Dosing regimen for reducing cytokine release syndrome

Abstract

A regimen of administration of an anti-CD3 * anti-CD20 bispecific antibody that mitigates cytokine release syndrome and infusion-related reactions is disclosed. The methods employ fractional administration in treatment for several weeks, with simultaneous administration of steroids and antihistamines.

Description

[0001] Reference to sequence listing

[0002] This application incorporates by reference a computer-readable sequence listing in ST.26 XML format, named 11150WO01_Sequence, created on February 17, 2023, and containing 26,237 bytes. Technical Field

[0003] The present invention belongs to the field of medicine and relates to a dosing regimen of a bispecific anti-CD3×anti-CD20 antibody that reduces the incidence and severity of cytokine release syndrome or infusion-related reactions in patients receiving immunotherapy. Background Art

[0004] Cytokine release syndrome (CRS) is a systemic inflammatory response that can be triggered by a variety of factors, including certain drugs. T cell-activated cancer immunotherapy is particularly at risk for CRS, which is usually due to the binding of bispecific antibodies or chimeric antigen receptor (CAR) T cells to their antigens, followed by the activation of bystander immune cells and non-immune cells (such as endothelial cells), thereby inducing on-target effects. Activation of bystander cells leads to the massive release of a series of cytokines. IL-6, IL-10, and interferon (IFN)-γ are core cytokines that are consistently elevated in the serum of patients with CRS. For T cell-activated therapies directed against tumor cells, activated T cells or tumor cells themselves release large amounts of IFN-γ, which triggers CRS. Secreted IFN-γ induces the activation of other immune cells, most importantly macrophages, which in turn produce excessive amounts of other cytokines, such as IL-6, TNF-α, and IL-10. IL-6 in particular leads to many of the main symptoms of CRS, including vascular leakage, complement activation, and the coagulation cascade that induces disseminated intravascular coagulation. In addition, IL-6 may contribute to cardiomyopathy by promoting myocardial dysfunction. Shimabukaro-Vornhagen et al., Journal for Immunotherapy of Cancer, 6:56, pp. 1-14, 2018. In some cases, if symptoms related to CRS occur less than six hours after the start of the infusion, it is called an infusion-related reaction (IRR), and if they occur more than six hours after the start of the infusion, it is called CRS.

[0005] Management of toxicities with cancer immunotherapy is a challenging clinical problem. Relief of CRS or IRR is a hallmark of administration of certain therapeutic modalities, such as CAR T cells and bispecific antibodies targeting T cells. Low-grade CRS is typically treated symptomatically with antihistamines, antipyretics, and fluid infusions. Severe CRS may represent a life-threatening adverse event and requires prompt and aggressive treatment. Reduction of tumor burden, limitation of the dose of administered therapy, premedication with steroids, and the use of anti-cytokine therapy have all reduced the incidence of severe CRS. Tocilizumab, an anti-IL-6 antibody, has become the standard initial treatment for severe CRS in some cases. Alternative strategies are still needed to mitigate the potentially life-threatening effects of CRS without negatively impacting the therapeutic benefits of immunotherapy. Summary of the invention

[0006] In one aspect, the present disclosure provides a dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject to treat a B-cell malignancy, the dosing regimen comprising: (a) administering an initial dose of 0.7 mg of the bispecific antibody to the subject, wherein the initial dose is divided into a first dose portion comprising 0.2 mg of the bispecific antibody and a second dose portion comprising 0.5 mg of the bispecific antibody, wherein the first dose portion is administered to the subject within two days during week 1 of the dosing regimen, followed by administration of the second dose portion; (b) administering a first intermediate dose of 4 mg of the bispecific antibody to the subject, wherein the first intermediate dose is divided into two equal portions (a first portion and a second portion), each portion comprising 2 mg of the bispecific antibody, wherein during the dosing regimen (c) administering to the subject a second intermediate dose of 20 mg of the bispecific antibody, wherein the second intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 10 mg of the bispecific antibody, wherein the two parts of the second intermediate dose are administered on two days during the third week of the dosing regimen; (d) during weeks 4 to 12 of the dosing regimen, administering to the subject a full dose of the bispecific antibody weekly; and (e) administering to the subject a maintenance dose of the bispecific antibody in week 14 of the dosing regimen, wherein the bispecific antibody comprises a first antigen binding region that binds to human CD20 and a second antigen binding region that binds to human CD3, wherein the first antigen binding region comprises a first antigen binding region comprising SEQ ID NO: 7, 8 and 9, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 containing the amino acid sequences of SEQ ID NO: 13, 14 and 15, respectively, and wherein the second antigen binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 containing the amino acid sequences of SEQ ID NO: 10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 containing the amino acid sequences of SEQ ID NO: 13, 14 and 15, respectively. In some embodiments, the initial dose (0.7 mg) can be divided into other parts, such as 0.1 mg and 0.6 mg, 0.15 mg and 0.55 mg, 0.25 mg and 0.45 mg, or 0.3 mg and 0.4 mg.

[0007] In some embodiments, the full dose is administered to the subject as a single dose during weeks 4 to 12 of the dosing regimen.

[0008] In some embodiments, if the subject experiences a Grade 3 event of cytokine release syndrome when administered the initial dose, the first intermediate dose, or the second intermediate dose, the full dose of the bispecific antibody administered to the subject during Week 4 is divided into two equal parts, and the two parts of the full dose are administered on two days during Week 4 of the dosing regimen, and wherein the full dose is administered to the subject as a single dose during Weeks 5 to 12 of the dosing regimen.

[0009] In some embodiments, starting with week 14 of the dosing regimen, the subject is administered a maintenance dose every two weeks.

[0010] In some embodiments, the subject is administered a maintenance dose every four or eight weeks starting in the subsequent week of the dosing regimen, wherein the subsequent week is at least week 36 of the dosing regimen.

[0011] In some embodiments, the second dose portion of the initial dose is administered to the subject 18 to 96 hours after the first dose portion of the initial dose. In some embodiments, the two portions of the first intermediate dose are administered to the subject 18 to 96 hours apart. In some embodiments, the two portions of the second intermediate dose are administered to the subject 18 to 96 hours apart. In some embodiments, the two portions of the full dose are administered to the subject 18 to 96 hours apart.

[0012] In some embodiments, the two days are consecutive days. In some embodiments, the two days are no more than three days apart.

[0013] In some embodiments, the B cell malignancy is a B cell non-Hodgkin lymphoma. In some instances, the B cell malignancy is follicular lymphoma, diffuse large B cell lymphoma, mantle cell lymphoma, or marginal zone lymphoma.

[0014] In some embodiments, a full dose of the bispecific antibody is 80 mg to 320 mg.

[0015] In some embodiments, the maintenance dose of the bispecific antibody is 160 mg to 320 mg.

[0016] In some embodiments, the B cell malignancy is follicular lymphoma, the full dose is 80 mg, and the maintenance dose is 160 mg or 320 mg. In some instances, the follicular lymphoma is grade 1-3a.

[0017] In some embodiments, the B cell malignancy is diffuse large B cell lymphoma, the full dose is 160 mg, and the maintenance dose is 320 mg. In some embodiments, the B cell malignancy is diffuse large B cell lymphoma, the full dose is 320 mg, and the maintenance dose is 320 mg. In some cases, the subject has failed a previous CAR-T therapy.

[0018] In some embodiments, the B cell malignancy is mantle cell lymphoma, the full dose is 160 mg, and the maintenance dose is 320 mg. In some cases, the subject has failed prior Bruton's tyrosine kinase (BTK) inhibitor therapy.

[0019] In some embodiments, the B cell malignancy is marginal zone lymphoma, the full dose is 80 mg, and the maintenance dose is 160 mg.

[0020] In some embodiments, the B-cell malignancy is non-Hodgkin lymphoma other than follicular lymphoma, diffuse large B-cell lymphoma, mantle cell lymphoma, or marginal zone lymphoma, the full dose is 160 mg, and the maintenance dose is 320 mg.

[0021] In some embodiments, the B-cell malignancy is an aggressive lymphoma, the full dose is 160 mg, and the maintenance dose is 320 mg.

[0022] In some embodiments, the subject has a documented CD20+ B-cell malignancy, has active disease, has not responded to prior therapy, has no standard of care options, and may be a candidate for treatment with an anti-CD20 antibody. In some embodiments, the subject has a documented aggressive B-NHL, has relapsed within one year of first-line therapy, and is contemplated for autologous stem cell transplantation (ASCT).

[0023] In some embodiments, the subject has not been previously treated with systemic anti-lymphoma therapy.In some embodiments, the subject has relapsed or refractory disease.

[0024] In some embodiments, the subject has relapsed after or is refractory to at least 2 prior lines of systemic therapy including an anti-CD20 antibody and an alkylating agent.

[0025] In some embodiments, the subject is refractory to anti-CD20 antibody on any prior line of therapy.

[0026] In some embodiments, the subject is doubly refractory to an alkylating agent and an anti-CD20 antibody in any prior line of therapy.

[0027] In some embodiments, the subject is a human aged ≥ 18 years.

[0028] In any of the various embodiments discussed in the above aspects of the disclosure, the bispecific antibody may be administered intravenously.

[0029] In one aspect, the present disclosure provides a dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating a B cell malignancy, the dosing regimen comprising: administering an initial dose of 1 mg or 2 mg of the bispecific antibody to the subject during week 1 of the dosing regimen; administering a first intermediate dose of 10 mg or 26 mg of the bispecific antibody to the subject during week 2 of the dosing regimen; administering a second intermediate dose of 50 mg or 100 mg of the bispecific antibody to the subject during week 3 of the dosing regimen; and administering a full dose of the bispecific antibody to the subject during week 4 and the following week of the dosing regimen, wherein the bispecific antibody comprises a first antigen binding region that binds to human CD20 and a second antigen binding region that binds to human CD3, wherein the first antigen binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2, and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8, and 9, respectively, and three light chain complementary determining regions LCDR1, LCDR2, and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14, and 15, respectively, and wherein the second antigen binding region comprises a first antigen binding region that binds to human CD20 and a second antigen binding region that binds to human CD3, wherein the first antigen binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2, and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14, and 15, respectively, and wherein the second antigen binding region comprises a second antigen binding region that binds to human CD3, respectively. The three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 contain the amino acid sequences of SEQ ID NOs: 10, 11 and 12, and the three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 contain the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively.

[0030] In some embodiments, the initial dose is 2 mg. In some embodiments, the first intermediate dose is 26 mg. In some embodiments, the second intermediate dose is 100 mg. In some embodiments, the full dose is 200 mg, 400 mg, or 600 mg. In some cases, the full dose is 400 mg. In some cases, the full dose is 600 mg.

[0031] In some embodiments, a full dose is administered to a subject once every three weeks. In some embodiments, a full dose is administered to a subject weekly. In some cases, a full dose is administered to a subject weekly for three weeks, and then a full dose is administered to a subject once every three weeks.

[0032] In some embodiments, the subject has relapsed or refractory disease. In some embodiments, the subject is refractory to anti-CD20 antibodies in any prior line of therapy.

[0033] In some embodiments, the B cell malignancy is follicular lymphoma. In some embodiments, the B cell malignancy is diffuse large B cell lymphoma.

[0034] In some embodiments, the subject is a human aged ≥ 18 years.

[0035] In any of the various embodiments discussed in the above aspects of the disclosure, the bispecific antibody may be administered subcutaneously.

[0036] In one aspect, the present disclosure provides a dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating a B cell malignancy, the dosing regimen comprising: administering an initial dose of the bispecific antibody to the subject, wherein the initial dose is divided into a first dose portion of the bispecific antibody and a second dose portion of the bispecific antibody, wherein the first dose portion is administered to the subject within two days during week 1 of the dosing regimen, followed by administration of the second dose portion; administering a first intermediate dose of the bispecific antibody to the subject, wherein the first intermediate dose is divided into two equal portions (a first portion and a second portion) of the bispecific antibody, wherein the first intermediate dose is administered to the subject within two days during week 2 of the dosing regimen, followed by administration of the second dose portion; administering a first intermediate dose of the bispecific antibody to the subject, wherein the first intermediate dose is divided into two equal portions (a first portion and a second portion) of the bispecific antibody, wherein the second intermediate dose is administered to the subject within two days during week 3 of the dosing regimen, followed by administration of the second dose portion; administering two portions of a first intermediate dose on two days during the dosing week; administering to the subject a second intermediate dose of the bispecific antibody, wherein the second intermediate dose is divided into two equal portions (a first portion and a second portion) of the bispecific antibody, wherein the two portions of the second intermediate dose are administered on two days during week 3 of the dosing regimen; administering to the subject a full dose of the bispecific antibody each week during weeks 4 to 12 of the dosing regimen; and administering to the subject a maintenance dose of the bispecific antibody in week 14 of the dosing regimen, wherein the initial dose, the first intermediate dose, the second intermediate dose, the full dose, and the maintenance dose depend on the subject's weight: (i) if the subject's weight is If the subject weighs 40 kg to less than 165 kg (e.g., 40-164 kg), the initial dose is 0.7 mg, the first dose portion of the initial dose is 0.2 mg, the second dose portion of the initial dose is 0.5 mg, the first intermediate dose is 4 mg, the two equal portions of the first intermediate dose each contain 2 mg, the second intermediate dose is 20 mg, the two equal portions of the second intermediate dose each contain 10 mg, the full dose is 160 mg, and the maintenance dose is 320 mg; (ii) if the subject weighs 20 kg to less than 40 kg (e.g., 20-39 kg), the initial dose is 0.4 mg, the first dose portion of the initial dose is 0.5 mg, the first intermediate dose is 4 mg, the two equal portions of the first intermediate dose each contain 2 mg, the second intermediate dose is 20 mg, the two equal portions of the second intermediate dose each contain 10 mg, the full dose is 160 mg, and the maintenance dose is 320 mg. .1 mg, the second dose portion of the initial dose is 0.3 mg, the first intermediate dose is 2 mg, the two equal portions of the first intermediate dose each contain 1 mg, the second intermediate dose is 12 mg, the two equal portions of the second intermediate dose each contain 6 mg, the full dose is 90 mg, and the maintenance dose is 150 mg; (iii) if the subject weighs 10 kg to less than 20 kg (e.g., 10-19 kg), the initial dose is 0.3 mg, the first dose portion of the initial dose is 0.1 mg, the second dose portion of the initial dose is 0.2 mg, the first intermediate dose is 1.6 mg, the two equal portions of the first intermediate dose each contain 0.or (iv) if the subject weighs 6 kg to less than 10 kg (e.g., 6-9 kg), the initial dose is 0.24 mg, the first dose portion of the initial dose is 0.07 mg, the second dose portion of the initial dose is 0.17 mg, the first intermediate dose is 1.2 mg, the two equal portions of the first intermediate dose each contain 0.6 mg, the second intermediate dose is 6 mg, the two equal portions of the second intermediate dose each contain 3 mg, the full dose is 45 mg, and the maintenance dose is 75 mg; and wherein the bispecific antibody comprises a first antigen-binding region that binds to human CD20 and a second antigen-binding region that binds to human CD3, wherein the first antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8 and 9, respectively, and NO:13, 14 and 15, and wherein the second antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 containing the amino acid sequences of SEQ ID NO:10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 containing the amino acid sequences of SEQ ID NO:13, 14 and 15, respectively.

[0037] In some embodiments, the full dose is administered to the subject as a single dose during weeks 4 to 12 of the dosing regimen. In some embodiments, starting from week 14 of the dosing regimen, the subject is administered a maintenance dose every two weeks.

[0038] In some embodiments, the second dose portion of the initial dose is administered to the subject 18 to 96 hours after the first dose portion of the initial dose. In some embodiments, the two portions of the first intermediate dose are administered to the subject 18 to 96 hours apart. In some embodiments, the two portions of the second intermediate dose are administered to the subject 18 to 96 hours apart.

[0039] In some embodiments, the two days are consecutive days. In some embodiments, the two days are no more than three days apart.

[0040] In some embodiments, the B cell malignancy is a B cell non-Hodgkin lymphoma. In some embodiments, the B cell malignancy is a follicular lymphoma, a diffuse large B cell lymphoma, a mantle cell lymphoma, or a marginal zone lymphoma.

[0041] In some embodiments, the subject is a human < 18 years old.

[0042] In any of the various embodiments discussed in the above aspects of the disclosure, the bispecific antibody may be administered intravenously.

[0043] In one aspect, the present disclosure provides a dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating follicular lymphoma, the dosing regimen comprising: (a) administering an initial dose of 0.7 mg of the bispecific antibody to the subject, wherein the initial dose is divided into a first dose portion comprising 0.2 mg of the bispecific antibody and a second dose portion comprising 0.5 mg of the bispecific antibody, wherein the first dose portion is administered to the subject on two days during Week 1 of the dosing regimen, followed by administration of the second dose portion; (b) administering a first intermediate dose of 4 mg of the bispecific antibody to the subject, wherein the first intermediate dose is divided into two equal portions (a first portion and a second portion), each portion comprising 2 mg of the bispecific antibody, wherein the first intermediate dose is administered to the subject on two days during Week 2 of the dosing regimen, followed by administration of the second dose portion. (c) administering to the subject a second intermediate dose of 20 mg of the bispecific antibody, wherein the second intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 10 mg of the bispecific antibody, wherein the two parts of the second intermediate dose are administered on two days during week 3 of the dosing regimen; (d) administering to the subject a full dose of 40 mg or 80 mg of the bispecific antibody weekly during weeks 4 to 12 of the dosing regimen; and (e) administering to the subject a maintenance dose of 80 mg or 160 mg of the bispecific antibody at week 14 of the dosing regimen, wherein the bispecific antibody comprises a first antigen-binding region that binds to human CD20 and a second antigen-binding region that binds to human CD3, wherein the first antigen-binding region comprises a first antigen-binding region comprising SEQ ID NO: 7, 8 and 9, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 containing the amino acid sequences of SEQ ID NO: 13, 14 and 15, respectively, and wherein the second antigen binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 containing the amino acid sequences of SEQ ID NO: 10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 containing the amino acid sequences of SEQ ID NO: 13, 14 and 15, respectively. In some embodiments, the initial dose (0.7 mg) can be divided into other parts, such as 0.1 mg and 0.6 mg, 0.15 mg and 0.55 mg, 0.25 mg and 0.45 mg, or 0.3 mg and 0.4 mg.

[0044] In one aspect, the present disclosure provides a dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating diffuse large B-cell lymphoma, the dosing regimen comprising: (a) administering an initial dose of 0.7 mg of the bispecific antibody to the subject, wherein the initial dose is divided into a first dose portion comprising 0.2 mg of the bispecific antibody and a second dose portion comprising 0.5 mg of the bispecific antibody, wherein the first dose portion is administered to the subject on two days during Week 1 of the dosing regimen, followed by administration of the second dose portion; (b) administering a first intermediate dose of 4 mg of the bispecific antibody to the subject, wherein the first intermediate dose is divided into two equal portions (a first portion and a second portion), each portion comprising 2 mg of the bispecific antibody, wherein the first intermediate dose is administered to the subject on two days during Week 2 of the dosing regimen, followed by administration of the second dose portion; (c) administering to the subject a second intermediate dose of 20 mg of the bispecific antibody, wherein the second intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 10 mg of the bispecific antibody, wherein the two parts of the second intermediate dose are administered on two days during the third week of the dosing regimen; (d) administering to the subject a full dose of 80 mg or 160 mg of the bispecific antibody weekly during weeks 4 to 12 of the dosing regimen; and (e) administering to the subject a maintenance dose of 160 mg or 320 mg of the bispecific antibody at week 13 or week 14 of the dosing regimen, wherein the bispecific antibody comprises a first antigen binding region that binds to human CD20 and a second antigen binding region that binds to human CD3, wherein the first antigen binding region comprises a first antigen binding region comprising SEQ ID NO: 7, 8 and 9, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 containing the amino acid sequences of SEQ ID NO: 13, 14 and 15, respectively, and wherein the second antigen binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 containing the amino acid sequences of SEQ ID NO: 10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 containing the amino acid sequences of SEQ ID NO: 13, 14 and 15, respectively. In some embodiments, the initial dose (0.7 mg) can be divided into other parts, such as 0.1 mg and 0.6 mg, 0.15 mg and 0.55 mg, 0.25 mg and 0.45 mg, or 0.3 mg and 0.4 mg.

[0045] In some embodiments, the full dose is administered to the subject as a single dose during weeks 4 to 12 of the dosing regimen.

[0046] In some embodiments, the maintenance dose is administered to the subject every two weeks starting from week 13 of the dosing regimen. In some embodiments, the maintenance dose is administered to the subject every two weeks starting from week 14 of the dosing regimen.

[0047] In some embodiments, the full dose is 40 mg. In some embodiments, the full dose is 80 mg. In some embodiments, the full dose is 160 mg. In some embodiments, the maintenance dose is 80 mg. In some embodiments, wherein the maintenance dose is 160 mg. In some embodiments, wherein the maintenance dose is 320 mg.

[0048] In some embodiments, the second dose portion of the initial dose is administered to the subject 18 to 96 hours after the first dose portion of the initial dose. In some embodiments, the two portions of the first intermediate dose are administered to the subject 18 to 96 hours apart. In some embodiments, the two portions of the second intermediate dose are administered to the subject 18 to 96 hours apart.

[0049] In some embodiments, the dosing regimen further comprises administering a combination of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). In some embodiments, the dosing regimen further comprises administering a combination of cyclophosphamide, vincristine, and prednisone (CVP). In some cases, CHOP / CVP is administered during the week prior to Week 1 of the dosing regimen and again during Weeks 3, 6, 9, 12, and 15 of the dosing regimen. In some cases, cyclophosphamide is administered at 750 mg / m 2 Doxorubicin was administered at a dose of 50 mg / m 2 vincristine was administered at a dose of 1.4 mg / m 2 The invention relates to a method of treating a patient with cyclophosphamide, doxorubicin, and vincristine in a dosage of 100 mg, wherein cyclophosphamide, doxorubicin, and vincristine are administered once in the week prior to Week 1 of the dosing regimen and once each in Weeks 3, 6, 9, 12, and 15 of the dosing regimen, and prednisone is administered for five consecutive days in the week prior to Week 1 of the dosing regimen and for five consecutive days each in Weeks 3, 6, 9, 12, and 15 of the dosing regimen.

[0050] In some embodiments, the subject has relapsed or refractory disease. In some cases, the subject is refractory to an anti-CD20 antibody in any previous line of therapy. In some cases, the subject is doubly refractory to an alkylating agent and an anti-CD20 antibody.

[0051] In some embodiments, the subject has not been previously treated with systemic anti-lymphoma therapy (ie, the subject is previously treatment naive).

[0052] In some embodiments, the subject has previously received an autologous stem cell transplant.

[0053] In some embodiments, the bispecific antibody is administered intravenously to the subject.

[0054] In some embodiments, the first antigen-binding region of the bispecific antibody comprises a heavy chain variable region (HCVR) comprising the amino acid sequence of SEQ ID NO:4 and a light chain variable region (LCVR) comprising the amino acid sequence of SEQ ID NO:6, and the second antigen-binding region of the bispecific antibody comprises a HCVR comprising the amino acid sequence of SEQ ID NO:5 and a LCVR comprising the amino acid sequence of SEQ ID NO:6.

[0055] In some embodiments, the bispecific antibody comprises a human IgG heavy chain constant region. In some cases, the human IgG heavy chain constant region is of isotype IgG1. In some cases, the human IgG heavy chain constant region is of isotype IgG4.

[0056] In some embodiments, the bispecific antibody comprises a first heavy chain constant region comprising the amino acid sequence of SEQ ID NO:16 and a second heavy chain constant region comprising the amino acid sequence of SEQ ID NO:17.

[0057] In some embodiments, the bispecific antibody comprises a first heavy chain constant region comprising the amino acid sequence of SEQ ID NO:18 and a second heavy chain constant region comprising the amino acid sequence of SEQ ID NO:19.

[0058] In some embodiments, the bispecific antibody comprises a first heavy chain comprising amino acid residues 1-452 of SEQ ID NO:1 paired with a common light chain comprising the amino acid sequence of SEQ ID NO:3, and a second heavy chain comprising amino acid residues 1-448 of SEQ ID NO:2 paired with a common light chain comprising the amino acid sequence of SEQ ID NO:3.

[0059] In some embodiments, the bispecific antibody comprises a first heavy chain comprising the amino acid sequence of SEQ ID NO: 1 paired with a common light chain comprising the amino acid sequence of SEQ ID NO: 3, and a second heavy chain comprising the amino acid sequence of SEQ ID NO: 2 paired with a common light chain comprising the amino acid sequence of SEQ ID NO: 3.

[0060] In any of the various embodiments discussed above or herein, the dosing regimen further comprises administering to the subject a dose of the steroid at the following times: 12 to 24 hours prior to administration of the first dose portion of the initial dose; 12 to 24 hours prior to administration of the first portion of the first intermediate dose; and 12 to 24 hours prior to administration of the first portion of the second intermediate dose.

[0061] In some embodiments, if the first dose portion of the initial dose and the second dose portion of the initial dose are not administered to the subject for consecutive days, the dosing regimen further includes administering a dose of steroids to the subject 12 to 24 hours before administering the second dose portion of the initial dose of the bispecific antibody. In some embodiments, if the first portion of the first intermediate dose and the second portion of the first intermediate dose are not administered to the subject for consecutive days, the dosing regimen further includes administering a dose of steroids to the subject 12 to 24 hours before administering the second portion of the first intermediate dose of the bispecific antibody. In some embodiments, if the first portion of the second intermediate dose and the second portion of the second intermediate dose are not administered to the subject for consecutive days, the dosing regimen further includes administering a dose of steroids to the subject 12 to 24 hours before administering the second portion of the second intermediate dose of the bispecific antibody.

[0062] In some embodiments, the dosing regimen further comprises administering to the subject a dose of a steroid 1 to 3 hours prior to administering the first dose portion of the initial dose; 1 to 3 hours prior to administering the second dose portion of the initial dose; and 1 to 3 hours prior to administering each portion of the first intermediate dose and the second intermediate dose, and administering to the subject a dose of an antihistamine 30 to 60 minutes prior to administering the first dose portion of the initial dose; 30 to 60 minutes prior to administering the second dose portion of the initial dose; and 30 to 60 minutes prior to administering each portion of the first intermediate dose and the second intermediate dose.

[0063] In some embodiments, the dosing regimen further comprises administering a dose of acetaminophen to the subject at the following times: 30 to 60 minutes prior to administering the first dose portion of the initial dose; 30 to 60 minutes prior to administering the second dose portion of the initial dose; and 30 to 60 minutes prior to administering each portion of the first intermediate dose and the second intermediate dose.

[0064] In some embodiments, the dosing regimen further comprises administering a dose of the steroid to the subject at the following times: 20 to 28 hours after the completion of the second dose portion of the initial dose; 20 to 28 hours after the completion of the second portion of the first intermediate dose; and 20 to 28 hours after the completion of the second portion of the second intermediate dose.

[0065] In some embodiments, the dosing regimen further comprises administering to the subject a dose of a steroid 1 to 3 hours prior to administering the full dose during week 4 of the dosing regimen, and administering to the subject a dose of an antihistamine 30 to 60 minutes prior to administering the full dose during week 4 of the dosing regimen.

[0066] In some embodiments, the dosing regimen further comprises administering to the subject a dose of acetaminophen 30 to 60 minutes prior to administering the full dose during week 4 of the dosing regimen.

[0067] In some embodiments, the dosing regimen further comprises administering to the subject a dose of the steroid 20 to 28 hours after the completion of administration of the full dose during week 4 of the dosing regimen.

[0068] In some embodiments, if a subject experiences a grade 3 event of cytokine release syndrome when administering the initial dose, the first intermediate dose, or the second intermediate dose, the full dose of the bispecific antibody administered to the subject during week 4 is divided into two equal parts (part 1 and part 2), and the two parts of the full dose are administered within two days during week 4 of the dosing regimen, and wherein the dosing regimen further comprises administering a dose of steroids to the subject 12 to 24 hours before administering the first part of the full dose. In some cases, if the subject is not administered a full dose of the first part and a full dose of the second part on consecutive days, the dosing regimen further comprises administering a dose of steroids to the subject 12 to 24 hours before administering the second part of the full dose of the bispecific antibody. In some cases, the dosing regimen further comprises: administering a dose of steroids to the subject 1 to 3 hours before administering the first part of the full dose, and administering a dose of antihistamines to the subject 30 to 60 minutes before administering the first part of the full dose. In some cases, the dosing regimen further comprises administering a dose of acetaminophen to the subject 30 to 60 minutes before administering the first part of the full dose. In some cases, the dosing regimen further includes administering a dose of a steroid to the subject 1 to 3 hours prior to administering the full dose during week 5 of the dosing regimen, and administering a dose of an antihistamine to the subject 30 to 60 minutes prior to administering the full dose during week 5 of the dosing regimen. In some cases, the dosing regimen further includes administering a dose of acetaminophen to the subject 30 to 60 minutes prior to administering the full dose during week 5 of the dosing regimen. In some cases, the dosing regimen further includes administering a dose of a steroid to the subject 20 to 28 hours after the end of administering the full dose during week 5 of the dosing regimen.

[0069] In some embodiments, administering a dose of a steroid, administering a dose of an antihistamine, or administering a dose of acetaminophen comprises instructing the subject to take the dose of a steroid, the dose of an antihistamine, or the dose of acetaminophen, respectively.

[0070] In some embodiments, administering a dose of a steroid or administering a dose of an antihistamine comprises administering the dose of a steroid or the dose of an antihistamine intravenously.

[0071] In some embodiments, the steroid is dexamethasone. In some cases, the dose of the steroid is 20 mg.

[0072] In some embodiments, the antihistamine is diphenhydramine. In some cases, the dosage of the antihistamine is 25 mg.

[0073] In some embodiments, the dose of acetaminophen is 650 mg.

[0074] In any of the various embodiments discussed above or herein, the dosing regimen further comprises administering an anti-IL-6 receptor antibody. In some cases, the anti-IL-6 receptor antibody is tocilizumab or salirumab.

[0075] In one aspect, the present disclosure provides a method of treating a B cell cancer in a subject, the method comprising: selecting a subject diagnosed with a B cell cancer; and administering a bispecific antibody to the subject according to a dosing regimen discussed above or herein.

[0076] In various embodiments of the treatment methods: (a) the subject has been diagnosed with follicular lymphoma; (b) the subject has been diagnosed with grade 1-3a follicular lymphoma; (c) the subject has been diagnosed with relapsed or refractory follicular lymphoma after at least 2 prior lines of systemic therapy; (d) the subject has been diagnosed with follicular lymphoma and has not previously received systemic anti-lymphoma therapy; (e) the subject has been diagnosed with follicular lymphoma and the full dose is 80 mg; and / or (f) the subject has been diagnosed with follicular lymphoma and the maintenance dose is 160 mg or 320 mg.

[0077] In various embodiments of the treatment methods: (a) the subject has been diagnosed with diffuse large B-cell lymphoma (DLBCL); (b) the subject has been diagnosed with DLBCL, and wherein the DLBCL is de novo or transformed from a low-grade tumor; (c) the subject has been diagnosed with DLBCL and is refractory to at least 2 previous lines of systemic therapy; (d) the subject has been diagnosed with relapsed or refractory DLBCL after at least 2 previous lines of systemic therapy (including CAR-T therapy); (e) the subject has been diagnosed with DLBCL and has not previously received systemic anti-lymphoma therapy; (f) the subject has been diagnosed with DLBCL and the full dose is 160 mg; and / or (g) the subject has been diagnosed with DLBCL and the maintenance dose is 320 mg.

[0078] The present disclosure also contemplates the use of an anti-CD20×anti-CD3 antibody (e.g., onitumumab) for the methods discussed above or herein, and the use of an anti-CD20×anti-CD3 antibody (e.g., onitumumab) in the manufacture of a medicament for treating a B-cell cancer (e.g., FL or DLBCL) in a subject according to the methods discussed above or herein.

[0079] In one aspect, the present disclosure provides a pharmaceutical kit comprising (i) a container comprising a bispecific antibody, and (ii) a label comprising instructions for administering the bispecific antibody according to a dosing regimen discussed above or herein.

[0080] In some embodiments, the label further includes instructions for administering the steroid and the antihistamine according to the dosing regimens discussed above or herein.

[0081] In various embodiments, any feature or assembly of any embodiment discussed above or herein can be combined, and such combination is contained in the scope of the present disclosure.Any specified value discussed above or herein can be combined with another related value discussed above or herein to list a range, and the value represents the upper and lower limits of the range, and such range is contained in the scope of the present disclosure.Therapeutic proteins for any method discussed herein, or the use of therapeutic proteins in the manufacture of medicines for any method discussed herein are also contained in the scope of the present disclosure.

[0082] Other embodiments will become apparent upon reading the ensuing detailed description. BRIEF DESCRIPTION OF THE DRAWINGS

[0083] Figure 1 The dosing regimen of onitumab for treating patients with follicular lymphoma according to one embodiment of the present invention is described. * 20 mg of dexamethasone intravenously 1 to 3 hours before each divided infusion or initial single infusion; Dexamethasone 10 mg orally 12 to 24 hours before the first divided infusion. Each day of the divided or single infusion: dexamethasone 20 mg IV 1 to 3 hours before infusion; diphenhydramine 25 mg IV or orally and acetaminophen 650 mg orally 30 to 60 minutes before infusion. CRS, cytokine release syndrome; D, day; IV, intravenous; Q2W, every 2 weeks.

[0084] Figure 2 It is shown that most patients with relapsed / refractory follicular lymphoma with evaluable efficacy (N=121) had significant tumor shrinkage after monotherapy with onitumumab. The figure shows the best change (%) of tumor SPD (sum of diameter products) relative to baseline. PD, progressive disease; CR / PR, complete response, partial response; NE, not estimable; SD, stable disease.

[0085] Figure 3 The antitumor efficacy of onitumumab monotherapy in efficacy-evaluable relapsed / refractory follicular lymphoma patients (N=121) and subgroups is shown. ASCT, autologous stem cell transplantation; CR, complete response; FLIPI, follicular lymphoma international prognostic index; ORR, objective response rate; POD24, disease progression within 24 months after starting first-line therapy.

[0086] Figure 4 Shown are responses and durability of complete responses in patients with relapsed / refractory follicular lymphoma treated with onitumumab monotherapy. CI, confidence interval; DOCR, duration of complete response; DOR, duration of response; NE, not estimable.

[0087] Figure 5 Progression-free survival and overall survival are shown for patients with relapsed / refractory follicular lymphoma treated with onitumumab monotherapy. CI, confidence interval; NE, not estimable; OS, overall survival; PFS, progression-free survival.

[0088] Figure 6 The dosing regimen of onitumab for treating patients with diffuse large B-cell lymphoma according to one embodiment of the present invention is described. * 20 mg of dexamethasone intravenously 1 to 3 hours before each divided infusion or initial single infusion; Dexamethasone 10 mg orally 12 to 24 hours before the first divided infusion. Each day of the divided or single infusion: dexamethasone 20 mg IV 1 to 3 hours before infusion; diphenhydramine 25 mg IV or orally and acetaminophen 650 mg orally 30 to 60 minutes before infusion. CRS, cytokine release syndrome; D, day; IV, intravenous; Q2W, every 2 weeks.

[0089] Figure 7 The antitumor efficacy of onitumumab monotherapy in efficacy-evaluable DLBCL patients (N=130) and subgroups is shown. ASCT, autologous stem cell transplantation; CI, confidence interval; CR, complete response; DLBCL, diffuse large B-cell lymphoma; ORR, objective response rate.

[0090] Figure 8 Responses and durability of complete responses in patients with relapsed / refractory DLBCL treated with onitumumab monotherapy are shown. CI, confidence interval; DOCR, duration of complete response; DOR, duration of response; NE, not evaluable.

[0091] Fig. 9 Progression-free survival is shown for patients with relapsed / refractory DLBCL treated with onitumumab monotherapy. CI, confidence interval; NE, not evaluable; PFS, progression-free survival.

