammatory Response (SIRS) and Sepsis

[0107] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat and / or prevent systemic inflammatory response syndrome (SIRS). SIRS is an inflammation that affects the entire body. In the case where SIRS is caused by infection, it is called sepsis. SIRS can also be caused by non-infectious events such as trauma, injury, burns, ischemia, hemorrhage and / or other conditions. A negative consequence associated with SIRS and / or sepsis is multiple organ failure (MOF). Complement inhibition at the C3 level in Gram-negative sepsis significantly protects organs from progressive MOF induced by E. coli, but also hinders bacterial clearance. The compounds and compositions described herein include such C5 complement component inhibitors: they can be administered to subjects with sepsis to provide organ protection benefits without adversely altering bacterial clearance.

[0108] In certain embodiments, the present disclosure provides methods for treating sepsis. Sepsis can be induced by a microbial infection. The microbial infection can include at least one Gram-negative infectious agent. As used herein, the term "infectious agent" means any entity that invades or otherwise infects a cell, tissue, organ, compartment, or fluid of a sample or subject. In some cases, the infectious agent can be a bacterium, virus, or other pathogen. Gram-negative infectious agents are Gram-negative bacteria. Gram-negative infectious agents can include, but are not limited to, Escherichia coli.

[0109] Methods for treating sepsis may include administering one or more C5 inhibitors to a subject. The C5 inhibitor may be R5000. According to some methods, complement activation may be reduced or prevented. Reduction or prevention of complement activity may be determined by detecting one or more products of complement activity in a sample from a subject. Such products may include C5 cleavage products (e.g., C5a and C5b) or downstream complexes formed as a result of C5 cleavage (e.g., C5b-9). In certain embodiments, the present disclosure provides methods for treating sepsis with R5000, wherein the levels of C5a and / or C5b-9 are reduced or eliminated in a subject and / or in at least one sample obtained from a subject. For example, C5a and / or C5b-9 levels can be reduced by about 0% to about 0.05%, about 0.01% to about 1%, about 0.05% to about 2%, about 0.1% to about 5%, about 0.5% to about 10%, about 1% to about 15%, about 5% to about 25%, about 10% to about 50%, about 20% to about 60%, about 25% to about 75%, about 50% to about 100% in a subject administered R5000 (or in a sample obtained from such a subject) when compared to subjects (or subject samples) not treated with R5000 (including subjects treated with other complement inhibitors), or when compared to the same subjects (or subject samples) in a pre-treatment period or an earlier treatment period.

[0110] In certain embodiments, the C5b-9 levels reduced by R5000 treatment are C5b-9 levels associated with one or more of the classical pathway of complement activation, the alternative pathway of complement activation, and the lectin pathway of complement activation.

[0111] In certain embodiments, by administering R5000 to a subject with sepsis, the presence, absence, and / or level of one or more factors associated with sepsis may be modulated. Using their detection assays, the presence or absence of such factors may be determined. Changes in factor levels may be determined by determining the levels of such factors in subjects with sepsis after R5000 treatment, and comparing those levels to earlier levels in the same subject (before R5000 treatment or in one or more earlier treatment stages) or to levels in subjects not treated with R5000 (including subjects with sepsis who did not receive treatment, or subjects who received some other form of treatment). The comparison may be presented by the percentage difference in factor levels between subjects treated with R5000 and subjects not treated with R5000.

[0112] C5 cleavage products may include any protein or complex that may be produced by C5 cleavage. In some cases, C5 cleavage products may include, but are not limited to, C5a and C5b. C5b cleavage products may go on to form complexes with complement proteins C6, C7, C8, and C9 (referred to herein as "C5b-9"). Thus, C5 cleavage products including C5b-9 may be detected and / or quantified to determine whether complement activity has been reduced or prevented. Detection of C5b-9 deposition may be performed, for example, by using ELISA (Euro Diagnostica, Malmo, Sweden) kit. As described by others (eg, see Bergseth G et al., 2013. Mol Immunol. 56:232-9, the contents of which are incorporated herein by reference in their entirety), quantification of cleavage products can be measured in "complement arbitrary units" (CAU).

[0113] In certain embodiments, treatment of sepsis with a C5 inhibitor (eg, R5000) can reduce or prevent C5b-9 production.

[0114] According to the present invention, the administration of R5000 to a subject can result in the regulation of bacterial clearance in the subject and / or in at least one sample obtained from the subject. Bacterial clearance mentioned herein is the partial or complete removal / reduction of bacteria from a subject or sample. Clearance can occur by killing or otherwise rendering the bacteria unable to grow and / or reproduce. In some cases, bacterial clearance can occur by bacterial lysis and / or immune destruction (e.g., by phagocytosis, bacterial cell lysis, opsonization, etc.). According to some methods, bacterial clearance in a subject treated with a C5 inhibitor (e.g., R5000) may have no effect or a beneficial effect on bacterial clearance. This may occur due to the absence or reduction of the effect of C5 inhibition on C3b levels. In certain embodiments, the method for treating sepsis with R5000 can avoid interfering with opsonization of C3b dependence or enhancing opsonization of C3b dependence.

[0115] In some cases, bacterial clearance with R5000 treatment can be enhanced compared to bacterial clearance in untreated subjects or in subjects treated with another form of complement inhibitor (e.g., C3 inhibitor). In certain embodiments, subjects with sepsis treated with R5000 can experience enhanced bacterial clearance of 0% to at least 100% when compared to bacterial clearance in subjects not treated with R5000 (including subjects treated with other complement inhibitors), or when compared to previous bacterial clearance levels in the same subjects prior to R5000 treatment or in an earlier treatment phase with R5000. For example, bacterial clearance in subjects treated with R5000 and / or in at least one sample obtained from such a subject can be enhanced by about 0% to about 0.05%, about 0.01% to about 1%, about 0.05% to about 2%, about 0.1% to about 5%, about 0.5% to about 10%, about 1% to about 15%, about 5% to about 25%, about 10% to about 50%, about 20% to about 60%, about 25% to about 75%, about 50% to about 100% when compared to subjects not treated with R5000 (including subjects treated with other complement inhibitors), or when compared to samples obtained from such subjects, or when compared to the same subjects at a pre-treatment stage or an earlier treatment stage, and / or when compared to samples obtained from the same subjects at a pre-treatment stage or an earlier treatment stage.

[0116] Bacterial clearance in a subject can be measured by directly measuring the level of bacteria in a subject and / or a sample of a subject, or by measuring one or more indicators of bacterial clearance (e.g., the level of bacterial components released after bacterial lysis). The level of bacterial clearance can then be determined by comparing with previous bacterial / indicator level measurements or with bacterial / indicator levels in subjects who have not received treatment or who have received a different treatment. In some cases, colony forming units (cfu) from collected blood are examined (e.g., to generate cfu / ml blood) to determine bacterial levels.

[0117] In certain embodiments, sepsis treatment using R5000 can be performed without an effect on phagocytosis or without substantial impairment of phagocytosis. This can include neutrophil-dependent and / or monocyte-dependent phagocytosis. Unimpaired or substantially unimpaired phagocytosis with treatment using R5000 can be due to limited or no changes in C3b levels with treatment using R5000.

[0118] Oxidative burst is a C5a-dependent process characterized by superoxide production by certain cells, particularly macrophages and neutrophils, following challenge with pathogens (see Mollnes TE et al., 2002. Blood 100, 1869-1877, the contents of which are incorporated herein by reference in their entirety).

[0119] In certain embodiments, after treatment with R5000, sudden oxidation can be reduced or prevented in subjects with sepsis. This can be due to the decline in C5a levels when using R5000-dependent C5 inhibition. When compared with subjects not treated with R5000 (including subjects treated with other complement inhibitors), or when compared with the same subjects in the pre-treatment stage or earlier treatment stage, sudden oxidation in subjects administered with R5000 can be reduced by about 0% to about 0.05%, about 0.01% to about 1%, about 0.05% to about 2%, about 0.1% to about 5%, about 0.5% to about 10%, about 1% to about 15%, about 5% to about 25%, about 10% to about 50%, about 20% to about 60%, about 25% to about 75%, about 50% to about 100%.

[0120] Lipopolysaccharide (LPS) is a component of the bacterial cell coat that is a known immune stimulant. Complement-dependent bacteriolysis can lead to the release of LPS, thereby promoting inflammatory responses, such as those characteristic of sepsis. In certain embodiments, sepsis treatment using R5000 can reduce LPS levels. This can be due to a reduction in complement-mediated bacteriolysis and inhibition of C5-dependent complement activity. In certain embodiments, LPS levels in a subject administered R5000 (or in a sample obtained from a subject) can be reduced or eliminated by about 0% to about 0.05%, about 0.01% to about 1%, about 0.05% to about 2%, about 0.1% to about 5%, about 0.5% to about 10%, about 1% to about 15%, about 5% to about 25%, about 10% to about 50%, about 20% to about 60%, about 25% to about 75%, about 50% to about 100% when compared to subjects (or subject samples) not treated with R5000 (including subjects treated with other complement inhibitors), or when compared to the same subjects (or subject samples) in a pre-treatment period or an earlier treatment period.

[0121] In certain embodiments, LPS levels in subjects (or subject samples) with sepsis treated with R5000 can be reduced by 100% compared to subjects (or subject samples) with sepsis not treated with R5000 (including subjects receiving one or more other treatment modalities), or when compared to the same subjects (or subject samples) in a pre-treatment phase or an earlier treatment phase.

[0122] In certain embodiments of the present disclosure, R5000 treatment can reduce the level of one or more cytokines induced by sepsis. Cytokines include many cell signaling molecules that stimulate the immune response to infection. A "cytokine storm" is a dramatic upregulation of at least four cytokines - interleukin (IL) -6, IL-8, monocyte chemoattractant protein -1 (MCP-1), and tumor necrosis factor alpha (TNFα), which can originate from bacterial infection and promote sepsis. C5a is known to induce the synthesis and activity of these cytokines. Therefore, inhibitors of C5 can reduce cytokine levels by reducing the level of C5a. Cytokine levels in a subject or a sample of a subject can be evaluated to evaluate the ability of a C5 inhibitor to reduce the level of one or more inflammatory cytokines that are upregulated during sepsis. IL-6, IL-8, MCP-1 and / or TNFα levels in subjects administered R5000 can be reduced by about 0% to about 0.05%, about 0.01% to about 1%, about 0.05% to about 2%, about 0.1% to about 5%, about 0.5% to about 10%, about 1% to about 15%, about 5% to about 25%, about 10% to about 50%, about 20% to about 60%, about 25% to about 75%, about 50% to about 100% when compared to subjects not treated with R5000 (including subjects treated with other complement inhibitors), or when compared to the same subjects in a pre-treatment period or an earlier treatment period. In certain embodiments, IL-6, IL-8, MCP-1 and / or TNFα levels in subjects with sepsis treated with R5000 can be reduced by 100% compared to subjects with sepsis not treated with R5000 (including subjects receiving one or more other treatment modalities) or when compared to the same subjects at a pre-treatment stage or an earlier treatment stage.

[0123] One complication associated with sepsis is dysregulation of coagulation and / or fibrinolysis pathways (Levi M., et al., 2013. Seminars in thrombosis and hemostasis 39, 559-66; Rittirsch D., et al., 2008. Nature Reviews Immunology 8, 776-87; and Dempfle C., 2004. A Thromb Haemost. 91 (2): 213-24, the contents of each of which are incorporated herein by reference in their entirety). Although controlled local activation of these pathways is important for defense against pathogens, systemic uncontrolled activation may be harmful. Complement activity associated with bacterial infection can promote dysregulation of coagulation and / or fibrinolysis (due to increased host cell and tissue damage associated with MAC formation). In certain embodiments, sepsis treatment using R5000 can normalize coagulation and / or fibrinolysis pathways.

[0124] Dysregulation of coagulation and / or fibrinolysis associated with sepsis can include disseminated intravascular coagulation (DIC). DIC is a condition that causes tissue and organ damage due to activation of coagulation and clot formation in small blood vessels. This activity reduces blood flow to tissues and organs and consumes blood factors required for coagulation in the rest of the body. The absence of these blood factors in the bloodstream can lead to uncontrolled bleeding in other parts of the body. In certain embodiments, sepsis treatment using R5000 can reduce or eliminate DIC.

[0125] Coagulation disorders associated with sepsis can be detected by measuring activated partial thromboplastin time (APTT) and / or prothrombin time (PT). These are tests performed on plasma samples to determine which coagulation factor levels are low. In subjects with DIC, APTT and / or PT are prolonged due to reduced coagulation factor levels. In certain embodiments, treatment of sepsis in subjects using R5000 can reduce and / or normalize APTT and / or PT in samples obtained from treated subjects.

[0126] Coagulation dysfunction associated with sepsis can be further evaluated by analyzing thrombin-antithrombin (TAT) complex levels and / or leukocyte expression of tissue factor (TF) mRNA. Increased TAT complex levels and leukocyte expression of TF mRNA are associated with coagulation dysfunction and are consistent with DIC. In certain embodiments, treatment of sepsis with R5000 can result in a decrease in TAT levels and / or leukocyte TF mRNA levels of about 0.005% to about 0.05%, about 0.01% to about 1%, about 0.05% to about 2%, about 0.1% to about 5%, about 0.5% to about 10%, about 1% to about 15%, about 5% to about 25%, about 10% to about 50%, about 20% to about 60%, about 25% to about 75%, about 50% to about 100%, when compared to subjects not treated with R5000 (including subjects treated with other complement inhibitors), or when compared to the same subjects in a pre-treatment period or an earlier treatment period. In certain embodiments, TAT levels and / or leukocyte TF mRNA levels in subjects with sepsis treated with R5000 may be reduced by 100% compared to subjects with sepsis not treated with R5000 (including subjects receiving one or more other treatment modalities) or when compared to the same subjects at a pre-treatment stage or an earlier treatment stage.

[0127] Factor XII is a factor important for normal coagulation in plasma. In plasma samples taken from subjects with coagulation disorders (e.g., DIC), factor XII levels may decrease due to the consumption of factor XII associated with coagulation in small blood vessels. In certain embodiments, sepsis treatment using R5000 can reduce factor XII consumption. Therefore, in plasma samples taken from subjects with sepsis after treatment with R5000, factor XII levels may increase. Factor XII levels in plasma samples may increase by about 0.005% to about 0.05%, about 0.01% to about 1%, about 0.05% to about 2%, about 0.1% to about 5%, about 0.5% to about 10%, about 1% to about 15%, about 5% to about 25%, about 10% to about 50%, about 20% to about 60%, about 25% to about 75%, about 50% to about 100% when compared to subjects not treated with R5000 (including subjects treated with other complement inhibitors), or when compared to plasma samples taken from the same subjects at a pre-treatment stage or an earlier treatment stage. In certain embodiments, the level of Factor XII in a plasma sample from a subject with sepsis treated with R5000 may be increased by 100% compared to a plasma sample from a subject with sepsis who is not treated with R5000 (including subjects receiving one or more other treatment modalities), or when compared to a plasma sample taken from the same subject at a pre-treatment stage or an earlier stage of treatment.

[0128] Fibrinolysis is the decomposition of fibrin caused by enzymatic activity, and this process is critical for clot formation. Fibrinolysis dysregulation can occur in severe sepsis, and it is reported that it will affect the normal coagulation in baboons attacked with E. coli (P. de Boer JP, et al., 1993. Circulatory shock. 39, 59-67, the contents of which are incorporated herein by reference in their entirety). The plasma index of sepsis-dependent fibrinolytic dysfunction (including, but not limited to the fibrinolytic dysfunction related to DIC) can include, but not limited to: reduced fibrinogen levels (indicating reduced ability to form fibrin clots), increased tissue plasminogen activator (tPA) levels, increased plasminogen activator inhibitor type 1 (PAI-1) levels, increased plasmin-antiplasmin (PAP) levels, increased fibrinogen / fibrin degradation products and increased D-dimer levels. In certain embodiments, treatment of sepsis with R5000 can result in a decrease in plasma fibrinogen levels of about 0.005% to about 0.05%, about 0.01% to about 1%, about 0.05% to about 2%, about 0.1% to about 5%, about 0.5% to about 10%, about 1% to about 15%, about 5% to about 25%, about 10% to about 50%, about 20% to about 60%, about 25% to about 75%, about 50% to about 100%, and / or an increase in plasma levels of tPA, PAI-1, PAP, fibrinogen / fibrin degradation products, and / or D-dimer when compared to levels in plasma samples from subjects not treated with R5000 (including subjects treated with other complement inhibitors), or when compared to levels in plasma samples taken from the same subject at a pre-treatment stage or an earlier treatment stage. In certain embodiments, a sepsis-associated decrease in plasma fibrinogen levels and / or a sepsis-associated increase in plasma levels of tPA, PAI-1, PAP, fibrinogen / fibrin degradation products, and / or D-dimers may differ by at least 10,000% when compared to levels in a plasma sample from a subject with sepsis treated with R5000.

[0129] Another consequence of overactive complement activity associated with sepsis is a decrease in red blood cells caused by complement-dependent hemolysis and / or C3b-dependent opsonization. According to the present disclosure, a method for treating sepsis with R5000 may include reducing complement-dependent hemolysis. A method for evaluating complement-dependent hemolysis associated with sepsis includes obtaining a complete blood cell count. The complete blood cell count can be obtained by an automated method for counting the cell types present in a blood sample. Results from a complete blood cell count analysis typically include hematocrit levels, red blood cell (RBC) counts, white blood cell (WBC) counts, and platelets. The hematocrit level is used to determine the percentage of blood (by volume) that is composed of red blood cells. The hematocrit level, platelet level, RBC level, and WBC level may be reduced in sepsis due to hemolysis. In certain embodiments, sepsis treatment using R5000 increases the hematocrit level, platelet level, RBC level, and / or WBC level. The increase may be immediate, or may occur over time during treatment (eg, single or multiple dose treatment).

[0130] In certain embodiments, treatment of a subject with R5000 can reduce activation of leukocytes (e.g., neutrophils and macrophages) associated with sepsis. "Activation" as used herein in the context of leukocytes refers to the mobilization and / or maturation of these cells to achieve relevant immune functions. Reduced leukocyte activation caused by R5000 treatment can be determined by evaluating a treated subject or a sample obtained from a treated subject.

[0131] In certain embodiments, sepsis treatment using R5000 can improve one or more vital signs in the subject being treated. Such vital signs can include, but are not limited to, heart rate, mean systemic arterial blood pressure (MSAP), respiratory rate, oxygen saturation, and body temperature.

[0132] In certain embodiments, sepsis treatment using R5000 can stabilize or reduce capillary leakage and / or endothelial barrier dysfunction associated with sepsis (i.e., maintain or improve capillary leakage and / or endothelial barrier dysfunction). Stabilization or reduction of capillary leakage and / or endothelial barrier dysfunction can be determined by measuring total plasma protein levels and / or plasma albumin levels. An increase in either level relative to a plasma level associated with sepsis can indicate reduced capillary leakage. Therefore, treatment of sepsis with R5000 can increase the levels of total plasma protein and / or plasma albumin.

[0133] The methods of the present disclosure may include methods of treating sepsis with R5000, wherein the level of one or more acute phase proteins is reduced. Acute phase proteins are proteins produced by the liver under inflammatory conditions. R5000 treatment may reduce inflammation associated with sepsis and result in a reduction in acute phase proteins produced by the liver.

[0134] According to some methods of the invention, sepsis-induced organ damage and / or organ dysfunction can be reduced, reversed or prevented by treatment with R5000. Indicators that may decrease with improved organ function may include, but are not limited to, plasma lactate (confirming improved vascular perfusion and clearance), creatinine, blood urea nitrogen (both indicating improved renal function), and liver transaminases (indicating improved liver function). In certain embodiments, the risk of febrile response, secondary infection, and / or the risk of sepsis recurrence is reduced in subjects treated for sepsis with R5000.

[0135] The methods of the present disclosure may include preventing sepsis-related deaths and / or improving the survival time of subjects suffering from sepsis by treatment with R5000. Improved survival time can be determined by comparing the survival time of subjects treated with R5000 with the survival time of untreated subjects (including subjects treated with one or more other treatment modalities). In certain embodiments, the survival time is increased by at least 1 day, at least 2 days, at least 3 days, at least 4 days, at least 5 days, at least 6 days, at least 7 days, at least 2 weeks, at least 1 month, at least 2 months, at least 4 months, at least 6 months, at least 1 year, at least 2 years, at least 5 years, or at least 10 years.

[0136] In certain embodiments, the administration of R5000 is performed in a single dose. In certain embodiments, the administration of R5000 is performed in multiple doses. For example, the administration of R5000 may include the administration of an initial dose, followed by one or more repeated doses. Repeated doses may be administered from about 1 hour to about 24 hours, from about 2 hours to about 48 hours, from about 4 hours to about 72 hours, from about 8 hours to about 96 hours, from about 12 hours to about 36 hours, or from about 18 hours to about 60 hours after the previous dose. In some cases, repeated doses may be administered 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 2 weeks, 4 weeks, 2 months, 4 months, 6 months, or more than 6 months after the previous dose. In some cases, repeated doses may be administered as needed to stabilize or alleviate sepsis or to stabilize or alleviate one or more effects associated with sepsis in a subject. Repeated doses may include the same amount of R5000, or may include different amounts.

[0137] The compounds and compositions of the present invention can be used to control and / or balance complement activation to prevent and treat SIRS, sepsis and / or MOF. Methods for treating SIRS and sepsis using complement inhibitors may include those in U.S. Publication No. US2013 / 0053302 or U.S. Patent No. 8,329,169 (the contents of each of which are incorporated herein by reference in their entirety).

[0138] Acute respiratory distress syndrome (ARDS)

[0139] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat and / or prevent the development of acute respiratory distress syndrome (ARDS). ARDS is a generalized inflammation of the lungs and can be caused by trauma, infection (e.g., sepsis), severe pneumonia, and / or inhalation of noxious substances. ARDS is usually a serious, life-threatening complication. Studies have shown that neutrophils can contribute to the development of ARDS by affecting the accumulation of polymorphonuclear cells in the damaged alveoli and interstitial tissues of the lungs. Therefore, the compounds and compositions of the present invention can be used to reduce and / or prevent the production of tissue factor in alveolar neutrophils. The compounds and compositions of the present invention can be further used to treat, prevent, and / or delay ARDS, in some cases, according to any of the methods taught in International Publication No. WO2009 / 014633 (the contents of which are incorporated herein by reference in their entirety).

[0140] Periodontitis

[0141] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat or prevent the development of periodontitis and / or related conditions. Periodontitis is a widespread, chronic inflammation that causes the destruction of periodontal tissues, which are tissues that support and surround teeth. The condition also involves the loss of alveolar bone (bone that supports teeth). Periodontitis may be caused by a lack of oral hygiene (which causes the accumulation of bacteria at the gum line, also known as dental plaque). Certain health conditions such as diabetes or malnutrition and / or habits such as smoking may increase the risk of periodontitis. Periodontitis can increase the risk of stroke, myocardial infarction, atherosclerosis, diabetes, osteoporosis, premature births, and other health problems. Studies have confirmed the correlation between periodontitis and local complement activity. Periodontal bacteria can inhibit or activate certain components of the complement cascade. Therefore, the compounds and compositions of the present invention can be used to prevent and / or treat periodontitis and related diseases and conditions. Complement activation inhibitors and treatment methods may include any of those taught by Hajishengallis in Biochem Pharmacol. 2010, 15;80(12):1 and Lambris or US Publication No. US2013 / 0344082 (the contents of each of which are incorporated herein by reference in their entirety).

[0142] Dermatomyositis

[0143] In certain embodiments, the compounds, compositions (e.g., pharmaceutical compositions) and / or methods of the present invention can be used to treat dermatomyositis. Dermatomyositis is an inflammatory myopathy characterized by muscle weakness and chronic muscle inflammation. Dermatomyositis often begins with a rash, which is accompanied by or precedes muscle weakness. The compounds, compositions and / or methods of the present invention can be used to alleviate or prevent dermatomyositis.

[0144] Trauma and Injury

[0145] The compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat different types of wounds and / or injuries, and / or promote the healing of different types of wounds and / or injuries. The term "injury" as used herein generally refers to physical trauma, but may include local infection or disease processes. Injury may be characterized by injury, damage or destruction caused by external events affecting body parts and / or organs. Trauma is associated with incisions, blows, burns and / or other impacts to the skin that break or damage the skin. Trauma and injury are often acute, but if not properly healed, they may lead to chronic complications and / or inflammation.

[0146] Trauma and burns

[0147] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat wounds and / or promote wound healing. Healthy skin provides a waterproof protective barrier against pathogens and other environmental effectors. The skin also controls body temperature and fluid evaporation. When the skin is injured, these functions are destroyed, making skin healing a challenge. Trauma triggers a set of physiological processes related to the immune system that repairs and regenerates tissues. Complement activation is one of these processes. Complement activation studies have identified several complement components involved in wound healing, as taught by van de Goot et al. in J Burn Care Res 2009, 30: 274-280 and Cazander et al. Clin Dev Immunol, 2012, 2012: 534291 (the contents of each of which are incorporated herein by reference in their entirety). In some cases, complement activation may be excessive, resulting in cell death and enhanced inflammation (leading to impaired wound healing and chronic wounds). In some cases, the compounds and compositions of the present invention can be used to reduce or eliminate such complement activation to promote wound healing. Treatment utilizing the compounds and compositions of the present invention may be performed according to any of the methods for treating wounds disclosed in International Publication No. WO2012 / 174055, the contents of which are incorporated herein by reference in their entirety.

[0148] Head injury

[0149] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat head injuries and / or promote the healing of head injuries. Head injuries include damage to the scalp, skull or brain. Examples of head injuries include, but are not limited to, concussions, contusions, skull fractures, traumatic brain injuries and / or other injuries. Head injuries can be mild or severe. In some cases, head injuries can lead to long-term physical and / or psychological complications or death. Studies indicate that head injuries can induce inappropriate intracranial complement cascade activation, which may lead to local inflammatory responses, promoting secondary brain injury through the occurrence of cerebral edema and / or neuronal death (Stahel et al. in Brain Research Reviews, 1998, 27: 243-56, the contents of which are incorporated herein by reference in their entirety). The compounds and compositions of the present invention can be used to treat head injuries and / or alleviate or prevent related secondary complications. Methods of controlling complement cascade activation in head injury using the compounds and compositions of the invention may include any of those taught by Holers et al. in US Pat. No. 8,911,733, the contents of which are incorporated herein by reference in their entirety.

[0150] Crush Injury

[0151] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat crush injuries and / or promote the healing of crush injuries. Crush injuries are injuries caused by force or pressure applied to the body, which cause bleeding, bruises, fractures, nerve damage, trauma, and / or other damage to the body. The compounds and compositions of the present invention can be used to reduce complement activation after crush injuries, thereby promoting healing after crush injuries (e.g., by promoting nerve regeneration, promoting fracture healing, preventing or treating inflammation and / or other related complications). According to any of the methods taught in U.S. Patent No. 8,703,136, International Publication No. WO2012 / 162215, WO2012 / 174055, or U.S. Publication No. US2006 / 0270590 (the contents of each of which are incorporated herein by reference in their entirety), the compounds and compositions of the present invention can be used to promote healing.

[0152] Ischemia / reperfusion injury

[0153] In certain embodiments, the compounds, compositions (e.g., pharmaceutical compositions) and / or methods of the present disclosure can be used to treat damage associated with ischemia and / or reperfusion. Such damage can be associated with surgical intervention (e.g., transplantation). Therefore, the compounds, compositions and / or methods of the present disclosure can be used to mitigate or prevent ischemia and / or reperfusion injury.

[0154] Autoimmune diseases

[0155] The compounds and compositions (e.g., pharmaceutical compositions) of the present invention can be used to treat subjects with autoimmune diseases and / or disorders. The immune system can be divided into an innate system and an adaptive system, representing nonspecific immediate defense mechanisms and more complex antigen-specific systems, respectively. The complement system is part of the innate immune system, which identifies and eliminates pathogens. In addition, complement proteins can regulate adaptive immunity, connecting innate responses with adaptive responses. Autoimmune diseases and disorders are immune abnormalities that cause systemic targeting of self-tissues and substances. Autoimmune diseases may involve certain tissues or organs of the body. The compounds and compositions of the present invention can be used to regulate complement in the treatment and / or prevention of autoimmune diseases. In some cases, according to the methods presented in Ballanti et al. Immunol Res (2013) 56: 477-491 (the contents of which are incorporated herein by reference in their entirety), such compounds and compositions can be used.

[0156] Antiphospholipid syndrome (APS) and catastrophic antiphospholipid syndrome (CAPS)

[0157] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent and / or treat antiphospholipid syndrome (APS) by controlling complement activation. APS is an autoimmune disorder caused by antiphospholipid antibodies that cause blood to clot. APS may lead to recurrent venous or arterial thrombosis in organs, as well as complications in the placental circulation, resulting in pregnancy-related complications such as miscarriage, stillbirth, preeclampsia, premature birth, and / or other complications. Catastrophic antiphospholipid syndrome (CAPS) is an extreme and acute form of a similar disorder that causes venous obstruction in several organs at the same time. Studies suggest that complement activation may contribute to APS-related complications, including pregnancy-related complications, thrombotic (coagulation) complications, and vascular complications. The compounds and compositions of the present invention can be used to treat APS-related disorders by reducing or eliminating complement activation. In certain instances, the compounds and compositions of the present invention may be used to treat APS and / or APS-related complications according to the methods taught by Salmon et al. Ann Rheum Dis 2002;61(Suppl II):ii46-ii50 and Mackworth-Young in Clin Exp Immunol 2004, 136:393-401 (the contents of which are incorporated herein by reference in their entirety).