[0092] Fig.10 The dosing schedule of onitumab plus chemotherapy by cycle is described. The DLT observation period is defined as the first 35 days starting from C1D8 (first onitumab administration) until 2 full doses of onitumab (whichever is later).

[0093] Fig.11 The dosing schedule of rituximab plus chemotherapy divided by cycle is described, which serves as a control. DETAILED DESCRIPTION

[0094] Before describing the present invention, it should be understood that the present invention is not limited to the specific methods and experimental conditions described, because such methods and conditions can vary. It should also be understood that the terminology used herein is only used for the purpose of describing specific embodiments, and is not intended to be limiting, because the scope of the present invention will be limited only by the appended claims.

[0095] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which the invention belongs. When used in reference to a specific recited numerical value, the term "about" means that the value may vary by no more than 1% from the recited value. For example, the expression "about 100" includes 99 and 101 and all values ​​therebetween (e.g., 99.1, 99.2, 99.3, 99.4, etc.).

[0096] Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods and materials are now described. All patents, applications and non-patent publications mentioned in this specification are incorporated herein by reference in their entirety.

[0097] definition

[0098] All references to proteins, polypeptides and protein fragments herein are intended to refer to the human form of the respective protein, polypeptide or protein fragment, unless it is explicitly stated that it is from a non-human species. Thus, the expressions "CD3" and "CD20" are intended to refer to human CD3 and human CD20, respectively, unless it is explicitly stated that it is from a non-human species.

[0099] The expression "CD3" refers to an antigen that is expressed on T cells as part of a multimolecular T cell receptor (TCR) and consists of a homodimer or heterodimer formed by the association of two of the four receptor chains: CD3-ε, CD3-δ, CD3-ζ and CD3-γ.

[0100] "Antigen binding domains that bind to CD3", "antigen binding regions that bind to CD3", "antibodies that bind to CD3" or "anti-CD3 antibodies" include antibodies and antigen-binding fragments thereof that specifically recognize a single CD3 subunit (e.g., ε, δ, γ or ζ), as well as antibodies and antigen-binding fragments thereof that specifically recognize a dimeric complex of two CD3 subunits (e.g., γ / ε, δ / ε and ζ / ζ CD3 dimers). The antibodies and antigen-binding fragments of the present invention can bind to soluble CD3 and / or CD3 expressed on the cell surface. Soluble CD3 includes natural CD3 protein as well as recombinant CD3 protein variants, such as monomeric and dimeric CD3 constructs, which lack a transmembrane domain or are not associated with a cell membrane.

[0101] The expression "CD20" refers to a non-glycosylated phosphoprotein expressed on the cell membrane of mature B cells. CD20 is considered a B-cell tumor-associated antigen because it is expressed by more than 95% of B-cell non-Hodgkin's lymphomas (NHL) and other B-cell malignancies, but it is not present on precursor B cells, dendritic cells, and plasma cells.

[0102] The “antigen binding domain that binds to CD20”, “antigen binding region that binds to CD20”, “antibody that binds to CD20” or “anti-CD20 antibody” include antibodies that specifically recognize CD20 and antigen-binding fragments thereof.

[0103] "Cytokine release syndrome" (CRS) refers to a disorder characterized by fever, shortness of breath, headache, tachycardia, hypotension, rash, and / or hypoxia, and is defined as an event occurring 6 hours or more after the start of the bispecific antibody infusion or more than 2 hours after the completion of the bispecific antibody infusion, whichever is later. The grades of CRS are defined in Tables 5, 6, and 11 of the Examples.

[0104] An "infusion-related reaction" (IRR) is an adverse event occurring less than 6 hours after the start of infusion of the bispecific antibody and is accompanied by typical signs and symptoms, including but not limited to flushing, tachycardia, hypotension, dyspnea, bronchospasm, back pain, fever, urticaria, edema, nausea, and rash. As used herein, signs and symptoms of IRR occurring 6 hours or more after the start of infusion are identified as cytokine release syndrome (CRS).

[0105] Non-Hodgkin lymphomas can be divided into two major prognostic groups: indolent (low-grade; slow-growing) lymphomas and aggressive (high-grade; fast-growing) lymphomas. “Aggressive lymphomas” are lymphomas characterized by one of the following subtypes based on the World Health Organization classification: diffuse large B-cell lymphoma (DLBCL), not otherwise specified (NOS), germinal center B-cell type; activated B-cell type; primary mediastinal (thymic) large B-cell lymphoma; T-cell / histiocyte-rich large B-cell lymphoma; Epstein-Barr virus (EBV)+ DLBCL, NOS; high-grade B-cell lymphoma with rearrangements of MYC and BCL2 and / or BCL6; high-grade B-cell lymphoma, NOS; B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin lymphoma; and follicular lymphoma, grade 3b, according to the WHO classification. Follicular lymphoma grades 1-3a is the most common form of indolent lymphoma.

[0106] The term "antibody" means any antigen binding molecule or molecular complex comprising at least one complementary determining region (CDR) that specifically binds or interacts with a specific antigen (e.g., CD20 or CD3). The term "antibody" includes immunoglobulin molecules and multimers thereof (e.g., IgM) comprising four polypeptide chains (two heavy (H) chains and two light (L) chains) interconnected by disulfide bonds. The term "antibody" also includes immunoglobulin molecules consisting of four polypeptide chains (two heavy chains (H) and two light chains (L)) interconnected by disulfide bonds. Each heavy chain comprises a heavy chain variable region (abbreviated herein as HCVR or V H ) and the heavy chain constant region. The heavy chain constant region contains three domains: C H 1. C H 2 and C H 3. Each light chain comprises a light chain variable region (abbreviated herein as LCVR or V L ) and the light chain constant region. The light chain constant region consists of a domain (C L 1). V H Area and V L The V region can be further subdivided into regions of hypervariability, termed complementarity determining regions (CDRs), interspersed with regions that are more conserved, termed framework regions (FRs). H and V LIt is composed of three CDRs and four FRs arranged in the following order from the amino terminus to the carboxyl terminus: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In different embodiments of the present invention, the FRs of the antibody (or its antigen-binding portion) may be identical to human germline sequences, or may be naturally or artificially modified. An amino acid consensus sequence may be defined based on a side-by-side analysis of two or more CDRs. Unless otherwise indicated, the term "antibody" includes "bispecific antibodies".

[0107] The term "antibody" also includes the antigen binding fragment of a complete antibody molecule. The term "antigen binding portion of an antibody", "antigen binding fragment of an antibody" etc. includes any naturally occurring, enzymatically available, synthetic or genetically engineered polypeptide or glycoprotein that specifically binds to an antigen to form a complex. Antigen binding fragments of an antibody can be derived from a full antibody molecule, for example, using any suitable standard technique (such as proteolytic digestion or the recombinant genetic engineering techniques involving the operation and expression of DNA encoding antibody variable domains and optionally antibody constant domains). Such DNA is known, and / or can be easily obtained from, for example, commercial sources, DNA libraries (including, for example, phage-antibody libraries), or can be synthesized. DNA sequencing can be performed, and chemically or by using molecular biological techniques, for example, to arrange one or more variable domains and / or constant domains into a suitable configuration, or to import codons, produce cysteine ​​residues, modify, add or delete amino acids, etc.

[0108] The expression "bispecific antigen binding molecule" refers to a protein, polypeptide or molecular complex comprising at least a first antigen binding domain and a second antigen binding domain. Each antigen binding domain within a bispecific antigen binding molecule comprises at least one CDR that specifically binds to a specific antigen, either alone or in combination with one or more additional CDRs and / or FRs. Bispecific antigen binding molecules include bispecific antibodies.

[0109] Non-limiting examples of antigen-binding fragments include: (i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single-chain Fv (scFv) molecules; (vi) dAb fragments; and (vii) the smallest recognition unit consisting of amino acid residues that mimic the hypervariable region of an antibody (e.g., an isolated complementary determining region (CDR), such as a CDR3 peptide), or a binding FR3-CDR3-FR4 peptide. Other engineered molecules (such as domain-specific antibodies, single domain antibodies, domain-deleted antibodies, chimeric antibodies, CDR-grafted antibodies, diabodies, tribodies, tetrabodies, microbodies, nanobodies (e.g., monovalent nanobodies, bivalent nanobodies, etc.), small modular immunopharmaceuticals (SMIPs), and shark variable IgNAR domains) are also encompassed within the expression "antigen-binding fragment".

[0110] The antigen-binding fragment of an antibody generally includes at least one variable domain. The variable domain can have any size or amino acid composition and will generally include at least one CDR adjacent to or in frame with one or more framework sequences. H Domain and V L In the antigen-binding fragment associated with the structural domain, V H and V L The domains may be positioned relative to each other in any suitable arrangement. For example, the variable region may be a dimer and contain V H -V H 、V H -V L or V L -V L Alternatively, the antigen-binding fragment of the antibody may contain a monomer V H or V L Structural domain.

[0111] In certain embodiments, the antigen-binding fragment of an antibody may contain at least one variable domain covalently linked to at least one constant domain. Non-limiting exemplary configurations of variable and constant domains that may be found within the antigen-binding fragment of an antibody of the invention include: (i) V H -C H 1; (ii) V H -C H 2; (iii) V H -C H 3; (iv) V H -C H 1-C H 2; (v) V H -C H 1-C H 2-C H 3; (vi) V H -CH 2-C H 3; (vii) V H -C L ; (viii) V L -C H 1; (ix) V L -C H 2; (x) V L -C H 3; (xi) V L -C H 1-C H 2; (xii) V L -C H 1-C H 2-C H 3; (xiii) V L -C H 2-C H 3; and (xiv) V L -C L . In any configuration of variable domains and constant domains (including any of the exemplary configurations listed above), the variable domains and constant domains may be directly connected to each other or may be connected through a full-length or partial hinge or linker region. The hinge region may be composed of at least 2 (e.g., 5, 10, 15, 20, 40, 60 or more) amino acids, which results in a flexible or semi-flexible connection between adjacent variable domains and / or constant domains in a single polypeptide molecule. In addition, the antigen-binding fragment of the antibody of the present invention may contain any of the variable domain and constant domain configurations listed above, which are connected to each other and / or to one or more monomer V H or V L The domains are in non-covalent association (eg, through disulfide bonds) as homodimers or heterodimers (or other multimers).

[0112] As with full antibody molecules, antigen-binding fragments can be monospecific or multispecific (e.g., bispecific). A multispecific antigen-binding fragment of an antibody will generally comprise at least two different variable domains, each of which is capable of specifically binding to a separate antigen or to a different epitope on the same antigen. Any multispecific antibody format, including the exemplary bispecific antibody formats disclosed herein, can be made suitable for use in the context of an antigen-binding fragment of an antibody of the present invention using conventional techniques available in the art.

[0113] The antibodies disclosed herein can act by complement-dependent cytotoxicity (CDC) or antibody-dependent cell-mediated cytotoxicity (ADCC). "Complement-dependent cytotoxicity" (CDC) refers to the cell expressing antigen by the antibody lysis of the present invention in the presence of complement. "Antibody-dependent cell-mediated cytotoxicity" (ADCC) refers to a cell-mediated reaction in which non-specific cytotoxic cells (e.g., natural killer (NK) cells, neutrophils and macrophages) expressing Fc receptors (FcR) recognize the antibody bound on the target cell and thus cause the lysis of the target cell. CDC and ADCC can be measured using assays well known in the art and available. (See, e.g., U.S. Patent Nos. 5,500,362 and 5,821,337, and Clynes et al. (1998) Proc. Natl. Acad. Sci. (USA) 95: 652-656). The constant region of an antibody is important for the ability of an antibody to fix complement and mediate cell-dependent cytotoxicity. Therefore, the isotype of an antibody can be selected based on whether an antibody is required for antibody-mediated cytotoxicity. The antibodies of the present disclosure may include human IgG heavy chains. In various embodiments, the heavy chain constant region may be of IgG1, IgG2, IgG3, or IgG4 isotype. In some cases, the heavy chain constant region is of isotype IgG1. In some cases, the heavy chain constant region is of isotype IgG4.

[0114] In certain embodiments, antibody or bispecific antibody is human antibody.Term " human antibody " is intended to include the antibody with variable region and constant region derived from human germline immunoglobulin sequence.Human antibody of the present invention can include amino acid residues (for example, mutation introduced by random or site-directed mutagenesis in vitro or by somatic mutation in vivo) not encoded by human germline immunoglobulin sequence, for example, in CDR, particularly in CDR3.However, term " human antibody " is not intended to include the antibody that CDR sequence derived from germline of another mammalian species (such as mouse) is implanted into human framework sequence.

[0115] In some embodiments, the antibody of the present invention can be a recombinant human antibody. The term "recombinant human antibody" is intended to include all human antibodies prepared, expressed, produced or separated by recombinant means, such as antibodies expressed by recombinant expression vectors transfected into host cells (described further below), antibodies separated from recombinant human antibody combinatorial libraries (described further below), antibodies separated from transgenic animals (e.g., mice) relative to human immunoglobulin genes (see, e.g., Taylor et al., (1992) Nucl. Acids Res. 20: 6287-6295) or antibodies prepared, expressed, produced or separated by any other means involving splicing of human immunoglobulin gene sequences to other DNA sequences. Such recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences. However, in certain embodiments, such recombinant human antibodies undergo in vitro mutagenesis (or, when using transgenic animals with respect to human Ig sequences, undergo in vivo somatic mutagenesis) and thus the V H and V L The amino acid sequence of the region is derived from human germline V H and V L Sequences that are related to but that may not naturally occur within the human antibody germline repertoire in vivo.

[0116] Human antibodies can exist in two forms related to hinge heterogeneity. In one form, the immunoglobulin molecule comprises a stable four-chain construct of about 150-160 kDa, in which the dimer is held together by an interchain heavy chain disulfide bond. In the second form, the dimer is not connected via an interchain disulfide bond, and the molecule of about 75-80 kDa is composed of covalently coupled light and heavy chains (half antibodies). Even after affinity purification, these forms are extremely difficult to separate.

[0117] The frequency of the second form in various intact IgG isotypes is due to, but not limited to, structural differences associated with the hinge region isotype of the antibody. A single amino acid substitution in the hinge region of the human IgG4 hinge can significantly reduce the occurrence of the second form (Angal et al. (1993) Molecular Immunology 30:105) to levels typically observed with the human IgG1 hinge. The present invention encompasses substitutions in the hinge, C H 2 or C H Antibodies with one or more mutations in region 3 may be desirable, for example, during production to increase the yield of a desired antibody form.

[0118] The antibody can be an isolated antibody. An "isolated antibody" means an antibody that has been identified and separated and / or recovered from at least one component of its natural environment. For example, for the purposes of the present invention, an antibody that has been separated or removed from at least one component of an organism, or from a tissue or cell in which the antibody naturally exists or is naturally produced, is an "isolated antibody." An isolated antibody also includes an in situ antibody within a recombinant cell.

[0119] An isolated antibody is one that has been subjected to at least one purification or separation step. According to certain embodiments, an isolated antibody may be substantially free of other cellular material and / or chemicals.

[0120] The term "epitope" refers to an antigenic determinant that interacts with a specific antigen binding site (called a paratope) in the variable region of an antibody molecule. A single antigen may have more than one epitope. Therefore, different antibodies may bind to different regions on the antigen and may have different biological effects. Epitopes may be conformational or linear. Conformational epitopes are produced by spatial juxtaposition of amino acids from different segments of a linear polypeptide chain. Linear epitopes are produced by adjacent amino acid residues in a polypeptide chain. In some cases, an epitope may include a sugar, a phosphoryl group, or a sulfonyl group moiety on an antigen.

[0121] The term "substantial identity" or "substantially identical" when referring to a nucleic acid or a fragment thereof indicates that when optimally aligned with another nucleic acid (or its complementary strand) by appropriate nucleotide insertions or deletions, at least about 95%, and more preferably at least about 96%, 97%, 98% or 99% of the nucleotide bases are identical in nucleotide sequence as measured by any of the well-known sequence identity algorithms discussed below, such as FASTA, BLAST or Gap. In some cases, a nucleic acid molecule having substantial identity to a reference nucleic acid molecule can encode a polypeptide having an identical or substantially similar amino acid sequence to a polypeptide encoded by the reference nucleic acid molecule.

[0122] When applied to polypeptides, the term "substantially similar" or "substantially similar" means that when two peptide sequences are optimally aligned, such as by the program GAP or BESTFIT using default gap weights, there is a total of at least 95% sequence identity, even more preferably at least 98% or 99% sequence identity. Preferably, the difference in the residue positions that are not identical is a conservative amino acid substitution. "Conservative amino acid substitution" is an amino acid substitution in which an amino acid residue is substituted by another amino acid residue with a side chain (R group) having similar chemical properties (e.g., charge or hydrophobicity). Generally, conservative amino acid substitutions do not substantially change the functional properties of proteins. In the case where the conservative substitutions of two or more amino acid sequences are different from each other, the sequence identity percentage or degree of similarity can be adjusted upward to correct the conservative nature of the substitution. The means for making this adjustment are well known to those skilled in the art. See, for example, Pearson (1994) Methods Mol.Biol.24:307-331, which is incorporated herein by reference. Examples of amino acid groups containing side chains with similar chemical properties include: (1) aliphatic side chains: glycine, alanine, valine, leucine, and isoleucine; (2) aliphatic-hydroxy side chains: serine and threonine; (3) amide-containing side chains: asparagine and glutamine; (4) aromatic side chains: phenylalanine, tyrosine, and tryptophan; (5) basic side chains: lysine, arginine, and histidine; (6) acidic side chains: aspartic acid and glutamic acid, and (7) sulfur-containing side chains, i.e., cysteine ​​and methionine. Preferred conservative amino acid substitution groups are: valine-leucine-isoleucine, phenylalanine-tyrosine, lysine-arginine, alanine-valine, glutamic acid-aspartic acid, and asparagine-glutamine. Alternatively, a conservative substitution is any change with a positive value in the PAM250 log-likelihood matrix disclosed in Gonnet et al. (1992) Science 256:1443-1445, which is incorporated herein by reference. A "moderately conservative" substitution is any change with a non-negative value in the PAM250 log-likelihood matrix.

[0123] Sequence analysis software is usually used to measure the sequence similarity of polypeptides, and the sequence similarity is also referred to as sequence identity. Protein analysis software uses similarity metrics about being assigned to various displacements, deletions and other modifications (including conservative amino acid substitutions) to match similar sequences. For example, GCG software contains programs such as Gap and Bestfit, and these programs can be used with default parameters to determine the sequence homology or sequence identity between closely related polypeptides (such as homologous polypeptides from organisms of different species), or between wild-type proteins and mutant proteins thereof. See, for example, GCG version 6.1. FASTA (the program in GCG version 6.1) can also be used to compare polypeptide sequences using default or recommended parameters. FASTA (for example, FASTA2 and FASTA3) provides comparison and sequence identity percentage (Pearson (2000) the same) of the best overlapping region between query and search sequence. When the sequence of the present invention is compared with a database containing a large number of sequences from different organisms, another preferred algorithm is the computer program BLAST using default parameters, especially BLASTP or TBLASTN. See, e.g., Altschul et al. (1990) J. Mol. Biol. 215:403-410 and Altschul et al. (1997) Nucleic Acids Res. 25:3389-402, each of which is incorporated herein by reference.

[0124] Dosage regimen

[0125] Provided in the present disclosure is a dosing regimen for treating B cell malignancies by administering bispecific antibodies to patients, thereby reducing the incidence or severity of cytokine release syndrome (CRS) or infusion-related reactions (IRR) or both. According to certain embodiments of the present invention, these dosing regimens include administering multiple doses of bispecific antibodies during a defined time course. The dosing regimen includes sequentially administering multiple defined doses of bispecific antibodies to the subject, and administering premedication (e.g., steroids and antihistamines) to minimize or eliminate the risk of adverse events associated with administering T cell engagement bispecific antibodies. "Sequential administration" means administering each dose of bispecific antibodies to the subject at different time points, such as at different days separated by a predetermined interval (e.g., hours, days, weeks or months). The present invention includes a dosing regimen, which includes sequentially administering bispecific antibodies in divided doses, followed by administering a single dose of bispecific antibodies. The administration regimen of the present invention allows for higher doses of therapeutic proteins, which is ideal for enhancing the therapeutic effect, but without the deleterious effects associated with CRS or IRR. Without intending to be bound by any particular theory, the administration regimens of the present invention provide for elicitation of an immune response to administration of the bispecific antibody to minimize the incidence and severity of CRS and IRR during the initial phase of the treatment regimen, and then allow for administration of higher doses of the bispecific antibody during subsequent phases of the treatment regimen without significant adverse events associated with CRS or IRR.

[0126] The dosing regimen according to the present invention comprises administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating a B-cell malignancy, wherein the dosing regimen comprises: (a) administering an initial dose of 0.7 mg of the bispecific antibody to the subject, wherein the initial dose is divided into a first dose portion comprising 0.2 mg of the bispecific antibody and a second dose portion comprising 0.5 mg of the bispecific antibody, wherein the first dose portion is administered to the subject within two days during week 1 of the dosing regimen, followed by administration of the second dose portion; (b) administering a first intermediate dose of 4 mg of the bispecific antibody to the subject, wherein the first intermediate dose is divided into two equal portions (a first portion and a second portion) and a second portion (b). (c) administering to the subject a second intermediate dose of 20 mg of the bispecific antibody, wherein the second intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 10 mg of the bispecific antibody, wherein the two parts of the second intermediate dose are administered on two days during the third week of the dosing regimen; (d) during weeks 4 to 12 of the dosing regimen, administering to the subject a full dose of the bispecific antibody each week; and (e) administering to the subject a maintenance dose of the bispecific antibody at week 14 of the dosing regimen. In some embodiments, the initial dose (0.7 mg) can be divided into other parts, such as 0.1 mg and 0.6 mg, 0.15 mg and 0.55 mg, 0.25 mg and 0.45 mg, or 0.3 mg and 0.4 mg.

[0127] If there are no Grade 3 or higher CRS events when the subject is administered the initial dose, the first intermediate dose, or the second intermediate dose, the full dose is administered to the subject as a single dose during Weeks 4 to 12 of the dosing regimen. On the other hand, if the subject experiences a Grade 3 or higher CRS event when the initial dose, the first intermediate dose, or the second intermediate dose is administered, the full dose of the bispecific antibody administered to the subject during Week 4 is divided into two equal parts, and the two parts of the full dose are administered on two days during Week 4 of the dosing regimen, and thereafter the full dose is administered to the subject as a single dose during Weeks 5 to 12 of the dosing regimen.

[0128] Because the weekly administration of the full dose is carried out from the 4th week to the 12th week of the dosing regimen, the first maintenance dose administered every other week (Q2W) will be administered at the 14th week of the dosing regimen. The Q2W administration of the maintenance dose can continue indefinitely, or if, for example, the subject has shown a lasting response of at least nine months after initially determining a complete response, it can be modified to administer a maintenance dose once every four weeks (Q4W). Therefore, in some embodiments, starting from the subsequent week of the dosing regimen, a maintenance dose is administered to the subject every four weeks, wherein the subsequent week is at least the 36th week of the dosing regimen. In various embodiments, the subsequent week can be the 36th, 37th, 38th, 39th, 40th, 41st, 42nd, 43rd, 44th, 45th, 46th, 47th, 48th, 49th, 50th, 51st, 52nd, 53rd, 54th, 55th, 56th, 57th, 58th, 59th or 60th week of the dosing regimen or a higher numbered week. The Q4W administration of the maintenance dose can also continue indefinitely.

[0129] In certain embodiments, the weekly administration of the full dose is carried out from the 4th week to the 6th week of the dosing regimen, and the first maintenance dose administered every other week (Q2W) will be administered at the beginning of the 8th week of the dosing regimen. The Q2W administration of the maintenance dose can be sustained for at least 2 cycles, and can be modified to administer a maintenance dose once every eight weeks (Q8W) afterwards. Therefore, in some embodiments, starting from the subsequent week of the dosing regimen, a maintenance dose is administered to the subject every eight weeks, wherein the subsequent week is at least the 18th week of the dosing regimen. In various embodiments, the subsequent week can be the 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30th, 31st, 32nd, 33rd, 34th, 35th, 36th week of the dosing regimen or a week with higher numbers. The Q8W administration of the maintenance dose can also continue indefinitely.

[0130] In certain embodiments, the dosing regimen may include a combination therapy including a bispecific anti-CD20×anti-CD3 antibody (e.g., onetumab) and CHOP (a combination of cyclophosphamide, doxorubicin, vincristine, and prednisone). In certain embodiments, the dosing regimen may include a combination therapy including a bispecific anti-CD20×anti-CD3 antibody (e.g., onetumab) and CVP (a combination of cyclophosphamide, vincristine, and prednisone). In embodiments where the bispecific antibody is combined with CHOP or CVP, the first CHOP / CVP administration may be given in the week prior to the first week of the dosing regimen (the first week is the time when the first dose of the bispecific antibody is administered), and the first maintenance dose of the bispecific antibody may be administered in the 13th week of the dosing regimen (rather than the 14th week). In some embodiments, CHOP / CVP is administered during weeks 3, 6, 9, 12, and 15 of the dosing regimen in addition to the week prior to the first week (i.e., in week 0 of the dosing regimen).

[0131] In some embodiments, cyclophosphamide is administered at 750 mg / m 2 Doxorubicin was administered at a dose of 50 mg / m 2 vincristine was administered at a dose of 1.4 mg / m 2 The invention relates to a method of treating a patient with cyclophosphamide, doxorubicin, and vincristine. The method comprises administering cyclophosphamide, doxorubicin, and vincristine once in Week 0 of the dosing regimen and once each in Weeks 3, 6, 9, 12, and 15 of the dosing regimen, and administering prednisone for five consecutive days in Week 0 of the dosing regimen and for five consecutive days each in Weeks 3, 6, 9, 12, and 15 of the dosing regimen.

[0132] As described above, the split dose (i.e., the initial dose, the first intermediate dose, and the second intermediate dose) is applied within two days during the relevant week of the dosing regimen. In this context, these two days refer to two calendar days (e.g., Monday and Tuesday, or May 10 and May 11). In some cases, these two days are consecutive days. In some cases, these two days are not consecutive days, but are no more than three days apart. For example, the first dose portion of the initial dose can be applied on Monday, and the second dose portion of the initial dose can be applied on Wednesday or Thursday. In some cases, the second dose portion of the initial dose is applied to the subject 18 to 96 hours after the first dose portion of the initial dose. In some cases, the second dose portion of the initial dose is applied to the subject 18 to 72 hours after the first dose portion of the initial dose. In some cases, the second dose portion of the initial dose is applied to the subject 24 to 48 hours after the first dose portion of the initial dose. In some cases, the two portions of the first intermediate dose are applied to the subject 18 to 96 hours apart. In some cases, the two portions of the first intermediate dose are applied to the subject 18 to 72 hours apart. In some cases, the two parts of the first intermediate dose are administered to the subject at a distance of 24 to 48 hours. In some cases, the two parts of the second intermediate dose are administered to the subject at a distance of 18 to 96 hours. In some cases, the two parts of the second intermediate dose are administered to the subject at a distance of 18 to 72 hours. In some cases, the two parts of the second intermediate dose are administered to the subject at a distance of 24 to 48 hours. In the case where a complete dose is divided into two parts, the two parts of a complete dose are administered to the subject at a distance of 18 to 96 hours. In some cases, the two parts of a complete dose are administered to the subject at a distance of 18 to 72 hours. In some cases, the two parts of a complete dose are administered to the subject at a distance of 24 to 48 hours. In any of these embodiments, no matter how many hours (e.g., 18 hours) the administration interval of the two parts, the two parts are administered on different calendar days.

[0133] In any of the various dosing regimens, the B cell malignancy that the subject is being treated for can be a B cell non-Hodgkin lymphoma. In some cases, the B cell malignancy is follicular lymphoma, diffuse large B cell lymphoma, mantle cell lymphoma or marginal zone lymphoma. In various embodiments, the subject is an adult (18 years old or more) diagnosed with a specific B cell malignancy.

[0134] In various embodiments of the dosing regimen, the full dose of the bispecific antibody is 40mg to 320mg, or 80mg to 320mg. In various embodiments of the dosing regimen, the maintenance dose of the bispecific antibody is 80mg to 320mg, or 160mg to 320mg. The full dose and / or maintenance dose of the bispecific antibody may vary according to the specific type of B cell malignancies treated. For example, when the cancer is follicular lymphoma (e.g., grade 1-3a), the full dose is 80mg and the maintenance dose is 160mg. In another example, when the cancer is diffuse large B cell lymphoma (e.g., DLBCL, where the subject's previous CAR-T therapy failed), the full dose is 160mg and the maintenance dose is 320mg, or the full dose is 320mg and the maintenance dose is 320mg. In another example, when the cancer is mantle cell lymphoma (e.g., MCL, in which the subject has failed prior Bruton's tyrosine kinase (BTK) inhibitor therapy), the full dose is 160 mg and the maintenance dose is 320 mg. In another example, when the cancer is marginal zone lymphoma, the full dose is 80 mg and the maintenance dose is 160 mg. In another example, when the cancer is non-Hodgkin's lymphoma other than follicular lymphoma, diffuse large B-cell lymphoma, mantle cell lymphoma, or marginal zone lymphoma, the full dose is 160 mg and the maintenance dose is 320 mg. In another example, when the cancer is an aggressive lymphoma, the full dose is 160 mg and the maintenance dose is 320 mg.

[0135] Although it is contemplated that subjects will receive the doses described herein in a dosing regimen over consecutive weeks (i.e., where, in terms of calendar weeks, Week 2 follows Week 1, Week 3 follows Week 2, etc.), in some cases, there may be a delay in dosing such that the next week does not immediately follow the previous calendar week. For example, Week 1 of a dosing regimen may correspond to Calendar Week 1, and Week 2 of a dosing regimen may correspond to Calendar Week 3 or Calendar Week 4.

[0136] In various embodiments, the dosing regimen also includes administering a dose of steroids to the subject at the following time: 12 to 24 hours before administering the first dose portion of the initial dose; 12 to 24 hours before administering the first portion of the first intermediate dose; and 12 to 24 hours before administering the first portion of the second intermediate dose. In those cases where the first dose portion of the initial dose and the second dose portion of the initial dose are not administered to the subject for consecutive days (i.e., consecutive calendar days), the dosing regimen also includes administering a dose of steroids to the subject 12 to 24 hours before administering the second dose portion of the initial dose of the bispecific antibody. Similarly, if the first portion of the first intermediate dose and the second portion of the first intermediate dose are not administered to the subject for consecutive days, and / or the first portion of the second intermediate dose and the second portion of the second intermediate dose are not administered to the subject for consecutive days, the dosing regimen also includes administering a dose of steroids to the subject 12 to 24 hours before administering the second portion of the first intermediate dose of the bispecific antibody, and / or administering a dose of steroids to the subject 12 to 24 hours before administering the second portion of the first intermediate dose of the bispecific antibody.

[0137] In some embodiments of the dosing regimen, the subject has relapsed or refractory disease. In some embodiments of the dosing regimen, the subject is refractory to anti-CD20 antibodies in any prior line of therapy.

[0138] In some embodiments of the dosing regimen, the subject is previously naive, ie, has not been previously treated with any systemic anti-lymphoma therapy.

[0139] In some embodiments of the dosing regimen, the B cell malignancy is follicular lymphoma. In some embodiments of the dosing regimen, the B cell malignancy is diffuse large B cell lymphoma.

[0140] In some embodiments of the dosing regimen, the subject is a human ≥ 18 years of age.

[0141] In various embodiments of the dosing regimens discussed above, the bispecific antibody is administered intravenously to the subject.

[0142] In other embodiments of the dosing regimen, the bispecific antibody is administered subcutaneously (SC) to the subject.

[0143] An exemplary SC dosing regimen comprises: administering to the subject an initial dose of 1 mg or 2 mg of the bispecific antibody during week 1 of the dosing regimen; administering to the subject a first intermediate dose of 10 mg or 26 mg of the bispecific antibody during week 2 of the dosing regimen; administering to the subject a second intermediate dose of 50 mg or 100 mg of the bispecific antibody during week 3 of the dosing regimen; and administering to the subject a full dose of the bispecific antibody during week 4 and the following week of the dosing regimen, wherein the bispecific antibody comprises a first antigen binding region that binds to human CD20 and a second antigen binding region that binds to human CD3, wherein the first antigen binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2, and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8, and 9, respectively, and three light chain complementary determining regions LCDR1, LCDR2, and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14, and 15, respectively, and wherein the second antigen binding region ... second antigen binding region that binds to human CD3, respectively. The three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 contain the amino acid sequences of SEQ ID NOs: 10, 11 and 12, and the three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 contain the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively.

[0144] In some embodiments of the SC dosing regimen, the initial dose is 2 mg. In some embodiments of the SC dosing regimen, the first intermediate dose is 26 mg. In some embodiments of the SC dosing regimen, the second intermediate dose is 100 mg. In some embodiments of the SC dosing regimen, the full dose is 200 mg, 400 mg, or 600 mg. In some cases, the full dose is 400 mg. In some cases, the full dose is 600 mg.

[0145] In some embodiments of the SC dosing regimen, a full dose is administered to the subject once every three weeks. In some embodiments of the SC dosing regimen, a full dose is administered to the subject weekly. In some cases of the SC dosing regimen, a full dose is administered to the subject weekly for three weeks, and then a full dose is administered to the subject once every three weeks.

[0146] In some embodiments of the SC dosing regimen, the subject has relapsed or refractory disease. In some embodiments of the SC dosing regimen, the subject is refractory to anti-CD20 antibody on any prior line of therapy.

[0147] In some embodiments of the SC dosing regimen, the subject is previously naive, ie, has not been previously treated with any systemic anti-lymphoma therapy.

[0148] In some embodiments of the SC dosing regimen, the B cell malignancy is follicular lymphoma. In some embodiments of the SC dosing regimen, the B cell malignancy is diffuse large B cell lymphoma.

[0149] In some embodiments of the SC dosing regimen, the subject is a human > 18 years of age.

[0150] In some embodiments, the dosing regimen is intended for administration of the bispecific antibody to pediatric subjects (eg, less than 18 years of age).

[0151] An exemplary pediatric dosing regimen comprises: administering to the subject an initial dose of the bispecific antibody, wherein the initial dose is divided into a first dose portion of the bispecific antibody and a second dose portion of the bispecific antibody, wherein the first dose portion is administered to the subject on two days during week 1 of the dosing regimen, followed by administration of the second dose portion; administering to the subject a first intermediate dose of the bispecific antibody, wherein the first intermediate dose is divided into two equal portions (a first portion and a second portion) of the bispecific antibody, wherein the two portions of the first intermediate dose are administered on two days during week 2 of the dosing regimen; administering to the subject a second intermediate dose of the bispecific antibody, wherein the second intermediate dose is divided into two equal portions (a first portion and a second portion) of the bispecific antibody, wherein the two portions of the first intermediate dose are administered on two days during week 3 of the dosing regimen; the first intermediate dose, the second intermediate dose, the full dose, and the maintenance dose depend on the weight of the subject: (i) if the subject weighs 40 kg to less than 165 kg, the initial dose is 0.7 mg, the first dose portion of the initial dose is 0.2 mg, the second dose portion of the initial dose is 0.5 mg, the first intermediate dose is 4 mg, and the two equal portions of the first intermediate dose each contain The first dose is 2 mg, the second intermediate dose is 20 mg, the two equal parts of the second intermediate dose each contain 10 mg, the full dose is 160 mg, and the maintenance dose is 320 mg; (ii) if the subject weighs 20 kg to less than 40 kg, the initial dose is 0.4 mg, the first dose part of the initial dose is 0.1 mg, the second dose part of the initial dose is 0.3 mg, the first intermediate dose is 2 mg, the two equal parts of the first intermediate dose each contain 1 mg, the second intermediate dose is 12 mg, the two equal parts of the second intermediate dose each contain 6 mg, the full dose is 90 mg, and the maintenance dose is 150 mg; (iii) if the subject weighs 10 kg to less than 20 kg g, the initial dose is 0.3 mg, the first dose portion of the initial dose is 0.1 mg, the second dose portion of the initial dose is 0.2 mg, the first intermediate dose is 1.6 mg, the two equal portions of the first intermediate dose each contain 0.8 mg, the second intermediate dose is 8 mg, the two equal portions of the second intermediate dose each contain 4 mg, the full dose is 60 mg, and the maintenance dose is 100 mg; or (iv) if the subject weighs 6 kg to less than 10 kg, the initial dose is 0.24 mg, the first dose portion of the initial dose is 0.07 mg, the second dose portion of the initial dose is 0.17 mg, the first intermediate dose is 1.2 mg, the two equal portions of the first intermediate dose each contain 0.6 mg, a second intermediate dose of 6 mg, two equal parts of the second intermediate dose each containing 3 mg, a full dose of 45 mg, and a maintenance dose of 75 mg; and wherein the bispecific antibody comprises a first antigen-binding region that binds to human CD20 and a second antigen-binding region that binds to human CD3, wherein the first antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8 and 9, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively, and wherein the second antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively. .