[0158] Cold agglutinin disease

[0159] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat cold agglutinin disease (CAD), which is also referred to as cold agglutinin-mediated hemolysis. CAD is an autoimmune disease caused by high concentrations of IgM antibodies that interact with red blood cells at low range body temperatures [Engelhardt et al. Blood, 2002, 100 (5): 1922-23]. CAD may cause symptoms such as anemia, fatigue, dyspnea, hemoglobinuria and / or acrocyanosis. CAD is associated with robust complement activation, and studies have confirmed that CAD may be treated with complement inhibitor therapy. Therefore, the present invention provides methods for treating CAD using the compounds and compositions of the present invention. In some cases, according to Roth et al. in Blood, 2009, 113: 3885-86 or the methods taught in International Publication No. WO2012 / 139081 (the contents of each of which are incorporated herein by reference in their entirety), the compounds and compositions of the present invention can be used to treat CAD.

[0160] Myasthenia gravis

[0161] In certain embodiments, the compounds, compositions (e.g., pharmaceutical compositions) and / or methods of the invention can be used to treat myasthenia gravis. Myasthenia gravis is a neuromuscular disease caused by autoimmunity. The compounds, compositions and / or methods of the invention can be used to alleviate or prevent neuromuscular problems associated with myasthenia gravis.

[0162] Guillain-Barre syndrome

[0163] In certain embodiments, the compounds, compositions (e.g., pharmaceutical compositions) and methods of the present invention can be used to treat Guillain-Barre syndrome (GBS). GBS is an autoimmune disease involving an autoimmune attack on the peripheral nervous system. The compounds, compositions and / or methods of the present invention can be used to alleviate or prevent peripheral nerve problems associated with GBS.

[0164] Vascular Indications

[0165] In certain embodiments, the compounds and compositions (e.g., pharmaceutical compositions) of the invention can be used to treat vascular indications affecting blood vessels (e.g., arteries, veins, and capillaries). Such indications can affect blood circulation, blood pressure, blood flow, organ function, and / or other body functions.

[0166] Thrombotic microangiopathy (TMA)

[0167] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat and / or prevent thrombotic microangiopathy (TMA) and related diseases. Microangiopathy affects the small blood vessels (capillaries) of the body, thickens the capillary walls, weakens and is prone to bleeding, and slows blood circulation. TMA tends to lead to the development of vascular thrombosis, endothelial cell damage, thrombocytopenia and hemolysis. Organs such as the brain, kidneys, muscles, gastrointestinal system, skin and lungs may be affected. TMA may be caused by medical surgery and / or illness, including, but not limited to hematopoietic stem cell transplantation (HSCT), renal disorders, diabetes and / or other illnesses. TMA may be caused by potential complement system dysfunction, as described in Meri et al. European Journal of Internal Medicine, 2013, 24: 496-502 (the contents of which are incorporated herein by reference in their entirety). Typically, TMA may be derived from increased levels of certain complement components, which lead to thrombosis. In some cases, this may be caused by mutations in complement proteins or related enzymes. The resulting complement dysfunction may lead to complement targeting of endothelial cells and platelets, resulting in increased thrombosis. In certain embodiments, the compounds and compositions of the present invention can be used to prevent and / or treat TMA. In some cases, according to the methods described in U.S. Publication Nos. US2012 / 0225056 or US2013 / 0246083 (the contents of each of which are incorporated herein by reference in their entirety), methods for treating TMA using the compounds and compositions of the present invention can be achieved.

[0168] Disseminated intravascular coagulation (DIC)

[0169] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent and / or treat disseminated intravascular coagulation (DIC) by controlling complement activation. DIC is a pathological condition in which the coagulation cascade in the blood is extensively activated and causes blood clot formation, especially in capillaries. DIC may cause tissue blood flow obstruction and may eventually damage organs. In addition, DIC can affect the normal process of blood coagulation, which may cause severe bleeding. The compounds and compositions of the present invention can be used to treat, prevent DIC or reduce the severity of DIC by regulating complement activity. In some cases, according to any of the DIC treatment methods taught in U.S. Patent No. 8,652,477 (the contents of which are incorporated herein by reference in their entirety), the compounds and compositions of the present invention can be used.

[0170] Vasculitis

[0171] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent and / or treat vasculitis. Typically, vasculitis is a disorder associated with inflammation of blood vessels (including veins and arteries), characterized by white blood cells that attack tissues and cause blood vessel swelling. Vasculitis may be associated with infection (such as Rocky Mountain spotted fever) or autoimmunity. An example of autoimmune-related vasculitis is anti-neutrophil cytoplasmic autoantibody (ANCA) vasculitis. ANCA vasculitis is caused by abnormal antibodies that attack the body's own cells and tissues. ANCA attacks the cytoplasm of certain white blood cells and neutrophils, causing them to attack the walls of blood vessels in certain organs and tissues of the body. ANCA vasculitis may affect the skin, lungs, eyes, and / or kidneys. Studies suggest that ANCA disease activates the alternative complement pathway and produces certain complement components, which cause an inflammatory amplification loop that leads to vascular damage (Jennette et al. 2013, Semin Nephrol. 33 (6): 557-64, the contents of which are incorporated herein by reference in their entirety). In certain instances, the compounds and compositions of the invention may be used to prevent and / or treat ANCA vasculitis by inhibiting complement activation.

[0172] Atypical hemolytic uremic syndrome

[0173] In certain embodiments, the compounds, compositions (e.g., pharmaceutical compositions) and / or methods of the present disclosure can be used to treat atypical hemolytic uremic syndrome (aHUS). aHUS is a rare disease caused by uninhibited complement activation, which is characterized by blood clot formation in small blood vessels. The compositions and methods of the present invention can be used to reduce or prevent complement activation associated with aHUS.

[0174] Neurological Indications

[0175] The compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent, treat, and / or alleviate the symptoms of neurological indications, including, but not limited to, neurodegenerative diseases and related disorders. Neurodegeneration is generally associated with loss of structure or function of neurons (including neuronal death). These disorders can be treated by inhibiting the effects of complement on neuronal cells using the compounds and compositions of the present invention. Neurodegeneration-related disorders include, but are not limited to, amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Parkinson's disease, and Alzheimer's disease.

[0176] Amyotrophic lateral sclerosis (ALS)

[0177] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent, treat ALS and / or alleviate the symptoms of ALS. ALS is a fatal motor neuron disease characterized by degeneration of spinal neurons, brainstem and motor cortex. ALS causes loss of muscle strength, ultimately leading to respiratory failure. Complement dysfunction can contribute to ALS, and therefore ALS can be prevented, treated and / or symptoms reduced by using the therapy of the compounds and compositions of the present invention targeting complement activity. In some cases, the compounds and compositions of the present invention can be used to promote neural regeneration. In some cases, according to any of the methods taught in U.S. Publication Nos. US2014 / 0234275 or US2010 / 0143344 (the contents of each of which are incorporated herein by reference in their entirety), the compounds and compositions of the present invention can be used as complement inhibitors.

[0178] Alzheimer's disease

[0179] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent and / or treat Alzheimer's disease by controlling complement activity. Alzheimer's disease is a chronic neurodegenerative disease with symptoms that may include disorientation, memory loss, mood instability, behavioral problems, and ultimate physical function loss. Alzheimer's disease is believed to be caused by extracellular brain deposition of amyloid protein, which is related to inflammation-related proteins such as complement proteins (Sjoberg et al. 2009. Trends in Immunology. 30 (2): 83-90, the contents of which are incorporated herein by reference in their entirety). In some cases, according to any of the Alzheimer's disease treatment methods taught in U.S. Publication No. US2014 / 0234275 (the contents of which are incorporated herein by reference in their entirety), the compounds and compositions of the present invention can be used as complement inhibitors.

[0180] Kidney-related indications

[0181] The compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to treat certain diseases, disorders and / or conditions associated with the kidney, in some cases, by inhibiting complement activity. The kidney is an organ responsible for removing metabolic waste products from the bloodstream. The kidney regulates blood pressure, urinary system and homeostasis functions, and is therefore essential for a variety of body functions. Due to unique structural features and exposure to blood, the kidney may be more severely affected by inflammation (relative to other organs). The kidney also produces its own complement proteins, which can be activated after infection, kidney disease and kidney transplantation. In some cases, according to Quigg, J Immunol 2003; 171: 3319-24 (the contents of which are incorporated herein by reference in their entirety) teaching methods, the compounds and compositions of the present invention can be used as complement inhibitors in the treatment of certain diseases, disorders and / or disorders of the kidney.

[0182] Lupus nephritis

[0183] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent and / or treat lupus nephritis by inhibiting complement activity. Lupus nephritis is a renal inflammation caused by an autoimmune disease called systemic lupus erythematosus (SLE). Symptoms of lupus nephritis include high blood pressure; foamy urine; swelling of the legs, feet, hands, or face; joint pain; muscle pain; fever; and rash. Lupus nephritis can be treated with inhibitors that control complement activity (including compounds and compositions of the present invention). Methods and compositions for preventing and / or treating lupus nephritis by complement inhibition may include any of those taught in U.S. Publication No. US2013 / 0345257 or U.S. Patent No. 8,377,437 (the contents of each of which are incorporated herein by reference in their entirety).

[0184] Membranous Glomerulonephritis (MGN)

[0185] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent and / or treat membranous glomerulonephritis (MGN) disorders by inhibiting the activation of certain complement components. MGN is a renal disorder that may cause inflammation and structural changes. MGN is caused by antibodies that bind to soluble antigens in the renal capillaries (glomeruli). MGN can affect renal function, such as filtering fluid, and may cause renal failure. According to the methods of preventing and / or treating MGN by complement inhibition as taught in U.S. Publication No. US2010 / 0015139 or in International Publication No. WO2000 / 021559 (the contents of each of which are incorporated herein by reference in their entirety), the compounds and compositions of the present invention can be used.

[0186] Complications of hemodialysis

[0187] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent and / or treat complications associated with hemodialysis by inhibiting complement activation. Hemodialysis is a medical procedure used to maintain renal function in subjects with renal failure. In hemodialysis, the removal of waste products (such as creatinine, urea, and free water) from the blood is performed externally. A common complication of hemodialysis treatment is chronic inflammation caused by contact between blood and the dialysis membrane. Another common complication is thrombosis, which refers to the formation of blood clots that block blood circulation. Studies have suggested that these complications are associated with complement activation. Hemodialysis can be combined with complement inhibitor therapy to provide a way to control inflammatory responses and pathology and / or prevent or treat thrombosis in subjects undergoing hemodialysis due to renal failure. Methods of treating hemodialysis complications using the compounds and compositions of the present invention can be accomplished according to any of the methods taught by DeAngelis et al. in Immunobiology, 2012, 217(11):1097-1105 or Kourtzelis et al. Blood, 2010, 116(4):631-639, the contents of each of which are incorporated herein by reference in their entirety.

[0188] Eye diseases

[0189] In certain embodiments, the compounds and compositions (e.g., pharmaceutical compositions) of the present invention can be used to prevent and / or treat certain eye-related diseases, disorders, and / or conditions. In healthy eyes, the complement system is activated at low levels and is continuously regulated by membrane-bound and soluble intraocular proteins that protect against pathogens. Therefore, the activation of complement plays an important role in several complications associated with the eye, and controlling complement activation can be used to treat such diseases. According to any of the methods taught by Jha et al. in Mol Immunol. 2007; 44 (16): 3901-3908 or in U.S. Pat. No. 8,753,625 (the contents of each of which are incorporated herein by reference in their entirety), the compounds and compositions of the present invention can be used as complement inhibitors in the treatment of eye diseases.

[0190] Age-related macular degeneration (AMD)

[0191] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent and / or treat age-related macular degeneration (AMD) by inhibiting ocular complement activation. AMD is a chronic eye disease that causes blurred central vision, blind spots in central vision, and / or eventual central vision loss. Central vision affects the ability to read, drive a vehicle, and / or recognize faces. AMD is generally divided into two categories, non-exudative (dry) and exudative (wet). Dry AMD represents the decline of the macula, which is the tissue in the center of the retina. Wet AMD represents the failure of blood vessels under the retina, which leads to leakage of blood and fluid. Several human and animal studies have identified complement proteins associated with AMD, and new treatment strategies include controlling complement activation pathways, as discussed by Jha et al. in Mol Immunol. 2007; 44 (16): 3901-8. Methods of the invention for preventing and / or treating AMD including use of the compounds and compositions of the invention may include any of those taught in US Publication Nos. US2011 / 0269807 or US2008 / 0269318, the contents of each of which are incorporated herein by reference in their entirety.

[0192] Corneal diseases

[0193] In certain embodiments, the compounds and compositions (e.g., pharmaceutical compositions) of the present invention can be used to prevent and / or treat corneal diseases by inhibiting ocular complement activation. The complement system plays an important role in protecting the cornea from pathogenic particles and / or inflammatory antigens. The cornea is the outermost anterior part of the eye that covers and protects the iris, pupil, and anterior chamber, and is therefore exposed to external factors. Corneal diseases include, but are not limited to, keratoconus, keratitis, ocular herpes, and / or other diseases. Corneal complications can cause pain, blurred vision, tearing, redness, photosensitivity, and / or corneal scarring. The complement system is critical for corneal protection, but complement activation can cause damage to corneal tissue after the infection is cleared because certain complement compounds are expressed in large quantities. The method of the present invention for regulating complement activity in the treatment of corneal diseases can include any of those taught by Jha et al. in Mol Immunol. 2007; 44 (16): 3901-8 (the contents of which are incorporated herein by reference in their entirety).

[0194] Autoimmune uveitis

[0195] In certain embodiments, the compounds and compositions (e.g., pharmaceutical compositions) of the present invention can be used to prevent and / or treat uveitis, which is an inflammation of the uveal layer of the eye. The uvea is the pigmented region of the eye that contains the choroid, iris, and ciliary body of the eye. Uveitis causes redness, blurred vision, pain, iris adhesions, and may eventually cause blindness. Studies have indicated that complement activation products are present in the eyes of patients with autoimmune uveitis, and complement plays an important role in the development of the disease. In some cases, according to any of the methods identified by Jha et al. in Mol Immunol. 2007. 44 (16): 3901-8 (the contents of which are incorporated herein by reference in their entirety), the compounds and compositions of the present invention can be used to treat and / or prevent uveitis.

[0196] Diabetic retinopathy

[0197] In certain embodiments, the compounds and compositions of the present invention (e.g., pharmaceutical compositions) can be used to prevent and / or treat diabetic retinopathy, a disease caused by changes in retinal blood vessels in diabetic patients. Retinopathy may cause swelling and fluid leakage of blood vessels and / or growth of abnormal blood vessels. Diabetic retinopathy can affect vision and may eventually lead to blindness. Studies have suggested that activation of complement plays an important role in the development of diabetic retinopathy. In some cases, the compounds and compositions of the present invention can be used according to the diabetic retinopathy treatment methods described by Jha et al. Mol Immunol. 2007; 44 (16): 3901-8 (the contents of which are incorporated herein by reference in their entirety).

[0198] Neuromyelitis optica (NMO)

[0199] In certain embodiments, the compounds, compositions (e.g., pharmaceutical compositions) and / or methods of the invention can be used to treat neuromyelitis optica (NMO). NMO is an autoimmune disease that causes destruction of the optic nerve. The compounds and / or methods of the invention can be used to prevent nerve damage in subjects with NMO.