[0152] In some embodiments of the pediatric dosing regimen, the full dose is administered as a single dose to the subject during weeks 4 to 12 of the dosing regimen. In some embodiments of the pediatric dosing regimen, the subject is administered a maintenance dose every two weeks starting from week 14 of the dosing regimen.

[0153] In some embodiments of the pediatric dosing regimen, the second dose portion of the initial dose is administered to the subject 18 to 96 hours after the first dose portion of the initial dose. In some embodiments of the pediatric dosing regimen, the two portions of the first intermediate dose are administered to the subject 18 to 96 hours apart. In some embodiments of the pediatric dosing regimen, the two portions of the second intermediate dose are administered to the subject 18 to 96 hours apart.

[0154] In some embodiments of the pediatric dosing regimen, the two days are consecutive days. In some embodiments of the pediatric dosing regimen, the two days are no more than three days apart.

[0155] In some embodiments of the pediatric dosing regimen, the B cell malignancy is a B cell non-Hodgkin lymphoma. In some embodiments of the pediatric dosing regimen, the B cell malignancy is a follicular lymphoma, a diffuse large B cell lymphoma, a mantle cell lymphoma, or a marginal zone lymphoma.

[0156] In any of the various embodiments of the pediatric dosing regimen, the bispecific antibody can be administered intravenously.

[0157] In various embodiments, the dosing regimen further comprises administering to the subject a dose of a steroid 1 to 3 hours prior to administering the first dose portion of the initial dose; 1 to 3 hours prior to administering the second dose portion of the initial dose; and 1 to 3 hours prior to administering each portion of the first intermediate dose and the second intermediate dose, and administering to the subject a dose of an antihistamine 30 to 60 minutes prior to administering the first dose portion of the initial dose; 30 to 60 minutes prior to administering the second dose portion of the initial dose; and 30 to 60 minutes prior to administering each portion of the first intermediate dose and the second intermediate dose, and optionally administering to the subject a dose of acetaminophen 30 to 60 minutes prior to administering the first dose portion of the initial dose; 30 to 60 minutes prior to administering the second dose portion of the initial dose; and 30 to 60 minutes prior to administering each portion of the first intermediate dose and the second intermediate dose.

[0158] In various embodiments, the dosing regimen further comprises administering to the subject a dose of the steroid at the following times: 20 to 28 hours after the completion of the second dose portion of the initial dose; 20 to 28 hours after the completion of the second portion of the first intermediate dose; and 20 to 28 hours after the completion of the second portion of the second intermediate dose.

[0159] In various embodiments in which the subject does not experience a Grade 3 or higher CRS event when the initial dose, the first intermediate dose, or the second intermediate dose is administered to the subject and the full dose is administered to the subject as a single dose during Week 4, the dosing regimen further includes: administering a dose of a steroid to the subject 1 to 3 hours prior to administering the full dose during Week 4 of the dosing regimen; and administering a dose of an antihistamine to the subject 30 to 60 minutes prior to administering the full dose during Week 4 of the dosing regimen, and optionally administering a dose of acetaminophen to the subject 30 to 60 minutes prior to administering the full dose during Week 4 of the dosing regimen. In addition, in some embodiments, the dosing regimen further includes administering a dose of a steroid to the subject 20 to 28 hours after the end of administering the full dose during Week 4 of the dosing regimen.

[0160] In those embodiments of the dosing regimen in which the subject experiences a Grade 3 or higher CRS event when the initial dose, the first intermediate dose, or the second intermediate dose is administered and the full dose of the bispecific antibody administered to the subject during Week 4 is divided into two equal parts (a first part and a second part), then the dosing regimen further includes: administering a dose of a steroid to the subject 12 to 24 hours before administering the full dose of the first part; administering a dose of a steroid to the subject 1 to 3 hours before administering the full dose of the first part; and administering a dose of an antihistamine to the subject 30 to 60 minutes before administering the full dose of the first part, and optionally administering a dose of acetaminophen to the subject 30 to 60 minutes before administering the full dose of the first part.

[0161] In those cases where the subject is not administered a full dose of the first part and a full dose of the second part on consecutive days, then the dosing regimen further includes administering to the subject a dose of a steroid 12 to 24 hours prior to administration of the full dose of the second part of the bispecific antibody.

[0162] In addition, in those cases where the subject experiences a grade 3 or higher CRS event when the initial dose, the first intermediate dose, or the second intermediate dose is administered, the dosing regimen further includes: administering a dose of steroids to the subject 1 to 3 hours before the full dose is administered during the 5th week of the dosing regimen; and administering a dose of antihistamine to the subject 30 to 60 minutes before the full dose is administered during the 5th week of the dosing regimen, and optionally administering a dose of acetaminophen to the subject 30 to 60 minutes before the full dose is administered during the 5th week of the dosing regimen. In addition, in some embodiments, the dosing regimen further includes administering a dose of steroids to the subject 20 to 28 hours after the full dose is administered during the 5th week of the dosing regimen.

[0163] In various embodiments, administering a dose of steroids, administering a dose of antihistamines, or administering a dose of acetaminophen includes instructing the subject to take the dose of steroids, the dose of antihistamines, or the dose of acetaminophen, respectively. In some cases, the subject can orally administer steroids, antihistamines, or acetaminophen by themselves, so the administration behavior is only the guidance of self-administering the drug. In other cases, administering a dose of steroids or administering a dose of antihistamines includes intravenously administering the dose of steroids or the dose of antihistamines. In some cases, steroids or antihistamines can be administered by a doctor, such as intravenously or by injection.

[0164] In various embodiments, the steroid is dexamethasone, and in some cases the dose is 20 mg. In other embodiments, the steroid is another equivalent steroid.

[0165] In various embodiments, the antihistamine is diphenhydramine, and the dosage is 25 mg. In other embodiments, the antihistamine is another equivalent antihistamine.

[0166] In various embodiments, the dose of acetaminophen is 650 mg. In some cases, acetaminophen may not be administered as part of the dosing regimen if, for example, the subject has received or taken acetaminophen within 4 hours prior to administration of the dose of the bispecific antibody, or if the subject is allergic to acetaminophen.

[0167] In various embodiments, the dosing regimen further comprises administering an anti-IL6 therapy (eg, an anti-IL6 receptor antibody such as salirumab or tocilizumab).

[0168] In those cases where the subject does not experience any grade of IRR or CRS after the first full dose of the bispecific antibody administered as a single dose (i.e., at week 4 or week 5 of the dosing regimen), the dose of steroids (e.g., dexamethasone) may be reduced to 10 mg for the subsequent full dose. Similarly, if the subject does not experience any grade of IRR or CRS after the full dose and the reduced steroid dose (e.g., 10 mg dexamethasone), subsequent doses of the bispecific antibody may be administered without premedication.

[0169] In any of the embodiments of the dosing regimens discussed above, the bispecific antibody may be as discussed herein or below.

[0170] Bispecific Antibodies

[0171] In various embodiments of the present disclosure, the bispecific antibody comprises A1-HCDR1, A1-HCDR2 and A1-HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8 and 9, respectively; A2-HCDR1, A2-HCDR2 and A2-HCDR3 comprising the amino acid sequences of SEQ ID NOs: 10, 11 and 12, respectively; and LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively.

[0172] In some embodiments, the first antigen binding domain comprises a HCVR having at least 90% identity to the amino acid sequence of SEQ ID NO: 4 and a LCVR having at least 90% identity to the amino acid sequence of SEQ ID NO: 6, and the second antigen binding domain comprises a HCVR having at least 90% identity to the amino acid sequence of SEQ ID NO: 5 and a LCVR having at least 90% identity to the amino acid sequence of SEQ ID NO: 6. In some embodiments, the first antigen binding domain comprises a HCVR having at least 95% identity to the amino acid sequence of SEQ ID NO: 4 and a LCVR having at least 95% identity to the amino acid sequence of SEQ ID NO: 6, and the second antigen binding domain comprises a HCVR having at least 95% identity to the amino acid sequence of SEQ ID NO: 5 and a LCVR having at least 95% identity to the amino acid sequence of SEQ ID NO: 6. In some embodiments, the first antigen binding domain comprises a HCVR that is at least 99% identical to the amino acid sequence of SEQ ID NO:4 and a LCVR that is at least 99% identical to the amino acid sequence of SEQ ID NO:6, and the second antigen binding domain comprises a HCVR that is at least 99% identical to the amino acid sequence of SEQ ID NO:5 and a LCVR that is at least 99% identical to the amino acid sequence of SEQ ID NO:6.

[0173] In various embodiments, the first antigen binding domain comprises a HCVR comprising the amino acid sequence of SEQ ID NO:4 and a LCVR comprising the amino acid sequence of SEQ ID NO:6, and the second antigen binding domain comprises a HCVR comprising the amino acid sequence of SEQ ID NO:5 and a LCVR comprising the amino acid sequence of SEQ ID NO:6.

[0174] The present disclosure also includes a first C H 3 domain and the second Ig C H 3-domain bispecific antibody, wherein the first and second Ig C H The at least one amino acid in the first Ig C domain and the second Ig C domain differs from each other, and wherein the at least one amino acid difference reduces binding of the bispecific antibody to protein A compared to a bispecific antibody lacking the amino acid difference. H 3 domains bind protein A and the second Ig C H The 3 domain contains a mutation that reduces or eliminates protein A binding, such as the H95R modification (according to IMGT exon numbering; H435R according to EU numbering). H3 may also contain a Y96F modification (according to IMGT; Y436F according to EU). See, e.g., U.S. Pat. No. 8,586,713. H Other modifications within 3 include: D16E, L18M, N44S, K52N, V57M and V82I (by IMGT; D356E, L358M, N384S, K392N, V397M and V422I by EU) in the case of IgG1 antibodies; N44S, K52N and V82I (IMGT; N384S, K392N and V422I by EU) in the case of IgG2 antibodies; and Q15R, N44S, K52N, V57M, R69K, E79Q and V82I (by IMGT; Q355R, N384S, K392N, V397M, R409K, E419Q and V422I by EU) in the case of IgG4 antibodies.

[0175] In some embodiments, the bispecific antibody comprises a human IgG heavy chain constant region attached to the HCVR of each of the first antigen-binding domain and the second antigen-binding domain. In some cases, the heavy chain constant region belongs to isotype IgG1. In some cases, the heavy chain constant region belongs to isotype IgG4. In some embodiments, the heavy chain constant region attached to the HCVR of the first antigen-binding domain or the heavy chain constant region attached to the HCVR of the second antigen-binding domain, but not both, contains amino acid modifications, which reduce the binding of protein A relative to the heavy chain of the same isotype that is not modified. In some cases, the modification includes H435R substitutions (EU numbering) in isotype IgG1 or IgG4 heavy chains. In some cases, the modification includes H435R substitutions and Y436F substitutions (EU numbering) in isotype IgG1 or IgG4 heavy chains.

[0176] In certain embodiments, the Fc domain can be chimeric, combining Fc sequences from more than one immunoglobulin isotype. For example, a chimeric Fc domain can comprise Fc sequences from human IgG1, human IgG2, or human IgG4. H C in Zone 2 H 2 sequence, and C derived from human IgG1, human IgG2 or human IgG4 H 3 sequence. The chimeric Fc domain may also contain a chimeric hinge region. For example, the chimeric hinge may comprise an "upper hinge" sequence derived from the hinge region of human IgG1, human IgG2, or human IgG4, combined with a "lower hinge" sequence derived from the hinge region of human IgG1, human IgG2, or human IgG4. Specific examples of chimeric Fc domains that may be included in any antigen-binding molecule described herein include, from N-terminus to C-terminus: [IgG4 CH 1]-[IgG4 upper hinge]-[IgG2 lower hinge]-[IgG4 CH2]-[IgG4 CH3]. Another example of a chimeric Fc domain that can be included in any antigen-binding molecule described herein comprises, from N-terminus to C-terminus: [IgG1 C H

[00136] In some embodiments, the chimeric Fc domains of the present invention may be included in any antigen-binding molecule of the present invention.

[00137] In some embodiments, the chimeric Fc domains of the present invention may be included in any antigen-binding molecule of the present invention.

[00138] In some embodiments, the chimeric Fc domains of the present invention may be included in any antigen-binding molecule of the present invention. [00139 ...1] In some embodiments, the chimeric Fc domains of the present invention may be included in any antigen-binding molecule of the present invention.

[00133] In some embodiments, the chimeric Fc domains of the present invention may be included in any antigen-binding molecule of the present invention.

[00134] In some embodiments, the chimeric Fc domains of the present invention may be included in any antigen-binding molecule of the present invention.

[00135]

[0177] In some embodiments, bispecific antibodies include chimeric hinges. For example, in embodiments, chimeric hinges include a first amino acid sequence or "upper hinge" sequence derived from a human IgG1 hinge region or a human IgG4 hinge region, and a second amino acid sequence or "lower hinge" sequence derived from a human IgG2 hinge region. In certain embodiments, the first or "upper hinge" sequence includes amino acid residues at positions 216 to 227 (according to EU numbering). In some embodiments, the second or "lower hinge" sequence includes amino acid residues at positions 228 to 236 (according to EU numbering). In some cases where the antibody heavy chain constant region belongs to isotype IgG4, the chimeric hinge includes an upper hinge sequence from human IgG4 (according to EU numbering of 216 to 227) and a lower hinge sequence from human IgG2 (according to EU numbering of 228 to 236). In some cases where the antibody heavy chain constant region belongs to isotype IgG1, the chimeric hinge comprises an upper hinge sequence from human IgG1 (according to positions 216 to 227 of EU numbering) and a lower hinge sequence from human IgG2 (according to positions 228 to 236 of EU numbering). In some embodiments where the heavy chain constant region belongs to isotype IgG1 and the antibody comprises a chimeric hinge, the CH2 domain of the IgG1 heavy chain constant region belongs to isotype IgG4 in addition. Unless otherwise indicated, reference to IgG1 or IgG4 heavy chain constant region includes a heavy chain constant region containing a chimeric hinge (e.g., an upper hinge sequence of IgG1 or IgG4 and a lower hinge sequence of IgG2, respectively). For example, reference to IgG1 heavy chain constant region includes an IgG1 heavy chain constant region containing an IgG2 lower hinge sequence, and reference to IgG4 heavy chain constant region includes an IgG4 heavy chain constant region containing an IgG2 lower hinge sequence.

[0178] In some embodiments, the bispecific antibody comprises a heavy chain constant region comprising an amino acid sequence selected from the group consisting of SEQ ID NOs: 16, 17, 18, and 19. In some embodiments, the bispecific antibody comprises a heavy chain constant region comprising the amino acid sequence of SEQ ID NO: 16 and a heavy chain constant region comprising the amino acid sequence of SEQ ID NO: 17. In some embodiments, the bispecific antibody comprises a heavy chain constant region comprising the amino acid sequence of SEQ ID NO: 18 and a heavy chain constant region comprising the amino acid sequence of SEQ ID NO: 19.

[0179] In various embodiments, the antibody comprises a first heavy chain comprising a HCVR comprising a first antigen binding domain and a second heavy chain comprising a HCVR comprising a second antigen binding domain, wherein the first heavy chain comprises residues 1-452 of the amino acid sequence of SEQ ID NO: 1 and the second heavy chain comprises residues 1-448 of the amino acid sequence of SEQ ID NO: 2. In some embodiments, the antibody further comprises a common light chain comprising a LCVR of the first and second antigen binding domains, wherein the common light chain comprises the amino acid sequence of SEQ ID NO: 3.

[0180] In various embodiments of any of the pharmaceutical compositions discussed above or herein, the antibody comprises a first heavy chain comprising a HCVR comprising a first antigen binding domain and a second heavy chain comprising a HCVR comprising a second antigen binding domain, wherein the first heavy chain comprises the amino acid sequence of SEQ ID NO: 1, and the second heavy chain comprises the amino acid sequence of SEQ ID NO: 2. In some embodiments, the antibody further comprises a common light chain comprising a LCVR of the first and second antigen binding domains, wherein the common light chain comprises the amino acid sequence of SEQ ID NO: 3.

[0181] The first antigen-binding domain and the second antigen-binding domain can be directly or indirectly connected to each other to form the bispecific antibody of the present invention. Alternatively, the first antigen-binding domain and the second antigen-binding domain can each be connected to a separate multimeric domain. The combination of a multimeric domain with another multimeric domain promotes the combination between the two antigen-binding domains, thereby forming a bispecific antigen-binding molecule. "Multimeric domain" is any macromolecule, protein, polypeptide, peptide or amino acid that has the ability to bind to a second multimeric domain of the same or similar structure or structure. For example, the multimeric domain can be a domain comprising immunoglobulin C H A non-limiting example of a multimeric component is the Fc portion of an immunoglobulin (comprising C H 2-C H3 domains), such as an Fc domain of IgG selected from the group consisting of isotypes IgG1, IgG2, IgG3, and IgG4, and any allotype of IgG within each isotype group.

[0182] The bispecific antibodies of the present disclosure generally comprise two multimerization domains, such as two Fc domains, which are respectively parts of a single antibody heavy chain. The first multimerization domain and the second multimerization domain may have the same IgG isotype, such as IgG1 / IgG1, IgG2 / IgG2, IgG4 / IgG4. Alternatively, the first multimerization domain and the second multimerization domain may have different IgG isotypes, such as IgG1 / IgG2, IgG1 / IgG4, IgG2 / IgG4, etc.

[0183] In certain embodiments, the multimerization domain is an Fc fragment or an amino acid sequence of 1 to about 200 amino acids in length, which comprises at least one cysteine ​​residue. In other embodiments, the multimerization domain is a cysteine ​​residue or a short peptide containing cysteine. Other multimerization domains include peptides or polypeptides comprising or consisting of a leucine zipper, a helical loop motif, or a coiled coil motif.

[0184] Combination characteristics

[0185] The term "binding" in the context of binding of an antibody (e.g., a bispecific antibody) to, for example, a predetermined antigen (such as a cell surface protein) or a fragment thereof, generally refers to an interaction or association between at least two entities or molecular structures, such as an antibody-antigen interaction.

[0186] For example, when measured by, for example, surface plasmon resonance (SPR) technology in a BIAcore 3000 instrument using an antigen as a ligand and an antibody, Ig, antibody binding fragment or Fc-containing protein as an analyte (or anti-ligand), binding affinity generally corresponds to a K D The value is about 10 -7 M or less, such as about 10 -8 M or less, such as about 10 -9 M or less. Cell-based binding strategies, such as fluorescence activated cell sorting (FACS) binding assays are also frequently used, and FACS data correlate well with other methods such as radioligand competition binding and SPR (Benedict, CA, J Immunol Methods. 1997, 201(2):223-31; Geuijen, CA et al., J Immunol Methods. 2005, 302(1-2):68-77).

[0187] Thus, the antibodies or antigen-binding proteins of the present invention bind to a predetermined antigen or cell surface molecule (receptor) with an affinity corresponding to KD The affinity of the binding agent K is at least ten times lower than its affinity for binding to non-specific antigens (e.g., BSA, casein). D Antibodies with affinities equal to or less than ten times that of the nonspecific antigen may be considered to have no detectable binding, yet such antibodies may be paired with a second antigen-binding arm for use in generating the bispecific antibodies of the invention.

[0188] The term "K D "(M)" refers to the dissociation equilibrium constant of a specific antibody-antigen interaction, or the dissociation equilibrium constant of the binding of an antibody or antibody binding fragment to an antigen. K D There is an inverse relationship between K and binding affinity, so K D The smaller the value, the higher the affinity, i.e. the stronger it is. Therefore, the term "higher affinity" or "stronger affinity" relates to a higher ability to form an interaction, and thus K D In contrast, the term "lower affinity" or "weaker affinity" relates to a lower ability to form an interaction, so K D In some cases, the value is larger than the numerator ( 例如 A higher binding affinity (or KD) of a particular molecule (e.g., an antibody) to its interacting partner molecule (e.g., antigen X) compared to the binding affinity of an antibody to another interacting partner molecule (e.g., antigen Y) can be expressed by substituting a larger KD for D value (lower or weaker affinity) divided by the smaller K D The binding ratio is determined by comparing the binding affinity of the target protein to that of the target protein (higher or stronger affinity), for example, expressed as a 5-fold or 10-fold greater binding affinity, as the case may be.

[0189] The term “k d "(seconds-1 or 1 / s) refers to the dissociation rate constant for a specific antibody-antigen interaction, or the dissociation rate constant of an antibody or antibody binding fragment. This value is also called k off value.

[0190] The term “k a "(M-1·sec-1 or 1 / M) refers to the association rate constant for a specific antibody-antigen interaction, or the association rate constant of an antibody or antibody binding fragment.

[0191] The term "K A ” (M-1 or 1 / M) refers to the binding equilibrium constant for a specific antibody-antigen interaction, or the binding equilibrium constant for an antibody or antibody binding fragment. The binding equilibrium constant is calculated by dividing k a Divide by k d To obtain.

[0192] The term "EC50" or "EC 50” refers to the half-maximal effective concentration, which includes the antibody concentration that induces a response halfway between baseline and maximum after a specified exposure time. EC 50 Essentially represents the antibody concentration at which 50% of the maximal effect is observed. 50 The EC value is equal to the concentration of an antibody of the invention that produces half-maximal binding to cells expressing, for example, CD3 or a tumor-associated antigen (e.g., CD20), as determined by, for example, a FACS binding assay. 50 or an increase in the half-maximal effect concentration value, a decrease or weakening of binding was observed.

[0193] In one embodiment, reduced binding can be defined as the number of ECs capable of binding to half the maximal number of target cells. 50 Increased antibody concentration.

[0194] In another embodiment, EC 50 The values ​​represent the concentration of the antibody of the invention that causes half-maximal depletion of target cells through T cell cytotoxic activity. Thus, as the EC50 or half-maximal effect concentration value decreases, an increase in cytotoxic activity is observed ( 例如 , T cell-mediated tumor cell killing).

[0195] Sequence variants

[0196] Compared to the corresponding germline sequence from which a separate antigen binding domain is derived, the antibodies of the present disclosure (e.g., bispecific antibodies) may include one or more amino acid substitutions, insertions and / or deletions in the framework region and / or CDR region of the heavy chain variable domain and the light chain variable domain. Such mutations can be easily determined by comparing the amino acid sequences disclosed herein with germline sequences that can be obtained, for example, from a public antibody sequence database. The antigen binding molecules of the present invention may include antigen binding domains derived from exemplary amino acid sequences disclosed herein, wherein one or more amino acids in one or more framework regions and / or CDR regions are mutated into corresponding residues of the germline sequence from which the antibody is derived, or corresponding residues of another human germline sequence, or conservative amino acid substitutions of corresponding germline residues (such sequence changes are collectively referred to herein as "germline mutations"). A person of ordinary skill in the art can easily produce a variety of antibodies and antigen binding fragments starting from the heavy chain and light chain variable region sequences disclosed herein, comprising one or more individual germline mutations or combinations thereof. In certain embodiments, V H and / or V LAll framework and / or CDR residues in the domain are mutated back to the residues present in the original germline sequence from which the antigen-binding domain was initially derived. In other embodiments, only some residues are mutated back to the original germline sequence, for example, only the mutated residues present in the first 8 amino acids of FR1 or the last 8 amino acids of FR4, or only the mutated residues present in CDR1, CDR2 or CDR3. In other embodiments, one or more mutations in the framework and / or CDR residues are mutated into one or more corresponding residues of different germline sequences (i.e., different from the germline sequence of the germline sequence from which the antigen-binding domain was initially derived). In addition, the antigen-binding domain can contain any combination of two or more germline mutations in the framework region and / or CDR region, for example, wherein some individual residues are mutated into the corresponding residues of a specific germline sequence, while some other residues different from the original germline sequence are retained or mutated into the corresponding residues of different germline sequences. After obtaining an antigen binding domain containing one or more germline mutations, the antigen binding domain can be easily tested for one or more desired properties, such as improved binding specificity, increased binding affinity, improved or enhanced antagonistic or agonistic biological properties (as the case may be), reduced immunogenicity, etc. Bispecific antigen binding molecules comprising one or more antigen binding domains obtained in this general manner are encompassed by the present invention.

[0197] The invention also includes antibodies comprising variants of any of the HCVR, LCVR, and / or CDR amino acid sequences disclosed herein having one or more conservative substitutions. For example, the invention includes antibodies having HCVR, LCVR, and / or CDR amino acid sequences having, e.g., 10 or fewer, 8 or fewer, 6 or fewer, 4 or fewer, etc., conservative amino acid substitutions relative to any of the HCVR, LCVR, and / or CDR amino acid sequences set forth herein.

[0198] pH-dependent binding

[0199] The present invention includes antibodies (e.g., bispecific antibodies) having pH-dependent binding characteristics. For example, the antibodies of the present invention may exhibit reduced binding to, for example, tumor antigens such as CD20 at acidic pH compared to neutral pH. Alternatively, the antibodies of the present invention may exhibit enhanced binding to, for example, tumor antigens such as CD20 at acidic pH compared to neutral pH. The expression "acidic pH" includes a pH value of less than about 6.2, such as about 6.0, 5.95, 5,9, 5.85, 5.8, 5.75, 5.7, 5.65, 5.6, 5.55, 5.5, 5.45, 5.4, 5.35, 5.3, 5.25, 5.2, 5.15, 5.1, 5.05, 5.0 or less. The expression "neutral pH" refers to a pH of about 7.0 to about 7.4. The expression "neutral pH" includes pH values ​​of about 7.0, 7.05, 7.1, 7.15, 7.2, 7.25, 7.3, 7.35 and 7.4.

[0200] In some cases, "reduced binding at acidic pH compared to neutral pH" refers to the K of an antibody binding to its antigen at acidic pH. D The K value of the antibody binding to its antigen at neutral pH D For example, for the purposes of the present invention, if an antibody or antigen-binding fragment thereof exhibits an acidic / neutral K D 0 or greater, then the antibody or antigen-binding fragment thereof may be considered to exhibit "reduced binding to, e.g., CD20, at acidic pH compared to neutral pH." In certain exemplary embodiments, the acidic / neutral K of an antibody or antigen-binding fragment of the invention is about 3.0 or greater. D The ratio may be about 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5, 7.0, 7.5, 8.0, 8.5, 9.0, 9.5, 10.0, 10.5, 11.0, 11.5, 12.0, 12.5, 13.0, 13.5, 14.0, 14.5, 15.0, 20.0, 25.0, 30.0, 40.0, 50.0, 60.0, 70.0, 100.0 or more.

[0201] Antibodies with pH-dependent binding characteristics can be obtained, for example, by screening an antibody population for reduced (or enhanced) binding to a specific antigen at an acidic pH compared to a neutral pH. In addition, antibodies with pH-dependent characteristics can be generated by modifying the antigen-binding domain at the amino acid level. For example, by replacing one or more amino acids of the antigen-binding domain (e.g., within a CDR) with a histidine residue, an antibody with reduced antigen binding at an acidic pH relative to a neutral pH can be obtained.

[0202] Fc variants

[0203] According to certain embodiments of the present invention, antibodies and bispecific antigen-binding molecules are provided that include an Fc domain having one or more mutations that enhance or attenuate binding of the antibody to an FcRn receptor at, for example, an acidic pH compared to a neutral pH. For example, the present invention includes antibodies that have a C-terminal region of the Fc domain. H 2 or C H In the 3rd region, mutations are included, wherein one or more mutations increase the affinity of the Fc domain to FcRn under an acidic environment (e.g., in an endosome with a pH range of from about 5.5 to about 6.0). When applied to an animal, such mutations can result in an increase in the serum half-life of the antibody. Non-limiting examples of such Fc modifications include, for example, position 250 (e.g., E or Q); 250 and 428 (e.g., L or F); 252 (e.g., L / Y / F / W or T), 254 (e.g., S or T) and 256 (e.g., S / R / Q / E / D or T); or position 428 and / or 433 (e.g., H / L / R / S / P / Q or K) and / or 434 (e.g., H / F or Y); or position 250 and / or 428; or position 307 or 308 (e.g., 308F, V308F) and 434. In one embodiment, modifications include 428L (e.g., M428L) and 434S (e.g., N434S) modifications; 428L, 259I (e.g., V259I) and 308F (e.g., V308F) modifications; 433K (e.g., H433K) and 434 (e.g., 434Y) modifications; 252, 254 and 256 (e.g., 252Y, 254T and 256E) modifications; 250Q and 428L modifications (e.g., T250Q and M428L); and 307 and / or 308 modifications (e.g., 308F or 308P).

[0204] For example, the invention includes antibodies and bispecific antigen binding molecules comprising an Fc domain having one or more pairs or one or more groups of mutations selected from the group consisting of: 250Q and 248L (e.g., T250Q and M248L); 252Y, 254T and 256E (e.g., M252Y, S254T and T256E); 428L and 434S (e.g., M428L and N434S); and 433K and 434F (e.g., H433K and N434F). All possible combinations of the aforementioned Fc domain mutations and other mutations within the antibody variable domains disclosed herein are contemplated within the scope of the invention.

[0205] Antibody preparation

[0206] Antigen binding domains specific for a particular antigen can be prepared by any antibody production technique known in the art. Once obtained, two different antigen binding domains specific for two different antigens (e.g., CD3 and CD20) can be appropriately arranged relative to each other to produce the bispecific antibodies of the present disclosure using conventional methods. In certain embodiments, one or more individual components (e.g., heavy chains and light chains) of the bispecific antibodies of the present disclosure are derived from chimeric, humanized or fully human antibodies. Methods for preparing such antibodies are well known in the art. For example, VELOCIMMUNE can be used. TM One or more heavy chains and / or light chains of the bispecific antibodies of the present disclosure are prepared using VELOCIMMUNE TM Techniques (or any other techniques for producing human antibodies) are used to first isolate high-affinity chimeric antibodies for a specific antigen (e.g., CD3 or CD20) having a human variable region and a mouse constant region. Antibodies are characterized and selected for desired characteristics, including affinity, selectivity, epitopes, etc. The mouse constant region is replaced with the desired human constant region to produce fully human heavy and / or light chains that can be incorporated into the bispecific antigen binding molecules of the present invention.

[0207] Genetically engineered animals can be used to prepare human bispecific antigen binding molecules.For example, genetically modified mice that cannot rearrange and express endogenous mouse immunoglobulin light chain variable sequences can be used, wherein the mice only express one or two human light chain variable domains encoded by human immunoglobulin sequences, and the human immunoglobulin sequences are operably connected to the mouse κ constant gene at the endogenous mouse κ locus.Such genetically modified mice can be used to produce fully human bispecific antibodies comprising two different heavy chains, and the heavy chain is associated with the same light chain comprising the variable domains derived from one of two different human light chain variable region gene segments.(See, for example, US2011 / 0195454).Fully human refers to an antibody or its antigen binding fragment or immunoglobulin domain, which comprises an amino acid sequence encoded by a DNA derived from a human sequence on the full length of each polypeptide of an antibody or its antigen binding fragment or immunoglobulin domain.In some cases, the full human sequence is derived from human endogenous proteins.In other cases, the full human protein or protein sequence comprises a chimeric sequence, wherein each constituent sequence is derived from a human sequence. While not being bound by any one theory, chimeric proteins or chimeric sequences are generally designed to minimize the generation of immunogenic epitopes at the junction of the constituent sequences, for example, as compared to any wild-type human immunoglobulin region or domain.

[0208] Bioequivalent

[0209] The present invention encompasses antigen binding molecules with amino acid sequences different from those of the exemplary molecules disclosed herein, but retains the ability to bind one or more identical antigens. When compared to the parent sequence, such variant molecules may include one or more amino acid additions, deletions or substitutions, but exhibit biological activity substantially equivalent to the described antibody (e.g., bispecific antibody).

[0210] The present invention includes antigen binding molecules that are bioequivalent to any exemplary antibody set forth herein. If for example two antigen binding proteins or antibodies are when applying the same molar dose with a single dose or multiple doses under similar experimental conditions, absorption rate and degree do not show a drug equivalent or drug substitute with significant differences, then it is considered as bioequivalent. If some antigen binding proteins are equivalent in absorption degree, but are not equivalent in absorption rate, then they will be considered as equivalents or drug substitutes, but because this difference in absorption rate is intentional and is reflected in the labeling, so it can be considered as bioequivalent, these antibodies are not necessary for, for example, reaching effective in vivo drug concentrations in long-term use, and are considered to have no clinical significance for the specific drug studied.

[0211] In one embodiment, two antigen binding proteins are bioequivalent if there are no clinically meaningful differences in safety, purity, and potency.

[0212] In one embodiment, two antigen binding proteins are bioequivalent if patients can make one or more switches between the reference product and the biological product without an expected increase in risk of adverse reactions, including clinically significant changes in immunogenicity, or decreased effectiveness, compared to continuous therapy without such switching.

[0213] In one embodiment, two antigen binding proteins are bioequivalent if they both act by one or more common mechanisms of action for one or more conditions of use, to the extent such mechanisms are known.

[0214] Bioequivalence can be demonstrated by in vivo and in vitro methods. Bioequivalence metrics include, for example, (a) in vivo tests in humans or other mammals, in which the concentration of the antibody or its metabolites in blood, plasma, serum or other biological fluids over time is measured; (b) in vitro tests that correlate with and can reasonably predict the in vivo bioavailability data in humans; (c) in vivo tests in humans or other mammals, in which the appropriate acute pharmacological effects of the antibody (or its target) are measured over time; and (d) well-controlled clinical trials to establish the safety, efficacy, or bioavailability or bioequivalence of the antigen-binding protein.

[0215] Bioequivalent variants of the exemplary antibodies (e.g., bispecific antibodies) described herein can be constructed by, for example, making various substitutions of residues or sequences or deleting terminal or internal residues or sequences that are not required for biological activity. For example, cysteine ​​residues that are not essential for biological activity can be deleted or replaced with other amino acids to prevent the formation of unnecessary or incorrect intramolecular disulfide bridges during renaturation. In other contexts, bioequivalent antigen binding proteins can include variants of the exemplary antibodies and bispecific antigen binding molecules described herein that include amino acid changes that modify the glycosylation characteristics of the molecule (e.g., mutations that eliminate or remove glycosylation).

[0216] Therapeutic formulation and delivery

[0217] The present invention provides pharmaceutical compositions comprising antibodies (e.g., bispecific antibodies) of the present disclosure. For example, specific pharmaceutical compositions of exemplary bispecific antibodies of the present disclosure are provided in WO2021 / 119135.

[0218] Various delivery systems are known and can be used to administer the pharmaceutical compositions of the invention, such as encapsulation in liposomes, microparticles, microcapsules, recombinant cells capable of expressing mutant viruses, receptor-mediated endosomes (see, e.g., Wu et al., 1987, J. Biol. Chem. 262: 4429-4432). Methods of introduction include, but are not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural, and oral routes. The composition can be administered by any convenient route, such as by infusion or bolus injection, by absorption through the epithelium or mucocutaneous lining (e.g., oral mucosa, rectal and intestinal mucosa, etc.), and can be administered with other bioactive agents. Administration can be systemic or local. In some embodiments, the therapeutic protein of the invention is administered via intravenous infusion or subcutaneous injection.