[0200] Sjögren's syndrome

[0201] In certain embodiments, the compounds, compositions (e.g., pharmaceutical compositions), and / or methods of the present disclosure can be used to treat Sjögren's syndrome. Sjögren's syndrome is an eye disease characterized by dry eyes (which may be hot and / or itchy). It is an autoimmune disorder in which the immune system targets glands in the eyes and mouth that are responsible for moistening those areas. The compounds, compositions, and / or methods of the present disclosure can be used to treat Sjögren's syndrome and / or alleviate the symptoms of Sjögren's syndrome.

[0202] Preeclampsia and HELLP syndrome

[0203] In certain embodiments, the compounds and compositions (e.g., pharmaceutical compositions) of the present invention can be used to prevent and / or treat pre-eclampsia and / or HELLP (an abbreviation representing the syndrome features of 1) hemolysis, 2) elevated liver enzymes, and 3) low platelet count) syndrome by complement inhibitor therapy. Pre-eclampsia is a pregnancy disorder with symptoms including elevated blood pressure, swelling, shortness of breath, renal dysfunction, impaired liver function, and / or low platelet count. Pre-eclampsia is usually diagnosed by high urine protein levels and high blood pressure. HELLP syndrome is a combination of hemolysis, elevated liver enzymes, and low platelet conditions. Hemolysis is a disease involving the rupture of red blood cells (causing hemoglobin to be released from red blood cells). Elevated liver enzymes may indicate a pregnancy-induced liver disorder. Low platelet levels lead to reduced clotting ability, thereby creating a risk of excessive bleeding. HELLP is associated with pre-eclampsia and liver disorders. HELLP syndrome usually occurs in the late stages of pregnancy or after delivery. It is usually diagnosed by blood tests that indicate the presence of the three conditions it involves. Typically, HELLP is treated by induction delivery.

[0204] Studies suggest that complement activation occurs during HELLP syndrome and pre-eclampsia, and certain complement components are present at increased levels during HELLP and pre-eclampsia. Complement inhibitors can be used as therapeutic agents to prevent and / or treat these conditions. The compounds and compositions of the present invention can be used according to the methods of preventing and / or treating HELLP and pre-eclampsia taught by Heager et al. in Obstetrics & Gynecology, 1992, 79 (1): 19-26 or in International Publication No. WO201 / 078622 (the contents of each of which are incorporated herein by reference in their entirety).

[0205] preparation

[0206] In certain embodiments, the compound of the present invention or composition (for example, pharmaceutical composition) is formulated in an aqueous solution. In some cases, the aqueous solution also includes one or more salts and / or one or more buffers. Salt can include sodium chloride, which can be included with a concentration of about 0.05mM to about 50mM, about 1mM to about 100mM, about 20mM to about 200mM, or about 50mM to about 500mM. Other solutions can include at least 500mM sodium chloride. In some cases, the aqueous solution includes sodium phosphate. Sodium phosphate can be included in an aqueous solution with a concentration of about 0.005mM to about 5mM, about 0.01mM to about 10mM, about 0.1mM to about 50mM, about 1mM to about 100mM, about 5mM to about 150mM, or about 10mM to about 250mM. In some cases, at least 250mM sodium phosphate concentration is used.

[0207] The compositions of the present invention may include a C5 inhibitor at a concentration of about 0.001 mg / mL to about 0.2 mg / mL, about 0.01 mg / mL to about 2 mg / mL, about 0.1 mg / mL to about 10 mg / mL, about 0.5 mg / mL to about 5 mg / mL, about 1 mg / mL to about 20 mg / mL, about 15 mg / mL to about 40 mg / mL, about 25 mg / mL to about 75 mg / mL, about 50 mg / mL to about 200 mg / mL, or about 100 mg / mL to about 400 mg / mL. In some cases, the compositions of the present invention include a C5 inhibitor at a concentration of at least 400 mg / mL.

[0208] The compositions of the invention may include a C5 inhibitor at a concentration of approximately, about, or exactly any of the following values: 0.001 mg / mL, 0.2 mg / mL, 0.01 mg / mL, 2 mg / mL, 0.1 mg / mL, 10 mg / mL, 0.5 mg / mL, 5 mg / mL, 1 mg / mL, 20 mg / mL, 15 mg / mL, 40 mg / mL, 25 mg / mL, 75 mg / mL, 50 mg / mL, 200 mg / mL, 100 mg / mL, or 400 mg / mL. In some cases, the compositions of the invention include a C5 inhibitor at a concentration of at least 40 mg / mL.

[0209] In certain embodiments, the compositions of the invention include aqueous compositions comprising at least water and a C5 inhibitor (e.g., a cyclic C5 inhibitor polypeptide). The aqueous C5 inhibitor compositions of the invention may also include one or more salts and / or one or more buffers. In some cases, the aqueous compositions of the invention include water, a cyclic C5 inhibitor polypeptide, a salt, and a buffer.

[0210] The aqueous C5 inhibitor formulations of the present invention can have a pH level of about 2.0 to about 3.0, about 2.5 to about 3.5, about 3.0 to about 4.0, about 3.5 to about 4.5, about 4.0 to about 5.0, about 4.5 to about 5.5, about 5.0 to about 6.0, about 5.5 to about 6.5, about 6.0 to about 7.0, about 6.5 to about 7.5, about 7.0 to about 8.0, about 7.5 to about 8.5, about 8.0 to about 9.0, about 8.5 to about 9.5, or about 9.0 to about 10.0.

[0211] In some cases, the compounds and compositions of the present invention are prepared according to good manufacturing practices (GMP) and / or current GMP (cGMP). Guidelines for achieving GMP and / or cGMP can be obtained from one or more of the U.S. Food and Drug Administration (FDA), the World Health Organization (WHO), and the International Conference on Harmonization of Drug Registration (ICH).

[0212] Dosage and Administration

[0213] For the treatment of human subjects, C5 inhibitors can be formulated as pharmaceutical compositions. Depending on the subject to be treated, the mode of administration, and the type of treatment desired (e.g., prevention, prevention, or treatment), C5 inhibitors can be formulated in a manner consistent with these parameters. Such techniques are summarized in: Remington: The Science and Practice of Pharmacy, 21st Edition, Lippincott Williams & Wilkins, (2005); and Encyclopedia of Pharmaceutical Technology, J. Swarbrick and JC Boylan, eds., 1988-1999, Marcel Dekker, New York, each of which is incorporated herein by reference.

[0214] The C5 inhibitors of the present invention can be provided in a therapeutically effective amount. In some cases, a therapeutically effective amount of a C5 inhibitor of the present invention can be achieved by administering a dose of about 0.1 mg to about 1 mg, about 0.5 mg to about 5 mg, about 1 mg to about 20 mg, about 5 mg to about 50 mg, about 10 mg to about 100 mg, about 20 mg to about 200 mg, or at least 200 mg of one or more C5 inhibitors.

[0215] In certain embodiments, a therapeutic amount of a C5 inhibitor may be administered to a subject based on the weight of such a subject. In certain instances, a C5 inhibitor may be administered to a subject at a dose of about 0.001 mg / kg to about 1.0 mg / kg, about 0.01 mg / kg to about 2.0 mg / kg, about 0.05 mg / kg to about 5.0 mg / kg, about 0.03 mg / kg to about 3.0 mg / kg, about 0.01 mg / kg to about 10 mg / kg, about 0.1 mg / kg to about 2.0 mg / kg, about 0.2 mg / kg to about 3.0 mg / kg, about 0.4 mg / kg to about 4.0 mg / kg, about 1.0 mg / kg to about 5.0 mg / kg, about 2.0 mg / kg The C5 inhibitor is administered at a dosage of about 4.0 mg / kg, about 1.5 mg / kg to about 7.5 mg / kg, about 5.0 mg / kg to about 15 mg / kg, about 7.5 mg / kg to about 12.5 mg / kg, about 10 mg / kg to about 20 mg / kg, about 15 mg / kg to about 30 mg / kg, about 20 mg / kg to about 40 mg / kg, about 30 mg / kg to about 60 mg / kg, about 40 mg / kg to about 80 mg / kg, about 50 mg / kg to about 100 mg / kg, or at least 100 mg / kg. Such a range may include a range suitable for administration to a human subject. The dosage level may be highly dependent on the nature of the condition; the efficacy of the drug; the condition of the patient; the judgment of the practitioner; and the frequency and mode of administration.

[0216] In some cases, the C5 inhibitor of the present invention is provided at a specific concentration, and the specific concentration is adjusted to achieve a desired C5 inhibitor level (e.g., plasma level in a subject) in a sample, a biological system, or a subject. In some cases, the desired C5 inhibitor concentration in a sample, a biological system, or a subject can include a concentration of about 0.001 μM to about 0.01 μM, about 0.005 μM to about 0.05 μM, about 0.02 μM to about 0.2 μM, about 0.03 μM to about 0.3 μM, about 0.05 μM to about 0.5 μM, about 0.01 μM to about 2.0 μM, about 0.1 μM to about 50 μM, about 0.1 μM to about 10 μM, about 0.1 μM to about 5 μM, or about 0.2 μM to about 20 μM. In some cases, the desired C5 inhibitor concentration in the subject's plasma can be about 0.1 μg / mL to about 1000 μg / mL. In other cases, the desired C5 inhibitor concentration in the subject's plasma can be about 0.01 μg / mL to about 2 μg / mL, about 0.02 μg / mL to about 4 μg / mL, about 0.05 μg / mL to about 5 μg / mL, about 0.1 μg / mL to about 1.0 μg / mL, about 0.2 μg / mL to about 2.0 μg / mL, about 0.5 μg / mL to about 5 μg / mL, about 1 μg / mL to about 5 μg / mL, or about 1 μg / mL to about 5 μg / mL. mL, about 2 μg / mL to about 10 μg / mL, about 3 μg / mL to about 9 μg / mL, about 5 μg / mL to about 20 μg / mL, about 10 μg / mL to about 40 μg / mL, about 30 μg / mL to about 60 μg / mL, about 40 μg / mL to about 80 μg / mL, about 50 μg / mL to about 100 μg / mL, about 75 μg / mL to about 150 μg / mL, or at least 150 μg / mL. In other embodiments, the maximum serum concentration (C) of at least 0.1 μg / mL, at least 0.5 μg / mL, at least 1 μg / mL, at least 5 μg / mL, at least 10 μg / mL, at least 50 μg / mL, at least 100 μg / mL, or at least 1000 μg / mL is sufficient to achieve. max ) doses of C5 inhibitor.

[0217] In certain embodiments, a dosage sufficient to support a C5 inhibitor level of about 0.1 μg / mL to about 20 μg / mL is provided to reduce hemolysis in a subject by about 25% to about 99%.

[0218] In certain embodiments, the C5 inhibitor is administered daily at a dose sufficient to deliver from about 0.1 mg / day to about 60 mg / day per kilogram of subject weight. maxFrom about 0.1 μg / mL to about 1000 μg / mL. In such cases, the area under the curve (AUC) between doses can be from about 200 μg*h / mL to about 10,000 μg*h / mL.

[0219] According to some methods of the invention, the C5 inhibitors of the invention are provided at the concentration required to achieve the desired effect. In some cases, the compounds and compositions of the invention are provided in an amount necessary to reduce a given reaction or process by half. The concentration required to achieve such a reduction is referred to herein as the half maximal inhibitory concentration or "IC 50 Alternatively, the compounds and compositions of the invention are provided in an amount necessary to increase a given reaction, activity or process by half. The concentration required for such an increase is referred to herein as the half maximal effective concentration or "EC 50 ”.

[0220] The C5 inhibitor of the present invention may be present in an amount of 0.1-95 wt % of the total weight of the composition. In some cases, the C5 inhibitor is provided by intravenous (IV) administration. In some cases, the C5 inhibitor is provided by subcutaneous (SC) administration.

[0221] In some cases, subcutaneous administration of the C5 inhibitor of the present invention can provide advantages over intravenous administration. Subcutaneous administration can allow patients to provide self-treatment. Such treatment may be advantageous because patients can provide treatment for themselves in their own homes, thereby avoiding the need to move to a provider or medical facility. In addition, subcutaneous treatment can allow patients to avoid long-term complications associated with intravenous administration, such as infection, loss of venous access, local thrombosis and hematoma. In certain embodiments, subcutaneous treatment can increase patient compliance, patient satisfaction, quality of life, and reduce treatment costs and / or drug requirements.

[0222] In some cases, daily subcutaneous administration provides steady-state C5 inhibitor concentrations achieved within 1-3 doses, 2-3 doses, 3-5 doses, or 5-10 doses. In some cases, a daily subcutaneous dose of 0.1 mg / kg can achieve sustained C5 inhibitor levels greater than or equal to 2.5 μg / mL and / or greater than 90% inhibition of complement activity.

[0223] The C5 inhibitors of the present invention may exhibit slow absorption kinetics (time to maximum observed concentration greater than 4-8 hours) and high bioavailability (about 75% to about 100%) following subcutaneous administration.

[0224] In certain embodiments, dosage and / or administration is modified to modulate the half-life (t 1 / 2 ) level. In some cases, t 1 / 2is at least 1 hour, at least 2 hours, at least 4 hours, at least 6 hours, at least 8 hours, at least 10 hours, at least 12 hours, at least 16 hours, at least 20 hours, at least 24 hours, at least 36 hours, at least 48 hours, at least 60 hours, at least 72 hours, at least 96 hours, at least 5 days, at least 6 days, at least 7 days, at least 8 days, at least 9 days, at least 10 days, at least 11 days, at least 12 days, at least 2 weeks, at least 3 weeks, at least 4 weeks, at least 5 weeks, at least 6 weeks, at least 7 weeks, at least 8 weeks, at least 9 weeks, at least 10 weeks, at least 11 weeks, at least 12 weeks, or at least 16 weeks.

[0225] In certain embodiments, the C5 inhibitors of the present invention may exhibit long terminal t 1 / 2 . Extended terminal t 1 / 2 This may be due to extensive target binding and / or additional plasma protein binding. In some cases, the C5 inhibitors of the invention exhibit a t of greater than 24 hours in plasma and whole blood. 1 / 2 In some cases, C5 inhibitors do not lose functional activity after incubation in human whole blood at 37°C for 16 hours.

[0226] In certain embodiments, the dosage and / or administration are changed to adjust the steady-state distribution volume of the C5 inhibitor. In certain cases, the steady-state distribution volume of the C5 inhibitor is about 0.1 mL / kg to about 1 mL / kg, about 0.5 mL / kg to about 5 mL / kg, about 1 mL / kg to about 10 mL / kg, about 5 mL / kg to about 20 mL / kg, about 15 mL / kg to about 30 mL / kg, about 10 mL / kg to about 200 mL / kg, about 20 mL / kg to about 60 mL / kg, about 30 mL / kg to about 70 mL / kg, about 50 mL / kg to about 200 mL / kg, about 100 mL / kg to about 500 mL / kg, or at least 500 mL / kg. In certain cases, the dosage and / or administration of the C5 inhibitor are adjusted to ensure that the steady-state distribution volume is equal to at least 50% of the total blood volume. In certain embodiments, the C5 inhibitor distribution can be restricted to the plasma compartment.

[0227] In certain embodiments, the C5 inhibitors of the invention exhibit a total clearance rate of about 0.001 mL / hr / kg to about 0.01 mL / hr / kg, about 0.005 mL / hr / kg to about 0.05 mL / hr / kg, about 0.01 mL / hr / kg to about 0.1 mL / hr / kg, about 0.05 mL / hr / kg to about 0.5 mL / hr / kg, about 0.1 mL / hr / kg to about 1 mL / hr / kg, about 0.5 mL / hr / kg to about 5 mL / hr / kg, about 0.04 mL / hr / kg to about 4 mL / hr / kg, about 1 mL / hr / kg to about 10 mL / hr / kg, about 5 mL / hr / kg to about 20 mL / hr / kg, about 15 mL / hr / kg to about 30 mL / hr / kg, or at least 30 mL / hr / kg.

[0228] By varying the dosage and / or administration (e.g., subcutaneous administration), the period of time (T) during which the maximum C5 inhibitor concentration is maintained in a subject (e.g., in the subject's serum) can be adjusted. max In some cases, the C5 inhibitor has a T of about 1 min to about 10 min, about 5 min to about 20 min, about 15 min to about 45 min, about 30 min to about 60 min, about 45 min to about 90 min, about 1 hour to about 48 hours, about 2 hours to about 10 hours, about 5 hours to about 20 hours, about 10 hours to about 60 hours, about 1 day to about 4 days, about 2 days to about 10 days, or at least 10 days. max value.

[0229] In certain embodiments, the C5 inhibitor of the present invention can be administered without off-target effects. In certain cases, the C5 inhibitor of the present invention does not inhibit hERG (human ether anesthesia chorea-related gene), even for concentrations less than or equal to 300 μM. Subcutaneous injection of the C5 inhibitor of the present invention (at a dose level of up to 10 mg / kg) can be well tolerated and does not cause any adverse effects on the cardiovascular system (e.g., increased risk of prolonged ventricular repolarization) and / or respiratory system.

[0230] The C5 inhibitor dose can be determined using the zero observed adverse effect level (NOAEL) observed in another species. Such species may include, but are not limited to, monkeys, rats, rabbits, and mice. In some cases, a human equivalent dose (HED) can be determined by allometric scaling from the NOAEL observed in other species. In some cases, the HED results in a therapeutic margin of about 2 to about 5 times, about 4 to about 12 times, about 5 to about 15 times, about 10 to about 30 times, or at least 30 times. In some cases, by using the exposure in primates and the estimated human C5 inhibitor dose in humans, the human equivalent dose (HED) can be determined. max level, determine the therapeutic window.

[0231] In certain embodiments, the C5 inhibitors of the invention allow for a rapid clearance period in situations of infection where prolonged inhibition of the complement system would prove detrimental.

[0232] The administration of C5 inhibitors according to the present invention can be changed to reduce the potential clinical risks of the subject. Neisseria meningitidis infection is a known risk of C5 inhibitors (including eculizumab). In some cases, the risk of infection of Neisseria meningitidis is minimized by setting one or more preventive steps. Such steps can include the exclusion of subjects where these bacteria may have settled. In some cases, the preventive steps can include co-administration with one or more antibiotics. In some cases, ciprofloxacin can be co-administered. In some cases, ciprofloxacin can be co-administered orally at a dosage of about 100 mg to about 1000 mg (e.g., 500 mg).

[0233] In certain embodiments, administration of a C5 inhibitor can be achieved using an automatic injector device. Such a device can allow for self-administration (e.g., daily administration).

[0234] Dosage frequency

[0235] In certain embodiments, the C5 inhibitor of the invention is administered every hour, every 2 hours, every 4 hours, every 6 hours, every 12 hours, every 18 hours, every 24 hours, every 36 hours, every 72 hours, every 84 hours, every 96 hours, every 5 days, every 7 days, every 10 days, every 14 days, every week, every 2 weeks, every 3 weeks, every 4 weeks, every month, every 2 months, every 3 months, every 4 months, every 5 months, every 6 months, every year, or at least every year. In some cases, the C5 inhibitor is administered once a day, or as 2, 3 or more sub-doses at appropriate intervals throughout the day.

[0236] In certain embodiments, the C5 inhibitor is administered in multiple daily doses. In some cases, the C5 inhibitor is administered daily for 7 days. In some cases, the C5 inhibitor is administered daily for 7-100 days. In some cases, the C5 inhibitor is administered daily for at least 100 days. In some cases, the C5 inhibitor is administered daily for an indefinite period.

[0237] The intravenously delivered C5 inhibitor can be delivered by infusion over a time period (such as a 5 minute, 10 minute, 15 minute, 20 minute or 25 minute time period). The administration can be repeated, for example, regularly, such as hourly, daily, weekly, every 2 weeks (i.e., every 2 weeks), for 1 month, 2 months, 3 months, 4 months or more than 4 months. After the initial treatment regimen, the treatment can be administered at a lower frequency. For example, after administration every 2 weeks for 3 months, the administration can be repeated once a month for 6 months or 1 year or more. The administration of the C5 inhibitor can reduce, decrease, increase or change the binding or any physiologically harmful process (e.g., in the patient's cells, tissues, blood, urine or other compartments) by at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 40%, at least 50%, at least 60%, at least 70%, at least 80% or at least 90% or more.

[0238] Prior to administering a full dose of a C5 inhibitor and / or C5 inhibitor composition, a smaller dose, such as 5% of the full dose, may be administered to the patient and monitored for adverse effects, such as allergic or infusion reactions, or for elevated lipid levels or blood pressure. In another embodiment, the patient may be monitored for undesirable immunostimulatory effects, such as increased cytokine (e.g., TNF-α, 11-1, 11-6, or 11-10) levels.

[0239] Genetic predisposition plays a role in the development of some diseases or disorders. Therefore, by considering family history, or, for example, screening for one or more genetic markers or variants, patients in need of C5 inhibitors can be identified. A health care provider (such as a doctor, nurse, or family member) can analyze family history before prescribing or administering the therapeutic composition of the invention.

[0240] III. Kit

[0241] Any C5 inhibitor described herein can be provided as part of a kit. In one non-limiting example, a C5 inhibitor can be included in a kit for treating a disease. The kit can include a bottle of sterile dry C5 inhibitor powder, a sterile solution for dissolving the dry powder, and a syringe for an infusion device for administering the C5 inhibitor.

[0242] When the C5 inhibitor is provided as a dry powder, it is contemplated that between 10 micrograms and 1000 milligrams of the C5 inhibitor (or at least or at most those amounts) will be provided in the kits of the invention.

[0243] A typical kit may include at least one vial, test tube, flask, bottle, syringe and / or other container or device in which the C5 inhibitor formulation is placed and preferably, appropriately dispensed. The kit may also include one or more second containers containing a sterile, pharmaceutically acceptable buffer and / or other diluent.

[0244] In certain embodiments, the compounds or compositions of the invention are provided in borosilicate vials. Such vials may include a cap (e.g., a rubber stopper). In certain cases, the cap includes Coated rubber stopper. The cap may be secured in place with a top seal (including, but not limited to, an aluminum pull-off top seal).

[0245] The kit may further include instructions for employing the kit components and for the use of any other reagents not included in the kit. The instructions may include variations that may be implemented.

[0246] IV. Definitions

[0247] Bioavailability: The term "bioavailability" as used herein refers to the systemic availability of a given amount of a compound (e.g., a C5 inhibitor) administered to a subject. Bioavailability is determined by measuring the area under the curve (AUC) or maximum serum or plasma concentration (C60) of the unchanged form of the compound after administration of the compound to a subject. max ), bioavailability can be assessed. AUC is a measure of the area under the curve when the serum or plasma concentration of a compound is depicted along the ordinate (Y-axis) and time is depicted along the abscissa (X-axis). Typically, the AUC of a particular compound can be calculated using methods known to those of ordinary skill in the art and / or as described in GS Banker, Modern Pharmaceutics, Drugs and the Pharmaceutical Sciences, 72nd edition, Marcel Dekker, New York, Inc., 1996 (the contents of which are incorporated herein by reference in their entirety).

[0248] Biological system: The term "biological system" as used herein refers to a cell, a collection of cells, a tissue, an organ, a collection of organs, an organelle, a biological fluid, a biological signaling pathway (e.g., a receptor activated signaling pathway, a charge activated signaling pathway, a metabolic pathway, a cell signaling pathway, etc.), a collection of proteins, a collection of nucleic acids, or a collection of molecules (including, but not limited to, biomolecules) that implement at least one biological function or biological task within a cell membrane, a cell compartment, a cell, a cell culture, a tissue, an organ, an organ system, an organism, a multicellular organism, a biological fluid, or any biological entity. In certain embodiments, a biological system is a cell signaling pathway comprising intracellular and / or extracellular signaling biomolecules. In certain embodiments, a biological system includes a proteolytic cascade (e.g., a complement cascade).

[0249] Buffer: As used herein, the term "buffer" refers to a compound used in a solution for the purpose of resisting changes in pH. Such compounds may include, but are not limited to, acetic acid, adipic acid, sodium acetate, benzoic acid, citric acid, sodium benzoate, maleic acid, sodium phosphate, tartaric acid, lactic acid, potassium metaphosphate, glycine, sodium bicarbonate, potassium phosphate, sodium citrate, and sodium tartrate.

[0250] Elimination rate: As used herein, the term "elimination rate" refers to the speed at which a particular compound is cleared from a biological system or fluid.

[0251] Compound: The term "compound" as used herein refers to a unique chemical entity. In certain embodiments, a particular compound may exist in one or more isomeric or isotopic forms (including, but not limited to stereoisomers, geometric isomers and isotopes). In certain embodiments, a compound is provided or utilized in only a single such form. In certain embodiments, a compound is provided or utilized as a mixture of two or more such forms (including, but not limited to a racemic mixture of stereoisomers). It will be appreciated by those skilled in the art that some compounds exist in different forms, exhibiting different properties and / or activities (including, but not limited to biological activity). In such cases, it is within the ordinary skill of those skilled in the art to select or avoid a specific form of a compound used in accordance with the present invention. For example, a compound containing an asymmetrically substituted carbon atom can be separated in an optically active or racemic form.

[0252] Cyclic or cyclized: As used herein, the term "cyclic" refers to the presence of a continuous ring. Circular molecules need not be circular, merely linked to form a continuous chain of subunits. Cyclic polypeptides may include a "cyclic ring" that is formed when two amino acids are linked by a bridging moiety. The cyclic ring contains amino acids along the polypeptide that are present between the bridged amino acids. The cyclic ring may contain 2, 3, 4, 5, 6, 7, 8, 9, 10 or more amino acids.

[0253] Downstream event: As used herein, the term "downstream" or "downstream event" refers to any event that occurs after and / or as a result of another event. In some cases, a downstream event is an event that occurs after or as a result of C5 cleavage and / or complement activation. Such events may include, but are not limited to, the generation of C5 cleavage products, activation of MAC, hemolysis, and hemolysis-related diseases (e.g., PNH).

[0254] Equilibrium dissociation constant: The term "equilibrium dissociation constant" or "K D " represents a value representing the tendency of two or more agents (e.g., two proteins) to reversibly separate. In some cases, K D Indicates the concentration of the first agent at which half of the total level of the second agent is bound to the first agent.

[0255] Half-life: The term “half-life” or “t 1 / 2 "Terminally, the time required for a given process or compound concentration to reach half of its final value is called "terminal half-life". 1 / 2 ” represents the time required for the plasma concentration of a factor to decrease by half after the concentration of the factor has reached pseudo-equilibrium.

[0256] Hemolysis: The term "hemolysis" as used herein means the destruction of red blood cells.

[0257] Identity: When referring to polypeptides or nucleic acids, the term "identity" as used herein refers to the comparison relationship between sequences. The term is used to describe the degree of sequence relatedness between polymer sequences, and can include the percentage of matching monomer components with gapped alignments (if necessary) achieved by a specific mathematical model or computer program (i.e., "algorithm"). The identity of related polypeptides can be easily calculated by known methods. Such methods include, but are not limited to, those previously described by others (Lesk, AM, ed., Computational Molecular Biology, Oxford University Press, New York, 1988; Smith, DW, ed., Biocomputing: Informatics and Genome Projects, Academic Press, New York, 1993; Griffin, AM et al., eds., Computer Analysis of Sequence Data, Part 1, Humana Press, New Jersey, 1994; von Heinje, G., Sequence Analysis in Molecular Biology, Academic Press, 1987; Gribskov, M. et al., eds., Sequence Analysis Primer, M. Stockton Press, New York, 1991; and Carillo et al., Applied Math, SIAM J, 1988, 48, 1073).

[0258] Inhibitor: As used herein, the term "inhibitor" means any agent that blocks or causes a reduction in the occurrence of a specific event; cell signaling; a chemical pathway; an enzyme reaction; a cellular process; an interaction between two or more entities; a biological event; a disease; a disorder; or a condition.

[0259] Intravenous: As used herein, the term "intravenous" refers to the area within a blood vessel. Intravenous administration generally refers to the delivery of a compound into the bloodstream by injection into a blood vessel (eg, a vein).

[0260] In vitro: As used herein, the term "in vitro" refers to events that occur in an artificial environment (eg, in a test tube or reaction vessel, in cell culture, in a petri dish, etc.), rather than within an organism (eg, an animal, plant, or microorganism).

[0261] In vivo: As used herein, the term "in vivo" refers to events that occur within an organism (eg, an animal, plant, or microorganism, or a cell or tissue thereof).

[0262] Lactam bridge: As used herein, the term "lactam bridge" refers to an amide bond that forms a bridge between chemical groups of a molecule. In certain instances, a lactam bridge is formed between amino acids of a polypeptide.

[0263] Linker: As used herein, the term "linker" refers to a group of atoms (e.g., 10-1,000 atoms), molecules, or other compounds used to connect two or more entities. Linkers can connect such entities through covalent or non-covalent (e.g., ionic or hydrophobic) interactions. Linkers can include a chain of two or more polyethylene glycol (PEG) units. In some cases, linkers can be cleavable.

[0264] Minute volume: As used herein, the term "minute volume" means the volume of air that is inhaled or expelled from the lungs of a subject per minute.

[0265] Non-proteinogenic: As used herein, the term "non-proteinogenic" refers to any non-natural protein, such as those having non-natural components, such as non-natural amino acids.

[0266] Patient: As used herein, "patient" refers to a subject who may seek or need treatment, requires treatment, is receiving treatment, will receive treatment, or is under the care of a trained professional for a particular disease or condition.

[0267] Pharmaceutical composition: As used herein, the term "pharmaceutical composition" means a composition comprising at least one active ingredient (eg, a C5 inhibitor) in a form and amount allowing the active ingredient to be therapeutically effective.

[0268] Pharmaceutically acceptable: The phrase "pharmaceutically acceptable" is used herein to refer to compounds, substances, compositions, and / or dosage forms that are, within the scope of sound medical judgment, suitable for use in contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problems or complications, commensurate with a reasonable benefit / risk ratio.