[0219] The pharmaceutical compositions of the present invention can be delivered subcutaneously or intravenously using a standard needle and syringe. In addition, for subcutaneous delivery, pen delivery devices are readily applicable to delivering the pharmaceutical compositions of the present invention. Such pen delivery devices can be reusable or disposable. Reusable pen delivery devices generally utilize a replaceable cartridge containing the pharmaceutical composition. Once all of the pharmaceutical composition in the cartridge has been administered and the cartridge becomes empty, the empty cartridge can be easily discarded and replaced with a new cartridge containing the pharmaceutical composition. The pen delivery device can then be reused. In a disposable pen delivery device, there is no replaceable cartridge. In fact, the disposable pen delivery device is pre-filled with the pharmaceutical composition in a reservoir within the device. Once the pharmaceutical composition in the reservoir is emptied, the entire device is discarded.

[0220] A variety of reusable pen delivery devices and auto-injector delivery devices are used for subcutaneous delivery of the pharmaceutical compositions of the present invention. Examples include, but are not limited to, AUTOPEN TM (Owen Mumford, Inc., Woodstock, UK), DISSETRONIC TM Pen (Disetronic Medical Systems, Bergdorf, Switzerland), HUMALOG MIX75 / 25 TM Pen, HUMALOG TM Pen, HUMALIN 70 / 30 TM Pen (Eli Lilly and Co., Indianapolis, IN), NOVOPEN TM I, II and III (Novo Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR TM (NovoNordisk,Copenhagen,Denmark)、BD TM Pen (Becton Dickinson, Franklin Lakes, NJ), OPTIPEN TM 、OPTIPEN PRO TM 、OPTIPEN STARLET TM and OPTICLIK TM (sanofi-aventis, Frankfurt, Germany) etc. Examples of disposable pen delivery devices that can be used for subcutaneous delivery of the pharmaceutical compositions of the present invention include, but are not limited to, SOLOSTAR TM Pen (sanofi-aventis), FLEXPEN TM (Novo Nordisk), and KWIKPEN TM (Eli Lilly), SURECLICK TM Autoinjector (Amgen, Thousand Oaks, CA), PENLET TM (Haselmeier, Stuttgart, Germany), EPIPEN (Dey, LP), and HUMIRA TM pen (Abbott Labs, Abbott Park IL), etc.

[0221] The injectable preparations may include dosage forms for intravenous, subcutaneous, intradermal and intramuscular injections, drip infusions, etc. These injectable preparations can be prepared by well-known methods.

[0222] The pharmaceutical composition of the present disclosure may be included in a kit comprising a container containing a bispecific antibody and a label having instructions for administering the bispecific antibody according to any one or more dosing regimens discussed herein. In some cases, the label also includes instructions for administering steroids and / or antihistamines to reduce the risk of CRS and / or IRR.

[0223] Therapeutic uses of antigen binding molecules

[0224] The present invention includes methods comprising administering to a subject in need thereof a therapeutically effective amount of a bispecific antibody of the present disclosure for use in treating a B cell malignancy. The bispecific antibody may be contained in a composition containing a pharmaceutically acceptable carrier or diluent. The expression "subject" or "subject in need thereof" means a human or non-human animal exhibiting one or more symptoms or signs of cancer (e.g., a subject exhibiting a tumor or suffering from any of the cancers mentioned below).

[0225] In some embodiments, bispecific anti-CD3 x anti-CD20 antibodies can be used to treat B cell malignancies, including non-Hodgkin lymphoma, Hodgkin lymphoma, chronic lymphocytic leukemia, acute lymphoblastic leukemia, small lymphocytic lymphoma, diffuse large B cell lymphoma, follicular lymphoma, mantle cell lymphoma, marginal zone lymphoma, Waldenstrom's macroglobulinemia, primary mediastinal B cell lymphoma, lymphoblastic lymphoma, or Burkitt's lymphoma. In some embodiments, the cancer is follicular lymphoma. In some embodiments, the cancer is diffuse large B cell lymphoma (DLBCL). In some embodiments, the cancer is mantle cell lymphoma. In some embodiments, the cancer is marginal zone lymphoma.

[0226] Non-Hodgkin lymphoma (NHL) is the most common hematological malignancy. In a heterogeneous group of NHLs, 85%-90% are derived from B cells and include follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL), mantle cell lymphoma (MCL), marginal zone lymphoma (MZL), and several other B-NHLs. Anti-CD20 antibodies in combination with chemotherapy are the standard of care for the treatment of B-NHL; however, despite initial responses, many patients relapse, and the duration of response gradually shortens and the outcome is poor in subsequent lines of therapy. Therefore, in some embodiments, the antigen binding molecule is a bispecific anti-CD3×anti-CD20 that binds to CD3+T cells and CD20+B cells, thereby targeting CD20+ tumor cells via T cell-mediated cytotoxicity. In some cases, anti-CD3×CD20 bispecific antibodies are used to treat B cell cancers (e.g., NHL) in subjects who have previously failed anti-CD20 monospecific antibody therapy.

[0227] For patients who do not fully respond to CAR-T therapy, the outcome is generally poor and there are no standard of care treatment options. Therefore, in some cases, the anti-CD3×CD20 bispecific antibodies of the present invention are used to treat B cell cancers (e.g., NHL such as DLBCL) in subjects who have failed previous CAR-T therapy or have not responded to previous CAR-T therapy (e.g., anti-CD19 CAR-T therapy).

[0228] In one embodiment, onitumumab is indicated for the treatment of adult patients with relapsed or refractory follicular lymphoma (FL) after at least two prior systemic therapies.

[0229] In one embodiment, onitumumab is indicated for the treatment of adult patients diagnosed with follicular lymphoma or DLBCL who have not been previously treated with any systemic anti-lymphoma therapy.

[0230] For relapsed or refractory follicular lymphoma (R / R FL), it can be administered via intravenous (IV) infusion. Treatment consists of step-up dosing in cycle 1, weekly dosing in cycles 2-4, and then maintenance dosing every 2 weeks until disease progression, for example, as shown in Table 1 below.

[0231] One treatment cycle (of FL) consisted of 21 days.

[0232] Cycle 1: Step Up -Administer onitumab as a 4-hour infusion. The recommended starting dose of onitumab is 0.2 mg on Day 1. If tolerated, administer 0.5 mg on Day 2. If tolerated, administer a dose of 2 mg on Day 8 and a dose of 2 mg on Day 9. If tolerated, administer a dose of 10 mg on Day 15 and a dose of 10 mg on Day 16. Administer Cycle 2 if tolerated.

[0233] Cycles 2-4: 80 mg per week - Administer 80 mg as a 4-hour infusion on Day 1 of Cycle 2. If tolerated, the infusion time for all subsequent doses may be reduced to 1 hour. Administer a dose of 80 mg on Days 1, 8, and 15.

[0234] Maintenance: 160 mg every 2 weeks - After cycle 4, administer onitumumab at a dose of 160 mg as a 1-hour infusion every 2 weeks. If the patient is in complete remission for 9 months, administer a dose of 160 mg every 4 weeks or a dose of 320 mg every 8 weeks.

[0235] Table 1: Recommended onitumumab dose and schedule for the treatment of R / R FL

[0236]

[0237] a. The Day 2 dose may be administered on Day 2, 3 or 4.

[0238] b. The Day 9 dose may be administered on Day 9, 10 or 11.

[0239] c. The Day 16 dose may be administered on Day 16, 17 or 18.

[0240] In one embodiment, onitumumab is indicated for the treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) after at least two prior systemic therapies.

[0241] For diffuse large B-cell lymphoma (DLBCL), it can be administered via intravenous (IV) infusion. Treatment consists of step-up dosing in cycle 1, weekly dosing in cycles 2-4, and then maintenance dosing every 2 weeks until disease progression, for example, as shown in Table 2 below.

[0242] One treatment cycle (for DLBCL) consists of 21 days.

[0243] Cycle 1: Step Up -Administer onitumab as a 4-hour infusion. The recommended starting dose of onitumab is 0.2 mg on Day 1. If tolerated, administer 0.5 mg on Day 2. If tolerated, administer a dose of 2 mg on Day 8 and a dose of 2 mg on Day 9. If tolerated, administer a dose of 10 mg on Day 15 and a dose of 10 mg on Day 16. Administer Cycle 2 if tolerated.

[0244] Cycles 2-4: 160 mg per week - Administer 160 mg as a 4-hour infusion on Day 1 of Cycle 2. If tolerated, the infusion time for all subsequent doses may be reduced to 1 hour. Administer a dose of 160 mg on Days 1, 8, and 15.

[0245] Maintenance: 320 mg every 2 weeks - After cycle 4, administer onitumumab at a dose of 320 mg as a 1-hour infusion every 2 weeks. If the patient is in complete remission for 9 months, administer a dose of 320 mg every 4 weeks.

[0246] Table 2: Recommended onituzumab dose and schedule for the treatment of R / R DLBCL

[0247]

[0248] a. The Day 2 dose may be administered on Day 2, 3 or 4.

[0249] b. The Day 9 dose may be administered on Day 9, 10 or 11.

[0250] c. The Day 16 dose may be administered on Day 16, 17 or 18.

[0251] In the indications mentioned above or herein, it may be desirable to administer premedication as detailed in Table 3A below to reduce the risk of cytokine release syndrome (CRS) and / or infusion-related reactions (IRR). Table 3B describes specific options for the management of CRS.

[0252] Table 3A: Premedication

[0253]

[0254] Table 3B: CRS classification and management guidelines

[0255]

[0256] Premedication can continue beyond Day 8 of Cycle 2 until the dose is tolerated and no IRR and / or CRS occurs. Early use of anti-IL6 therapy (e.g., tocilizumab) is recommended for patients aged >65 years or those with complications.

[0257] Combination therapy

[0258] The present invention provides a method, which includes administering a pharmaceutical composition comprising any exemplary antibody described herein (e.g., bispecific antibody) in combination with one or more additional therapeutic agents. Exemplary additional therapeutic agents that can be combined with the antigen binding molecules of the present invention or administered in combination include, for example, anti-tumor agents (e.g., chemotherapeutic agents as disclosed elsewhere herein). In certain embodiments, additional therapeutic agents are regimens including radiotherapy or hematopoietic stem cell transplantation. In certain embodiments, additional therapeutic agents may be immunomodulators. In certain embodiments, additional therapeutic agents may be monoclonal antibodies, antibody drug conjugates, bispecific antibodies conjugated to anti-tumor agents, immune checkpoint inhibitors (e.g., PD-1 or CTLA-4, or combinations thereof), or combinations thereof.

[0259] The additional therapeutically active component may be administered prior to, concurrently with, or immediately after administration of the antigen binding molecules of the invention; (for purposes of this disclosure, such administration regimens are considered administration of the antigen binding molecules "in combination" with the additional therapeutically active component).

[0260] The invention includes pharmaceutical compositions in which the antigen binding molecules of the invention are co-formulated together with additional therapeutically active ingredients as described elsewhere herein.

[0261] sequence

[0262] A summary of the sequences cited herein and the corresponding SEQ ID NOs is shown below in Table 4. The anti-CD3 x anti-CD20 antibodies comprising the heavy and common light chains of SEQ ID NOs: 1-3, the HCVRs and LCVRs of SEQ ID NOs: 4-6, and the CDRs of SEQ ID NOs: 7-15 are also referred to herein as onituzumabs.

[0263] Table 4: Sequence summary

[0264]

[0265]

[0266] Example

[0267] The following examples are provided to provide a person of ordinary skill in the art with a complete disclosure and description of how to prepare and use the methods and compositions of the present invention, but are not intended to limit the scope of what the inventors consider to be their invention. Efforts have been made to ensure the accuracy of the numbers used (e.g., amounts, temperatures, etc.), but certain experimental errors and deviations should be considered. Unless otherwise indicated, parts are parts by weight, molecular weights are average molecular weights, temperatures are in degrees Celsius, and pressures are at or near atmospheric pressure.

[0268] Example 1: Clinical evaluation of anti-CD3×anti-CD20 bispecific antibodies in patients with CD20+ B cell malignancies

[0269] This is an open-label, multicenter, dose-escalation study of onitumumab (anti-CD3 × anti-CD20) administered as an intravenous infusion. The study consists of a dose-escalation portion of the B-NHL and CLL cohorts and disease-specific expansions in DLBCL after CAR-T therapy failure, aggressive lymphomas (excluding prior CAR-T therapy), and grade 1-3a follicular lymphoma.

[0270] Duration of treatment will consist of 12 weekly (QW) doses followed by once-every-two-week (Q2W) dosing until disease progression or other protocol-defined reasons for treatment discontinuation. In addition, if a patient demonstrates a complete response (CR) and shows a durable response lasting at least 9 months after the initial determination of CR, the assigned dose of study drug administration will be reduced from Q2W to once every four weeks (Q4W) intervals.

[0271] Patients will receive an initial dose of 0.7 mg of onitumab (administered in divided doses of 0.2 mg / 0.5 mg) in treatment week 1, followed by 4 mg of intermediate dose-1 (administered in divided doses of 2 mg / 2 mg) in treatment week 2, 20 mg of intermediate dose-2 (administered in divided doses of 10 mg / 10 mg) in treatment week 3, and then receive the designated full QW dose in treatment weeks 4 to 12, followed by Q2W dosing. The initial dose (0.7 mg) and 4 mg of intermediate dose-1 and 20 mg of intermediate dose-2 are always administered as divided infusions over 2 days (preferably consecutively, but no more than 3 days apart), even if these doses are delayed until after treatment week 3. QW dosing will continue only if the full initial dose and full intermediate doses 1 and 2 are accepted and tolerated. If the patient does not experience grade 3 CRS at the initial dose and intermediate dose, QW doses of onitumab will be administered as a single infusion in treatment week 4 and beyond. However, if a patient develops grade 3 CRS at the initial or intermediate dose, the first onitumumab QW dose will be administered as a divided infusion over 2 days.

[0272] Premedication is required prior to the start of onituzumab infusion for each fractionated initial dose, each fractionated intermediate dose, each fractionated QW dose (if applicable), and the first QW dose administered as a single infusion; premedication will be administered as detailed in Example 3. If no IRR / CRS of any grade occurs after the first QW dose administered as a single infusion, the investigator may begin tapering dexamethasone premedication with subsequent administrations of the Week 5 dose of onituzumab, as detailed in Example 3. Implementation of boosted tocilizumab use will depend on the incidence of Grade ≥ 3 CRS events observed at any time.

[0273] Patients will receive the designated dose of onitumab QW during a 4-week induction period, followed by an additional 8 QW doses, and will be treated Q2W at the designated dose until disease progression or other protocol-defined reasons for treatment discontinuation. If the patient demonstrates a CR and shows a durable response lasting at least 9 months after the initial determination of CR, the designated dose of study drug administration frequency will be reduced from a Q2W to a Q4W interval. Patients must receive the full dose of Q2W dosing in at least the first 3 doses before switching from Q2W to Q4W dosing.

[0274] Inclusion criteria

[0275] Patients must meet the following criteria to be eligible for inclusion in this study:

[0276] 1. Patients with documented CD20+ B-cell malignancies, active disease, unresponsive to prior therapy, who have no standard of care options and may be suitable for treatment with anti-CD20 antibodies:

[0277] ● Diagnosed as B-NHL according to the 2007 NCI Working Group criteria

[0278] ● CLL was diagnosed according to the 2008 International Workshop on Chronic Lymphocytic Leukemia (IWCLL) Working Group criteria

[0279] - Patients with small lymphocytic lymphoma (SLL) will be enrolled in the CLL group and will be subject to B-NHL evaluation

[0280] NOTE: Patients who had a CD20-negative lymph node (NHL) biopsy per standard of care prior to enrollment are still eligible for this study if they have previously documented CD20+ disease and have been previously treated with rituximab or other CD20-directed antibody therapy within approximately 6 months.

[0281] 2. B-NHL patients must have been previously treated with anti-CD20 antibody therapy. If CLL patients have failed treatment with BTK inhibitors or PI3K inhibitors and the attending physician believes that the patient is suitable for entering the Phase 1 trial, the patient is not required to have been previously treated with anti-CD20 antibody therapy. Refractory is defined as no response (SD / PD) or relapse within ≤6 months of the last treatment.

[0282] ●To be included in the FL grade 1-3a expansion cohort, patients must have received at least 2 prior lines of systemic therapy, including an anti-CD20 antibody and an alkylating agent; patients needed to have failed lenalidomide plus rituximab combination therapy (if approved or deemed by the investigator to be ineligible for this therapy).

[0283] ●To be included in the disease-specific expansion cohort recruiting patients with DLBCL after failure of CAR-T therapy, patients must have recovered from lymphodepleting therapy and toxicity of CAR-T infusion. It is not required that the previous CAR-T therapy was the most recent line of therapy before study enrollment.

[0284] Patients with aggressive lymphoma assigned to the aggressive lymphoma expansion cohort must have previously received at least one line of therapy consisting of an anti-CD20 antibody. Patients who have previously received CAR-T therapy will not be included in this cohort.

[0285] Patients with lymphoma eligible for the aggressive lymphoma expansion cohort include the following subtypes based on the WHO classification:

[0286] - DLBCL not otherwise specified (NOS)

[0287] - Germinal center B cell type

[0288] - Activated B cell type

[0289] (Note: DLBCL includes newly diagnosed DLBCL and DLBCL transformed from indolent lymphoma / CLL)

[0290] - Primary mediastinal (thymic) large B-cell lymphoma

[0291] - T cell / histiocyte-rich large B cell lymphoma

[0292] - Epstein-Barr virus (EBV) + DLBCL, NOS

[0293] - High-grade B-cell lymphoma with rearrangements of MYC and BCL2 and / or BCL6

[0294] - High-grade B-cell lymphoma, NOS

[0295] - B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin lymphoma

[0296] -Follicular lymphoma, grade 3b

[0297] 3. All patients (B-cell NHL and CLL) must have at least one bidimensionally measurable lesion with the longest diameter ≥1.5 cm documented by CT or MRI scan (if CT scan is not available).

[0298] 4. CLL patients must have white blood cell (WBC) ≤ 200 × 109 / L. As of protocol amendment 16, recruitment of CLL patients has ended.

[0299] 5. Age ≥ 18 years old

[0300] 6. Eastern Cooperative Oncology Group (ECOG) performance status ≤ 1

[0301] 7. Life expectancy is at least 6 months

[0302] 8. Adequate bone marrow function as documented by the following data:

[0303] a. Platelet count ≥ 75 × 10 9 / L

[0304] b. Hb level ≥ 9 g / dL

[0305] c.ANC≥1×10 9 / L

[0306] Note: Patients may be considered for enrollment if the investigator believes that the cell counts below the above thresholds are due to bone marrow infiltration or splenic sequestration caused by the underlying disease.

[0307] Patients with bone marrow involvement or splenic sequestration should meet the following hematologic parameters:

[0308] - Platelet count ≥25×109 / L. Patients may not receive platelet transfusion therapy within 3 days before the first dose of onitumumab to meet the platelet eligibility criteria.

[0309] - Hemoglobin ≥7.0 g / dL

[0310] - Absolute neutrophil count (ANC) ≥ 0.5 × 109 / L. Patients may not receive granulocyte colony-stimulating factor within 2 days before the first dose of onitumumab to meet the ANC eligibility criteria.

[0311] 9. Adequate organ function recorded by the following data:

[0312] Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤ 2.5 × ULN

[0313] Total bilirubin ≤1.5 × ULN

[0314] NOTE: Patients with Gilbert's syndrome do not need to meet this requirement as long as their total bilirubin does not change from baseline.

[0315] Creatinine clearance calculated by Cockcroft-Gault ≥50 mL / min

[0316] Note: If the investigator believes that the abnormal laboratory results are due to underlying disease, the patient may be considered for enrollment.

[0317] Note: Patients with borderline creatinine clearance according to Cockcroft-Gault may be considered for enrollment if the measured creatinine clearance (based on 24-hour urine or other reliable method) is ≥50 mL / min.

[0318] 10. Willing to undergo mandatory tumor biopsy before treatment if the investigator believes that the patient has a palpable lesion and the lesion can be biopsied without significant risk to the patient.

[0319] 11. Willing and able to comply with clinical visits and study-related procedures

[0320] 12. Provide signed informed consent or legal representative

[0321] Exclusion criteria

[0322] Patients who meet any of the following criteria will be excluded from the study:

[0323] 1. Primary central nervous system (CNS) lymphoma or known or suspected non-primary CNS NHL involving the CNS

[0324] 2. Have a history of or currently have relevant CNS symptoms, such as:

[0325] ● Epilepsy, seizures, paresis, aphasia, stroke, severe head injury, cerebellar disease, organic brain syndrome, psychosis or

[0326] Brain MRI showing evidence of inflammatory lesions and / or vasculitis

[0327] 3. Standard anti-tumor chemotherapy (non-biological) within 5 times the half-life or 28 days before the first administration of study drug, whichever is shorter.

[0328] 4. Standard radiotherapy within 14 days of the first administration of study drug.

[0329] Note: Palliative radiation therapy to symptomatic lymph nodes / lesions is permitted provided that the irradiated lesion or lymph node is not included as a target lesion for tumor assessment

[0330] 5. Allogeneic stem cell transplantation

[0331] 6. Treatment with rituximab, alemtuzumab or other investigational or commercial biologics within 12 weeks prior to the first administration of study drug.

[0332] NOTE: For patients with aggressive lymphoma who require immediate treatment, the washout period may be shortened to 28 days.

[0333] 7. Immunosuppressive therapy (except biological therapy) within 28 days of the first administration of study drug.

[0334] 8. Treatment with investigational non-biological agents within 28 days of first administration of study drug.

[0335] 9. History of allergic reactions to compounds similar to the chemical or biological components of the study drug.

[0336] 10. History of hypersensitivity reaction to any compound in the tetracycline group of antibiotics.

[0337] 11. The patient is undergoing treatment for concurrent active malignant tumors.

[0338] 12. Known active bacterial, viral, fungal, mycobacterial or other infections, or any major infectious event requiring hospitalization or intravenous anti-infective drug treatment within 4 weeks of the first administration.

[0339] 13. Evidence of significant concurrent illness or medical condition that may interfere with the conduct of the study or place the patient at significant risk, including but not limited to significant cardiovascular disease (e.g., New York Heart Association class III or IV heart disease, myocardial infarction within the past 6 months, unstable arrhythmia, or unstable angina) and / or significant pulmonary disease (e.g., history of obstructive pulmonary disease and symptomatic bronchospasm).

[0340] Note: Before the first administration of onitumumab, patients with a history of cardiac disease should be evaluated by ECHO or multiple gated acquisition scanning (MUGA) to ensure adequate cardiac reserve and function.

[0341] 14. Patients are currently receiving systemic corticosteroid therapy, except for corticosteroids used for other (non-tumor and non-immunosuppressive) indications, with a maximum dose of 10 mg / day of prednisone or equivalent.

[0342] 15. Human immunodeficiency virus (HIV) infection or chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV).

[0343] Patients with hepatitis B (HepBsAg+) whose infection was controlled (serum HBV DNA below the limit of detection and receiving HBV antiviral therapy) were allowed to be enrolled after consultation with the physician managing the infection.

[0344] 16. Known hypersensitivity to allopurinol and rasburicase.

[0345] 17. Pregnant or breastfeeding women.

[0346] 18. Females of childbearing potential* or males who are unwilling to take highly effective contraceptive measures before the first study drug treatment, during the study, and for at least 6 months after the last dose. Highly effective contraceptive measures include stable use of combined (estrogen and progestin) hormonal contraceptives (oral, vaginal, transdermal) or progestin-only hormonal contraceptives (oral, injectable, implantable) associated with ovulation inhibition, intrauterine devices, intrauterine hormone-releasing systems, bilateral tubal ligation, partners who have undergone vasectomy, and / or abstinence from sex for 2 or more menstrual cycles prior to screening.

[0347] * Postmenopausal women must have had amenorrhea for at least 12 months to be considered out of childbearing potential. Women with a documented hysterectomy or tubal ligation do not need pregnancy testing and contraception.

[0348] Sexual abstinence is considered a highly effective approach only when it is defined as abstention from heterosexual intercourse for the entire period of risk associated with the study treatment. The reliability of sexual abstinence needs to be evaluated based on the duration of the clinical trial and the patient's preferences and usual lifestyle.

[0349] Periodic abstinence (calendar, symptom-temperature, and postovulation methods), withdrawal (coitus interruptus), spermicide use alone, and the lactational amenorrhea method (LAM) are unacceptable methods of contraception. Female and male condoms should not be used together.

[0350] 19. Live vaccination within 28 days of first administration of study drug.

[0351] Table 5: CRS toxicity grading

[0352]

[0353] CPAP = continuous positive airway pressure, bilevel positive airway pressure, BiPAP = bilevel positive airway pressure.

[0354] Organ toxicities associated with CRS can be graded according to CTCAE v4.03, but they do not affect the CRS grade.

[0355] 1 Fever is defined as a body temperature ≥ 38°C not caused by any other reason. After CRS patients receive antipyretic or anticytokine therapy (such as tocilizumab or steroids), fever is no longer a necessary condition for subsequent CRS severity classification. In this case, CRS classification is driven by hypotension and / or hypoxia.

[0356] 2 The grade of CRS is determined by the more severe event: hypotension or hypoxia not due to any other cause. For example, a patient with a temperature of 39.5°C who develops hypotension requiring 1 vasopressor and hypoxia requiring a low-flow nasal cannula is classified as grade 3 CRS.

[0357] 3 Low-flow nasal cannula is defined as oxygen delivery ≤ 6 L / min. Low flow also includes blow-through oxygen delivery, which is sometimes used in pediatrics. High-flow nasal cannula is defined as oxygen delivery > 6 L / min.

[0358] Example 2: Clinical evaluation of an anti-CD3×anti-CD20 bispecific antibody in patients with relapsed or refractory B-cell non-Hodgkin's lymphoma

[0359] This is a phase 2, open-label, multi-cohort, multicenter study of onitumab (anti-CD3 × anti-CD20) administered as an intravenous infusion in patients with B-NHL who have relapsed after or are refractory to prior systemic therapy. The study consisted of 5 disease-specific cohorts, each with independent parallel recruitment. Patients in the DLBCL cohort were randomized 1:1 to either cohort 1 or cohort 2 in the initial step of the cohort, using 2 different onitumab dosing schedules. Cohort assignment was based on the patient's diagnosis and treatment history at study recruitment.

[0360] The treatment period consisted of 12 weekly doses followed by every 2 weeks (Q2W) dosing until disease progression or other protocol-defined reasons for treatment discontinuation. In addition, if the patient demonstrated a CR and showed a durable response lasting at least 9 months after the initial determination of CR, the assigned dose of study drug administration was reduced from Q2W to every 4 weeks (Q4W) intervals based on the local investigator's assessment. Prior to switching from Q2W to Q4W dosing, patients must have received the assigned QW full (nominal) dose on a Q2W dosing schedule for at least the first 3 doses.

[0361] Onitumab was administered intravenously (IV) as a single agent with an initial divided dose of 0.7 mg (0.2 / 0.5 mg), followed by a 4 mg intermediate divided dose-1, and then a 20 mg intermediate divided dose-2. Subsequently, dosing in each disease-specific cohort was as follows:

[0362] FL 1-3a cohort: 80 mg QW, followed by 160 mg Q2W

[0363] DLBCL cohort 1: 160 mg QW followed by 320 mg Q2W

[0364] DLBCL cohort 2: 320 mg QW followed by 320 mg Q2W

[0365] MCL following BTK inhibitor therapy: 160 mg QW, then 320 mg Q2W

[0366] MZL: 80 mg once a week, then 160 mg every 2 weeks

[0367] Other B-NHL: 160 mg qw, then 320 mg q2w

[0368] Patients in the DLBCL cohort were randomized 1:1 to either Group 1 or Group 2 in the initial step of the cohort, using 2 different onitumumab dosing schedules. Group 1 patients received a full QW dose of 160 mg during the QW dosing period, followed by 320 mg during the Q2W dosing period. Group 2 patients received a full QW dose of 320 mg during the QW dosing period, followed by 320 mg during the Q2W dosing period.

[0369] The study population for each of the five independently recruited disease-specific cohorts consisted of:

[0370] ●FL grade 1-3a cohort: patients with FL who have relapsed after or are refractory to at least 2 prior lines of systemic therapy (including anti-CD20 antibodies and alkylating agents); patients must have failed lenalidomide and rituximab combination therapy (if approved or deemed by the investigator to be ineligible for this therapy).

[0371] ●DLBCL Cohort: Patients with DLBCL who have relapsed after at least 2 prior lines of systemic therapy (including anti-CD20 antibodies and alkylating agents) or who are refractory to these systemic therapies. Patients with de novo DLBCL or DLBCL transformed from a low-grade tumor (e.g., FL or CLL) may be enrolled. Patients with DLBCL transformed from a prior CLL may be enrolled only if they do not have a leukemic CLL component. For patients with transformed DLBCL, prior systemic therapy for a low-grade tumor will not be considered as one of the prior lines of treatment for the purpose of determining eligibility.

[0372] ●MZL cohort: MZL patients who have relapsed after at least 2 prior lines of systemic therapy or are refractory to these systemic therapies.

[0373] ●Other B-NHL cohort: patients with other B-NHL subtypes (excluding WM, SLL, CLL, Burkitt lymphoma, and Burkitt-like lymphoma with 11q aberration) who have relapsed after at least 2 prior lines of systemic therapy or are refractory to these systemic therapies.

[0374] ●MCL after BTK inhibitor therapy cohort: MCL patients who have failed prior Bruton's tyrosine kinase (BTK) inhibitor therapy.

[0375] The initial dose (0.7 mg [0.2 / 0.5 mg]), intermediate dose-1 of 4 mg, and intermediate dose-2 of 20 mg were always administered as divided infusions over 2 days (preferably consecutively, but not more than 3 days apart), even if these doses were delayed until after treatment week 3. If the full initial dose, full intermediate dose-1, and intermediate dose-2 were received and tolerated, continue to administer the full (nominal) dose QW.

[0376] In patients who did not experience Grade 3 cytokine release syndrome (CRS) on the initial dose, intermediate dose-1, and intermediate dose-2, the full QW dose of onitumab was administered as a single infusion. Patients received the full initial dose before intermediate dose-1; patients received the full intermediate dose-1 before intermediate dose-2 and received the full intermediate dose-2 before receiving the full single infusion. For doses after treatment week 4, onitumab was administered as a single infusion.

[0377] When the first full QW dose is tolerated as a single infusion, subsequent doses are administered as a single infusion over 1 to 4 hours depending on previous tolerability.

[0378] Duration of treatment consisted of 12 QW doses followed by Q2W dosing until disease progression or other protocol-defined reasons for treatment discontinuation. In addition, if a patient demonstrated a CR and showed a durable response lasting at least 9 months after the initial determination of CR, the assigned dose of study drug administration was reduced from a Q2W to a Q4W interval based on the local investigator's assessment. Prior to switching from Q2W to Q4W dosing, patients must have received the assigned full QW doses on a Q2W dosing schedule for at least the first 3 doses. Patients were followed for efficacy until disease progression or initiation of non-protocol anti-lymphoma therapy.

[0379] Inclusion criteria

[0380] Each patient must meet the following criteria to be eligible for inclusion in this study:

[0381] 1. Aged 18 or above

[0382] 2. Only for FL grade 1-3a cohort: Central histopathological confirmation of FL grade 1 to 3a diagnosis must be obtained prior to study recruitment. Patients with FL grade 3b are not eligible for this cohort but may be included in the "Other B-NHL" cohort. Follicular lymphoma typing is based on the World Health Organization (WHO) classification.

[0383] 3. Disease-specific cohorts:

[0384] Patients should require systemic therapy for lymphoma at the time of study enrollment, based on the investigator's judgment, and should be considered ineligible for any other approved therapy with established benefit for this indication. Refractory was defined as no response (SD / PD) or relapse within ≤6 months of last treatment.

[0385] ●FL grade 1-3a cohort: patients with FL grade 1-3a who have relapsed after or are refractory to at least 2 prior lines of systemic therapy (including anti-CD20 antibodies and alkylating agents); patients must have failed lenalidomide and rituximab combination therapy (if approved or deemed ineligible by the investigator).

[0386] ●DLBCL Cohort: Patients with DLBCL who have relapsed after at least 2 prior lines of systemic therapy (including anti-CD20 antibodies and alkylating agents) or who are refractory to these systemic therapies. Patients with de novo DLBCL or DLBCL transformed from a low-grade tumor (e.g., FL or CLL) may be enrolled. Patients with DLBCL transformed from a prior CLL may be enrolled only if they do not have a leukemic CLL component. For patients with transformed DLBCL, prior systemic therapy for a low-grade tumor will not be considered as one of the prior lines of treatment for the purpose of determining eligibility.

[0387] The following subtypes based on the WHO classification are eligible:

[0388] -DLBCL not otherwise specified (NOS)

[0389] - Germinal center B cell type

[0390] - Activated B cell type

[0391] ●MCL after BTK inhibitor therapy cohort: MCL patients who have failed prior Bruton's tyrosine kinase (BTK) inhibitor therapy.

[0392] ●MZL cohort: MZL patients who have relapsed after at least 2 prior lines of systemic therapy or are refractory to these systemic therapies.

[0393] The following subtypes based on the WHO classification are eligible:

[0394] - Extranodal MZL of mucosa-associated lymphoid tissue (MALT lymphoma)

[0395] - Nodal marginal zone lymphoma

[0396] - Splenic marginal zone lymphoma

[0397] ●Other B-NHL cohort: patients with B-NHL other than FL grade 1-3a, DLBCL, MCL, or MZL who have relapsed after at least 2 prior lines of systemic therapy or are refractory to these systemic therapies.

[0398] based on WHO The following subtypes of classification are eligible:

[0399] - Primary mediastinal (thymic) large B-cell lymphoma

[0400] - T cell / histiocyte-rich large B cell lymphoma

[0401] - Epstein-Barr virus (EBV) + DLBCL, NOS

[0402] - High-grade B-cell lymphoma with rearrangements of MYC and BCL2 and / or BCL6

[0403] - High-grade B-cell lymphoma, NOS

[0404] - B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin lymphoma

[0405] -Follicular lymphoma, grade 3b

[0406] Patients with Waldenstrom's macroglobulinemia (WM, lymphoplasmacytic lymphoma), small lymphocytic leukemia (SLL) and chronic lymphocytic leukemia (CLL), Burkitt's lymphoma, and Burkitt-like lymphoma with 11q aberration were excluded.

[0407] 4. Measurable disease on cross-sectional imaging documented by diagnostic imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) (defined as at least 1 two-dimensionally measurable nodular lesion with greatest transverse diameter (GTD) ≥1.5 cm, regardless of short-axis diameter).

[0408] 5. Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1.

[0409] 6. Adequate bone marrow function as documented by the following data:

[0410] a. Platelet count ≥50×10 9 / L. Patients may not receive platelet transfusion therapy within 7 days prior to the first dose of onitumumab to meet platelet eligibility criteria.

[0411] b. Hemoglobin ≥ 9.0 g / dL

[0412] c. Absolute neutrophil count (ANC) ≥ 1.0 × 10 9 / L. Patients may not receive granulocyte colony-stimulating factor within 2 days before the first dose of onitumumab to meet ANC eligibility criteria.

[0413] Patients with bone marrow involvement or splenic sequestration should meet the following hematologic parameters:

[0414] – Platelet count ≥ 25 × 10 9 / L. Patients may not receive platelet transfusion therapy within 3 days prior to the first dose of onitumumab to meet platelet eligibility criteria.

[0415] – Hemoglobin ≥7.0 g / dL

[0416] – Absolute neutrophil count (ANC) ≥ 0.5 × 10 9 / L. Patients may not receive granulocyte colony-stimulating factor within 2 days before the first dose of onitumumab to meet ANC eligibility criteria.

[0417] 7. Adequate Liver Function:

[0418] a. Total bilirubin ≤1.5×ULN (≤3×ULN if due to lymphomatous hepatic infiltration)

[0419] b. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 2.5 × ULN (≤ 5 × ULN if due to lymphoma liver infiltration)

[0420] c. Alkaline phosphatase (ALP) ≤ 2.5 × ULN (≤ 5 × ULN if due to lymphoma liver infiltration)

[0421] Note:

[0422] * Patients with AST>2.5×ULN and / or ALT>2.5×ULN and total bilirubin>1.5×ULN will be excluded regardless of the presence of lymphoma infiltration in the liver.