[0269] Pharmaceutically acceptable excipients: The phrase "pharmaceutically acceptable excipients" used herein refers to any ingredient present in a pharmaceutical composition except an active agent (e.g., R5000 or a variant thereof), and it has substantially non-toxic and non-inflammatory properties in a patient. In certain embodiments, a pharmaceutically acceptable excipient is a vehicle capable of suspending or dissolving an active agent. Excipients may include, for example: anti-adherents, antioxidants, adhesives, coatings, compression aids, disintegrants, dyes (colorants), softeners, emulsifiers, fillers (diluents), film formers or coatings, flavoring agents, flavoring agents, glidants (flow promoters), lubricants, preservatives, printing inks, sorbents, suspending agents or dispersants, sweeteners, and hydration water. Exemplary excipients include, but are not limited to, butylated hydroxytoluene (BHT), calcium carbonate, calcium phosphate (dicalcium phosphate), calcium stearate, croscarmellose, cross-linked polyvinyl pyrrolidone, citric acid, crospovidone, cysteine, ethylcellulose, gelatin, hydroxypropyl cellulose, hydroxypropyl methylcellulose, lactose, magnesium stearate, maltitol, mannitol, methionine, methylcellulose, methylparaben, microcrystalline cellulose, polyethylene glycol, polyvinyl pyrrolidone, povidone, pregelatinized starch, propylparaben, retinyl palmitate, shellac, silicon dioxide, sodium carboxymethylcellulose, sodium citrate, sodium starch glycolate, sorbitol, starch (corn), stearic acid, sucrose, talc, titanium dioxide, vitamin A, vitamin E, vitamin C, and xylitol.

[0270] Plasma compartment: As used herein, the term "plasma compartment" refers to the intravascular space occupied by plasma.

[0271] Salt: As used herein, the term "salt" refers to a compound composed of a cation and a combined anion. Such compounds may include sodium chloride (NaCl) or other types of salts, including, but not limited to, acetates, chlorides, carbonates, cyanides, nitrites, nitrates, sulfates, and phosphates.

[0272] Sample: The term "sample" as used herein means an aliquot or part obtained from a source and / or provided for analysis or processing. In certain embodiments, the sample is from a biological source such as a tissue, cell or component (e.g., body fluid, including, but not limited to blood, mucus, lymph, synovial fluid, cerebrospinal fluid, saliva, amniotic fluid, amniotic cord blood, urine, vaginal fluid and semen). In certain embodiments, the sample can be or comprise a homogenate, lysate or extract prepared from a complete organism or a subset of its tissue, cell or component, or a fraction or part thereof, including, but not limited to, for example, plasma, serum, cerebrospinal fluid, lymph, skin, respiratory tract, intestinal and urogenital tract surface parts, tears, saliva, milk, blood cells, tumors or organs. In certain embodiments, the sample is or comprises a culture medium, such as a nutrient broth or gel, which may contain cell components, such as proteins. In certain embodiments, a "primary" sample is an aliquot of the source. In certain embodiments, the primary sample is subjected to one or more processing (eg, separation, purification, etc.) steps to prepare the sample for analysis or other use.

[0273] Subcutaneous: As used herein, the term "subcutaneous" refers to the space beneath the skin. Subcutaneous administration is the delivery of a compound beneath the skin.

[0274] Subject: The term "subject" as used herein refers to any organism to which a compound according to the invention can be administered, e.g., for experimental, diagnostic, preventive and / or therapeutic purposes. Typical subjects include animals (e.g., mammals such as mice, rats, rabbits, porcine subjects, non-human primates and humans).

[0275] Substantially: The term "substantially" as used herein refers to the qualitative condition of exhibiting a total or nearly total degree or degree of a target characteristic or property. One of ordinary skill in the biological field will understand that biological and chemical phenomena rarely, if ever, reach completion and / or advance to completeness or achieve or avoid an absolute result. The term "substantially" is therefore used herein to capture the potential lack of completeness inherent in many biological and chemical phenomena.

[0276] Therapeutically effective amount: As used herein, the term "therapeutically effective amount" refers to the amount of an agent (e.g., a C5 inhibitor) to be delivered, which, when administered to a subject suffering from or susceptible to a disease, disorder, and / or condition, is sufficient to treat, diagnose, prevent, ameliorate the symptoms of, and / or delay the onset of the disease, disorder, and / or condition.

[0277] Tidal volume: The term "tidal volume" as used herein refers to the normal lung volume of air displaced between breaths (in the absence of any additional effort).

[0278] T maxThe term “T” used in this article max " refers to the period of time during which the maximum concentration of a compound in a subject or fluid is maintained.

[0279] Treat: As used herein, the term "treat" means to partially or completely alleviate, ameliorate, improve, relieve, delay development, inhibit progression, lessen severity, and / or reduce the incidence of one or more symptoms or features of a particular disease, disorder, and / or condition. Treatment may be administered to subjects who do not exhibit signs of a disease, disorder, and / or condition, and / or to subjects who exhibit only early signs of a disease, disorder, and / or condition, for the purpose of reducing the risk of developing pathology associated with the disease, disorder, and / or condition.

[0280] Volume of distribution: The term “volume of distribution” or “V dist "Volume of distribution" refers to the volume of fluid required to contain the total amount of a compound in vivo at the same concentration as in blood or plasma. The volume of distribution can reflect the extent to which a compound is present in extravascular tissues. A large volume of distribution reflects the tendency of a compound to bind to tissue components compared to plasma protein components. In clinical situations, V can be used. dist The loading dose of the compound is determined to achieve a steady-state concentration of the compound.

[0281] V. Equivalent Programs and Scope

[0282] While various embodiments of the present invention have been particularly shown and described, it will be understood by those skilled in the art that various changes in form and details may be made therein without departing from the spirit and scope of the invention as defined by the following claims.

[0283] Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments of the invention described herein.The scope of the present invention is not intended to be limited to the above description, but rather is set forth in the appended claims.

[0284] In the claims, articles such as "a", "an", and "the" may refer to one or more than one, unless indicated to the contrary or otherwise apparent from the context. Claims or descriptions including "or" between one or more members of a group are deemed satisfied if one, more than one, or all of the members of the group are present in, used in, or otherwise associated with a specified product or process, unless indicated to the contrary or otherwise apparent from the context. The invention includes embodiments in which exactly one member of the group is present in, used in, or otherwise associated with a given product or method. The invention includes embodiments in which more than one or all of the members of the group are present in, used in, or otherwise associated with a given product or method.

[0285] It should also be noted that the term "comprising" is intended to be open ended and allows but does not require the inclusion of additional elements or steps. When the term "comprising" is used herein, the terms "consisting of" and "or including" are also included and disclosed.

[0286] In the case of giving a range, the endpoints are included. In addition, it should be understood that, unless otherwise indicated or otherwise obvious from the context and the understanding of a person of ordinary skill in the art, the numerical values ​​expressed in the range can present any specific numerical value or sub-range within the range in different embodiments of the present invention, which is accurate to one tenth of the lower limit unit of the range, unless the context clearly indicates otherwise.

[0287] In addition, it should be understood that any specific embodiment of the present invention that falls within the prior art can be explicitly excluded from any one or more claims. Because such embodiments are considered to be known to those of ordinary skill in the art, they can be excluded even if the exclusion is not explicitly stated herein. Any specific embodiment of the composition of the present invention (e.g., any nucleic acid or protein encoded thereby; any production method; any method of use; etc.) can be excluded from any one or more claims for any reason, whether or not related to the existence of the prior art.

[0288] All cited sources, e.g., references, publications, databases, database entries, and papers cited herein, are incorporated by reference into this application, even if not explicitly stated in the citation. In the event of a conflict between the description of a cited source and this application, the description in this application shall control.

[0289] The section and table headings are not intended to be limiting.

[0290] Example

[0291] Example 1. Preparation of R5000 aqueous solution

[0292] The peptides were synthesized using a standard solid phase Fmoc / tBu method. The synthesis was performed on a Liberty automated microwave peptide synthesizer (CEM, Matthews NC) using a standard protocol with Rink amide resin, although other automated synthesizers without microwave capabilities may also be used. All amino acids were obtained from commercial sources. The coupling agent used was 2-(6-chloro-1-H-benzotriazole-1-yl)-1,1,3,3,-tetramethylammonium hexafluorophosphate (HCTU), and the base was diisopropylethylamine (DIEA). The peptides were cut from the resin for 3 hours with 95% TFA, 2.5% TIS, and 2.5% water and separated by precipitation with ether. The crude peptides were purified on a reverse phase preparative HPLC using a C18 column with a gradient of 0.1% TFA in acetonitrile / water from 20% to 50% in 30 min. The fractions containing the pure peptides were collected and lyophilized, and all peptides were analyzed by LC-MS.

[0293] R5000 (SEQ ID NO: 1) was prepared as a cyclic peptide containing 15 amino acids (4 of which are unnatural amino acids), an acetylated N-terminal and C-terminal carboxylic acids. The C-terminal lysine of the core peptide has a modified side chain to form an N-ε-(PEG24-γ-glutamic acid-N-α-hexadecanoyl)lysine residue. The modified side chain includes a polyethylene glycol spacer (PEG24) connected to an L-γ glutamic acid residue that is derivatized with a palmitoyl group. The cyclization of R5000 is via a lactam bridge between the side chains of L-Lys1 and L-Asp6. All amino acids in R5000 are L-amino acids. R5000 has a molecular weight of 3562.23 g / mol and a C 172 H 278 N 24 O 55 The chemical formula of .

[0294] Like eculizumab, R5000 blocks the proteolytic cleavage of C5 into C5a and C5b. Unlike eculizumab, R5000 can also bind C5b and block C6 binding, which prevents the subsequent assembly of the MAC.

[0295] R5000 was prepared as an aqueous solution for injection containing 40 mg / mL R5000 in a formulation of 50 mM sodium phosphate and 75.7 mM sodium chloride at a pH of 7.0 ± 0.3.

[0296] Example 2. R5000 Administration and Storage

[0297] R5000 is administered by subcutaneous (SC) or intravenous (IV) injection, and the dose (dose volume) administered is adjusted based on the subject's weight (in mg / kg). This is achieved using a set of fixed doses (aligned with a set of weight brackets). In general, human doses support a wide weight range of 43-109 kg. Subjects with higher body weight (>109 kg) are adjusted on a case-by-case basis according to medical monitoring equipment.

[0298] Store R5000 at 2°C to 8°C [36° to 46°F]. Once distributed to subjects, store R5000 at controlled room temperature (20°C to 25°C [68°F to 77°F]) for up to 30 days and protect from sources of excessive temperature fluctuations, such as high heat or exposure to light. Storage of R5000 other than room temperature is preferably avoided. Under these conditions, R5000 can be stored for up to 30 days.

[0299] Example 3. Stability test

[0300] Stability testing was performed according to International Conference on Harmonisation (ICH) Q1A "Stability of New Drug Substances and Products". Samples of the aqueous solution from Example 1 were kept at 3 temperatures: -20°C, 5°C and 25°C. The testing intervals were 1, 2 and 3 months, and every 3 months thereafter until 24 months. Samples were tested for appearance (e.g., clarity, color, presence of precipitate), pH, osmotic pressure, concentration, purity, target activity (e.g., determined by RBC lysis), particulate levels, endotoxin levels and sterility. Samples were considered stable if, at each tested temperature condition, they had a clear, colorless appearance (and no visible particles), a pH of 7 ± 0.3, an osmotic pressure of 260-340 mOsm / kg, a purity of ≥ 95% (and no single impurity > 3%), target activity comparable to the reference standard, a particle level of ≤ 6,000 particles per bottle for particles ≥ 10 μm and ≤ 600 particles per bottle for particles ≥ 25 μm, an endotoxin level of ≤ 100 EU / mL, and no microbial growth.

[0301] Example 4. Freeze-thaw stability

[0302] A study was conducted to test the stability of the aqueous solution of Example 1 when exposed to multiple freeze-thaw cycles. After 5 freeze-thaw cycles, R5000 showed no degradation or other changes.

[0303] Example 5. Binding evaluation based on surface plasmon resonance (SPR)

[0304] The binding interaction between R5000 and C5 was measured using surface plasmon resonance. R5000 has an equilibrium dissociation constant (K) of 0.42 nM at 25 °C. D )(n=3) and a K of 0.78 nM at 37°C D (n=3) Binding to C5. When combined with analysis of the high resolution co-crystal structure, the overall surface plasmon resonance data indicated that R5000 exhibits specific, strong and rapid binding to C5 and a slow dissociation rate.

[0305] Example 6. Evaluation of C5 cleavage inhibition

[0306] R5000 was evaluated for inhibition of C5 cleavage into C5a and C5b. The inhibitory activity of R5000 on host C5 is an important factor in selecting an appropriate animal model for drug safety. Inhibition of C5 cleavage is the basis for the clinical efficacy of eculizumab, the only currently approved therapeutic agent for the treatment of PNH. R5000 demonstrated a dose-dependent inhibition of C5a formation (IC 50 =4.8nM; Figure 1 ) and dose-dependent inhibition of C5b (as measured by C5b-9 or MAC formation) following activation of the classical and alternative complement pathways (IC 50 =5.1nM; Figure 2 ).

[0307] Example 7. Inhibition of complement-induced red blood cell (RBC) hemolysis

[0308] The RBC lysis assay is a reliable method for screening the relative activity of complement inhibitors and comparative test materials in serum / plasma from different species. In order to evaluate the inhibitory activity of peptides (including R5000) for complement function in several species, an in vitro functional assay is used. This assay tests the functional ability of sheep RBCs pre-coated with rabbit anti-sheep RBC antibodies for the complement component lysis of the classical pathway. When the antibody-coated RBCs are incubated with the test serum, the classical complement pathway is activated, and hemolysis is generated and monitored by the release of hemoglobin. Sheep red blood cells sensitized with antibodies are used as the medium for lysis in this assay, and at their predetermined 50% hemolytic complement activity (CH 50 ) using serum and / or plasma from different species.

[0309] R5000 demonstrated potent inhibition of complement-induced RBC hemolysis in human, non-human primate and porcine serum and / or plasma (see table below).

[0310] Table 1. Inhibition of red blood cell hemolysis by R5000 in multiple species

[0311] Species <![CDATA[IC 50 (nM)]]> people 6.6 Non-human primates (4 species) 3.5-17.6 dog >4700 rabbit >67000 Pigs (2 species) 51.9-118.6 Rodents (3 species) 591 to >100,000

[0312] Weak activity was observed in rat plasma (>100-fold lower than in cynomolgus monkeys), and little to no activity was seen in other rodents, dogs, or rabbits. Structural data from co-crystals of human C5 and closely related molecules of R5000 provide an explanation for this species selectivity by careful analysis of the basic amino acid sequence at the drug binding site of the target protein. Although the primate sequence is 100% conserved within the residues responsible for R5000 interaction, there are significant differences in these residues in rodents and especially dogs (where the same portion of the protein is not present). These amino acid differences are sufficient to explain the spectrum of activity of R5000 in different species.

[0313] R5000 was also tested for its ability to inhibit complement-mediated lysis of erythrocytes via the classical and alternative complement activation pathways. The classical pathway was evaluated using two different assays utilizing antibody-sensitized sheep erythrocytes. In one method, hemolysis was evaluated using 1% normal human serum, while the second assay utilized 1.5% C5-depleted human serum containing 0.5 nM human C5. Inhibition of the alternative complement activation pathway was evaluated using rabbit erythrocytes in 6% normal human serum in the absence of calcium (see table below).

[0314] Table 2. Inhibition of hemolysis by R5000 in the complement activation pathway

[0315] way <![CDATA[IC 50 (nM)]]> Classical pathway 4.9 Classical pathway of serum depletion of C5 2.4 Bypass pathway 59.2

[0316] R5000 exhibited complement-mediated lysis in both the classical pathway assay and the alternative pathway assay.

[0317] Example 8. Pharmacodynamics in cynomolgus monkeys

[0318] R5000 is a potent inhibitor of complement in primates, so cynomolgus monkeys were selected for multiple dose studies to evaluate the inhibitory activity of R5000 in an animal model. Plasma drug concentrations were determined by LC-MS, and complement activity was determined using the RBC lysis assay described in the above examples. The overall results from these studies indicate that plasma drug levels in monkeys should be at or above 2.5 μg / mL to achieve >90% inhibition of complement activity (see Figure 3 ).

[0319] R5000 was administered to cynomolgus monkeys by subcutaneous injection (SC) at multiple daily doses in a 7-day study. Blood samples were analyzed for hemolysis (as an indicator of complement activity) at the indicated time points (for days 1, 4, and 7, data are reported as days after the first dose, but before dosing on each day). Drug levels were determined from the same samples using an LC-MS method specific for R5000. As shown in the following table and Figure 4A and Figure 4B As shown in , when R5000 was administered daily at 0.21 or 4.2 mg / kg for 7 days, minimal (< 3% of pre-dose) complement activity was seen throughout the dosing period.

[0320] Table 3. Mean pharmacodynamic values

[0321]

[0322] After the first dose in the 0.21 mg / kg group, during the dosing phase, and until 24 hours after the last dose, hemolysis in the ex vivo assay remained below 90% of baseline. Increasing levels of hemolysis were seen after discontinuation of treatment. Figure 4A This is consistent with the plasma levels measured for the compound during and after dosing ( Figure 4A The second group of animals in the multiple dose study was given a daily dose of 4.2 mg / kg of R5000. In this group, hemolysis was essentially completely inhibited during dosing (at <1%) and remained below 3% 48 hours after the last dose (Day 9; Figure 4B 216 hours in the study). 4 days after the final dose ( Figure 4B Hemolysis reached approximately 10% of baseline at 264 hours in the dosing phase (Figure 2A). This result again confirms the inhibition of complement activity during the dosing phase that correlates with plasma drug concentrations (relative to pre-dose results) and confirms the excellent correlation between pharmacokinetic and pharmacodynamic values.

[0323] The complement inhibition activity of R5000 was evaluated in a 28-day repeat dose study in cynomolgus monkeys using an ex vivo RBC hemolysis assay. R5000 was administered subcutaneously daily at 0, 1, 2 or 4 mg / kg / day for 28 days (Day 1: Figure 7 , and day 28: Figure 8 ). The results demonstrated complete inhibition of hemolysis from 2 hours after the first dose to 28 days of dosing, with hemolysis percentages <5% in the 1, 2, and 4 mg / kg / day groups compared to >90% in the control group. After the 28-day recovery period, sample values ​​returned to near baseline hemolysis levels, and minimal to no inhibition of the complement system was observed. The absence of complement inhibitory activity at the end of the recovery period indicated clearance of the drug from the animals.

[0324] Complement inhibition was also tested as part of a 13-week repeat dose study in cynomolgus monkeys. Monkey samples were analyzed using an in vitro RBC hemolysis assay. R5000 was administered by subcutaneous injection every day for 13 weeks at 0, 0.25, 1, 2 or 10 mg / kg / day dosage. Similar to a 28-day study, the results from a 13-week study confirmed that the in vitro hemolysis of 13 weeks of administration from 2 hours after the first dose was used was completely inhibited, with a hemolysis percentage <5% in 0.25, 1, 2 and 10 mg / kg / day groups, compared to >90% in a control group. After the 28-day recovery period, sample values ​​returned to near baseline hemolysis levels, and the complement system was observed to be minimal to no inhibition. The absence of complement inhibition activity at the end of the recovery period indicated the removal of the drug from the animal.

[0325] Example 9. Safety Pharmacology

[0326] When R5000 was administered to cynomolgus monkeys, no adverse effects on cardiovascular, respiratory or central nervous system parameters were observed. Safety pharmacology parameters were evaluated in vitro using the human ether anesthesia chorea-related gene (hERG) assay and in vivo using monkeys (for cardiovascular, respiratory and CNS parameters). CNS safety pharmacology assessments were performed as part of a 28-day non-human primate toxicology study. A summary of the safety pharmacology studies using R5000 is presented in the table below.

[0327] Table 4. Results from safety pharmacology studies

[0328]

[0329] The effect of R5000 on cloned hERG potassium channel current (I Kr The highest concentration tested (300 μM) did not result in greater than 50% inhibition of hERG, and thus the IC of R5000 was estimated. 50 Greater than 300 μM (1.07 mg / mL).

[0330] In vivo cardiovascular and respiratory safety pharmacology studies were carried out in conscious male cynomolgus monkeys. There was no death or major clinical events after the administration of R5000. At any R5000 dose (at the 1st and 8th day, 2 or 10 mg / kg), the effects of R5000 on morphology and the entire heartbeat interval were not seen. Only normal circadian rhythm changes (comparable to the readings of vehicle treatment) were observed in electrocardiograms and body temperature. In addition, at doses up to 10 mg / kg and at plasma drug levels up to 79.1 μg / mL, there was no change in heart rate and arterial blood pressure attributable to R5000.

[0331] There were no changes in any respiratory parameters (respiratory rate, tidal volume and minute volume) following treatment with 2 or 10 mg / kg of R5000 relative to values ​​obtained before dosing or after vehicle administration.

[0332] R5000 was administered to cynomolgus monkeys by subcutaneous injection every day at 1, 2 or 4 mg / kg / day, and its effect on the central nervous system (CNS) was studied. The parameters evaluated included overall attitude, behavior, motor function, cranial nerves, proprioception, postural response and spinal nerves. After treatment with R5000, no neurological changes were observed.

[0333] In summary, at dose levels up to 10 mg / kg (which resulted in a C max ) were well tolerated and did not result in any adverse effects on the cardiovascular (no increased risk of QT prolongation (a measure of delayed ventricular repolarization)), respiratory, or central nervous system in conscious cynomolgus monkeys.

[0334] Example 10. Pharmacokinetics and drug metabolism in animals

[0335] The in vitro and in vivo studies evaluating the absorption, distribution, metabolism and excretion of R5000 are listed in the table below. In the table below, CYP means cytochrome P450 enzyme and UGT means UDP-glucuronosyltransferase.

[0336] Table 5. Nonclinical drug metabolism and pharmacokinetic (DMPK) studies of R5000

[0337]

[0338] Although R5000 is highly stable in rat, monkey, and human plasma in vitro, its pharmacokinetic properties in monkeys after intravenous (IV) and subcutaneous administration differ from those in rats ( Figure 5AThe slow elimination kinetics seen in monkeys are primarily driven by high affinity interactions with the target protein C5 and other plasma proteins (e.g., albumin). The lack of specific target binding in rats results in a faster elimination of R5000, which is reflected in a terminal t of 4-5 hours. 1 / 2 In monkeys, this compares to >3 days.

[0339] In summary, preclinical data demonstrated high bioavailability (>75%) of R5000 after subcutaneous administration. In monkeys, maximum blood concentrations (t max ), indicating a relatively slow absorption from the subcutaneous space. The aggregate data in whole blood (including volume of distribution, high plasma protein binding, and partitioning into the plasma compartment) indicate that R5000 is primarily confined to the plasma space with minimal distribution into tissues.

[0340] absorb

[0341] Pharmacokinetic (PK) studies were performed in rats (single dose) and cynomolgus monkeys (single and multiple doses) using R5000 in phosphate buffered saline formulation (pH 7.0).

[0342] For rat studies, a single dose of R5000 was injected subcutaneously at 1 mg / kg or 10 mg / kg into male Sprague Dawley rats (n=3). The pharmacokinetic (PK) parameters measured included C max (maximum plasma drug concentration), T max (the time required to reach maximum plasma concentration after drug administration), t 1 / 2 (half-life), AUC 0-最后 (area under the plasma concentration-time curve between the first and last dose) and AUC 0-∞ (Area under the plasma concentration-time curve from time zero to infinity). The results are summarized in the table below.

[0343] Table 6. Pharmacokinetic parameters

[0344]

[0345] The mean AUC at 1 mg / kg and 10 mg / kg 0-最后 The values ​​all suggest dose-proportional exposure.

[0346] For primate studies, pharmacokinetic analysis was performed in cynomolgus monkeys following a single intravenous or subcutaneous dose of 0.4 or 0.5 mg / kg. Pharmacokinetic (PK) parameters measured included clearance (CL), V z (Volume of distribution), V ss(apparent volume of distribution at steady state), C max (maximum plasma drug concentration), T max (the time required to reach maximum plasma concentration after drug administration), t 1 / 2 (half-life), AUC 0-最后 (area under the plasma concentration-time curve between the first and last dose), AUC 0-∞ (area under the plasma concentration-time curve from time zero to infinity) and %F (fraction). The results are presented in the table below; NA indicates not applicable.

[0347] Table 7. Pharmacokinetic parameters in cynomolgus monkeys

[0348]

[0349] A single subcutaneous dose of 0.4 mg / kg resulted in plasma exposures (AUC 2.0, 2.0, and 3.1 ng*h / mL) of R5000 after intravenous and subcutaneous doses, respectively. 最后 The maximum plasma concentration (C max ) were 4,745.5 and 2,490 ng / mL, and T max is 8 hours. The subcutaneous bioavailability at 0.4 mg / kg was determined to be 75.7%. For both intravenous and subcutaneous doses, the mean t 1 / 2 182.5 and 177.5 hours respectively. z The mean distribution volume associated with the release (CL) and clearance (CL) was determined to be 175.5 mL / kg and 0.011 mL / min / kg, respectively. This behavior is different from that of rats, where no appreciable binding was expected based on in vitro activity studies, and thus the t of R5000 was 1 / 2 4-5 hours (see Figure 5A ).

[0350] Repeated dose pharmacokinetic studies in monkeys included 2 subcutaneous dose levels of 0.21 and 4.2 mg / kg administered daily for 7 days, with PK assessed daily for 14 days after the last dose. max Increases with subsequent doses until steady-state peak and trough drug levels are reached (after 2-3 doses; see Figure 4A , Figure 4B and Figure 5B Plasma concentrations in the 0.2 and 4 mg / kg dose groups reached mean C values ​​after the first dose of 2,615 and 51,700 ng / mL, respectively. max Due to the long half-life of the molecule, Cmax Increased with each successive dose. At the fourth dose, the mean C max They were 5,305 and 68,750 ng / mL, respectively, or 2.0 and 1.3 times the first dose.

[0351] In summary, absorption can be characterized as slow from the subcutaneous space, with a subcutaneous dose having a high bioavailability.

[0352] distributed

[0353] In vitro plasma protein binding in human, rat, and monkey plasma is >99.9% as determined by equilibrium dialysis at drug concentrations of 10 and 100 μM. The high protein binding and limited volume of distribution indicate that R5000 may be primarily confined to the plasma compartment and does not distribute readily into the perivascular space.

[0354] Blood distribution

[0355] The partition ratio of the drug between plasma and red blood cells was calculated as it is a key parameter required to evaluate the pharmacokinetic properties of the drug (see table below). In the table below, RBC indicates red blood cells, P indicates plasma, and WB indicates whole blood.

[0356] Table 8. Blood distribution of R5000

[0357]

[0358] In the whole blood partitioning assay, R5000 was found to be primarily present in the plasma fraction and did not show significant distribution into the erythrocyte fraction.

[0359] Pharmacokinetic drug interactions

[0360] A commonly administered drug in patients with paroxysmal nocturnal hemoglobinuria (PNH) is cyclosporine (CsA). The potential for drug-drug interactions between R5000 and CsA was evaluated in cynomolgus monkeys, as R5000 will likely be co-administered with CsA in PNH patients enrolled in planned clinical trials.

[0361] R5000 (2 mg / kg, subcutaneous, single dose) and cyclosporine A (CsA) (15 mg / kg, subcutaneous, single dose) were administered separately or together in two male monkeys, and plasma levels were evaluated using LC-MS / MS methods. No significant changes in plasma exposure of either drug were observed, indicating a low potential for drug-drug interactions (see the table below). In the table below, CsA maxIndicates the maximum plasma drug concentration, and AUC indicates the area under the plasma concentration-time curve, and "a" of the adjacent exposure difference indicates the exposure ratio of R5000+cyclosporine / R5000. "b" of the adjacent exposure difference indicates the exposure ratio of cyclosporine+R5000 / cyclosporine.

[0362] Table 9. Effects of co-administration

[0363]

[0364] No changes were observed in serum chemistry parameters including bilirubin (an endogenous substrate for OATP1 and OATP1B3), indicating that there was no additive effect of CsA and R5000 on these transporters. In summary, co-administration of CsA with R5000 had a low drug-drug interaction potential and was well tolerated, with no effect on serum chemistry parameters at plasma levels close to or above values ​​expected in clinical use.

[0365] Example 11. Pharmacokinetic / pharmacodynamic modeling and human pharmacokinetic simulations

[0366] A PK / PD model was constructed in silico using in vivo data obtained in cynomolgus monkeys. Model fit and accuracy were estimated by comparing the results of the simulations with newly generated experimental data. Once validated in monkeys, the final model was used to predict human pharmacokinetics by applying allometric scaling to its parameters. The resulting simulations supported a planned dosing interval of once daily or less frequent in humans, with a daily dose of 0.1 mg / kg maintaining close to 90% target inhibition at steady state (see Figure 6 ). Because of the long half-life of R5000, several doses are required to reach the final peak and trough drug levels. As drug levels reach steady state, plasma C is expected to increase after 1 week of daily dosing. max It is about 3 times the first dose.

[0367] Example 12. Effects in humans: Phase I clinical trial study design.

[0368] A randomized, placebo-controlled, double-blind, single ascending dose and multiple dose study was conducted to evaluate the safety and pharmacokinetics of R5000 in healthy volunteers aged 18-65 years (excluding children and elderly individuals). In the first part of the study, a single ascending dose (SAD) of R5000 or placebo was administered to a separate subject group. In the second part of the study, 0.2 mg / kg of R5000 (n=4) or placebo (n=2) was administered to multiple dose groups (MD) every day for 7 days. All R5000 doses were administered by subcutaneous injection, and the dose volume depended on the dose requirements of the group and the weight of the subject. Subjects who were pregnant or breast-feeding and any subject with systemic infection or colonization of Neisseria meningitidis were excluded. In addition, all subjects received ciprofloxacin prophylaxis, and the subjects in the highest single dose group (i.e., 0.4 mg / kg) and the subjects in the multiple dose group were vaccinated against Neisseria meningitidis at least 14 days before the study.