[0423] *Patients with known Gilbert's syndrome were excluded if total bilirubin values ​​were >4× upper limit of normal (ULN) for the local general population.

[0424] 8. Serum creatinine ≤1.5×ULN, or creatinine clearance calculated by Cockcroft-Gault formula ≥50mL / min.

[0425] Note: Patients with calculated creatinine clearance <50 mL / min may be considered for enrollment if the measured creatinine clearance (based on a 24-hour urine collection or other reliable method) is ≥50 mL / min.

[0426] 9. Willingness to undergo a tumor biopsy at baseline If the investigator has determined that a baseline tumor biopsy cannot be obtained safely, the sponsor may grant an exception to the biopsy requirement only after discussion with and approval by the medical monitor.

[0427] 10. Be able to understand the purpose and risks of the research and provide signed and dated informed consent and authorization for the use of protected health information (in accordance with national and local subject privacy regulations).

[0428] 11. Willing and able to comply with clinical visits and study-related procedures

[0429] 12. Provide the informed consent signed by the research patient or legal representative

[0430] 13. Able to understand and complete research-related questionnaires

[0431] Exclusion criteria

[0432] Patients who meet any of the following criteria have been / will be excluded from the study:

[0433] 1. Primary central nervous system (CNS) lymphoma or known non-primary CNS NHL involvement (in addition to the mandatory head CT or MRI, lumbar puncture should be performed to evaluate suspected CNS lymphoma as appropriate).

[0434] 2. Receiving any systemic anti-lymphoma therapy within 5 half-lives or 28 days before the first administration of study drug (whichever is shorter).

[0435] 3. History of allogeneic stem cell transplantation.

[0436] 4. Previously received any chimeric antigen receptor T cell (CAR-T) therapy.

[0437] 5. Continuous systemic corticosteroid treatment with more than 10 mg per day of prednisone or anti-inflammatory equivalents within 72 hours of study drug initiation.

[0438] 6. History of neurodegenerative disease or CNS movement disorder. Patients with a history of epileptic seizures within 12 months prior to study recruitment were excluded.

[0439] 7. Vaccination with a replication-competent vector within 28 days prior to the first study drug administration.

[0440] 8. Another malignancy other than B-NHL in the past 5 years, except non-melanoma skin cancer or cervical cancer in situ that has received potentially curative therapy, or any other tumor that is considered to have been effectively treated with clear local control and curative intent.

[0441] 9. Evidence of significant concurrent illness or medical condition that may interfere with the conduct of the study or place the patient at significant risk, including but not limited to significant cardiovascular disease (e.g., New York Heart Association class III or IV heart disease, myocardial infarction within the past 6 months, unstable arrhythmia, or unstable angina) and / or significant pulmonary disease (e.g., history of obstructive pulmonary disease and symptomatic bronchospasm).

[0442] 10. Cardiac ejection fraction <40% as determined by echocardiography or multiple gated acquisition (MUGA) scan.

[0443] 11. Any infection requiring hospitalization or intravenous anti-infective drug treatment within 2 weeks after the first administration of study drug.

[0444] 12. Uncontrolled human immunodeficiency virus (HIV) infection, hepatitis B or hepatitis C infection; or other uncontrolled infection.

[0445] a. HIV patients whose infection was controlled (undetectable viral load and CD4 count above 350 cells / μL, either spontaneously or while receiving a stable antiviral regimen) were allowed to be included.

[0446] b. Patients with hepatitis B (HepBsAg+) whose infection was controlled (serum hepatitis B virus DNA polymerase chain reaction [PCR] below the limit of detection and receiving hepatitis B antiviral therapy) were allowed to be included.

[0447] c. Patients who were HCV antibody positive (HCV Ab+) and whose infection was controlled (undetectable HCV RNA by PCR either spontaneously or as a response to previous successful anti-HCV therapy) were allowed to be included.

[0448] 13. History of severe allergic reactions to compounds with similar chemical or biological composition to the study drug or excipients. For this purpose, severe allergic reactions are defined as reactions requiring hospitalization and / or treatment with epinephrine.

[0449] 14. Known hypersensitivity to allopurinol and rasburicase

[0450] 15. Women of childbearing potential (WOCBP) with a positive serum β-hCG pregnancy test are not eligible for this study.

[0451] 16. Pregnant or breastfeeding women.

[0452] 17. Women of childbearing potential* or men who are unwilling to take highly effective contraceptive measures before the first dose / start of first treatment, during the study, and for at least 6 months after the last dose. Sperm donation is prohibited during the study and within 6 months after the last dose of study drug. Highly effective contraceptive measures include:

[0453] a. Stable use of combined (estrogen and progestin) hormonal contraceptives (oral, vaginal, transdermal) or progestin-only hormonal contraceptives (oral, injectable, implantable) associated with ovulation suppression for 2 or more menstrual cycles prior to screening

[0454] b. Intrauterine device (IUD); intrauterine hormone-releasing system (IUS)

[0455] c. Bilateral tubal ligation

[0456] d. A partner who has undergone a vasectomy (provided that the male partner who has undergone a vasectomy is the study participant's only sexual partner and the partner has been medically evaluated as having had a successful surgery).

[0457] e. and / or abstinence

[0458] *Women of childbearing potential are defined as women who remain fertile from menarche until menopause unless they are permanently sterile. Permanent sterilization methods include hysterectomy, bilateral salpingectomy, and bilateral oophorectomy.

[0459] The postmenopausal state is defined as the absence of menstruation for 12 months without an alternative medical reason. High follicle stimulating hormone (FSH) levels in the postmenopausal range can be used to confirm the postmenopausal state in women who are not using hormonal contraception or hormone replacement therapy. However, in the absence of 12 months of amenorrhea, a single FSH measurement is insufficient to determine the occurrence of the postmenopausal state. The above definition is based on the guidance of the Clinical Trial Facilitation Group (CTFG).

[0460] Women who have had a documented hysterectomy or tubal ligation do not need pregnancy testing or contraception.

[0461] Sexual abstinence is considered a highly effective approach only if it is defined as abstention from heterosexual intercourse during the entire risk period associated with the study drug. The reliability of sexual abstinence needs to be evaluated based on the duration of the clinical trial and the patient's preferences and usual lifestyle.

[0462] Periodic abstinence (calendar, symptom temperature, postovulation method), withdrawal (coitus interruptus), spermicide use alone, and the lactational amenorrhea method (LAM) are unacceptable methods of contraception. Female and male condoms should not be used together.

[0463] 18. Prior treatment with anti-CD20 × anti-CD3 bispecific therapy.

[0464] Table 6: CRS toxicity grading

[0465]

[0466] CPAP = continuous positive airway pressure, bilevel positive airway pressure, BiPAP = bilevel positive airway pressure.

[0467] Organ toxicities associated with CRS can be graded according to CTCAE v4.03, but they do not affect the CRS grade.

[0468] 1 Fever is defined as a body temperature ≥ 38°C not caused by any other reason. After CRS patients receive antipyretic or anticytokine therapy (such as tocilizumab or steroids), fever is no longer a necessary condition for subsequent CRS severity classification. In this case, CRS classification is driven by hypotension and / or hypoxia.

[0469] 2 The grade of CRS is determined by the more severe event: hypotension or hypoxia not due to any other cause. For example, a patient with a temperature of 39.5°C who develops hypotension requiring 1 vasopressor and hypoxia requiring a low-flow nasal cannula is classified as grade 3 CRS.

[0470] 3 Low-flow nasal cannula is defined as oxygen delivery ≤ 6 L / min. Low flow also includes blow-through oxygen delivery, which is sometimes used in pediatrics. High-flow nasal cannula is defined as oxygen delivery > 6 L / min.

[0471] Outcomes of Follicular Lymphoma

[0472] As discussed herein, Onitumumab is a hinge-stabilized, human IgG4-based CD20×CD3 bispecific antibody that binds CD20 on B cells and CD3 on T cells, thereby inducing T cell-mediated cytotoxicity to malignant B cells. In a Phase I study (discussed in Example 4), the ORR of FL 1-3a grade patients who had previously received ≥2 lines of therapy and received a dose of ≥5mg Onitumumab treatment was 91% and the CR rate was 72%. The response was durable, with a 4-year progression-free survival (PFS) rate of 54%. The Phase II dose for R / R FL patients was determined to be 80mg per week. The following are the results of a pre-specified analysis of the FL 1-3a grade cohort in a Phase II study, which used an ascending regimen designed to maintain efficacy while minimizing acute toxicity, including cytokine release syndrome (CRS).

[0473] In the Phase II study, adult patients with FL grade 1-3a who had relapsed after ≥2 lines of previous therapy (including anti-CD20 antibodies and alkylating agents) or were refractory to these therapies were recruited. Onitumumab was administered intravenously in a 21-day cycle, with steroid prevention and weekly escalation during cycle 1 (C1) to reduce the risk of acute toxicity. The initial escalation regimen consisted of 1 mg administered in fractions on C1 day 1 (D1) and C1D2, and 20 mg administered in fractions on C1D8 and C1D9, followed by a full dose of 80 mg on C1D15 (1 / 20 regimen). The 1 / 20 regimen was modified during the study to further reduce the risk of CRS by increasing the intermediate escalation dose. The modified regimen consisted of 0.7 mg divided into fractions in C1D1 (0.2 mg) and C1D2 (0.5 mg), 4 mg divided into fractions in C1D8 and C1D9, and 20 mg divided into fractions in C1D15 and C1D16, followed by a full dose of 80 mg in C2D1 (0.7 / 4 / 20 regimen). 80 mg per week continued until the end of C4. After C4, maintenance treatment with 160 mg of onitumumab was performed every 2 weeks until disease progression or unacceptable toxicity. The primary endpoint was ORR assessed by independent central review (ICR) according to the Lugano 2014 criteria. CRS was assessed using the 2019 ASTCT criteria.

[0474] As of April 20, 2022, 96 patients were evaluable for safety; 85 were evaluable for efficacy. The median age was 59 years (range 22-84), 52% were male, 58% FLIPI 3-5, 15.6% had bulky disease, and the median prior treatment line was 3 (range 2-13). 74% were refractory to the most recent therapy, 79% were refractory to prior anti-CD20 therapy, and 48% had disease progression within 2 years (POD24). The median duration of study follow-up was 17.3 months. The ICR-confirmed ORR and CR rates were 81% (69 / 85) and 75% (64 / 85), respectively. ORR and CR rates were consistent in high-risk subgroups, including patients aged ≥65 years, POD24, FLIPI 3-5, and patients refractory to the last line of therapy; ORR and CR rates were also consistent in the subgroup of patients treated with a 0.7 / 4 / 20 ascending regimen. The response was durable, with a median duration of response and a median duration of CR of 18.2 months. The median PFS was 20.2 months, and the median OS was not reached (95% CI 23.0 months-not estimable).

[0475] TEAEs occurred in 95 (99%) patients, of which 86 (90%) were considered treatment-related. In the overall safety-evaluable population, the most common TEAEs (>30% all grades) were CRS (51%), pyrexia (32%), anemia (31%), and infusion-related reactions (31%). Grade 1 CRS was observed in 39% of patients following a 0.7 / 4 / 20 escalation schedule in C1; no grade ≥ 2 CRS were reported. All CRS events resolved, and only 1 patient received tocilizumab for CRS management. No ICANS were reported after revised escalation dosing, compared with 3% in the 1 / 20 schedule. Two (2%) patients reported treatment-related grade 5 AEs; 6 (6%) patients discontinued due to treatment-related AEs.

[0476] Consistent with the Phase I study, in the Phase II study, onitumumab showed impressive efficacy in patients with FL grade 1-3a who had previously received ≥2 lines of therapy, with ICR confirming CR in 75% of patients. Durability of response and good survival outcomes are clinically important in the setting of heavily pretreated, highly R / R FL, where the prognosis is generally poor. The overall tolerability profile of the 0.7 / 4 / 20 step-up regimen was good, with only grade 1 CRS observed during C1.

[0477] Outcome of Diffuse Large B-Cell Lymphoma

[0478] As discussed herein, Onitumab is a hinge-stabilized, human IgG4-based CD20×CD3 bispecific antibody that binds CD20 on B cells and CD3 on T cells, thereby inducing T cell-mediated cytotoxicity to malignant B cells. In a Phase I study (discussed in Example 4), Onitumab showed encouraging activity in DLBCL patients who had previously received ≥2 lines of therapy. The ORR of DLBCL patients treated with a dose of ≥80mg Onitumab was 53% and the CR rate was 53%. The response was persistent, with a probability of 88% for 12 months of sustained response. The Phase II dose for expansion in R / R DLBCL patients was determined to be 160mg per week. The following are the results of a pre-specified analysis of the 160mg DLBCL cohort in a Phase II study, which used an ascending regimen designed to maintain efficacy while minimizing acute toxicity, including cytokine release syndrome (CRS).

[0479] In the Phase II study, adult patients with DLBCL who had relapsed after ≥2 lines of prior therapy (including anti-CD20 antibodies and alkylating agents) or were refractory to these therapies were recruited. Onitumumab was administered intravenously in 21-day cycles, with steroid prevention and weekly escalation during cycle 1 (C1) to reduce the risk of acute toxicity. The initial escalation regimen consisted of 1 mg administered in fractions on C1 day 1 (D1) and C1D2, and 20 mg administered in fractions on C1D8 and C1D9, followed by a full dose of 160 mg on C1D15 (1 / 20 regimen). The 1 / 20 regimen was modified during the study to further reduce the risk of CRS by increasing the intermediate escalation dose. The modified regimen consisted of 0.7 mg divided into fractions in C1D1 (0.2 mg) and C1D2 (0.5 mg), 4 mg divided into fractions in C1D8 and C1D9, and 20 mg divided into fractions in C1D15 and C1D16, followed by a full dose of 160 mg in C2D1 (0.7 / 4 / 20 regimen). 160 mg per week continued until the end of C4. After C4, maintenance therapy was 320 mg of onitumumab every 2 weeks until disease progression or unacceptable toxicity. The primary endpoint was ORR assessed by independent central review (ICR) according to the Lugano 2014 criteria. CRS was assessed using the 2019 ASTCT criteria.

[0480] As of April 20, 2022, 121 DLBCL patients were evaluable for safety; 90 were evaluable for efficacy. The median age was 67 years (range, 24-88), 60% were male, 80% were Ann Arbor III–IV stage, IPI score ≥3.58%, and the median previous treatment line was 2 (range, 2-8). 56% were primary refractory, and 65% were double refractory. The median duration of study follow-up was 17.1 months. The ICR-confirmed ORR and CR rates were 53% (48 / 90) and 37% (33 / 90), respectively. The ORR and CR rates were consistent in the high-risk subgroup and the subgroup of patients treated with a 0.7 / 4 / 20 step-up regimen. CR was durable; the median duration of CR was not reached (95% CI: 10.2 months-not estimable), and the probability of 9-month sustained CR was 70%.

[0481] TEAEs occurred in 117 (97%) patients, and 102 (84%) were considered treatment-related. In the overall safety-evaluable population, the most common TEAEs (>30% all grades) were CRS (53%), fever (41%), and anemia (34%). No grade 3 CRS events were observed after the 0.7 / 4 / 20 step-up regimen was implemented in C1. Grade 1 and 2 CRS were only observed in 35% and 13% of DLBCL patients, respectively. All CRS events resolved after supportive measures; 20% of patients received tocilizumab, and no one required vasopressors or mechanical ventilation for CRS management. After the revision of the step-up dosing, only 2 patients (3%) reported ICANS, all of which were low-grade, and 6% of patients experienced ICANS in the 1 / 20 regimen. Two patients (2%) experienced treatment-related grade 5 AEs, and 8 patients (7%) discontinued onitumab due to treatment-related AEs.

[0482] In the Phase II study, Onitumumab demonstrated clinically meaningful efficacy, durable CR, and a favorable safety profile in a population of patients with refractory, highly aggressive R / R DLBCL. The results of this Phase 2 study confirmed the activity observed in Phase I, and together demonstrated that Onitumab has compelling activity and a tolerable safety profile both before and after CAR-T therapy.

[0483] The 0.7 / 4 / 20 escalating dose regimen of onitumumab in C1 mitigated the risk of high-grade CRS, which is consistent with observations of other bispecific agents and CAR-T therapies. In addition, only low-grade ICANS were reported for the 0.7 / 4 / 20 regimen.

[0484] Example 3: Premedication for intravenous administration of onitumumab

[0485] As discussed in the Examples herein, the following premedication will apply to the administration of onitumumab from the initial dose to the first once weekly (QW) dose in a single infusion format.

[0486] If a patient experiences an infusion-related reaction (IRR) and / or cytokine release syndrome (CRS) of any grade after receiving the first QW dose, premedication will continue until the full QW dose is tolerated without IRR or CRS:

[0487] 1. If each onitumumab dose is administered on non-consecutive days, 12 to 24 hours before the scheduled start time of the first divided infusion and 12 to 24 hours before the scheduled start time of the second divided infusion

[0488] a. Oral administration of 20 mg dexamethasone or equivalent dose of steroids;

[0489] 2. Premedication on each day of fractionated infusion of Onitumumab and on the day of single infusion of full QW dose:

[0490] a. Dexamethasone 20 mg intravenously 1 to 3 hours before the start of the infusion on the day of treatment

[0491] b. 25 mg diphenhydramine intravenously or orally 30 to 60 minutes before (another equivalent antihistamine may be substituted)

[0492] c. Take 650 mg of acetaminophen orally 30 to 60 minutes before infusion, unless the patient has received acetaminophen in the past 4 hours before infusion of onitumab or is allergic to acetaminophen

[0493] 3. 24 (± 4) hours after the second divided infusion or the first full QW dose of a single infusion:

[0494] a. Oral administration of 20 mg dexamethasone or equivalent dose of steroids

[0495] With dexamethasone 20 mg IV, the first dose administered after the full QW dose as a single infusion was free of any grade IRR and / or CRS:

[0496] a. Dexamethasone 10 mg intravenously 1 to 3 hours before the start of the infusion on the day of treatment

[0497] b. 25 mg diphenhydramine intravenously or orally 30 to 60 minutes before (another equivalent antihistamine may be substituted)

[0498] c. Take 650 mg of acetaminophen orally 30 to 60 minutes before infusion, unless the patient has received acetaminophen in the past 4 hours before infusion of onitumab or is allergic to acetaminophen

[0499] For subsequent doses, premedication is not required if a single infusion of 10 mg dexamethasone at a reduced dose is tolerated without the occurrence of any grade IRR and / or CRS.

[0500] Anti-IL6 therapy (eg, tocilizumab) 8 mg / kg infused over 1 hour, not to exceed 800 mg

[0501] Example 4: Onitumumab (a human CD20×CD3 bispecific antibody) for relapsed or refractory B-cell non-Hodgkin's lymphoma

[0502] Onitumab is a hinge-stabilized, fully human IgG4-based CD20×CD3 bispecific antibody that binds to CD3+ T cells and malignant B cells. The following are the results of a first-in-human study of Onitumab in patients with relapsed / refractory (R / R) B-cell non-Hodgkin lymphoma (B-NHL).

[0503] This Phase 1 study enrolled patients with CD20-positive relapsed / refractory (R / R) B-cell malignancies who had been previously treated with CD20-directed antibody therapy. Eligible patients aged ≥18 years and with an ECOG performance status ≤1 received intravenous onitumab, which consisted of escalating dosing in cycle 1, followed by weekly treatment at a target dose level ranging from 0.1-320 mg in cycles 2-4. Maintenance treatment was every 2 weeks until disease progression. The primary endpoints were safety, pharmacokinetics, maximum tolerated dose, and preliminary antitumor activity.

[0504] A total of 145 patients were recruited (dose escalation, n = 94; dose expansion, n = 51). Patients had previously received a median of three lines of therapy (range: 1-11), 42 patients (29.0%) had previously received chimeric antigen receptor (CAR) T cell therapy, and 119 patients (82.1%) were refractory to the last line of therapy. The median duration of follow-up was 4.2 months (interquartile range 1.6-11.5). During dose escalation, the maximum dose of onitumab administered was 320 mg per week, and no dose-limiting toxicity was observed. The recommended dose of onitumab 80 mg was selected for dose expansion in patients with R / R follicular lymphoma (FL) grade 1-3a, and onitumab 160 mg was selected for dose expansion in patients with R / R diffuse large B-cell lymphoma (DLBCL). The most common adverse events were fever, cytokine release syndrome (CRS), chills, anemia, and fatigue. CRS and neurotoxicity were mainly low grade and did not lead to treatment discontinuation.

[0505] The objective response rate (ORR) was 51% across all B-NHL subtypes in patients treated with all doses of onitumab, with 37% having a complete response. In patients with FL 1–3a (n=32) treated with onitumab at doses ≥5 mg, the ORR was 91%, with 72% having a complete response. In patients with CAR T-naive DLBCL (n=15) treated with onitumab at doses ≥80 mg, the ORR was 53%, with all complete responses. In patients with CAR T-naive DLBCL (n=30) treated with onitumab at doses ≥80 mg, the ORR was 33%, with 27% having a complete response. Responses appeared durable, with 12-month ongoing complete responses of 60%, 88%, and 100% in patients with FL 1-3a, CAR T-naive DLBCL, and DLBCL after CAR T, respectively.

[0506] Study Design and Treatment

[0507] Patients were eligible if they were ≥18 years of age, had documented B-NHL, had at least one measurable lesion, had received prior anti-CD20 antibody therapy, had an Eastern Cooperative Oncology Group performance status (ECOGPS) of 0 or 1, and had adequate hematologic and organ function. Patients with primary central nervous system (CNS) lymphoma or who had received prior allogeneic stem cell transplantation were excluded.

[0508] A traditional 3+3 dose escalation design was implemented during the dose escalation period. In cycle 1, patients received onitumab intravenously according to an ascending dosing schedule, and then received weekly treatment at a target dose level ranging from 0.1-320 mg in cycles 2-4 (each cycle was 21 days). Maintenance treatment was once every 2 weeks until disease progression or unacceptable toxicity occurred. During the dose escalation process, preventive measures to reduce the risk of cytokine release syndrome (CRS) were implemented, including steroid prevention, fractionated dosing, and ascending dosing.

[0509] Before ascending administration, the field availability of tocilizumab was confirmed. Onituzumab was administered intravenously within 4 hours during the 1st cycle (1st, 2nd, 8th, 9th, 15th, 16th day), and the first complete dose was administered on the 1st day of the 2nd cycle. During the 2nd-4th cycle and maintenance treatment, the infusion duration of the subsequent dose was reduced to 60 minutes. During the 1st day of the 1st cycle and the 2nd cycle, the patient was monitored in an inpatient setting within about 24 hours after the end of each infusion. Subsequent doses were performed in an outpatient setting. Pre-medication was administered during the 1st cycle to further reduce the risk of CRS; full details are provided in Example 3. In short, preventive steroids were administered 1 day before infusion, on the day of infusion, and 1 day after infusion. In addition, acetaminophen and diphenhydramine were administered 30-60 minutes before infusion. Steroid pre-medication was gradually reduced in the 8th day dose of the 2nd cycle, and all pre-medications were deactivated in subsequent doses. Treatment at the target dose level was administered on Days 1, 8, and 15 of Cycles 2-4, followed by maintenance dosing every 2 weeks.

[0510] Patients were allowed to receive supportive care medications required for the management of CRS (including antipyretics, corticosteroids, intravenous fluids, vasopressors, tocilizumab, oxygen, and mechanical ventilation), uric acid-lowering agents for the management of tumor lysis syndrome (TLS), and anti-infective prophylaxis according to local institutional guidelines, including Pneumocystis jirovecii pneumonia prophylaxis, IVIG supplementation, and appropriate antiviral prophylaxis for patients with prior herpes simplex virus, cytomegalovirus, or hepatitis B virus infection. Transfusions of blood products and the use of granulocyte colony-stimulating factor were permitted according to standard of care.

[0511] Study End Points and Assessments

[0512] The primary objectives are to evaluate safety, tolerability, and dose-limiting toxicity (DLT). Secondary objectives are to evaluate antitumor activity, pharmacokinetics (PK), and immunogenicity.

[0513] The primary endpoint is safety, assessed by the incidence of adverse events (AEs) and DLTs, to determine the maximum tolerated dose (MTD) and / or phase 2 dose of onituzumab. Key secondary endpoints include pharmacokinetics, immunogenicity, and antitumor activity, as measured by objective response rate (ORR), duration of response (DoR), and progression-free survival (PFS). The treatment-emergent period is defined as the time from the first administration of study drug to 90 days after the last dose of study drug. Relative dose intensity is defined as the actual dose intensity (dose administered per unit time) divided by the planned dose intensity. The severity of AEs was graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.03, and CRS was graded according to the criteria, depending on the patient recruitment date. Based on investigator assessment, AEs were considered to be related to the study drug.

[0514] The antitumor activity of onitumumab was measured as the objective response rate (ORR), which was assessed every 12 weeks according to the NCI-International Working Group's revised response criteria for malignant lymphomas using the Lugano classification.

[0515] Blood samples for onitumab concentration measurements were collected by intensive PK sampling during weeks 1 to 12 and by less intensive sampling thereafter. Onitumab concentrations in serum were measured using a validated enzyme-linked immunosorbent assay (lower limit of quantitation 0.003 mg / L). Descriptive statistics were used to summarize changes in serum onitumab concentrations over time.

[0516] A primary exposure-response (ER) analysis was performed by logistic regression using data on the best overall response of patients with FL or DLBCL who had not previously received chimeric antigen receptor T-cell (CAR T) therapy to a dose range of 2 to 320 mg of onitumumab intravenous regimen during dose escalation. The analysis assessed exposure measures (mean concentrations over time [C avg ] or area under the curve [AUC] and pre-dose concentration at week 12 [C min ]) and the relationship between ORR and complete response (CR) rate.

[0517] Statistical analysis

[0518] Based on the 3+3 design and the number of dose levels, a dose escalation sample size of 102 B-NHL patients was determined. A total of 130 B-NHL patients were planned to be enrolled in the expansion cohort to further evaluate the safety and efficacy of the recommended dose. No formal statistical assumptions were implemented in this study. All B-NHL patients in the dose escalation and dose expansion parts of the study were pooled for analysis. For the analysis of baseline characteristics and safety, all treated patients were included, and the data were also evaluated by dose group. In patients who had the opportunity to be evaluated for response at 12 weeks, efficacy endpoints were analyzed by B-NHL subtype and dose group. For continuous variables, descriptive statistics are provided, including the number of patients (n), mean, median, standard deviation, minimum, and maximum values ​​reflected in the calculation. For categorical or ordinal variables, the frequency and percentage of each category are shown. For event time variables, medians and 95% confidence intervals (CI) are provided by the Kaplan-Meier method, if applicable. ORR (proportion of patients with a best overall response of CR / PR according to the Lugano classification) and CR rate (proportion of patients with a best overall response of CR according to the Lugano classification) were summarized with two-sided 95% exact binomial CIs using the Clopper-Pearson method. Patients who could not be assessed for best overall response were considered nonresponders. Duration of response (time from first CR / PR to disease progression or death), duration of CR (time from first CR to disease progression or death), and PFS (time from the start of treatment to disease progression or death) were analyzed by Kaplan-Meier estimates; patients without disease progression or death were censored at the time of the last adequate tumor assessment on or before the data cutoff date.

[0519] result

[0520] A total of 145 patients were enrolled; 94 entered the dose escalation portion of the study and 51 entered the dose expansion portion of the study. Of the 145 B-NHL patients, 98 (68%) patients had aggressive B-NHL (DLBCL, n=85; MCL, n=12; FL3b grade, n=1) and 47 (32%) patients had indolent B-NHL (FL 1-3a grade, n=40; ​​MZL, n=6; Waldenstrom's macroglobulinemia, n=1). Of the DLBCL patients, 35 were enrolled after failure of prior CD19-directed CAR T therapy.

[0521] Patient demographics were summarized as follows: median age was 67 years (interquartile range, 57-73 years), and the majority of patients (n = 101; 70%) were male. At study entry, all patients had an ECOGPS of 0 (n = 58; 40%) or 1 (n = 87; 60%), 85% (n = 123) had Ann Arbor stage III–IV disease, and 34% (n = 49) had bulky disease. These patients included a heavily pretreated, refractory population who had previously received a median of three lines of systemic therapy (interquartile range, 2-5), including autologous stem cell transplantation (ASCT; n = 12; 8%) and CAR T therapy (n = 42; 29%). Overall, 119 (82%) patients were refractory to the last line of therapy; 123 (85%) were refractory to anti-CD20 antibodies in any line of therapy, and 100 (69%) were double refractory to both alkylating agents and anti-CD20 antibodies in any line of therapy.

[0522] At the time of data cutoff, seven (5%) patients continued to receive treatment (all included in the dose expansion cohort), 33 (23%) patients completed treatment, and 105 (72%) patients discontinued treatment, mainly due to disease progression (n=63, 43%). The median duration of follow-up was 4.2 months (interquartile range 1.6-11.5 months). During the dose escalation period, the maximum administered dose of onitumab was 320 mg per week; no DLT was observed, the MTD was not reached, and there was no dose-dependent increase in toxicity. Seven patients (5%) received retreatment with onitumab, three of whom had FL, three with DLBCL, and one with MCL. Six retreated patients received a dose of <5 mg, and one patient received 160 mg; all cases of retreatment occurred in patients recruited in the dose escalation phase of the study.

[0523] Patients received a median of 10 doses of onitumab (interquartile range 4-20) and a median exposure time of 13.1 weeks (interquartile range 5.0-32.9 weeks). The median relative dose intensity was 1.0. Clinical activity was observed in all dose groups, with a significant increase in FL patients (n=32) receiving onitumab ≥5 mg and in DLBCL patients (n=45) receiving onitumab ≥80 mg.

[0524] After intravenous infusion, peak serum concentrations of onitumab were observed at the end of infusion or 4 hours after infusion on Day 2 of Week 1 and Day 2 of Week 2 (split dosing). The median serum concentration of onitumab generally increased in a dose-dependent manner. Onitumab showed nonlinear PK characteristics and target-mediated drug disposal. Between Week 3 and Week 12, within the full dose range of 12 mg to 320 mg, the weekly drug accumulation ratio was up to three times the median peak concentration and approximately two to six times the median trough concentration.

[0525] A preliminary exposure-response (ER) analysis evaluated the relationship between exposure measures and ORR and CR rates during the 12-week treatment period using data from 40 FL patients and 38 DLBCL patients who had not previously received CAR T therapy and were enrolled during the dose escalation period. avg Compared with AUC, C min The best correlation with clinical response was observed in patients with FL or DLBCL who had not previously received CAR T. The ORR or CR probability was observed in patients with FL and DLBCL at week 12 with C min There was a positive correlation, and the highest CR rate was observed at doses ≥80 mg.

[0526] Immunogenicity to onitumab was low. Among 137 patients with B-NHL for whom anti-drug antibody (ADA) data were available, one patient who received onitumab 2 mg had very low titers of treatment-emergent ADA only at the last visit of safety follow-up (30 days after the last dose).

[0527] All 145 patients experienced at least one treatment-emergent adverse event (TEAE) of any grade, and 93% (n=135) of patients experienced at least one treatment-related TEAE. The most common TEAEs of any grade were pyrexia (n=107; 74%), CRS (n=89; 61%), chills (n=68; 47%), anemia (n=55; 38%), and fatigue (n=47; 32%). Grade ≥3 TEAEs occurred in 119 patients (82%); these TEAEs occurring in >10% of patients included anemia (n=36; 25%; treatment-related: n=22; 15%), lymphopenia (n=28; 19%; treatment-related: n=24; 17%), hypophosphatemia (n=27; 19%; treatment-related: n=18; 12%), neutropenia (n=27; 19%; treatment-related: n=21; 14%), and thrombocytopenia (n=20; 14%; treatment-related: n=11; 8%). Febrile neutropenia occurred in four patients (3%; treatment-related: n=3; 2%). A total of 71 (49%) patients experienced infections; 33 (23%) patients had grade ≥ 3 infections (grade 3, n = 28; 19%; grade 4, n = 1; 1%; grade 5, n = 4; 3%), the most common of which was pneumonia (n = 12; 8%).

[0528] TEAEs of particular concern occurred, including infusion-related reactions (IRR), CRS, CNS / ICANS-like events, tumor lysis syndrome (TLS), and infections. Most CRS events were grade 1 (n=52; 36%) or grade 2 (n=27; 19%). Nine (6%) patients had grade 3 CRS events, and during dose expansion, one MCL patient (1%) had a grade 4 CRS event in the setting of grade 5 TLS. CRS was primarily limited to cycle 1 (escalating dosing) and resolved within a median of 2 days with supportive measures. All grade ≥3 CRS events occurred before optimization of CRS risk mitigation measures during cycle 1. In seven (5%) patients, tocilizumab was used to manage grade ≥3 CRS, and no patient discontinued treatment due to CRS. 18 (12%) patients had ICANS-like events, and four (2.8%) patients had grade 3 events (confusional state, somnolence, encephalopathy, aphasia, and cognitive impairment, n=1 each). Most neurologic TEAEs were transient and resolved within a median of 3 days; none led to treatment discontinuation, and there were no grade 4 or 5 events.

[0529] Serious TEAEs occurred in 89 (61%) of 145 patients, the most common of which were CRS (n=41, 28%), pyrexia (n=11, 8%), pneumonia (n=9, 6%), and IRR (n=6, 4%). Sixty-eight (47%) patients experienced serious TEAEs in the first 4 weeks of treatment, and 88 (61%) patients had to prolong their hospital stay or be readmitted due to serious TEAEs.

[0530] Of the 145 patients, 70 (48%) experienced TEAEs leading to treatment discontinuation / delay, and 14 (10%) experienced TEAEs leading to dose reduction. Twelve (8%) patients discontinued onitumab due to TEAEs; ten TEAEs were considered treatment-related (grade 1 cytomegalovirus infection, n=1; grade 1 gait disorder, n=1; grade 3 pneumonia, n=2; grade 3 hemolysis, n=1; grade 3 toxoplasmosis, n=1; grade 3 fatigue, n=2; grade 4 AST increase, n=1; grade 5 TLS, n=1) and three were not treatment-related (grade 3 neck abscess in a patient who had prior spinal surgery, n=1; grade 3 device-related infection, n=1; leukemia, n=1). Seventeen patients died during treatment or within 30 days after the last dose; 12 of these deaths were due to disease progression and four were due to AEs, three of which were considered treatment-related (gastric perforation in one patient with gastric involvement by lymphoma [n = 1; time between last study drug dose and event = 6 days], lung infection [n = 1; 22 days], and TLS [n = 1, 3 days]). One fatal cardiac arrest event was considered by the investigator to be unrelated to study drug (occurred 22 days after the last study drug dose). In one patient, the primary cause of death was esophagogastric cancer recurrence / progression.

[0531] There were no additional safety signals in patients who received retreatment with onitumab (n=7). The most common TEAEs in these patients were nausea (n=4), anemia (n=3), and back pain (n=3). One patient experienced grade 1 CRS, and four grade ≥3 TEAEs were reported: hyponatremia, hypophosphatemia, lymphopenia, and disc herniation (n=1 each). No serious TEAEs or TEAEs leading to treatment discontinuation were reported in retreatment patients.

[0532] Overall, no dose-safety relationship was observed in all patients dosed at all dose levels.

[0533] Antitumor activity was observed in all dose groups (0.03-320 mg) and all lymphoma subtypes. Of the 145 patients dosed, 142 were evaluable for efficacy by response assessment at week 12. The ORR for all patients was 51% (n=72; 95% CI: 42-59), and the CR rate was 37% (n=52; 95% CI: 29-45). In patients with FL grade 1-3a (n=40), the ORR and CR rates were 78% (n=31; 95% CI: 62%-89%) and 63% (n=25; 95% CI: 46-77). Responses occurred early, with a median CR time of 2.6 months (interquartile range 2.5-2.9). The median duration of response (DoR) was 12.7 months (95% CI: 6.1, not estimable [NE]; observed range: 1.2–53.0+; interquartile range 4.4-19.9), and the median duration of CR (DoCR) was 14.5 months (95% CI: 8.8, NE; observed range: 0.0+–53.0+; interquartile range 3.9-19.9). In patients with R / R FL who received onitumumab ≥5 mg (n=32), the ORR and CR rates were 91% (n=29; 95% CI: 75-98) and 72% (n=23; 95% CI: 53-86), respectively; the median duration of response (DoR) was 15.8 months (95% CI: 6.4, NE; interquartile range 5.2-19.9), with the longest CR ongoing at 53.0+ months. The estimated probability of maintaining CR at 12 months was 60% (95% CI: 34-79) and 54% (95% CI: 28-74) at 48 months. The median progression-free survival (PFS) was 17.1 months (95% CI: 7.5, NE).

[0534] In all patients with DLBCL who had not previously received CAR T (n = 49) who received onitumumab (0.03-320 mg), the ORR and CR rates were 39% (n = 19; 95% CI: 25-54) and 24% (n = 12; 95% CI 13-39), respectively. The median CR time was 2.3 months (interquartile range 1.0-2.8), the median DoR was 4.4 months (95% CI: 2.9, NE; observed range: 1.5–41.4+; interquartile range 2.8-21.0), and the median DoCR was not reached (95% CI: 4.0, NE; observed range: 2.9–34.9+; interquartile range 4.2-21.4). In patients (n=15) treated with onitumab ≥80 mg (a dose determined as an active dose range for aggressive lymphoma), the ORR was 53% (n=8; 95% CI: 27-79), and all responses were complete responses; the median DoR was not reached (95% CI: 2.9, NE; interquartile range 4.4-21.2), and the longest CR lasted 32.4+ months. The estimated probabilities of maintaining CR at 12 months and 24 months were 88% (95% CI: 39-98) and 66% (95% CI: 16-91), respectively. The median PFS was 11.5 months (95% CI: 0.5, NE).

[0535] Among all patients with DLBCL previously treated with CAR T who received onitumab (0.03-320 mg) (n=33), the ORR and CR rates were 33% (n=11; 95% CI: 18-52) and 24% (n=8; 95% CI 11-42), respectively. The median CR time was 1.5 months (interquartile range 0.8-2.6), and the median DoR (95% CI: 1.6, NE; observed range: 0.0+–20.5+; interquartile range 1.6-12.8) and the median DoCR (95% CI: NE, NE; observed range: 0.0+–20.5+; interquartile range 2.6-15.8) were not reached. In patients treated with ≥80 mg of onitumab (n=30), the ORR and CR rates were 33% (n=10; 95% CI: 17-53) and 27% (n=8; 95% CI: 12-46), respectively; the median DoR was not reached (95% CI: 1.6, NE; interquartile range 1.6-12.8), and the longest CR lasted 20.5+ months. Importantly, in the specific group of DLBCL patients treated with ≥80 mg of onitumab, the estimated probability of maintaining CR at 12 months was 100% (95% CI: NE, NE). The median PFS was 2.0 months (95% CI: 0.9, 2.8).

[0536] No additional responses were achieved in patients who were retreated with onitumumab.

[0537] discuss

[0538] In this first-in-human study, onitumumab monotherapy demonstrated encouraging antitumor activity, strong durability of response, and an overall manageable safety profile in heavily pretreated, highly refractory, and difficult-to-treat B-NHL patients. Escalating dosing effectively reduced the risk of CRS, which occurred primarily in cycle 1 and resolved within a median of 2 days with supportive care measures. Most patients achieved full target dose exposure with minimal treatment delays; no patients experienced DLTs, and the MTD was not reached. In patients with R / R FL 1–3a, 80 mg was selected as the recommended dose for further expansion, and 160 mg was selected as the recommended dose for patients with R / R DLBCL. This is the first study to report long-term treatment outcomes for a CD20×CD3 bispecific antibody that included patients treated during the dose-escalation and dose-expansion portions of the trial.

[0539] Early studies typically recruited diverse and heterogeneous patient populations. Overall, the baseline characteristics of patients recruited in this study were consistent with those represented in contemporary CD20×CD3 bispecific antibody trials. The patient population included older, heavily pretreated patients, most of whom were double refractory to prior alkylating agents and anti-CD20 therapy. However, a notable difference was that 29% of patients recruited in this study had failed prior CAR T therapy at study entry, which is substantially higher than the 2% and 9% rates reported in recent studies of gefuzumab and icoretuzumab, respectively. Therefore, the population included in this trial may present a particularly poor prognosis, as these patients would be exposed to potential long-term toxicities unique to CAR T therapy and its associated preconditioning regimens. The proportion of patients who had previously undergone ASCT was 8%, which is numerically lower than some recent studies investigating CD20xCD3 bispecifics; however, this may be due in part to the presence of an elderly population and high chemotherapy refractoriness in this patient population.

[0540] Acute immune responses leading to transient cytokine release are common side effects of T cell engagement therapy. Premedication and ascending dosing of steroids have been used to reduce the occurrence of CRS after treatment with CD20×CD3 bispecific antibodies, regardless of whether the route of administration was intravenous or subcutaneous. In this study, ascending dosing and additional preventive measures were systematically introduced during the study, which effectively reduced the risk of CRS. In most cases, CRS was limited to the first cycle, of low grade (1 or 2), and resolved with supportive treatment without sequelae. No patient discontinued treatment or had significant treatment delays due to CRS. After intravenous treatment with onitumab, the frequency of ≥3 CRS was 7%. All ≥3 CRS events occurred before the ascending dosing schedule was optimized during the first cycle to include three steps. The reporting rate of ≥3 CRS is similar to that reported for other intravenously administered CD20×CD3 bispecific antibodies. In a phase 1 study of intravenous gefitinomab in patients with R / RB-NHL, grade ≥3 CRS was observed in 6% of patients treated at the RP2D. 2 The reported rates of grade ≥3 CRS ranged between 1% and 6% following intravenous administration of omotuzumab, palagrotuzumab, and IGM-2323. Ixorezumab has also been studied in R / R B-NHL, and no events of grade ≥3 CRS have been reported to date in a phase 1 / 2 study using the subcutaneous route of administration.

[0541] CAR T therapy is the basis for managing R / R B-NHL, and new data suggest that this may become a new approach for some patients with first relapse of DLBCL. However, many patients are still not suitable candidates for CAR T therapy at relapse because they have a rapidly progressive phenotype and require apheresis, ex vivo gene manipulation, T cell expansion, and intensive preconditioning before administration, which may lead to prolonged cytopenia. Since both CD20×CD3 bispecific drugs and CAR T therapy redirect T cells to trigger malignant B cell killing, early toxicity, such as CRS, has been observed in both types of therapy. In this study, patients receiving onitumumab were hospitalized for observation during the first cycle of ascending dosing, when CRS events most often occurred. With the ongoing implementation of a modified ascending regimen study (as described in detail in Examples 1 and 2), the requirements for hospitalization may be reassessed, and it may be feasible to administer onitumumab entirely in an outpatient setting.

[0542] Neurotoxicity with T-cell engager therapies has been observed in patients with B-NHL. The Phase 1 study of gefuzumab reported ICANS-like events in 5% of patients using a list of 12 terms provided by the sponsor, and in the Phase 1 / 2 study of icoretuzumab, neurologic symptoms were reported at a rate of 6%. Following treatment with icoretuzumab, CNS / ICANS-like events were primarily grade 1 or 2, with only four patients (3%) experiencing grade 3 events. No patients experienced grade 4 or 5 neurologic TEAEs or discontinued icoretuzumab treatment due to neurologic TEAEs. The utility of cross-study comparisons is somewhat limited by the absence of standardized criteria for reporting ICANS-like events.

[0543] There remains a very high unmet need for safe, effective and accessible treatment options for patients with R / R B-NHL. This unmet need is amplified in the setting where patients have disease progression following CAR T therapy, in whom the prognosis for salvage therapy remains dismal. This study provides evidence that onitumumab provides durable, clinically relevant benefit in heavily pretreated patients with R / R B-NHL, including those with disease progression following CAR T therapy.

[0544] In this study, treatment with onitumumab at a treatment-relevant dose of ≥80 mg was associated with an ORR (all CRs) of 53% in patients with R / R DLBCL who had not previously received CAR T therapy, with an estimated 88% of CRs lasting 12 months. Importantly, although the ORR and CR rates were lower in patients with DLBCL who had disease progression after prior CAR T therapy (33% and 27%, respectively), an estimated 100% of complete responses were ongoing at 12 months. These results may mark a clinically important advance in the post-CAR T setting, where few options remain other than salvage chemotherapy.

[0545] Early observations from dose-escalation studies of CD20×CD3 bispecifics have been reported in patients with R / R DLBCL. Recently, IV gefituzumab demonstrated an ORR and CR rate of 79% and 71%, respectively, in 14 patients treated at the recommended dose. Results from subcutaneous icoruzumab have also been reported, demonstrating an ORR and CR rate of 91% and 55%, respectively, in 11 patients treated at doses of 48 mg or higher. In the first-in-human study of palamuxomab, the ORR was 43% for all patients with non-Hodgkin lymphoma and 38% for the subgroup of patients with DLBCL. Preliminary data from IGM-2323 showed an ORR of 31% in patients with DLBCL. Longer-term follow-up is needed to assess the response and durability of CRs with these agents.

[0546] CAR T therapy has recently become an option for FL patients whose disease has progressed after at least two previous lines of therapy. Results from the single-group ZUMA-5 study support the recent approval of axicabtagene ciloleucel in this patient population. In this study, axicabtagene ciloleucel therapy demonstrated an ORR of 91%, with 60% complete responses. The sustained remission rates at 12 and 18 months were 76% and 74%, respectively. Although CAR T therapy represents an important advancement in the management of B-NHL, not all FL patients are eligible for this treatment due to potential severe toxicities, manufacturing complexity, and potential barriers to access in the community. In this study, onitumumab demonstrated an ORR of 91% and a CR rate of 72% in R / R FL patients at a dose of ≥5 mg, most of whom received a large number of previous treatments. Importantly, the sustained complete remission rate at 48 months was estimated to be 54%. This is the first study of a CD20×CD3 bispecific antibody that demonstrated that more than half of the complete responders sustained a 4-year remission. Administration of onituzumab may provide an important readily available and convenient option for patients with R / R FL who may be considered candidates for CAR T therapy after disease progression on two or more lines of therapy. Other studies have reported early experience with CD20×CD3 bispecific agents in patients with R / R FL. Recently, intravenous mosetuzumab reported an ORR and CR rate of 79% and 58%, respectively, and early data from a first-in-human subcutaneous study of icariotuzumab reported an ORR and CR rate of 90% and 50%, respectively, in 10 evaluable patients with R / R FL. Longer-term follow-up is awaited in these studies.

[0547] Patients treated in this study received a median of 10 doses of onitumab therapy, including escalating doses. Although the treatment regimen was modified during dose expansion to allow treatment until disease progression, some patients were able to achieve durable responses with shorter treatment durations. The optimal duration of treatment for this class of agents remains to be determined. It is unclear whether there are differences in clinical outcomes between patients who choose to retreat after limited cycles of therapy or those who receive continuous therapy until disease progression. In this study, a subset of patients received limited cycles of therapy, and seven patients were treated again at disease progression, mostly at lower doses. No patients responded on retreatment. A recent study has suggested that loss of CD20 may be associated with acquired resistance to onitumab. Although most patients were retreated with a low dose, acquired resistance, including loss of CD20, may in some cases explain the lack of observed efficacy with retreatment, supporting the recommended treatment paradigm of continuous dosing. Further studies are needed to characterize resistance mechanisms to this class of CD20×CD3 bispecifics to inform future clinical studies.

[0548] The development of CD20×CD3 bispecific antibody drug classes heralds great potential for improving the lives of B-NHL patients and is a highly concerned area in ongoing clinical trials. Continue to study onitumab monotherapy, as described in detail in Examples 1 and 2. Although the results reported so far show very encouraging monotherapy activity and manageable tolerance profiles, the chemotherapy-free regimen of onitumab combination with other immunomodulators (such as checkpoint inhibitors or co-stimulatory antibodies) may provide important opportunities for improving the prognosis of the most difficult-to-treat B-NHL patients. In short, onitumab has shown promising clinical activity, manageable safety and durable responses in patients with highly refractory B-NHL who have received a large number of previous treatments. Onitumab is likely to provide ready-made convenience for B-NHL patients (including those with rapidly progressive diseases) and supports further research on onitumab in a monotherapy or in combination with other modes.

[0549] Example 5: Clinical evaluation of anti-CD3×anti-CD20 bispecific antibodies in patients with CD20+ B-cell malignancies who have previously received CD20-directed antibody therapy

[0550] This is an open-label, multicenter study of onitumab administered as a subcutaneous (SC) injection in patients with relapsed / refractory B-cell malignancies. The SC study of onitumab in B-NHL will include:

[0551] Dose-finding cohorts in patients with follicular lymphoma (FL) grades 1-3a and diffuse large B-cell lymphoma (DLBCL)

[0552] ●Expansion cohorts to explore dosing frequency in FL grades 1-3a and DLBCL

[0553] The total duration of study participation for each patient varied according to the occurrence of 1 or more of the following: disease progression, withdrawal of consent, meeting other study withdrawal criteria, or death.

[0554] The study will consist of 3 phases, including:

[0555] Screening Period (up to 28 days): The Screening Period begins with signing of the Informed Consent Form (ICF) and ends when the patient is confirmed to be eligible for the study and begins treatment, or when the patient is determined to be ineligible and designated as a Screening Failure.

[0556] Treatment Period: The treatment period begins with the initiation of treatment and continues until disease progression or other protocol-defined reasons for treatment discontinuation. Dosing frequency varies by cohort.

[0557] Follow-up period: After treatment cessation, patients will be followed for safety and efficacy within the first 90 days after the last dose (safety follow-up period) or until they start another anti-lymphoma therapy (whichever comes first). Patients who discontinue treatment for reasons other than disease progression will continue to receive long-term follow-up after safety follow-up (disease response assessments are performed Q12W until the end of the first year and every 6 months thereafter). After long-term follow-up, all study patients will be followed for survival status at Q12W intervals until death, loss to follow-up, patient withdrawal of follow-up consent, or study termination by the sponsor, whichever comes first.

[0558] A maximum of 102 patients is planned. The actual sample size will depend on the number of patients observed to experience DLTs and whether any additional escalating dosing regimens are implemented. Patients with the same disease subtype / regimen who participated in the dose-finding portion at the recommended Phase II dose (RP2D) will be included in the corresponding expansion cohort for analysis.

[0559] ● In the dose-finding portion, approximately 24 patients will be enrolled, assuming a maximum of 2 dose-finding regimens are evaluated for FL and DLBCL each. A maximum of 6 patients will be enrolled in each dose-finding regimen disease cohort.

[0560] ●In the expansion portion, each cohort will enroll a total of 15 patients (including patients added from the dose-finding cohort)

[0561] o In the FL expansion, up to 24 FL grade 1-3a patients will be enrolled in 2 cohorts (6 patients in the FL dose-finding cohort will be included in FL cohort 1 for analysis)

[0562] o In the DLBCL expansion, up to 54 patients with DLBCL will be enrolled across 4 cohorts (6 patients in the DLBCL dose-finding cohort will be included in the DLBCL Cohort 1 analysis)

[0563] Patients must have a documented CD20+ B-cell malignancy, have active disease, have relapsed after or are refractory to prior therapy, have no standard of care options, and may be suitable for treatment with an anti-CD20 antibody.

[0564] Patients will receive the designated dose of Onitumab in a 21-day cycle. Cycle 1 will include weekly escalating doses until the escalating regimen is completed. The escalating regimen will include the initial dose and intermediate doses 1 and 2. After the escalating administration of Cycle 1, a full dose treatment cycle will be performed every 21 days until disease progression or other regimen-defined treatment discontinuation reasons occur. During the treatment period, the dosing regimen (dosing frequency) varies from cohort to cohort. Unless otherwise specified, the cycle length is defined as 3 weeks (21 days). For Cycle 1, the cycle length can be extended until the escalating regimen is completed. The escalating regimen will consist of an initial dose and intermediate doses 1 and 2.

[0565] For FL: The treatment period will consist of a 3-week ascending regimen with dosing on Days 1, 8, and 15 for Cycle 1 or until completion of the ascending regimen, followed by Q3W dosing (21-day cycles, dosing on Day 1 of each cycle) from Cycles 2 to 8, followed by extended treatment starting in Cycle 9. Extended treatment cycles will continue until disease progression or other protocol-defined reasons for treatment discontinuation, and starting in Cycle 9, have the following dosing frequencies in the FL dose-finding and expansion cohorts (FL Cohort 1 and FL Cohort 2):

[0566] ●FL dose-finding cohort and FL cohort 1: 21-day cycles, 400 mg subcutaneously on day 1 of each cycle.

[0567] FL Cohort 2: 8-week cycles, 400 mg subcutaneously on day 1 of each cycle.

[0568] For DLBCL (previously treated and naive with CAR-T): The treatment period will consist of a 3-week ascending regimen during Cycle 1, with dosing on Days 1, 8, and 15 or until completion of the ascending regimen, followed by full dosing on Days 1, 8, and 15 of Cycle 2, followed by From cycle 3 Treatment was extended in the following cohorts (DLBCL dose-finding cohort and expansion cohort [DLBCL cohorts 1-4]) until disease progression or other protocol-defined reasons for treatment discontinuation:

[0569] DLBCL dose-finding cohort and DLBCL cohort 1: 400 mg subcutaneously on day 1 of each 21-day cycle.

[0570] DLBCL Cohort 2: 600 mg subcutaneously on day 1 of a 21-day cycle.

[0571] DLBCL cohort 3: 21-day cycles, 400 mg subcutaneously on days 1, 8, and 15 of cycle 3, followed by 400 mg subcutaneously on day 1 of each cycle starting in cycle 4

[0572] ●DLBCL Cohort 4 (DLBCL after CAR-T failure): 21-day cycles with RP2D (selected from Cohorts 1-3). If there are fewer than 15 patients with DLBCL after CAR-T in Expansion Cohorts 1-3, this cohort will be open.

[0573] Inclusion criteria

[0574] Patients must meet the following criteria to be eligible for inclusion in this study:

[0575] 1. Have a documented CD20+ B-cell malignancy, active disease, unresponsive to previous therapy, who has no standard of care options and may be suitable for anti-CD20 antibody treatment: Confirmed B-NHL requiring treatment as defined by the 2017 WHO classification

[0576] NOTE: Patients who had a CD20-negative lymph node (NHL) biopsy per standard of care prior to enrollment are still eligible for this study if they have previously documented CD20+ disease and have been previously treated with rituximab or other CD20-directed antibody therapy within approximately 6 months.

[0577] 2. B-NHL patients must have been previously treated with anti-CD20 antibody therapy. Refractory is defined as no response (SD / PD) or relapse within ≤6 months of the last treatment.

[0578] ●To be included in the FL grade 1-3a expansion cohort, patients must have received at least 2 prior lines of systemic therapy, including an anti-CD20 antibody and an alkylating agent; patients needed to have failed lenalidomide plus rituximab combination therapy (if approved or deemed by the investigator to be ineligible for this therapy).

[0579] ● To be included in the disease-specific expansion cohorts recruiting patients with DLBCL after failure of CAR-T therapy, patients must have recovered from toxicities of lymphodepletion therapy and CAR-T infusion. It is not required that the previous CAR-T therapy was the most recent line of therapy prior to study enrollment. Prior to enrollment, verbal communication and documentation of previous CAR-T therapy-related toxicities and their resolution must be conducted between the investigator and the medical monitor.

[0580] Patients with aggressive lymphoma assigned to the aggressive lymphoma expansion cohort must have previously received at least one line of therapy consisting of an anti-CD20 antibody. Patients who have previously received CAR-T therapy will not be included in this cohort.

[0581] ●Patients with FL grade 1-3a and DLBCL must have received at least 2 prior lines of systemic therapy, including anti-CD20 antibodies and alkylating agents.

[0582] 3. All patients must have at least one two-dimensionally measurable lesion with a longest diameter ≥1.5 cm as documented by CT or MRI scan (if CT scan is not available).

[0583] 4. Age ≥ 18 years old

[0584] 5. Eastern Cooperative Oncology Group (ECOG) performance status ≤ 1

[0585] 6. Life expectancy is at least 6 months

[0586] 7. Adequate bone marrow function as documented by the following data:

[0587] a. Platelet count ≥ 75 × 10 9 / L

[0588] b. Hb level ≥ 9 g / dL

[0589] c.ANC≥1×10 9 / L

[0590] Note: Patients with cell counts below the thresholds listed above may be considered for enrollment.

[0591] Patients with bone marrow involvement or splenic sequestration should meet the following hematologic parameters:

[0592] - Platelet count ≥25 x 10 9 / L. Patients may not receive platelet transfusion therapy within 3 days prior to the first dose of onitumumab to meet platelet eligibility criteria.

[0593] - Hemoglobin ≥7.0 g / dL

[0594] - Absolute neutrophil count (ANC) ≥ 0.5 × 10 9 / L. Patients may not receive granulocyte colony-stimulating factor within 2 days before the first dose of onitumumab to meet ANC eligibility criteria.

[0595] 8. Adequate organ function recorded by the following data:

[0596] Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) ≤ 2.5 × ULN

[0597] Total bilirubin ≤1.5 × ULN

[0598] NOTE: Patients with Gilbert's syndrome do not need to meet this requirement as long as their total bilirubin does not change from baseline.

[0599] Creatinine clearance calculated by Cockcroft-Gault ≥50 mL / min

[0600] Note: If the investigator believes that the abnormal laboratory results are due to underlying disease, the patient may be considered for enrollment.

[0601] Note: Patients with borderline creatinine clearance according to Cockcroft-Gault may be considered for enrollment if the measured creatinine clearance (based on 24-hour urine or other reliable method) is ≥50 mL / min.

[0602] 9. Willing to undergo mandatory tumor biopsy before treatment if the investigator believes that the patient has a palpable lesion and the lesion can be biopsied without significant risk to the patient.

[0603] Exclusion criteria

[0604] Patients who meet any of the following criteria will be excluded from the study:

[0605] 1. Primary central nervous system (CNS) lymphoma or known or suspected non-primary CNS NHL involving the CNS

[0606] 2. Have a history of or currently have relevant CNS symptoms, such as:

[0607] ● Epilepsy, seizures, paresis, aphasia, stroke, severe head injury, cerebellar disease, organic brain syndrome, psychosis or

[0608] Brain MRI showing evidence of inflammatory lesions and / or vasculitis

[0609] 3. Standard anti-tumor chemotherapy (non-biological) within 5 times the half-life or 28 days before the first administration of study drug, whichever is shorter.

[0610] 4. Standard radiotherapy within 14 days of the first administration of study drug.

[0611] Note: Palliative radiation therapy to symptomatic lymph nodes / lesions is permitted provided that the irradiated lesion or lymph node is not included as a target lesion for tumor assessment

[0612] 5. Allogeneic stem cell transplantation

[0613] 6. Treatment with rituximab, alemtuzumab or other investigational or commercial biologics within 12 weeks prior to the first administration of study drug.

[0614] 7. Immunosuppressive therapy (except biological therapy) within 28 days of the first administration of study drug.

[0615] 8. Treatment with investigational non-biological agents within 28 days of first administration of study drug.

[0616] 9. History of allergic reactions to compounds similar to the chemical or biological components of the study drug.

[0617] 10. History of hypersensitivity reaction to any compound in the tetracycline group of antibiotics.

[0618] 11. The patient is undergoing treatment for concurrent active malignant tumors.

[0619] 12. Known active bacterial, viral, fungal, mycobacterial or other infections, or any major infectious event requiring hospitalization or intravenous anti-infective drug treatment within 4 weeks of the first administration.

[0620] 13. Evidence of significant concurrent illness or medical condition that may interfere with the conduct of the study or place the patient at significant risk, including but not limited to significant cardiovascular disease (e.g., New York Heart Association class III or IV heart disease, myocardial infarction within the past 6 months, unstable arrhythmia, or unstable angina) and / or significant pulmonary disease (e.g., history of obstructive pulmonary disease and symptomatic bronchospasm).

[0621] Note: Before the first administration of onitumumab, patients with a history of cardiac disease should be evaluated by ECHO or multiple gated acquisition scanning (MUGA) to ensure adequate cardiac reserve and function.

[0622] 14. Patients are currently receiving systemic corticosteroid therapy, except for corticosteroids used for other (non-tumor and non-immunosuppressive) indications, with a maximum dose of 10 mg / day of prednisone or equivalent.

[0623] 15. Human immunodeficiency virus (HIV) infection or chronic infection with hepatitis B virus (HBV), hepatitis C virus (HCV), or cytomegalovirus (CMV) infection (as shown by detectable levels by blood PCR assay).

[0624] a. Patients with hepatitis B (HepBsAg+) whose infection was controlled (serum HBV DNA below the limit of detection and receiving HBV antiviral therapy) were allowed to be enrolled after consultation with the physician managing the infection.

[0625] b. Patients who demonstrate detectable CMV levels at screening will need to be treated with appropriate antiviral therapy and demonstrate at least 2 undetectable CMV levels by PCR assay (at least 7 days apart) before being reconsidered for eligibility.

[0626] 16. Known hypersensitivity to allopurinol and rasburicase.

[0627] 17. Pregnant or breastfeeding women.

[0628] 18. Females of childbearing potential* or males who are unwilling to use highly effective contraceptive measures before the first study drug treatment, during the study, and for at least 6 months after the last dose.

[0629] 19. Live vaccination within 28 days of first administration of study drug.

[0630] Two extended-treatment dosing schedules in FL and three dosing schedules in DLBCL are being investigated to evaluate the frequency of SC dosing. The proposed SC dosing schedule includes escalating dosing (2 mg / 26 mg / 100 mg) in cycle 1, 400 mg (full dose) in cycle 2, and 400 mg or 600 mg in subsequent cycles (Tables 7 and 8).

[0631] Table 7: Onituzumab SC regimen in the FL grade 1-3a expansion cohort

[0632]

[0633] *1 cycle = 21 days unless otherwise specified

[0634] Table 8: Onituzumab SC regimen in the DLBCL expansion cohort

[0635]

[0636] *1 cycle = 21 days

[0637] If two or more patients develop Grade ≥3 CRS in either the SC-1N or SC-2N cohorts (combined), the escalation schedule will be modified as follows (Tables 9 and 10) based on the dose at which the CRS event ensued.

[0638] Table 9: Dose exploration for FL 1-3a (subcutaneous administration)

[0639]

[0640]

[0641] *The initial (Cycle 1) step-up regimen may be extended with weekly ascending doses until the step-up regimen is completed.

[0642] If SC-1N or SC-2N (combination) results in grade ≥3 CRS in two or more patients, the escalation schedule will be modified for the dose-finding cohorts for both subtypes.

[0643] Table 10: Dose exploration in DLBCL (subcutaneous administration)

[0644]

[0645] *The initial (Cycle 1) step-up regimen may be extended with weekly ascending doses until the step-up regimen is completed.

[0646] If SC-2N or SC-1N (combination) results in two or more patients experiencing grade ≥3 CRS, the escalation schedule will be modified for both subtype dose-finding cohorts.

[0647] In preclinical studies in cynomolgus monkeys, subcutaneous administration of onitumab was associated with lower serum cytokine levels and induced sustained B cell depletion to levels similar to intravenous administration. Therefore, subcutaneous administration of onitumab in patients is expected to simplify the drug administration process, improve overall patient convenience, and enhance tolerability by further reducing cytokine release.

[0648] Table 11: CRS toxicity grading

[0649]

[0650] CPAP = continuous positive airway pressure, bilevel positive airway pressure, BiPAP = bilevel positive airway pressure.

[0651] Organ toxicities associated with CRS can be graded according to CTCAE v4.03, but they do not affect the CRS grade.

[0652] 1Fever is defined as a body temperature ≥ 38°C not caused by any other reason. After CRS patients receive antipyretic or anticytokine therapy (such as tocilizumab or steroids), fever is no longer a necessary condition for subsequent CRS severity classification. In this case, CRS classification is driven by hypotension and / or hypoxia.

[0653] 2 The grade of CRS is determined by the more severe event: hypotension or hypoxia not due to any other cause. For example, a patient with a temperature of 39.5°C who develops hypotension requiring 1 vasopressor and hypoxia requiring a low-flow nasal cannula is classified as grade 3 CRS.

[0654] 3 Low-flow nasal cannula is defined as oxygen delivery ≤ 6 L / min. Low flow also includes blow-through oxygen delivery, which is sometimes used in pediatrics. High-flow nasal cannula is defined as oxygen delivery > 6 L / min.

[0655] Example 6: Premedication for subcutaneous administration of onitumumab

[0656] The following premedication should be used from the initial dose to the first full dose of onitumab. If the patient experienced CRS of any grade at the first full dose, premedication was continued until the full dose was tolerated without the occurrence of CRS:

[0657] 1. 12 to 24 hours prior to the scheduled start time of subcutaneous injection during ascending dosing and the first full dose of onitumumab:

[0658] a. Oral (PO) dexamethasone 10 mg or equivalent dose of steroids

[0659] 2. On the day of subcutaneous injection during ascending dosing and the first full dose of onitumumab:

[0660] a. Dexamethasone 20 mg intravenously or orally 1 to 3 hours before subcutaneous injection on the day of treatment

[0661] b. 25 mg diphenhydramine intravenously or orally 30 to 60 minutes before (another equivalent antihistamine may be substituted)

[0662] c. Take 650 mg of acetaminophen orally 30 to 60 minutes before injection, unless the patient has received acetaminophen in the past 4 hours before injection of onitumumab or is allergic to acetaminophen

[0663] 3. 24 (± 4) hours after injection of onitumab during ascending dosing and the first full dose of onitumab:

[0664] a. Oral administration of 10 mg dexamethasone or equivalent dose of steroids

[0665] No CRS of any grade occurred after the first dose was administered with 20 mg dexamethasone either intravenously or orally

[0666] 4. Premedication on the day of subcutaneous injection of Onitumumab after the first full dose:

[0667] a. Dexamethasone 10 mg intravenously or orally 1 to 3 hours before subcutaneous injection on the day of treatment

[0668] b. 25 mg diphenhydramine intravenously or orally 30 to 60 minutes before (another equivalent antihistamine may be substituted)

[0669] c. Oral acetaminophen 650 mg 30 to 60 minutes before, unless the patient has received acetaminophen in the past 4 hours before the subcutaneous injection of onitumumab or is allergic to acetaminophen

[0670] For subsequent doses, premedication is not required if dexamethasone 10 mg subcutaneously is tolerated with a reduced dose of IV or oral administration and no CRS of any grade occurs.

[0671] Example 7: Modeling and simulation to support subcutaneous dose selection of onitumumab in adult patients with indolent or aggressive non-Hodgkin's lymphoma

[0672] Onitumab is a hinge-stabilized, human CD20×CD3 IgG4-based bispecific antibody that binds CD20-expressing cells and CD3 on T cells, thereby eliciting T cell-mediated cytotoxicity independent of T cell receptor-mediated recognition. Studies of intravenous (IV) onitumab in patients with previously treated CD20-positive B-cell malignancies are ongoing and have shown promising efficacy. The IV regimen consists of ascending dosing in cycle 1, i.e., doses of 0.7 / 4 / 20 mg (each dose divided over 2 days) are administered over 3 weeks to mitigate the risk of cytokine release syndrome (CRS). Onitumab is subsequently administered at 80 mg once weekly (QW) in cycles 2-4 for the treatment of indolent non-Hodgkin lymphoma (NHL) and at 160 mg QW for the treatment of aggressive NHL. To further improve overall tolerability, patient convenience, and reduce hospital resource utilization, subcutaneous (SC) administration of onitumab is being explored. This modeling and simulation-based analysis was performed to determine the SC regimen for clinical studies.

[0673] The analysis included six steps: 1) developing a population pharmacokinetic (PK) model to estimate IV onitumumab PK parameters using observed concentration data from patients with B-cell NHL participating in the clinical trials described in Examples 1 and 2; 2) adding predicted absorption rate constants (based on data for Regeneron IgG4-based antibodies) and predicted SC bioavailability parameters (based on studies of subcutaneous onitumumab in cynomolgus monkeys) to the model for SC PK profile simulations; 3) performing exposure-response analyses to determine target exposure parameters for clinical efficacy of the IV regimen in patients with indolent and aggressive NHL; 4) simulating SC PK profiles to determine the maximum concentration (C ) that achieves the efficacy target exposure without exceeding the highest evaluated IV dose. max ) regimens; 5) develop a quantitative systems pharmacology (QSP) model to predict the interleukin (IL)-6 profile after SC ascending dosing; and 6) simulate onitumumab SC regimens to select those regimens that predict IL-6 levels will not exceed those of the IV regimen.

[0674] Based on modeling and simulation results, the recommended SC regimen selected for escalation in both indolent and aggressive NHL is 2 / 26 / 100 mg (unfractionated) in cycle 1. The simulated median C of 2 mg SC during the first week was max Lower than 0.7 mg IV in divided doses (0.2 / 0.5 mg). SC to reach C max The prediction time is about 4 days, which is much later than IV (where C max Appears near the end of the infusion). C max Longer duration of therapy reduces the risk of CRS, which mostly occurs within 1-2 days after divided-dose IV administration. For indolent NHL, the recommended SC dose is 400 mg every 3 weeks (Q3W) after cycle 1, and for aggressive NHL, 400 mg QW in cycle 2 and 400 mg Q3W after cycle 2. Based on clinical observations, additional SC regimens suitable for indolent and aggressive NHL are recommended for testing.

[0675] Based on simulation results, the proposed SC regimen maintains the required effective oninumab concentrations during the first 4 treatment cycles when most tumor responses are expected to occur. The simulated IL-6 profiles obtained using the SC QSP model showed that the IL-6 peak would not exceed 0.7 / 4 / 20 mg IV during cycle 1 using the proposed SC ascending dosing regimen (2 / 26 / 100 mg).

[0676] SC administration of onitumumab may be simpler and more convenient than IV administration. PK and IL-6 modeling and simulation analyses allowed us to identify SC regimens for clinical evaluation that improve overall tolerability while maintaining efficacy in patients with B-cell NHL.

[0677] Example 8: Selection of a pediatric dosing regimen of onitumab for aggressive non-Hodgkin's lymphoma using modeling and simulation methods

[0678] Onitumab is a hinge-stabilized, human CD20×CD3 IgG4-based bispecific antibody that binds to CD20-expressing cells and CD3 on T cells, thereby targeting CD20+ cells via T cell-mediated cytotoxicity independent of T cell receptor-mediated recognition. Clinical studies of Onitumab in adult patients with relapsed / refractory CD20+ B-cell malignancies are ongoing. Encouraging efficacy in patients has been reported. Approximately 800 new cases of pediatric non-Hodgkin lymphoma (NHL) are diagnosed each year in the United States. Pediatric patients need improved treatment options, especially those with relapsed / refractory disease after chemoimmunotherapy, who have poor outcomes. A study of Onitumab in pediatric patients with relapsed / refractory B-cell NHL (B-NHL) is being planned. The goal of this analysis is to identify intravenous (IV) regimens tested in pediatric patients that achieve similar exposures to those achieved in adults.

[0679] The analysis was performed in 6 steps: 1) a population pharmacokinetic (PK) model was developed using data from adults who received intravenous onitumumab and the effect of body weight (WT) on drug clearance (CL) and volume of distribution (V) was assessed; 2) a virtual pediatric population was created using demographic data obtained from the 2017-2018 National Health and Nutrition Examination Survey database; 3) pediatric model parameters were extrapolated from the adult model parameters by appropriately applying the effects of WT and age on CL and V, in addition to the effect of body weight in infants younger than 1 year of age. The study considered maturation effects on nonspecific elimination; 4) simulated the onitumumab PK profile in virtual pediatric patients aged 6 months to 18 years in four weight categories (≥40 kg, 20–39 kg, 10–19 kg, 6–9 kg) using extrapolated pediatric population model parameters; 5) adjusted the onitumumab dose in each weight category during the weekly (QW) and biweekly (Q2W) dosing periods with the goal of matching exposure in adult patients; and 6) selected pediatric regimens for testing based on 2 criteria. First, for safety reasons, the median maximum concentration (C max ) is in the range of 80%–125% of the adult value. Second, to achieve efficacy, the median minimum concentration (Cmin ) is not less than the adult value.