[0369] A total of 22 subjects were enrolled in the single dose cohort study (n=14), of which 2 received 0.05 mg / kg of R5000 and 4 each at 0.10, 0.20 and 0.40 mg / kg. These doses were selected using the estimated safety margin in humans (see the above examples and the table below). In the table below, C max Indicates the maximum plasma drug concentration and AUC 0-最后 The area under the plasma concentration-time curve between the first and last doses is indicated.

[0370] Table 10. Comparison of plasma exposures in animals following multiple doses at the NOAEL and the highest recommended single clinical dose of 0.8 mg / kg

[0371]

[0372] The initial dose of 0.05 mg / kg is well below 1 / 10 of the estimated human equivalent dose (HED). This dose is considered appropriate because no significant complement inhibition is expected at this dose. The final (day 28) exposure at the NOAEL in monkeys exceeds the systemic exposure of the highest recommended single subcutaneous dose (0.8 mg / kg) predicted in follow-up studies.

[0373] In the multiple dose cohort, 6 subjects were enrolled, 4 of whom received R5000 (0.2 mg / kg) and 2 received placebo.

[0374] Example 13. Treatment of Patients with PNH

[0375] Patients suffering from PNH were treated with R5000 at effective doses ranging from 0.1 mg / kg / day to 40 mg / kg / day. Complement inhibition greater than or equal to 90% was observed in these patients, and C max .

[0376] Example 14. Multiple-dose clinical study of R5000

[0377] A Phase 1 multiple dose clinical pharmacology study in healthy human volunteers was conducted, which was designed to evaluate the safety, tolerability, pharmacokinetics and pharmacodynamics of R5000 after subcutaneous (SC) injection once a day for 7 days. The study was single-center, randomized, double-blind and placebo (PBO) controlled. Subjects received 0.2 mg / kg of R5000 or daily subcutaneous doses of matching PBO for 7 days while remaining in the clinical pharmacology unit. Safety was assessed by centralized clinical monitoring, and daily blood samples were obtained immediately before dosing, and 3 hours and 6 hours after daily doses for determination of R5000 concentration by liquid chromatography / high resolution mass spectrometry and the ability to inhibit complement-mediated RBC lysis in an ex vivo antibody-sensitized sheep erythrocyte hemolysis assay.

[0378] A total of 6 subjects were enrolled in the study (4 receiving R5000 and 2 receiving PBO). Subject demographics are presented in the table below.

[0379] Table 11. Subject Demographics

[0380]

[0381] As shown in the following table and related Fig. 9A As seen in the (showing the percentage of hemolysis and plasma concentrations over 7 days), plasma concentrations showed a steady increase in exposure over the 7 days of dosing. From these data, the half-life of R5000 was determined to be 7 days. Plasma levels recovered to about 2000 ng / ml by day 15 and to about 1000 ng / ml on day 21 ( Fig. 9B ).

[0382] Table 12. Plasma concentrations of R5000

[0383]

[0384]

[0385] The PK parameters of R5000 after multiple dose subcutaneous administration (0.2 mg / kg / day) over 7 days are presented in the table below. The pharmacokinetic (PK) parameters measured included clearance (CL), C max(maximum plasma drug concentration), T max (the time required to reach maximum plasma concentration after drug administration), t 1 / 2 (half-life), AUC tau (area under the plasma concentration-time curve from time zero to 24 hours), AUC 0-inf (the area under the plasma concentration-time curve from time zero to infinity), V z / F (apparent distribution volume), K el (clearance rate) and F (fraction).

[0386] Table 13. Summary of PK parameters

[0387]

[0388] Average C on day 1 max and AUC tau The results of the 0.2 mg / kg single dose group in the same post-dose period were consistent with those of the 2533 ng / mL and 50,010 ng*h / mL, respectively. max and AUC tau increased by approximately 2.9 times (average C max =7290 ng / mL) and 3.0 times (mean AUC on day 7 tau =151,300 ng*h / mL). The maximum plasma concentration (T max ) was 3.0 hours, which is similar to the T max Consistent (median day 1 T max =3.0-4.6 hours). This indicates a consistent rate of absorption of R5000 under repeated dosing. The mean 7-day apparent systemic clearance of R5000 (7-day CL / F = 1.3 mL / h / kg) was slightly increased relative to the systemic clearance after a single subcutaneous dose of 0.2 mg / kg [single ascending dose (SAD) 0.2 mg / kg CL / F = 0.29 mL / h / kg]. However, the clearance rate constant (K el ) were consistent after single and repeated dosing (mean K el =0.0041h -1 ; 0.2mg / kg MD average K on day 7 el =0.0043h -1 ), indicating that the clearance of R5000 did not change significantly with repeated administration. For multiple doses of R5000, the apparent distribution volume (V z / F) showed some increase (0.2mg / kg SAD mean V z / F=71.4mL / kg;0.2mg / kg MD average V on the 7th day z / F=311.6mL / kg). However, R5000 V z / F is still less than total body water, suggesting that R5000 does not partition into the extravascular space after repeated subcutaneous administration.

[0389] Table 14. Hemolysis analysis

[0390]

[0391] The mean inhibition percentage of hemolysis relative to baseline reached ≥95% from the first time point after dosing (3 hours after dosing on Day 1) and continued during the 7-day dosing (see table below). All individual subjects showed ≥90% reduction in hemolysis at all time points. Hemolysis of ≤3% was observed on Day 8 (24 hours after receiving the last dose) in all subjects. Hemolysis returned to pre-dose levels within 2 weeks after the last dose.

[0392] Studies suggest that low daily doses will achieve steady-state levels suitable for complete and sustained inhibition of complement and suppression of hemolysis. Studies also suggest that once-weekly dosing may be sufficient to inhibit complement activity and reduce hemolysis in humans.

[0393] pass ELISA (Euro Diagnostica, Malmo, Sweden) analysis was used to determine complement activity in subject plasma samples. This assay measures the alternative pathway of complement activation. Inhibition of complement activity, as measured by this assay, was rapid, complete, and sustained in all subjects during the dosing period (see Fig. 10A In the following tables, SEM indicates standard error of the mean.

[0394] Table 15. % Complement Activity in Multiple Dose Studies

[0395]

[0396] Complement activity ≤5% was observed on Day 8 (24 hours after the last dose) in all subjects. Complement activity returned to pre-dose levels within 2 weeks after the last dose ( Fig. 10B ).

[0397] R5000 was safe and well tolerated in healthy volunteers, with no pain, induration, tenderness or swelling, except for some injection site erythema (ISE) in 3 of 6 subjects. All resolved spontaneously. No clinically significant changes in vital signs, clinical laboratory parameters (hematology, blood chemistry, coagulation and urinalysis), physical examination and ECG were observed.

[0398] R5000 was measured in the 0.20 mg / kg dose group in the multiple dose arm of the study (see table below). In the table below, C max represents the maximum plasma drug concentration, and AUC 0-24 It represents the area under the plasma concentration-time curve from time zero to 24 hours.

[0399] Table 16. Average exposure of R5000

[0400]

[0401]

[0402] Example 15. Phase 1 single ascending dose clinical study of R5000

[0403] A phase 1 single ascending dose clinical pharmacology study in healthy volunteers was conducted, which was designed to evaluate the safety, tolerability, pharmacokinetics and pharmacodynamics of R5000 after subcutaneous (SC) injection. The study was randomized, double-blind and placebo (PBO) controlled, with 4 subcutaneous single ascending dose groups, staying in the clinical pharmacology unit for 3 days. All subjects received 1 dose of R5000 on the 1st day. The lowest dose level (0.05 mg / kg) was applied to 4 subjects (2 received R5000 and 2 received PBO), and 3 higher dose levels (0.1, 0.2 and 0.4 mg / kg) were applied to 6 subjects in each group (4 received R5000 and 2 received PBO) successively. Subject demographic information is provided in the table below.

[0404] Table 17. Subject Demographics

[0405]

[0406] Safety was assessed by centralized clinical monitoring, and frequent blood samples were obtained for determination of R5000 concentration by liquid chromatography / high-resolution mass spectrometry and the ability to inhibit complement-mediated RBC lysis in an ex vivo antibody-sensitized sheep erythrocyte hemolysis assay.

[0407] The pharmacokinetic (PK) parameters measured in this study included clearance (CL), C max (maximum plasma drug concentration, Fig.11A), T max (the time required to reach maximum plasma concentration after drug administration), t 1 / 2 (half-life), AUC 0-24 (The area under the plasma concentration-time curve from time zero to 24 hours; for changes in plasma concentration over time, see Fig. 11B ), AUC 0-inf (The area under the plasma concentration-time curve from time zero to infinity; for changes in plasma concentration over time, see Fig. 11B ), V z (apparent volume of distribution in the terminal phase), K (clearance rate) and F (fraction). The results for each parameter are presented in the table below.

[0408] Table 18. Pharmacokinetic parameters

[0409]

[0410]

[0411] All cohorts achieved C values ​​consistent with those predicted from an in silico PK model generated using data from nonhuman primate (NHP) studies. max Levels. Plasma concentrations following a single subcutaneous injection indicated that C max The linear relationship between the dose level ( Fig.11A ) and demonstrated dose-dependent exposure at all dose levels ( Fig. 11B The mean maximum plasma concentration (C max ) ranged from 1010 to 5873 ng / mL between doses. The mean area under the concentration-time curve (AUC 0-24 ) ranged from 21,440 to 112,300 ng*h / mL between doses. These results indicate that there is a plasma concentration (C max ) and exposure (AUC 0-24 The median time to maximum observed plasma concentration (t max ) ranged from 3.0 to 4.6 hours between doses, indicating that R5000 exhibits an intermediate absorption rate from the subcutaneous space to the central (blood) compartment. The mean apparent systemic clearance (CL / F) following R5000 administration was low and ranged from 0.2481 to 0.4711 mL / h / kg. The mean half-life (t 1 / 2 ) was consistent across dose levels and ranged from 155.6 to 185.4 hours. The mean apparent total volume of distribution (V z / F) ranged from 61.89 to 105.1 mL / kg, indicating that R5000 was mainly confined to the circulating blood compartment with minor extravascular distribution. Approximate t 1 / 2 It was determined to be 7 days.

[0412] R5000 also showed rapid dose-dependent inhibition of hemolysis [direct hemolysis ( Fig. 12A ) and %CH 50 ( Fig. 12B ) and time-dependent red blood cell lysis in 1% plasma ( Fig. 12C )] and inhibition of complement activity (e.g., by Determined by ELISA, see Fig.13 ). The maximum pharmacodynamic effect was observed approximately 3 hours after dosing. The results demonstrated that at maximum plasma concentration, the maximum hemolysis inhibition percentage relative to baseline reached >90% for the 0.1, 0.2, and 0.4 mg / kg dose groups, and reached 60% for the lowest dose (0.05 mg / kg) group. For the 0.1, 0.2, and 0.4 mg / kg dose groups, dose-dependent hemolysis inhibition was observed up to 4 days. It is noteworthy that mean hemolysis remained above baseline in the 0.05 mg / kg group until 2 days, and remained above baseline in the 0.1 mg / kg group until 4 days, and remained above baseline in the 0.2 and 0.4 mg / kg groups until 7 days.

[0413] Similarly, analysis of complement activity demonstrated that inhibition of complement activity remained robust over the 4-day course following 0.4 mg / kg injection (see Fig.13 ). Human plasma samples from subjects who received 0.4 mg / kg injections were analyzed. ELISA (Euro Diagnostica, Malmo, Sweden) analysis. This assay measures the alternative pathway of complement activity. As measured by this assay, complement activity was inhibited to 3% 3 hours after dosing and remained below 13% 96 hours after receiving R5000.

[0414] A single subcutaneous dose of R5000 is safe and well tolerated in healthy volunteers. ISE was observed in 3 subjects at the highest dose and was mild (grade 1), without pain, induration, tenderness or swelling, and resolved spontaneously within 2-5 hours after injection. No clinically significant changes were observed in vital signs, clinical laboratory parameters, physical examinations and ECG.

[0415] This study suggests that low daily doses can achieve steady-state levels suitable for >80% inhibition of hemolysis, and once-weekly dosing may be sufficient. Specifically, 0.2 mg / kg can result in complete inhibition of complement activity and complete inhibition of hemolysis.

Claims

1. An aqueous pharmaceutical composition comprising: a) a C5 inhibitor polypeptide whose sequence is shown in SEQ ID NO: 1; b) salt; and c) Buffer.

2. The aqueous pharmaceutical composition of claim 1, wherein the salt is sodium chloride.

3. The aqueous pharmaceutical composition of claim 1, wherein the buffer is sodium phosphate.

4. The aqueous pharmaceutical composition of claim 2, wherein the buffer is sodium phosphate.

5. The aqueous pharmaceutical composition of claim 1, wherein the aqueous pharmaceutical composition comprises sodium chloride at a concentration of 25 mM to 100 mM.

6. The aqueous pharmaceutical composition of claim 1, wherein the aqueous pharmaceutical composition comprises sodium phosphate at a concentration of 10 mM to 100 mM.

7. The aqueous pharmaceutical composition of claim 4, wherein the aqueous pharmaceutical composition comprises sodium phosphate at a concentration of 10 mM to 100 mM.

8. The aqueous pharmaceutical composition according to claim 1: a) it has a pH of 6.5 to 7.5; b) wherein the polypeptide is present at a concentration of 1 mg / mL to 400 mg / mL; c) wherein the polypeptide has an equilibrium dissociation constant (K) of 0.1 nM to 1 nM D ) combined with C5; d) wherein the polypeptide blocks the generation of C5a following activation of the alternative pathway of complement activation; or e) wherein the polypeptide blocks the formation of a membrane attack complex (MAC) following activation of the classical pathway, the alternative pathway or the lectin pathway of complement activation.

9. The aqueous pharmaceutical composition according to claim 7: a) it has a pH of 6.5 to 7.5; b) wherein the polypeptide is present at a concentration of 1 mg / mL to 400 mg / mL; c) wherein the polypeptide has an equilibrium dissociation constant (K) of 0.1 nM to 1 nM D ) combined with C5; d) wherein the polypeptide blocks the generation of C5a following activation of the alternative pathway of complement activation; or e) wherein the polypeptide blocks the formation of a membrane attack complex (MAC) following activation of the classical pathway, the alternative pathway or the lectin pathway of complement activation.

10. The aqueous pharmaceutical composition of claim 8 or 9, wherein the polypeptide is present at a concentration of 40 mg / mL.

11. The aqueous pharmaceutical composition of claim 1, wherein the aqueous pharmaceutical composition comprises a C5 inhibitor polypeptide at a concentration of 40 mg / mL, 75.7 mM sodium chloride and 50 mM sodium phosphate, and the pH of the aqueous pharmaceutical composition is 6.7-7.

3.

12. The aqueous pharmaceutical composition of claim 11, wherein the aqueous pharmaceutical composition is formulated for subcutaneous (SC) or intravenous (IV) administration.

13. The aqueous pharmaceutical composition of claim 12, wherein the aqueous pharmaceutical composition is co-administered with one or more antibiotics to minimize the risk of infection by Neisseria meningitidis.

14. The aqueous pharmaceutical composition of claim 11, wherein the aqueous pharmaceutical composition is administered in combination with eculizumab.

15. An automatic injector device comprising the aqueous pharmaceutical composition according to any one of claims 1-14.

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