[0680] Following IV administration of doses ranging from 0.03 to 320 mg in patients with relapsed / refractory B-NHL, serum onitumumab concentrations decayed biexponentially, which was adequately described by a two-compartment model with parallel first-order elimination and a modified Michaelis elimination term. The latter was not only concentration-dependent but also time-dependent. Body weight was found to be an important covariate for linear CL and V. Based on the estimated values ​​of the PK parameters, onitumumab IV dosing regimens for pediatric patients were simulated by weight segment, as shown in Table 12. As with the adult regimen, dose escalation was implemented during cycle 1 to limit C max Children weighing ≥40 kg will receive the adult regimen, while those weighing <40 kg will receive a reduced dose.

[0681] The proposed regimen is expected to achieve similar exposure to onitumumab as the adult regimen during ascending doses (weeks 1-3) and weekly and biweekly treatment periods. max There was no significant difference; the median C in the pediatric WT group relative to that in adults max The ratio ranged from 0.831 to 1.24. The median C min Values ​​were no lower than those observed in adults, and no differences in C were observed between weight groups. min significant differences.

[0682] Additional exploratory simulations were performed to evaluate uniform weight-based dosing (mg / kg) for the entire pediatric population. This approach was inferior to a stratified approach by WT segment, as concentrations in individuals weighing ≥20 kg were above target, while concentrations in individuals weighing 6-9 kg were below target.

[0683] This modeling and simulation approach allowed the identification of a dosing regimen that may be appropriate for children with B-NHL. Based on the predicted PK profile, a pediatric dosing regimen stratified by WT segment should maintain the efficacy of onitumumab observed in adults without increasing the risk of acute toxicity.

[0684] Table 12: Suggested weight-stratified dosing regimens based on simulations in virtual patients

[0685]

[0686] The doses administered in weeks 1-3 were divided and administered on days 1 and 2 of each week. The divided doses (mg) are shown in parentheses. QW, once a week; Q2W, once every 2 weeks; WT, body weight.

[0687] Example 9: Intravenous onitumab escalation regimen for reducing the risk of high-grade cytokine release syndrome

[0688] Onitumumab is a hinge-stabilized, human CD20×CD3 IgG4-based bispecific antibody that binds to CD20-expressing cells and CD3 on T cells, thereby targeting CD20+ cells via T cell-mediated cytotoxicity independent of T cell receptor-mediated recognition. Transient cytokine release is a common phenomenon with T cell-engaging bispecific antibodies, especially in the first few weeks of treatment. This is associated with an increased risk of cytokine release syndrome (CRS), a serious, potentially life-threatening adverse event. Because the intensity of cytokine release is positively correlated with drug exposure, especially in the first 3 weeks of treatment, administering a lower dose before the full therapeutic dose (i.e., escalating dosing) is a way to mitigate the risk of CRS.

[0689] Intravenous (IV) onitumumab has shown encouraging efficacy in patients with B-cell non-Hodgkin lymphoma (B-NHL). Typically, CRS is low grade (Gr), but Gr ≥ 3 occurs in 7% of patients with B-NHL histology, even with the implementation of an ascending dosing regimen (1 mg / 20 mg in 2-day fractions in weeks 1-2) and steroid prophylaxis. The aim of this work was to determine an ascending regimen to reduce the incidence of Gr ≥ 3 CRS.

[0690] The following escalating dosing conditions were evaluated: 1) the effect of dose on peak oninumab concentrations in weeks 1-3, including fractionated dosing and adding more intermediate doses via pharmacokinetic model-based simulations; 2) the temporal profiles of interleukin (IL)-6, a surrogate cytokine associated with CRS, predicted by the quantitative systems pharmacology (QSP) model under various dosing scenarios; 3) the effect of type and timing of premedication on the occurrence of CRS; and 4) baseline cytokine levels as a risk factor for Gr≥3 CRS.

[0691] Based on the evaluation of multiple factors as described above, the ascending dosing regimen consisted of the following: 0.7 mg (0.2 / 0.5 mg, divided over 2 days) in Week 1; 4 mg (2 / 2 divided) in Week 2 and 20 mg (10 / 10 divided) in Week 3. Early administration of premedication (12-24 hours before the first divided dose and on the day of each divided dose compared to only on the day of each divided dose) significantly reduced baseline (pre-treatment) cytokine levels.

[0692] Compared with the previously tested regimen, the new regimen reduced the total initial dose (week 1) by 30% (from 1 mg to 0.7 mg) and more significantly by 60% (from 0.5 mg to 0.2 mg) on ​​day 1. This resulted in an approximately 50% reduction in the median peak drug concentration observed on day 1, with a median peak IL-6 concentration of 21.1 pg / mL (range 0.6-1163) after treatment, equivalent to a 17% reduction compared with 0.5 mg on day 1 (median 25.5 pg / mL [range 0.8-3560]).

[0693] According to QSP simulations, a dose reduction on day 1 of week 1 and an increase in the intermediate dose of 4 mg in week 2 reduced the intensity of cytokine release compared to the previously tested 1 mg (0.5 / 0.5) / 20 mg (10 / 10) dose. This new regimen has been tested in clinical studies in patients with follicular lymphoma and diffuse large B-cell lymphoma. As of April 2022, no Gr ≥ 3 CRS occurred in the first 100 patients treated with this regimen.

[0694] Importantly, although the onitumab IV escalating dosing regimen showed lower onitumab concentrations than the original regimen during weeks 1-3, concentrations were similar after the first full dose, and trough concentrations were similar after week 4. This suggests that both regimens achieve the same therapeutic levels, which is beneficial for the treatment of the disease.

[0695] This onitumab dosing schedule was associated with a lower risk of CRS and lower baseline cytokine levels compared with the original regimen. Drug exposure was lower in the first 3 weeks, when the risk of CRS was greater, but after receiving the full dose of treatment, it was comparable to the original regimen, ensuring the onitumab dose level required to maintain efficacy.

[0696] Example 10: Quantitative Systems Pharmacology Modeling Framework for Assessing Cytokine Release Mediated by Intravenous Onitumumab Monotherapy in Patients with B-Cell Non-Hodgkin Lymphoma

[0697] Onitumab is a hinge-stabilized, human CD20×CD3 IgG4-based bispecific antibody that binds to CD20-expressing cells and CD3 on T cells, thereby targeting CD20+ cells via T cell-mediated cytotoxicity independent of T cell receptor-mediated recognition. T cell activation following onitumab administration can lead to a transient increase in circulating cytokine levels, which is associated with the risk of cytokine release syndrome (CRS). CRS is a recognized safety issue for all T cell-engaging bispecific antibodies, primarily occurring in the first treatment cycle.

[0698] This study was performed to evaluate the cytokine profiles, specifically interleukin (IL)-6, a surrogate cytokine associated with CRS, in patients with B-cell non-Hodgkin lymphoma (B-NHL) receiving intravenous (IV) onitumumab monotherapy. Quantitative systems pharmacology (QSP) modeling is an emerging mathematical modeling approach that builds on and integrates our understanding of disease biology and the mechanisms of action of drugs of interest. A range of problems that arise in drug research and clinical development can be evaluated and addressed using QSP methods. The goal of this work was to identify ascending dosing regimens that improve safety profiles using QSP models.

[0699] The QSP model was developed using onitumab pharmacokinetic (PK) data, cellular kinetics of T cells and B cells, and disease characteristics of patients with B-NHL. The semimechanistic model was adjusted and modified to describe the IL-6 distribution profile. A time-dependent negative feedback loop was added to account for the observed attenuation of IL-6 release after repeated doses. Model parameters were created using in vivo and in vitro preclinical data and relevant literature information and calibrated using clinically observed IL-6 data from patients treated with onitumab monotherapy, observed serum onitumab concentrations, B cell counts, CD8+ T cell counts, and tumor size data obtained from clinical studies.

[0700] The calibrated model was used to estimate the temporal profiles of IL-6 release associated with different onitumumab dosing regimens. These assessments were performed using a virtual population of B-NHL patients (n=300 per dosing regimen).

[0701] The calibrated QSP model was used to simulate IL-6 profiles for different proposed escalating dosing scenarios, including testing different dose levels in weeks 1-4, weekly split or unsplit doses, ratios of split doses over 2 days per week, and a 2-4 week escalating dosing period before full dose treatment. Simulations showed that split doses in weeks 1, 2, and 3 reduced the likelihood of IL-6 release in the first few weeks of treatment. The highest IL-6 peak was expected to occur in week 1, and an uneven split ratio (0.2 / 0.5 mg) of the 0.7 mg dose over the 2 days of week 1 would mediate the highest IL-6 release on day 1 while maintaining similar or lower IL-6 release on day 2. As IL-6 release is likely to be higher in week 2, a low dose of 4 (2 / 2 split) mg is expected to release less IL-6 than doses >4 mg. After comparing the simulation results of various dosing scenarios, an ascending dosing regimen was determined to be tested in the clinical trial, namely 0.7 (0.2 / 0.5) mg in week 1, 4 (2 / 2) mg in week 2, and 20 (10 / 10) mg in week 3.

[0702] In addition, the QSP model included the variability of the PK parameters of onitumab and predicted a PK profile of onitumab in the virtual B-NHL population that showed exposures comparable to onitumab concentrations observed after the previously tested escalating dosing regimens of 1 mg (week 1), 20 mg (week 2), and 160 mg (week 3). The model was also able to predict the profiles of CD8+ T cells and B cells over time after a fractionated IV onitumab dosing regimen.

[0703] The QSP model was developed to address safety concerns associated with CRS following treatment with onitumab. This work demonstrated that QSP modeling is a powerful tool to identify escalating dosing of onitumab to minimize the risk of higher-grade (i.e., grade 2 and 3) CRS in patients with lymphoma receiving onitumab.

[0704] Example 11: Evaluation of the kinetics of IL-6 release during ascending dosing of subcutaneously administered onitumumab via a quantitative systems pharmacology modeling approach

[0705] Onitumab is a hinge-stabilized, human CD20×CD3 IgG4-based bispecific antibody that binds to CD20-expressing cells and CD3 on T cells, thereby inducing T cell-mediated cytotoxicity independent of T cell receptor-mediated recognition. T cell activation after onitumab administration can lead to a transient but clinically significant increase in circulating cytokine concentrations. This can lead to cytokine release syndrome (CRS), which is one of the most important safety issues of T cell engagement therapy. As most cytokine release occurs in the first few weeks of treatment, an ascending dosing strategy before the administration of the full therapeutic dose appears to be a successful strategy to reduce the level of cytokine release and reduce the occurrence of CRS.

[0706] This study was conducted to evaluate the interleukin (IL)-6 profile following subcutaneous (SC) administration of onitumab during ascending dosing (weeks 1-3) in patients with B-cell non-Hodgkin lymphoma (B-NHL) during cycle 1. Quantitative systems pharmacology (QSP) modeling, an emerging mathematical modeling approach that can help improve the understanding of drug-disease interactions and can be used to evaluate what-if scenarios in preclinical and clinical settings, was developed and applied to determine SC ascending doses of onitumab appropriate for investigation in clinical studies.

[0707] A QSP model that can describe the IL-6 profile after intravenous (IV) injection of Onitumab (a surrogate cytokine associated with CRS) has been previously developed and calibrated using pharmacodynamic data from clinical studies (Example 10). The IV QSP model was updated by adding relevant components (e.g., drug absorption compartment, lymph node compartment) to be able to describe the IL-6 profile after subcutaneous administration of Onitumab. The model parameters were calibrated using IL-6 concentration data for other CD20×CD3 bispecific antibodies administered subcutaneously reported in the literature.

[0708] The SC ascending doses of Onitumab of interest were proposed, and the IL-6 distribution profiles of these schemes were simulated using the SC QSP model. In each dosing regimen, the IL-6 distribution profiles were simulated in 300 virtual patients. The cytokine release criterion for regimen selection is that the peak IL-6 concentration of the SC ascending regimen should be lower than the peak IL-6 concentration observed with the previously tested IV regimen.

[0709] The simulation results show that the predicted IL-6 profile is similar regardless of whether the dose is divided or not; the former is effectively used in the IV regimen for managing CRS. The predicted highest peak IL-6 value in week 1 with a 2 mg SC dose was significantly lower than that with an IV dose of 0.7 mg (0.2 mg and 0.5 mg were divided over 2 days in week 1). The predicted maximum IL-6 concentration with 2 mg SC was 150 pg / mL, and the predicted maximum IL-6 concentration with 0.7 mg IV was 2,100 pg / mL, indicating a reduction of more than 90%. The predicted IL-6 profiles at week 4 were similar when a 160 mg IV or 400 mg SC dose was used. Based on a comparison of the IL-6 profiles for multiple SC dosing scenarios, SC ascending doses of 2 mg in week 1, 26 mg in week 2, and 100 mg in week 3 were selected, followed by a full dose of 400 mg. The proposed SC regimen is being tested for safety and efficacy evaluation in the clinical study described in Example 5.

[0710] QSP modeling supported the selection of a SC escalation dosing regimen for onitumab in a clinical study evaluating patients with B-NHL. The selected escalation schedule for SC onitumumab allowed adequate escalation to an effective therapeutic dose while simplifying and improving overall convenience. These simulations demonstrated that SC administration would not require fractionated dosing, which could further reduce the overall resource burden on hospitals and the requirement for inpatient monitoring.

[0711] Example 12: Onitumumab in patients with relapsed / refractory (R / R) follicular lymphoma (FL) grades 1-3a: results of pre-specified analysis of a pivotal phase II study

[0712] Results from a phase 2 study of onitumab monotherapy in patients with relapsed / refractory (refractory to or relapsed after ≥2 prior lines of therapy, including an anti-CD20 antibody and an alkylating agent) follicular lymphoma (grade 1-3a) (ECOG performance status 0 or 1) are presented below.

[0713] The study started with a 1 / 20 mg ascending dosing regimen and was then modified to a 0.7 / 4 / 20 mg ascending dosing regimen. Figure 1 As shown, to further reduce the risk of cytokine release syndrome (CRS). In the modified dosing regimen, the initial dose (0.7 mg) is divided into two dose portions of 0.2 mg and 0.5 mg administered within two days during the first week of the dosing regimen, and then the first intermediate dose (4 mg) is divided into two dose portions of 2 mg each administered within two days during the second week of the dosing regimen, and then the second intermediate dose (20 mg) is divided into two dose portions of 10 mg each administered within two days during the third week of the dosing regimen. Then during weeks 4 to 12 of the dosing regimen, a full dose (80 mg) is administered weekly, followed by a maintenance dose (160 mg) of Onitumumab administered every other week.

[0714] Baseline characteristics of treated patients (N=131) included: 30.5% had prior autologous stem cell transplantation (ASCT), 13.7% had prior phosphatidylinositol 3-kinase (PI3K) therapy, 13.7% had prior immunomodulatory drug therapy, 71.0% were refractory to last line of therapy, 74.8% were refractory to anti-CD20 antibody therapy, 43.5% were double refractory to alkylating agent / anti-CD20 antibody therapy, and 48.1% had disease progression within 24 months of starting first-line therapy.

[0715] The disposition of these 131 patients is shown in Table 13 below.

[0716] Table 13: Disposition of FL patients

[0717]

[0718] The objective response rates for the 121 efficacy-evaluable patients are shown in Table 14 below, including a comparison between the 1 / 20 ascending dosing schedule and the 0.7 / 4 / 20 ascending dosing schedule. Regardless of the 1st cycle ascending schedule, consistent efficacy was observed at week 12, and most patients achieved a complete response.

[0719] Table 14: Objective response rate in FL patients

[0720]

[0721] *Complete response + partial response; CI, confidence interval

[0722] Figure 2 , 3 Additional efficacy data for these 121 efficacy-evaluable patients are shown in Figures 4 and 5, confirming that the majority of relapsed / refractory FL patients had significant tumor shrinkage ( Figure 2 ), with consistent antitumor activity in high-risk subgroups ( Figure 3 ), the responses observed appeared to be durable ( Figure 4 ), and the treatment had a positive impact on progression-free survival and overall survival ( Figure 5 ).

[0723] The safety profile of onitumab administration in the study is shown in Tables 15, 16 and 17 below, including the comparison of the ratio / grade of CRS and other adverse events in patients receiving a 1 / 20 ascending dosing regimen or a 0.7 / 4 / 20 ascending dosing regimen. As shown in Table 16, the 0.7 / 4 / 20 ascending dosing regimen reduced the incidence of grade 2 and grade 3 CRS, and about half of the recurrent / refractory follicular lymphoma patients had CRS (mostly grade 1). All CRS events subsided within a median of 2 days (range 1-51), and no patient required mechanical ventilation or was transferred to the ICU to manage CRS.

[0724] Table 15: Safety profile of Onitumumab (N=131)

[0725]

[0726] * Grade 5 TRAEs: pneumonia, PML, systemic fungal disease (n=1 each) ** TRAEs leading to treatment discontinuation: IRR (n=3), ALT increase, arthralgia, CRS, seizure, PML, tremor, viral bronchitis, weight loss (n=1 each)

[0727] AE, adverse event; ALT, alanine aminotransferase; CRS, cytokine release syndrome; IRR, infusion-related reaction; PML, progressive multifocal leukoencephalopathy; TEAE, treatment-emergent adverse event; TRAE, treatment-related AE

[0728] Table 16: Cytokine Release Syndrome

[0729] n(％) 1 / 20 plan (N=68) 0.7 / 4 / 20 scheme (N=63) CRS, any level 38(55.9％) 36(57.1％) Level 1 22(32.4％) 28(44.4％) Level 2 12(17.6％) 7(11.1％) Level 3 4(5.9％) 1(1.6％) Level 4 0 0 Level 5 0 0 Corticosteroids 11(16.2％) 17(27.0％) Tocilizumab 9(13.2％) 12(19.0％) Vasopressors 4(5.9％) 1(1.6％)

[0730] Table 17: All events of interest

[0731]

[0732] ICANS, immune effector cell-associated neurotoxicity syndrome

[0733] Overall, these results show that onitumab monotherapy is effective in patients with heavily pretreated relapsed / refractory follicular lymphoma (ORR 81.8%, CR 75.2%, and 92% of responders were complete responders, and responses were durable with a median progression-free survival of 20.2 months). In addition, onitumab monotherapy showed a manageable safety profile, especially when using a modified 0.7 / 4 / 20 ascending dosing schedule.

[0734] As of the data cutoff on September 18, 2022, 86 (51.9%) of the 166 patients treated with the revised escalation regimen of 07 / 4 / 20 mg experienced CRS, with the highest CRS grade observed being Grade 1 in 62 (37.3%) patients, Grade 2 in 21 (12.7%) patients, and Grade 3 in 3 (1.8%) patients. The revised (0.7 / 4 / 20) escalation dosing regimen successfully further reduced the incidence and severity of CRS events. The incidence of CRS events of any grade decreased from 183 / 300 (61%) patients using the 1 / 20 regimen to 86 / 166 (51.8%) patients using the revised regimen, and CRS events of grade 3 or higher decreased from 8.7% using the 1 / 20 regimen to 1.8% using the revised regimen. In addition, the overall incidence of grade 2 or higher CRS events decreased from 28.3% with the 1 / 20 regimen to 14.5% with the amended regimen.

[0735] Example 13: Onitumumab in patients with relapsed / refractory (R / R) diffuse large B-cell lymphoma (DLBCL): results of pre-specified analysis of a pivotal Phase II study

[0736] Results from a phase 2 study of onitumab monotherapy in patients with relapsed / refractory (refractory to or relapsed after ≥2 prior lines of therapy, including an anti-CD20 antibody and an alkylating agent) diffuse large B-cell lymphoma (according to the 2016 WHO classification) (ECOG performance status of 0 or 1) are presented below.

[0737] The study started with a 1 / 20 mg ascending dosing regimen and was then modified to a 0.7 / 4 / 20 mg ascending dosing regimen. Figure 6As shown, to further reduce the risk of cytokine release syndrome (CRS). In the modified dosing regimen, the initial dose (0.7 mg) is divided into two dose portions of 0.2 mg and 0.5 mg administered within two days during the first week of the dosing regimen, and then the first intermediate dose (4 mg) is divided into two dose portions of 2 mg each administered within two days during the second week of the dosing regimen, and then the second intermediate dose (20 mg) is divided into two dose portions of 10 mg each administered within two days during the third week of the dosing regimen. Then during weeks 4 to 12 of the dosing regimen, a full dose (160 mg) is administered weekly, followed by a maintenance dose (320 mg) of Onitumumab administered every other week.

[0738] Baseline characteristics of treated patients (N=140) included: 15.7% had previously received autologous stem cell transplantation (ASCT), 57.1% were primary refractory, 90.7% were refractory to any previous line of therapy, 86.4% were refractory to the last line of therapy, 78.6% were refractory to anti-CD20 antibody therapy in any line of therapy, and 65.7% were double refractory to alkylating agent / anti-CD20 antibody therapy in any line of therapy.

[0739] The disposition of these 140 patients is shown in Table 18 below.

[0740] Table 18: Disposition of patients with DLBCL

[0741]

[0742] The objective response rates for the 130 efficacy-evaluable patients are shown in Table 19 below, including a comparison between the 1 / 20 ascending dosing schedule and the 0.7 / 4 / 20 ascending dosing schedule. Consistent efficacy was observed at Week 12 regardless of the Cycle 1 ascending schedule, with 62% of responders achieving a complete response.

[0743] Table 19: Objective response rate in patients with DLBCL

[0744]

[0745] *Complete response + partial response; CI, confidence interval

[0746] The objective response rates of these 31 patients who had previously received CAR-T therapy and were evaluable for efficacy are shown in Table 20 below.

[0747] Table 20: Objective response rate in patients with DLBCL who had previously received CAR-T

[0748] Best overall response Independent central review (N=31) Objective response rate (ORR)* 48.4% [95% CI; 30.2%-66.9%] Complete response 32.3％ Partial response 16.1％ Stable condition 6.5％ Disease progression 9.7％

[0749] *Complete response + partial response; CI, confidence interval; NE, not evaluable

[0750] Figure 7 , 8 Additional efficacy data from these 130 efficacy-evaluable patients are shown in Figures 1 and 9, demonstrating consistent antitumor activity in the high-risk subgroup ( Figure 7 ), the responses observed appeared to be durable ( Figure 8 ), and the treatment had a positive impact on progression-free survival ( Fig. 9 ).

[0751] The safety profile of onitumab administration in the study is shown in Tables 21, 22 and 23 below, including the comparison of the ratio / grade of CRS and other adverse events in patients receiving 1 / 20 ascending dosing regimens or 0.7 / 4 / 20 ascending dosing regimens. As shown in Table 22, the 0.7 / 4 / 20 ascending dosing regimen reduced the incidence of grade 2 and grade 3 CRS, and about half of the recurrent / refractory DLBCL patients had CRS (mostly grade 1). All CRS events subsided within a median of 2 days (range 1-133), and no patient required mechanical ventilation or was transferred to the ICU to manage CRS.

[0752] Table 21: Safety profile of Onitumumab (N=140)

[0753]

[0754] *Grade 5 TRAEs: CMV reactivation, COVID-19, interstitial lung disease, pneumonia, CMV pneumonia, fungal pneumonia, and Pseudomonas sepsis (n=1 each) **TRAEs leading to treatment discontinuation: CRS, encephalopathy (n=2 each), CMV reactivation, pneumonia, PJP pneumonia, fungal pneumonia, aphasia, neutropenia, cough, interstitial lung disease, supraventricular tachycardia, tachycardia, pancreatitis, sclerosing cholangitis, and septic shock (n=1 each)

[0755] AEs according to NCI-CTCAE v5.0. CRS according to Lee 2019 criteria. AE, adverse event; CMV, cytomegalovirus; CRS, cytokine release syndrome; IRR, infusion-related reaction; PJP, Pneumocystis jiroveci pneumonia; TEAE, treatment-emergent adverse event; TRAE, treatment-related AE

[0756] Table 22: Cytokine Release Syndrome

[0757]

[0758]

[0759] Table 23: All events of interest

[0760]

[0761] *Grade 3 ICANS events = encephalopathy. ICANS, immune effector cell-associated neurotoxicity syndrome

[0762] Overall, these results show that onitumab monotherapy is effective in patients with heavily pretreated relapsed / refractory diffuse large B-cell lymphoma before and after CAR-T therapy (ORR 49.2%, CR 30.8%, and durable responses with a median duration of complete response of 17.9 months). In addition, onitumab monotherapy showed a manageable safety profile, especially when using a modified 0.7 / 4 / 20 ascending dosing schedule.

[0763] As of September 18, 2022, CRS occurred in 86 (51.8%) of the 166 patients treated with the revised escalation regimen of 0.7 / 4 / 20 mg. The highest grade CRS (cytokine release syndrome) observed was Grade 1 in 62 (37.3%) participants, Grade 2 in 21 (12.7%) participants, and Grade 3 in 3 (1.8%) participants. The revised escalation dosing regimen successfully reduced the incidence and severity of CRS events. The incidence of CRS events of any grade decreased from 183 / 300 (61%) participants using the 1 / 20 regimen to 86 / 166 (51.8%) participants using the revised regimen, and grade 3 or higher CRS events decreased from 8.7% using the 1 / 20 regimen to 1.8% using the revised regimen. The overall incidence of grade 2 or higher CRS events decreased from 28.3% with the 1 / 20 regimen to 14.5% with the amended regimen.

[0764] Example 14: Clinical Evaluation of Onitutumab (REGN1979), an Anti-CD20 x Anti-CD3 Bispecific Antibody, Compared to Investigator's Choice in Participants with Previously Untreated Follicular Lymphoma

[0765] This is an open-label, multicenter, randomized, Phase 3 study to compare the efficacy and safety of onitumab versus the investigator's choice of chemotherapy (rituximab-CHOP, rituximab-CVP, or rituximab-bendamustine) in participants with previously untreated follicular lymphoma. In Part 1 (safety run-in), the dose of onitumab monotherapy expected to continue into Part 2 (randomization phase) will be tested. The efficacy and safety of the recommended dose of onitumab will be evaluated against the investigator's choice of chemotherapy in Part 2. All participants will receive 6 cycles of induction. Participants with a complete response (CR) or partial response (PR) at the end of the 6th cycle of induction will continue to receive a maintenance therapy period of onitumab or rituximab (depending on the study group) monotherapy. Participants who relapse / progress during treatment or have stable disease (SD) at the end of induction will be withdrawn from treatment and continue to be followed for safety and survival.

[0766] Participants with high-risk FL (Follicular Lymphoma International Prognostic Index 1 [FLIPI 1] score of 3-5) will be enrolled in the safety run-in portion (12-24 patients). Approximately 446 participants will be enrolled and randomly assigned in a 1:1 ratio to receive (A) induction with onitumab followed by maintenance with onitumab or (B) the investigator's choice of immunochemotherapy followed by maintenance with rituximab. The choice of therapy (CHOP, CVP, or bendamustine) will be based on the investigator's clinical judgment. For participants assigned to receive onitumab, onitumab will be administered as monotherapy at the dose selected during Part 1 for 6 cycles (see Table 24). At the end of Cycle 6, participants who achieve a CR or PR based on the Week 24 scan assessment will continue to receive onitumab monotherapy at a dose of 320 mg Q8W for up to 12 doses or until disease progression, loss to follow-up, or withdrawal of consent, whichever comes first. For participants assigned to receive rituximab in combination with chemotherapy, treatment will be according to standard practice, with 6 cycles of induction chemotherapy followed by up to 12 doses of rituximab monotherapy at intervals of Q8W (for participants who achieve CR and PR only) or until disease progression, loss to follow-up, or withdrawal of consent, whichever comes first.

[0767] Table 24: Onitumumab dose reduction schedule

[0768]

[0769] The study population will consist of patients 18 years and older with previously untreated CD20 + Composition of FL (based on World Health Organization (WHO) classification) participants.

[0770] Inclusion criteria: Participants must meet the following criteria to be eligible for inclusion in this study:

[0771] 1. Diagnosed with CD20 + FL 1-3a, stage II bulky or stage III / IV: CD20 must be obtained before study enrollment + Local histopathological confirmation of FL grade 1 to 3a. The biopsy must be obtained within 18 months prior to study recruitment. The corresponding tumor biopsy specimen should be submitted to the central laboratory.

[0772] For Part 1 (Safety Run-in) only: FLIP1 score of 3 to 5.

[0773] 2. Treatment as indicated is required: presence of ≥ 1 of the following: B symptoms, large tumor mass (characterized by lymphoma > 3 cm in diameter in 3 or more areas or lymphoma > 6 cm in diameter in 1 area), and / or presence of lymphoma-related complications.

[0774] 3. Measurable disease on cross-sectional imaging documented by diagnostic imaging CT or MRI (measurable disease was defined as at least 1 two-dimensionally measurable nodal lesion with greatest transverse diameter (GTD) >1.5 cm or extranodal disease >1 cm, regardless of short-axis diameter).

[0775] 4. Eastern Cooperative Oncology Group (ECOG) performance status of 0-2

[0776] 5. Age 3 18 years old

[0777] 6. Adequate bone marrow function as documented by the following data:

[0778] a. Platelet count 3 50×10 9 Participants may not receive platelet transfusion therapy within 7 days prior to the first dose of onitumumab to meet platelet eligibility criteria.

[0779] b.Hemoglobin 3 9.0 g / dL

[0780] c. Absolute neutrophil count (ANC) 3 1.0×10 9 / L. Participants may not receive G-CSF within 2 days before the first dose of onitumumab to meet ANC eligibility criteria.

[0781] d. Participants with bone marrow involvement or splenic sequestration should meet the following hematologic parameters:

[0782] ■ Platelet count 3 25×109 / L. Participants may not receive platelet transfusion therapy within 3 days prior to the first dose of onitumumab to meet platelet eligibility criteria.

[0783] ■ Hemoglobin 3 7.0 g / dL

[0784] ■ ANC ≥ 0.5 × 10 9 / L. Participants may not receive G-CSF within 2 days before the first dose of onitumumab to meet ANC eligibility criteria.

[0785] 7. Participants with adequate liver function:

[0786] a. Total bilirubin ≤1.5× upper limit of normal (ULN) (≤3× ULN if due to lymphomatous hepatic infiltration).

[0787] b. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 2.5×ULN (≤ 5×ULN if due to lymphoma liver infiltration).

[0788] c. Alkaline phosphatase (ALP) ≤ 2.5×ULN (≤ 5×ULN if due to lymphoma liver infiltration).

[0789] Note:

[0790] * Participants with AST>2.5×ULN and / or ALT>2.5×ULN and total bilirubin>1.5×ULN will be excluded regardless of the presence of lymphoma infiltration in the liver.

[0791] *Participants with known Gilbert's syndrome were excluded if total bilirubin values ​​were >4× the ULN for the local general population.

[0792] 8. Creatinine clearance calculated according to Cockcroft-Gault formula 3 50mL / min.

[0793] Note: Participants with calculated creatinine clearance <50 mL / min may be considered for enrollment if the measured creatinine clearance (based on a 24-hour urine collection or other reliable method) is ≥50 mL / min.

[0794] 9. The research participant or legal representative is able to understand the purpose and risks of the research and provides signed and dated informed consent and authorization for the use of protected health information (in accordance with state and local participant privacy regulations).

[0795] 10. Willing and able to comply with clinic visits and study-related procedures.

[0796] 11. Ability to understand and complete research-related questionnaires.

[0797] Exclusion criteria: Participants who meet any of the following criteria will be excluded from the study:

[0798] 1. Participants with central nervous system (CNS) lymphoma or leptomeningeal lymphoma.

[0799] a. Primary CNS lymphoma or known involvement of non-primary CNS lymphoma (even if treated to complete remission).

[0800] b. Suspected CNS involvement by lymphoma must be evaluated with CNS imaging (MRI or CT) and lumbar puncture as appropriate.

[0801] 2. Participants with histological evidence of transformation to high-grade or diffuse large B-cell lymphoma.

[0802] 3. Participants with Waldenstrom's macroglobulinemia (WM, lymphoplasmacytic lymphoma), grade 3b follicular lymphoma, chronic lymphocytic leukemia, or small lymphocytic lymphoma.

[0803] 4. Receiving any systemic anti-lymphoma therapy.

[0804] 5. Recent major surgery (within 4 weeks before the start of designated study treatment).

[0805] 6. Standard radiotherapy within 14 days of the first administration of designated study treatment.

[0806] 7. History of solid organ transplantation.

[0807] 8. Continuous systemic corticosteroid treatment with more than 10 mg per day of prednisone or anti-inflammatory equivalents within 72 hours of study drug initiation.

[0808] 9. Malignancies other than NHL unless the participant has received adequate and definitive treatment and has been cancer-free for at least 3 years, with the exception of localized prostate cancer, in situ cervical cancer, in situ breast cancer, or definitive treated non-melanoma skin cancer receiving hormonal therapy or focal radiation therapy (i.e., microscopy).

[0809] 10. Any other significant active illness or medical condition that may interfere with the conduct of the study or expose the participant to significant risk, including but not limited to significant cardiovascular disease (e.g., New York Heart Association class III or IV heart disease, myocardial infarction within the past 6 months, unstable arrhythmia, or unstable angina); significant pulmonary disease (e.g., obstructive pulmonary disease and history of symptomatic bronchospasm); or gastrointestinal, hepatic, renal, endocrine, hematological, autoimmune, psychiatric, or neurological disorders.

[0810] 11. History of or current occurrence of relevant CNS conditions, such as epilepsy, seizures, paresis, aphasia, stroke, severe head injury, cerebellar disease, organic brain syndrome, psychosis, inflammatory lesions and / or vasculitis.

[0811] 12. Vaccination with a replication-competent vector within 28 days prior to the first administration of study drug.

[0812] 13. Cardiac ejection fraction <50% as determined by echocardiography or multiple gated acquisition (MUGA) scan.

[0813] 14. Pregnant or breastfeeding women.

[0814] 15. Women of childbearing potential (WOCBP)* or males who are unwilling to use highly effective contraceptive measures before the first dose / start of first treatment, during the study, and for at least 6 months after the last dose. Sperm donation is prohibited during the study and within 6 months after the last dose of study drug. Highly effective contraceptive measures include:

[0815] a. Stable use of combined (estrogen and progestin) hormonal contraceptives (oral, vaginal, transdermal) or progestin-only hormonal contraceptives (oral, injectable, implantable) associated with ovulation suppression for 2 or more menstrual cycles prior to screening;

[0816] b. Intrauterine device (IUD); intrauterine hormone-releasing system (IUS);

[0817] c. Bilateral fallopian tube obstruction / ligation;

[0818] d. A vasectomized partner (provided that the vasectomized male partner is the WOCBP study participant's only sexual partner and the vasectomized partner has received a medical evaluation that the procedure was successful); and / or

[0819] e. Abstinence.

[0820] 16. History of clinically significant cardiovascular, respiratory, hepatic, renal, gastrointestinal, endocrine, hematological, psychiatric, or neurological diseases assessed by the investigator that may confound the study results or impose additional risks on participants due to participation in the study.

[0821] 17. A history of active tuberculosis or systemic fungal disease within 6 months.

[0822] 18. Infection:

[0823] Infection requiring hospitalization or intravenous anti-infective medication within 2 weeks of the first dose of assigned study treatment. There should be evidence that the infection has cleared or is well controlled at the start of study treatment.

[0824] Evidence of any active infection (bacterial, viral, fungal, mycobacterial, parasitic or other) at the time of study enrollment or within 2 weeks of study enrollment (if continued treatment is required and / or if immunosuppression is present that could result in disseminated disease or serious infection).

[0825] Active COVID-19 infection defined as PCR+

[0826] Uncontrolled human immunodeficiency virus (HIV), hepatitis B (HBV), or hepatitis C (HCV) infection.

[0827] Cytomegalovirus (CMV) infection as demonstrated by detectable levels by peripheral blood PCR assay. Participants who demonstrate detectable CMV levels at screening will be required to be treated with appropriate antiviral therapy and demonstrate at least 2 undetectable CMV levels by PCR assay (at least 7 days apart) before being reconsidered for eligibility.

[0828] Note: HIV participants whose infection was controlled (undetectable viral load and CD4 count above 350 cells / μL, either spontaneously or while on a stable antiviral regimen) were allowed to be included.

[0829] Note: Participants who are HBsAg-positive or HBsAg-positive should be evaluated by a specialist and considered for antiviral prophylaxis before being allowed to participate in the study.

[0830] Note: Participants who were HCV antibody positive (HCV Ab+) and whose infection was controlled (undetectable HCV RNA by PCR either spontaneously or as a response to previous successful anti-HCV therapy) were allowed to be included.

[0831] 19. Allergic / hypersensitivity reactions:

[0832] a. History of serious allergic reactions to compounds with similar chemical or biological composition to the study drug or excipients.

[0833] b. Known hypersensitivity to allopurinol and rasburicase.

[0834] 20. Participation in any clinical study evaluating another investigational drug (including biologics) or therapy (including specific immunotherapy) within 90 days or at least 5 half-lives of the investigational biological drug (whichever is longer) or at least 4 weeks of other investigational drugs prior to the screening visit.

[0835] 21. Participants who have been committed to an institution pursuant to an order issued by a judicial or administrative authority.

[0836] The study interventions implemented in this study are shown in Table 25 below.

[0837] Table 25: Study interventions implemented

[0838]

[0839] CP-cyclophosphamide; DX-doxorubicin; VC-vincristine; PN-prednisone; BD-bendamustine

[0840] The dose of Onitumab administered is a fixed dose, independent of the participant's weight or body surface area. During the induction treatment period, Onitumab will be administered intravenously and administered in ascending doses in the first cycle to reduce the risk of CRS. The first cycle will consist of an initial dose of 0.7 mg (divided into 0.2 mg on the first day of the first cycle and 0.5 mg on the second day of the first cycle), an intermediate dose 1 of 4 mg (divided into 2 mg on the 8th day of the first cycle and 2 mg on the 9th day of the first cycle) and an intermediate dose 2 of 20 mg (divided into 10 mg on the 15th day of the first cycle and 10 mg on the 16th day of the first cycle). From the second cycle to the fourth cycle, Onitumab will be administered intravenously with 80 mg on days 1, 8 and 15, and from the fifth and sixth cycles, Onitumab will be administered intravenously with 160 mg on days 1 and 15 of the 8th day of the fifth cycle and the 1st and 15th day of the 6th cycle (Table 26). During the monotherapy maintenance treatment period, onitumab will be administered intravenously at 320 mg Q8W (Table 26). The first dose of onitumab during the maintenance period (320 mg) will be administered 6 weeks after the last dose (160 mg) given during induction on Day 15 of Cycle 6.

[0841] Table 26: Onitumumab Administration

[0842]

[0843] For the initial dose, intermediate dose 1, and intermediate dose 2, treatment will be divided into 2 separate infusions given on 2 separate days (preferably consecutively, but no more than 3 days apart). Each divided infusion during cycle 1 and the first full dose QW infusion (day 1 of cycle 2) should be given within 4 hours. Subsequent treatments can be administered as a single infusion or as 2 separate infusions and can be administered over at least 1 hour depending on tolerability.

[0844] Premedication to reduce the risk of CRS and reduce the severity of CRS is detailed in Example 3. CRS toxicity grading is shown, for example, in Table 6.

[0845] For this study, the use of rituximab or biosimilars is permitted. Rituximab must be administered according to institutional guidelines or according to the instructions in the product package insert. Rituximab will be administered at 375 mg / m on Day 1 of each cycle. 2 Rituximab is administered intravenously at a dose of . The frequency and duration of rituximab combined with induction chemotherapy (CHOP / CVP) is Q3W, a total of 6 cycles, 21 days per cycle, and the frequency and duration of the combination with induction bendamustine is Q4W, a total of 6 cycles, 28 days per cycle (induction treatment phase). After the end of the combined treatment period or early termination of chemotherapy, rituximab will continue as a monotherapy Q8W, up to 12 maintenance doses (if the participant obtains CR or PR), unless the participant stops the drug in advance due to toxicity, disease progression, or the start of subsequent lymphoma therapy or self-determined reasons (participants or researchers). Rituximab and chemotherapy administration are described in Table 27. For details about CHOP / CVP and bendamustine, including formulations and administration, please refer to the product package insert. Eight weeks after the dose on day 1 of cycle 6, participants (with CR or PR) will start the maintenance treatment period of rituximab monotherapy according to the Q8W schedule.

[0846] Table 27: CHOP / CVP and bendamustine dosage

[0847]

[0848] Example 15: Clinical Evaluation of Onituzumab (REGN1979), an Anti-CD20 × Anti-CD3 Bispecific Antibody, in Combination with CHOP (O-CHOP) and Rituximab in Combination with CHOP (R-CHOP) in Participants with Previously Untreated Diffuse Large B-Cell Lymphoma

[0849] This is a phase 3, open-label, randomized, multicenter study comparing the combination of onitumumab with CHOP (O-CHOP) and the combination of rituximab with CHOP (R-CHOP) in participants with previously untreated DLBCL with an International Prognostic Index (IPI) score of 2 or higher. This study consists of 2 parts: Part 1 of the study is a safety run-in, which aims to evaluate the safety and tolerability of O-CHOP and determine the expected dose regimen of O-CHOP in Part 2; Part 2 is the randomized part of the study, which evaluates the efficacy and safety of O-CHOP compared with R-CHOP.

[0850] All participants will receive only onitumab (without rituximab) in Part 1. Up to 48 participants will be recruited and treated at a lower dose level 1 (DL1) according to Table 28, and then upgraded to DL2. The dose-limiting toxicity (DLT) and tolerability of O-CHOP will also be evaluated. Table 28 provides the dosing regimen of onitumab combined (with CHOP) in Part 1 (safety run-in). The dosing level will start with 80 mg onitumab full dose (DL 1). The CHOP dose remains unchanged in each dose level; CHOP for all DLs starts from Day 1 of Cycle 1 (C1D1). CHOP is given once every 21 days for a total of 6 cycles (1 cycle = 21 days). All DL onitumab will start from C1D8.

[0851] Table 28: Onituzumab dose escalation schedule

[0852]

[0853]

[0854] C = cycle; D = day; QW = once a week; Q2W = once every 2 weeks

[0855] Note:...

Claims

1. A dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating a B-cell malignancy, comprising: administering to the subject an initial dose of 0.7 mg of the bispecific antibody, wherein the initial dose is divided into a first dose portion comprising 0.2 mg of the bispecific antibody and a second dose portion comprising 0.5 mg of the bispecific antibody, wherein the first dose portion is administered to the subject within two days during week 1 of the dosing regimen, followed by administration of the second dose portion; administering to the subject a first intermediate dose of 4 mg of the bispecific antibody, wherein the first intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 2 mg of the bispecific antibody, wherein the two parts of the first intermediate dose are administered on two days during week 2 of the dosing regimen; administering to the subject a second intermediate dose of 20 mg of the bispecific antibody, wherein the second intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 10 mg of the bispecific antibody, wherein the two parts of the second intermediate dose are administered on two days during week 3 of the dosing regimen; During weeks 4 to 12 of the dosing regimen, administering a full dose of the bispecific antibody to the subject each week; as well as administering to the subject a maintenance dose of the bispecific antibody in week 14 of the dosing regimen, wherein the bispecific antibody comprises a first antigen-binding region that binds to human CD20 and a second antigen-binding region that binds to human CD3, wherein the first antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8 and 9, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively, and wherein the second antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively.

2. The dosing regimen of claim 1, wherein the full dose is administered to the subject as a single dose during weeks 4 to 12 of the dosing regimen.

3. The dosing regimen of claim 1, wherein if the subject experiences a Grade 3 event of cytokine release syndrome when administering the initial dose, the first intermediate dose, or the second intermediate dose, the full dose of the bispecific antibody administered to the subject during Week 4 is divided into two equal parts and the two parts of the full dose are administered on two days during Week 4 of the dosing regimen, and wherein the full dose is administered to the subject as a single dose during Weeks 5 to 12 of the dosing regimen.

4. The dosing regimen of any one of claims 1 to 3, wherein the maintenance dose is administered to the subject every two weeks starting from week 14 of the dosing regimen.

5. The dosing regimen of any one of claims 1 to 4, wherein the maintenance dose is administered to the subject every four weeks or every eight weeks starting from a subsequent week of the dosing regimen, wherein the subsequent week is at least week 36 of the dosing regimen.

6. The dosing regimen of any one of claims 1 to 5, wherein the second dose portion of the initial dose is administered to the subject 18 to 96 hours after the first dose portion of the initial dose.

7. The dosing regimen of any one of claims 1 to 6, wherein the two portions of the first intermediate dose are administered to the subject 18 to 96 hours apart.

8. The dosing regimen of any one of claims 1 to 7, wherein the two portions of the second intermediate dose are administered to the subject 18 to 96 hours apart.

9. The dosing regimen of claim 3, wherein the two portions of the full dose are administered to the subject 18 to 96 hours apart.

10. The dosing regimen of any one of claims 1 to 5, wherein the two days are consecutive days.

11. The dosing regimen of any one of claims 1 to 5, wherein the two days are no more than three days apart.

12. The dosing regimen of any one of claims 1 to 11, wherein the B-cell malignancy is B-cell non-Hodgkin's lymphoma.

13. The dosing regimen of claim 12, wherein the B-cell malignancy is follicular lymphoma, diffuse large B-cell lymphoma, mantle cell lymphoma, or marginal zone lymphoma.

14. The dosing regimen of any one of claims 1 to 13, wherein the full dose of the bispecific antibody is 80 mg to 320 mg.

15. The dosing regimen of any one of claims 1 to 14, wherein the maintenance dose of the bispecific antibody is 160 mg to 320 mg.

16. The dosing regimen of any one of claims 1 to 15, wherein the cancer is follicular lymphoma, the full dose is 80 mg, and the maintenance dose is 160 mg.

17. The dosing regimen of claim 16, wherein the follicular lymphoma is grade 1-3a.

18. The dosing regimen of any one of claims 1 to 15, wherein the cancer is diffuse large B-cell lymphoma, the full dose is 160 mg, and the maintenance dose is 320 mg.

19. The dosing regimen of any one of claims 1 to 15, wherein the cancer is diffuse large B-cell lymphoma, the full dose is 320 mg, and the maintenance dose is 320 mg.

20. The dosing regimen of claim 18 or 19, wherein the subject has previously failed CAR-T therapy.

21. The dosing regimen of any one of claims 1 to 15, wherein the cancer is mantle cell lymphoma, the full dose is 160 mg, and the maintenance dose is 320 mg.

22. The dosing regimen of claim 21, wherein the subject has failed prior Bruton's tyrosine kinase (BTK) inhibitor therapy.

23. The dosing regimen of any one of claims 1 to 15, wherein the cancer is marginal zone lymphoma, the full dose is 80 mg, and the maintenance dose is 160 mg.

24. The dosing regimen of any one of claims 1 to 15, wherein the cancer is non-Hodgkin lymphoma other than follicular lymphoma, diffuse large B-cell lymphoma, mantle cell lymphoma, or marginal zone lymphoma, the full dose is 160 mg, and the maintenance dose is 320 mg.

25. The dosing regimen of any one of claims 1 to 15, wherein the cancer is an aggressive lymphoma, the full dose is 160 mg, and the maintenance dose is 320 mg.

26. The dosing regimen of any one of claims 1 to 25, wherein: (a) the subject has a documented CD20+ B-cell malignancy with active disease that has not responded to prior therapy, has no standard of care options, and may be a candidate for treatment with an anti-CD20 antibody; or (b) the subject has a documented aggressive B-NHL that has relapsed within one year of first-line therapy and is contemplated for autologous stem cell transplantation (ASCT).

27. The dosing regimen of any one of claims 1 to 26, wherein the subject has relapsed or refractory disease.

28. The dosing regimen of any one of claims 1 to 27, wherein the subject has relapsed after or is refractory to at least 2 prior lines of systemic therapy comprising an anti-CD20 antibody and an alkylating agent.

29. The dosing regimen of any one of claims 1 to 28, wherein the subject is refractory to anti-CD20 antibodies on any prior line of therapy.

30. The dosing regimen of any one of claims 1 to 29, wherein the subject is double refractory to an alkylating agent and an anti-CD20 antibody in any prior line of therapy.

31. The dosing regimen of any one of claims 1 to 30, wherein the subject is a human aged ≥ 18 years.

32. The dosing regimen of any one of claims 1 to 31, wherein the bispecific antibody is administered intravenously.

33. A dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating a B-cell malignancy, comprising: administering to the subject an initial dose of 1 mg or 2 mg of the bispecific antibody during week 1 of the dosing regimen; administering to the subject a first intermediate dose of 10 mg or 26 mg of the bispecific antibody during week 2 of the dosing regimen; administering to the subject a second intermediate dose of 50 mg or 100 mg of the bispecific antibody during week 3 of the dosing regimen; as well as administering to the subject a full dose of the bispecific antibody during week 4 of the dosing regimen and during the following week, wherein the bispecific antibody comprises a first antigen-binding region that binds to human CD20 and a second antigen-binding region that binds to human CD3, wherein the first antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8 and 9, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively, and wherein the second antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively.

34. The method of claim 33, wherein the initial dose is 2 mg.

35. The method of claim 33 or 34, wherein the first intermediate dose is 26 mg.

36. The method of any one of claims 33 to 35, wherein the second intermediate dose is 100 mg.

37. The method of any one of claims 33 to 36, wherein the full dose is 200 mg, 400 mg or 600 mg.

38. The method of claim 37, wherein the full dose is 400 mg.

39. The method of claim 37, wherein the full dose is 600 mg.

40. The method of any one of claims 33 to 39, wherein the full dose is administered to the subject once every three weeks.

41. The method of any one of claims 33 to 39, wherein the full dose is administered to the subject weekly.

42. The method of claim 41, wherein the full dose is administered to the subject weekly for three weeks and then the full dose is administered to the subject once every three weeks.

43. The dosing regimen of any one of claims 33 to 42, wherein the subject has relapsed or refractory disease.

44. The dosing regimen of any one of claims 33 to 43, wherein the subject is refractory to anti-CD20 antibody on any prior line of therapy.

45. The dosing regimen of any one of claims 33 to 44, wherein the B cell malignancy is follicular lymphoma.

46. ​​The dosing regimen of any one of claims 33 to 44, wherein the B cell malignancy is diffuse large B cell lymphoma.

47. The dosing regimen of any one of claims 33 to 46, wherein the subject is a human aged ≥ 18 years.

48. The method of any one of claims 33 to 47, wherein the bispecific antibody is administered subcutaneously.

49. A dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating a B-cell malignancy, comprising: administering an initial dose of the bispecific antibody to the subject, wherein the initial dose is divided into a first dose portion of the bispecific antibody and a second dose portion of the bispecific antibody, wherein the first dose portion is administered to the subject within two days during week 1 of the dosing regimen, followed by administration of the second dose portion; administering to the subject a first intermediate dose of the bispecific antibody, wherein the first intermediate dose is divided into two equal portions (a first portion and a second portion) of the bispecific antibody, wherein the two portions of the first intermediate dose are administered on two days during week 2 of the dosing regimen; administering to the subject a second intermediate dose of the bispecific antibody, wherein the second intermediate dose is divided into two equal parts (a first part and a second part) of the bispecific antibody, wherein the two parts of the second intermediate dose are administered on two days during week 3 of the dosing regimen; During weeks 4 to 12 of the dosing regimen, administering a full dose of the bispecific antibody to the subject each week; as well as administering to the subject a maintenance dose of the bispecific antibody in week 14 of the dosing regimen, Wherein the initial dose, the first intermediate dose, the second intermediate dose, the full dose and the maintenance dose depend on the weight of the subject: (i) if the subject weighs 40 kg to less than 164 kg, the initial dose is 0.7 mg, the first dose portion of the initial dose is 0.2 mg, the second dose portion of the initial dose is 0.5 mg, the first intermediate dose is 4 mg, the two equal portions of the first intermediate dose each contain 2 mg, the second intermediate dose is 20 mg, the two equal portions of the second intermediate dose each contain 10 mg, the full dose is 160 mg, and the maintenance dose is 320 mg; (ii) if the subject weighs 20 kg to less than 39 kg, the initial dose is 0.4 mg, the first dose portion of the initial dose is 0.1 mg, the second dose portion of the initial dose is 0.3 mg, the first intermediate dose is 2 mg, the two equal portions of the first intermediate dose each contain 1 mg, the second intermediate dose is 12 mg, the two equal portions of the second intermediate dose each contain 6 mg, the full dose is 90 mg, and the maintenance dose is 150 mg; (iii) if the subject weighs 10 kg to less than 19 kg, the initial dose is 0.3 mg, the first dose portion of the initial dose is 0.1 mg, the second dose portion of the initial dose is 0.2 mg, the first intermediate dose is 1.6 mg, the two equal portions of the first intermediate dose each contain 0.8 mg, the second intermediate dose is 8 mg, the two equal portions of the second intermediate dose each contain 4 mg, the full dose is 60 mg, and the maintenance dose is 100 mg; or (iv) if the subject weighs 6 kg to less than 9 kg, the initial dose is 0.24 mg, the first dose portion of the initial dose is 0.07 mg, the second dose portion of the initial dose is 0.17 mg, the first intermediate dose is 1.2 mg, the two equal portions of the first intermediate dose each contain 0.6 mg, the second intermediate dose is 6 mg, the two equal portions of the second intermediate dose each contain 3 mg, the full dose is 45 mg, and the maintenance dose is 75 mg; and wherein the bispecific antibody comprises a first antigen-binding region that binds to human CD20 and a second antigen-binding region that binds to human CD3, wherein the first antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8 and 9, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively, and wherein the second antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively.

50. The dosing regimen of claim 49, wherein the full dose is administered to the subject as a single dose during weeks 4 to 12 of the dosing regimen.

51. The dosing regimen of claim 49 or 50, wherein the maintenance dose is administered to the subject every two weeks starting from week 14 of the dosing regimen.

52. The dosing regimen of any one of claims 49 to 51, wherein the second dose portion of the initial dose is administered to the subject 18 to 96 hours after the first dose portion of the initial dose.

53. The dosing regimen of any one of claims 49 to 52, wherein the two portions of the first intermediate dose are administered to the subject 18 to 96 hours apart.

54. The dosing regimen of any one of claims 49 to 53, wherein the two portions of the second intermediate dose are administered to the subject 18 to 96 hours apart.

55. The dosing regimen of any one of claims 49 to 51, wherein the two days are consecutive days.

56. The dosing regimen of any one of claims 49 to 51, wherein the two days are no more than three days apart.

57. The dosing regimen of any one of claims 49 to 56, wherein the B cell malignancy is a B cell non-Hodgkin lymphoma.

58. The dosing regimen of claim 57, wherein the B cell malignancy is follicular lymphoma, diffuse large B cell lymphoma, mantle cell lymphoma, or marginal zone lymphoma.

59. The dosing regimen of any one of claims 49 to 58, wherein the bispecific antibody is administered intravenously to the subject.

60. The dosing regimen of any one of claims 49 to 59, wherein the subject is a human < 18 years old.

61. A dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating follicular lymphoma, comprising: administering to the subject an initial dose of 0.7 mg of the bispecific antibody, wherein the initial dose is divided into a first dose portion comprising 0.2 mg of the bispecific antibody and a second dose portion comprising 0.5 mg of the bispecific antibody, wherein the first dose portion is administered to the subject within two days during week 1 of the dosing regimen, followed by administration of the second dose portion; administering to the subject a first intermediate dose of 4 mg of the bispecific antibody, wherein the first intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 2 mg of the bispecific antibody, wherein the two parts of the first intermediate dose are administered on two days during week 2 of the dosing regimen; administering to the subject a second intermediate dose of 20 mg of the bispecific antibody, wherein the second intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 10 mg of the bispecific antibody, wherein the two parts of the second intermediate dose are administered on two days during week 3 of the dosing regimen; During weeks 4 to 12 of the dosing regimen, a full dose of 40 mg or 80 mg of the bispecific antibody is administered to the subject weekly; as well as In week 14 of the dosing regimen, a maintenance dose of 80 mg or 160 mg of the bispecific antibody is administered to the subject, wherein the bispecific antibody comprises a first antigen-binding region that binds to human CD20 and a second antigen-binding region that binds to human CD3, wherein the first antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8 and 9, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively, and wherein the second antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively.

62. A dosing regimen for administering an anti-CD3×anti-CD20 bispecific antibody to a subject for treating diffuse large B-cell lymphoma, comprising: administering to the subject an initial dose of 0.7 mg of the bispecific antibody, wherein the initial dose is divided into a first dose portion comprising 0.2 mg of the bispecific antibody and a second dose portion comprising 0.5 mg of the bispecific antibody, wherein the first dose portion is administered to the subject within two days during week 1 of the dosing regimen, followed by administration of the second dose portion; administering to the subject a first intermediate dose of 4 mg of the bispecific antibody, wherein the first intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 2 mg of the bispecific antibody, wherein the two parts of the first intermediate dose are administered on two days during week 2 of the dosing regimen; administering to the subject a second intermediate dose of 20 mg of the bispecific antibody, wherein the second intermediate dose is divided into two equal parts (a first part and a second part), each part comprising 10 mg of the bispecific antibody, wherein the two parts of the second intermediate dose are administered on two days during week 3 of the dosing regimen; During weeks 4 to 12 of the dosing regimen, administering to the subject a full dose of 80 mg or 160 mg of the bispecific antibody weekly; as well as administering to the subject a maintenance dose of 160 mg or 320 mg of the bispecific antibody in week 13 or week 14 of the dosing regimen, wherein the bispecific antibody comprises a first antigen-binding region that binds to human CD20 and a second antigen-binding region that binds to human CD3, wherein the first antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 7, 8 and 9, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively, and wherein the second antigen-binding region comprises three heavy chain complementary determining regions HCDR1, HCDR2 and HCDR3 comprising the amino acid sequences of SEQ ID NOs: 10, 11 and 12, respectively, and three light chain complementary determining regions LCDR1, LCDR2 and LCDR3 comprising the amino acid sequences of SEQ ID NOs: 13, 14 and 15, respectively.

63. The dosing regimen of claim 61 or 62, wherein the full dose is administered to the subject as a single dose during weeks 4 to 12 of the dosing regimen.

64. The dosing regimen of any one of claims 61 to 63, wherein the maintenance dose is administered to the subject every two weeks starting from week 13 or week 14 of the dosing regimen.

65. The dosing regimen of any one of claims 61 to 63, wherein the maintenance dose is administered to the subject every four weeks or every eight weeks.

66. The dosing regimen of any one of claims 61 and 63 to 65, wherein the full dose is 40 mg.

67. The dosing regimen of any one of claims 61 to 65, wherein the full dose is 80 mg.

68. The dosing regimen of any one of claims 62 to 65, wherein the full dose is 160 mg.

69. The dosing regimen of any one of claims 61 and 63 to 67, wherein the maintenance dose is 80 mg.

70. The dosing regimen of any one of claims 61 to 68, wherein the maintenance dose is 160 mg.

71. The dosing regimen of any one of claims 62 to 65, 67 and 68, wherein the maintenance dose is 320 mg.

72. The dosing regimen of any one of claims 61 to 71, wherein the second dose portion of the initial dose is administered to the subject 18 to 96 hours after the first dose portion of the initial dose.

73. The dosing regimen of any one of claims 61 to 72, wherein the two portions of the first intermediate dose are administered to the subject 18 to 96 hours apart.

74. The dosing regimen of any one of claims 61 to 73, wherein the two portions of the second intermediate dose are administered to the subject 18 to 96 hours apart.

75. The dosing regimen of any one of claims 61 to 74, wherein the dosing regimen further comprises administering a combination of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP).

76. The dosing regimen of claim 75, wherein the CHOP is administered during the week prior to week 1 of the dosing regimen and again during weeks 3, 6, 9, 12, and 15 of the dosing regimen.

77. The dosing regimen of claim 75 or 76, wherein the cyclophosphamide is administered at 750 mg / m 2 The doxorubicin was administered at a dose of 50 mg / m 2 The dose of vincristine was 1.4 mg / m 2 The invention relates to a method of treating a cyclophosphamide-containing drug and a doxorubicin-containing drug, wherein the cyclophosphamide, the doxorubicin and the vincristine are administered once in the week prior to Week 1 of the dosing regimen and once each in Weeks 3, 6, 9, 12 and 15 of the dosing regimen, and the prednisone is administered for five consecutive days in the week prior to Week 1 of the dosing regimen and for five consecutive days each in Weeks 3, 6, 9, 12 and 15 of the dosing regimen.

78. The dosing regimen of any one of claims 61 to 77, wherein the subject has relapsed or refractory disease.

79. The dosing regimen of any one of claims 61 to 78, wherein the subject is refractory to anti-CD20 antibody on any prior line of therapy.

80. The dosing regimen of any one of claims 61 to 79, wherein the subject is doubly refractory to an alkylating agent and an anti-CD20 antibody.

81. The dosing regimen of any one of claims 61 to 80, wherein the subject has previously received an autologous stem cell transplant.

82. The dosing regimen of any one of claims 61 to 77, wherein the subject has not been previously treated with systemic anti-lymphoma therapy.

83. The dosing regimen of any one of claims 61 to 82, wherein the bispecific antibody is administered intravenously to the subject.

84. The dosing regimen of any one of claims 1 to 83, wherein the first antigen-binding region of the bispecific antibody comprises a heavy chain variable region (HCVR) comprising the amino acid sequence of SEQ ID NO:4 and a light chain variable region (LCVR) comprising the amino acid sequence of SEQ ID NO:6, and the second antigen-binding region of the bispecific antibody comprises a HCVR comprising the amino acid sequence of SEQ ID NO:5 and a LCVR comprising the amino acid sequence of SEQ ID NO:

6.

85. The dosing regimen of any one of claims 1 to 74, wherein the bispecific antibody comprises a human IgG heavy chain constant region.

86. The dosing regimen of claim 85, wherein the human IgG heavy chain constant region is of the isotype IgGl.

87. The dosing regimen of claim 85, wherein the human IgG heavy chain constant region is of isotype IgG4.

88. The dosing regimen of any one of claims 1 to 84, wherein the bispecific antibody comprises a first heavy chain constant region comprising the amino acid sequence of SEQ ID NO: 16 and a second heavy chain constant region comprising the amino acid sequence of SEQ ID NO:

17.

89. The dosing regimen of any one of claims 1 to 84, wherein the bispecific antibody comprises a first heavy chain constant region comprising the amino acid sequence of SEQ ID NO: 18 and a second heavy chain constant region comprising the amino acid sequence of SEQ ID NO:

19.

90. The dosing regimen of any one of claims 1 to 84, wherein the bispecific antibody comprises a first heavy chain comprising amino acid residues 1-452 of SEQ ID NO: 1 paired with a common light chain comprising the amino acid sequence of SEQ ID NO: 3, and a second heavy chain comprising amino acid residues 1-448 of SEQ ID NO: 2 paired with a common light chain comprising the amino acid sequence of SEQ ID NO:

3.

91. The dosing regimen of any one of claims 1 to 84, wherein the bispecific antibody comprises a first heavy chain comprising an amino acid sequence of SEQ ID NO: 1 paired with a common light chain comprising an amino acid sequence of SEQ ID NO: 3, and a second heavy chain comprising an amino acid sequence of SEQ ID NO: 2 paired with a common light chain comprising an amino acid sequence of SEQ ID NO:

3.

92. The dosing regimen of any one of claims 1 to 91, wherein the dosing regimen further comprises administering to the subject a dose of a steroid at the following times: 12 to 24 hours prior to administering the first dose portion of the initial dose; 12 to 24 hours prior to administering the first portion of the first intermediate dose; and 12 to 24 hours prior to administering the first portion of the second intermediate dose.

93. The dosing regimen of claim 92, wherein if the first dose portion of the initial dose and the second dose portion of the initial dose are not administered to the subject on consecutive days, the dosing regimen further comprises administering a dose of a steroid to the subject 12 to 24 hours prior to administering the second dose portion of the initial dose of the bispecific antibody.

94. The dosing regimen of claim 92 or 93, wherein if the first portion of the first intermediate dose and the second portion of the first intermediate dose are not administered to the subject on consecutive days, the dosing regimen further comprises administering a dose of a steroid to the subject 12 to 24 hours prior to administering the second portion of the first intermediate dose of the bispecific antibody.

95. The dosing regimen of any one of claims 92 to 94, wherein if the first portion of the second intermediate dose and the second portion of the second intermediate dose are not administered to the subject on consecutive days, the dosing regimen further comprises administering a dose of a steroid to the subject 12 to 24 hours prior to administering the second portion of the second intermediate dose of the bispecific antibody.

96. The dosing regimen of any one of claims 92 to 95, wherein the dosing regimen further comprises: administering a dose of a steroid to the subject at: 1 to 3 hours prior to administering the first dose portion of the initial dose; 1 to 3 hours before administering said second dosage portion of said initial dose; and 1 to 3 hours before administration of each portion of the first intermediate dose and the second intermediate dose, and administering to the subject a dose of an antihistamine: 30 to 60 minutes prior to administering the first dosage portion of the initial dose; 30 to 60 minutes prior to administering the second dosage portion of the initial dose; and 30 to 60 minutes before administering each portion of the first intermediate dose and the second intermediate dose.

97. The dosing regimen of claim 96, wherein the dosing regimen further comprises administering to the subject a dose of acetaminophen 30 to 60 minutes prior to administering the first dose portion of the initial dose; 30 to 60 minutes prior to administering the second dose portion of the initial dose; and 30 to 60 minutes prior to administering each portion of the first intermediate dose and the second intermediate dose.

98. The dosing regimen of any one of claims 92 to 97, wherein the dosing regimen further comprises administering to the subject a dose of a steroid 20 to 28 hours after the completion of the second dose portion of the initial dose; 20 to 28 hours after the completion of the second portion of the first intermediate dose; and 20 to 28 hours after the completion of the second portion of the second intermediate dose.

99. The dosing regimen of any one of claims 92 to 98, wherein the dosing regimen further comprises: administering to the subject a dose of a steroid 1 to 3 hours prior to administration of the full dose during week 4 of the dosing regimen, and The subject is administered a dose of an antihistamine 30 to 60 minutes prior to administration of the full dose during week 4 of the dosing regimen.

100. The dosing regimen of claim 99, wherein the dosing regimen further comprises administering to the subject a dose of acetaminophen 30 to 60 minutes prior to administering the full dose during week 4 of the dosing regimen.

101. The dosing regimen of claim 100, wherein the dosing regimen further comprises administering to the subject a dose of a steroid 20 to 28 hours after completion of administration of the full dose during week 4 of the dosing regimen.

102. The dosing regimen of any one of claims 92 to 98, wherein if the subject experiences a Grade 3 event of cytokine release syndrome when administering the initial dose, the first intermediate dose, or the second intermediate dose, the full dose of the bispecific antibody administered to the subject during Week 4 is divided into two equal parts (a first part and a second part), and the two parts of the full dose are administered within two days during Week 4 of the dosing regimen, and wherein the dosing regimen further comprises administering a dose of a steroid to the subject 12 to 24 hours prior to administering the first part of the full dose.

103. The dosing regimen of claim 102, wherein if the full dose of the first portion and the full dose of the second portion are not administered to the subject on consecutive days, the dosing regimen further comprises administering to the subject a dose of a steroid 12 to 24 hours prior to administering the full dose of the second portion of the bispecific antibody.

104. The dosing regimen of claim 102 or 103, wherein the dosing regimen further comprises: administering to said subject a dose of a steroid 1 to 3 hours prior to administering said first portion of said full dose, and Between 30 and 60 minutes prior to administering the first portion of the full dose, a dose of an antihistamine is administered to the subject.

105. The dosing regimen of claim 104, wherein the dosing regimen further comprises administering to the subject a dose of acetaminophen 30 to 60 minutes prior to administering the first portion of the full dose.

106. The dosing regimen of any one of claims 102 to 105, wherein the dosing regimen further comprises: administering to the subject a dose of a steroid 1 to 3 hours prior to administration of the full dose during week 5 of the dosing regimen, and The subject is administered a dose of an antihistamine 30 to 60 minutes prior to administration of the full dose during week 5 of the dosing regimen.

107. The dosing regimen of claim 106, wherein the dosing regimen further comprises administering to the subject a dose of acetaminophen 30 to 60 minutes prior to administering the full dose during week 5 of the dosing regimen.

108. The dosing regimen of claim 107, wherein the dosing regimen further comprises administering to the subject a dose of a steroid 20 to 28 hours after completion of administration of the full dose during week 5 of the dosing regimen.

109. The dosing regimen of any one of claims 92 to 108, wherein administering a dose of a steroid, administering a dose of an antihistamine, or administering a dose of acetaminophen comprises instructing the subject to ingest the dose of a steroid, the dose of an antihistamine, or the dose of acetaminophen, respectively.

110. The dosing regimen of any one of claims 92 to 108, wherein administering a dose of a steroid or administering a dose of an antihistamine comprises administering the dose of a steroid or the dose of an antihistamine intravenously.

111. The dosing regimen of any one of claims 92 to 110, wherein the steroid is dexamethasone.

112. The dosing regimen of claim 111, wherein the dose of steroid is 20 mg.

113. The dosing regimen of any one of claims 96 to 112, wherein the antihistamine is diphenhydramine.

114. The dosing regimen of claim 113, wherein the dose of antihistamine is 25 mg.

115. The dosing regimen of any one of claims 97 to 114, wherein the dose of acetaminophen is 650 mg.

116. The dosing regimen of any one of claims 1 to 115, wherein the dosing regimen further comprises administering an anti-IL-6 receptor antibody.

117. The dosing regimen of claim 116, wherein the anti-IL-6 receptor antibody is tocilizumab or salirumab.

118. A method of treating a B-cell cancer in a subject, comprising: Subjects diagnosed with B-cell cancer were selected; as well as The bispecific antibody is administered to the subject according to the dosing regimen of any one of claims 1 to 117.

119. The method of claim 118, wherein: (a) the subject has been diagnosed with follicular lymphoma; (b) the subject has been diagnosed with grade 1-3a follicular lymphoma; (c) the subject has been diagnosed with relapsed or refractory follicular lymphoma after at least 2 prior lines of systemic therapy; (d) the subject has been diagnosed with follicular lymphoma and has not previously been treated with systemic anti-lymphoma therapy; (e) the subject has been diagnosed with follicular lymphoma and the full dose is 80 mg; and / or (f) the subject has been diagnosed with follicular lymphoma, and the maintenance dose is 160 mg or 320 mg.

120. The method of claim 118, wherein: (a) the subject has been diagnosed with diffuse large B-cell lymphoma (DLBCL); (b) the subject has been diagnosed with DLBCL, and wherein the DLBCL is de novo or transformed from a low-grade tumor; (c) the subject has been diagnosed with DLBCL and is refractory to at least 2 previous lines of systemic therapy; (d) the subject has been diagnosed with relapsed or refractory DLBCL after at least 2 prior lines of systemic therapy including CAR-T therapy; (e) the subject has been diagnosed with DLBCL and has not previously received systemic anti-lymphoma therapy; (f) the subject has been diagnosed with DLBCL and the full dose is 160 mg; and / or (g) The subject has been diagnosed with DLBCL, and the maintenance dose is 320 mg.

121. A pharmaceutical kit comprising (i) a container containing the bispecific antibody, and (ii) a label including instructions for administering the bispecific antibody according to the dosing regimen of any one of claims 1 to 91.

122. The pharmaceutical kit of claim 121, wherein the label comprises instructions for administering the steroid and the antihistamine and / or the anti-IL-6 receptor antibody of claim 116 or 117 according to the dosing regimen of any one of claims 92 to 115.

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