Subcutaneous doses and administration of anti-C5 antibodies for treatment of paroxysmal sleep hemoglobinuria (PNH)

Abstract

Provided are methods of clinical treatment of paroxysmal sleep hemoglobinuria (PNH) comprising administering to a patient an anti-C5 antibody or antigen-binding fragment thereof wherein the anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously (or for subcutaneous administration) according to a specific clinical dosage regimen (i.e., at a specific dosage and according to a specific administration schedule). In one embodiment, the patient has been previously treated with Epibezumab # imgabs0 #.

Description

[0001] This application is a divisional application of an invention patent application that entered the Chinese national phase on April 23, 2021, with application number 201980070341.7, application date October 30, 2019, and invention name “Subcutaneous dose and administration of anti-C5 antibodies for the treatment of paroxysmal nocturnal hemoglobinuria (PNH)”.

[0002] Related Applications

[0003] This application claims priority to and the benefit of U.S. Provisional Application No. 62 / 752,563 (filed on October 30, 2018), the entire contents of which are incorporated herein by reference. Background Art

[0004] The complement system works with the rest of the body's immune system to defend against invasion by cellular and viral pathogens. There are at least 25 complement proteins, which have been found to be a complex collection of plasma proteins and membrane cofactors. Plasma proteins account for about 10% of the globulin in vertebrate serum. Complement components interact through a series of complex but precise enzymatic cleavage and membrane binding events to achieve their immune defense function. The resulting complement cascade produces products with conditioning, immunomodulatory and lytic functions. A concise summary of the biological activities associated with complement activation is provided in, for example, The Merck Manual, 16th edition.

[0005] Although a properly functioning complement system provides a powerful defense against microbial infection, improper regulation or activation of the complement pathway has been implicated in the pathogenesis of a variety of conditions, including paroxysmalnocturnal hemoglobinuria (PNH). PNH is an extremely rare condition caused by chronic, uncontrolled complement activation. The resulting inflammation and cellular damage lead to the devastating clinical manifestations of the disease.

[0006] PNH is a disorder caused primarily by intravascular hemolysis and platelet activation, in which uncontrolled complement activity can lead to systemic complications (see Socié G et al., French Society of Haematology. Lancet. 1996; 348(9027): 573-577; and Brodsky, R., Blood. 2014; 124(18): 2804-2811). Sustained intravascular hemolysis can be triggered by a variety of stressors, such as infection or physical exertion, leading to smooth muscle contraction (free hemoglobin), chronic anemia, and an increased risk of severe thromboembolism. Thromboembolism is the most common cause of death in PNH patients and can lead to pulmonary hypertension and end-organ damage to important organs such as the liver, kidneys, brain, and intestines (Hillmen, P. et al., Am. J. Hematol. 2010; 85(8): 553-559). As a result of these adverse pathological processes, PNH patients experience a decreased quality of life (QoL), which may include debilitating fatigue, chronic pain, poor physical function, shortness of breath, abdominal pain, erectile dysfunction, the need for anticoagulation, transfusions, and in some cases, dialysis (Weitz, IC. et al., Thromb Res. 2012; 130(3):361-368).

[0007] PNH patients are at high risk of morbidity and mortality. It is therefore an object of the present invention to provide improved methods for treating PNH patients. Summary of the invention

[0008] Provided herein are compositions and methods for treating PNH in a human patient, the methods comprising administering to the patient an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously (or for subcutaneous administration) according to a specific clinical dosing regimen (i.e., at a specific dose and according to a specific dosing schedule). In one embodiment, the patient has previously been treated with eculizumab. treat.

[0009] An exemplary anti-C5 antibody is ravulizumab (also known as Ultomiris TM, ALXN1210 and antibody BNJ441), the antibody comprising a heavy chain and a light chain having the sequences shown in SEQ ID NOs: 14 and 11, respectively, or an antigen-binding fragment and variant thereof. In other embodiments, the antibody comprises the heavy chain and light chain complementary determining regions (CDRs) or variable regions (VRs) of lavalizumab. Thus, in one embodiment, the antibody comprises the CDR1, CDR2 and CDR3 domains of the heavy chain variable (VH) region of lavalizumab having the sequence shown in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the light chain variable (VL) region of lavalizumab having the sequence shown in SEQ ID NO: 8. In another embodiment, the antibody comprises the CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and the CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6.

[0010] In another embodiment, the antibody comprises VH and VL regions having amino acid sequences as shown in SEQ ID NO: 12 and SEQ ID NO: 8, respectively. In another embodiment, the antibody comprises a heavy chain constant region as shown in SEQ ID NO: 13. In another embodiment, the antibody comprises a heavy chain polypeptide as shown in SEQ ID NO: 14 and a light chain polypeptide as shown in SEQ ID NO: 11. In another embodiment, the antibody comprises a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each of which is numbered in EU.

[0011] In another embodiment, the antibody comprises the CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively; and the CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively; and a variant human Fc constant region that binds to human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each of which is numbered according to EU.

[0012] In another embodiment, the antibody competes for binding and / or binds to the same epitope on C5 as the above antibodies. In another embodiment, the antibody has at least about 90% variable region amino acid sequence identity with the above antibodies (e.g., at least about 90%, 95%, or 99% variable region identity with SEQ ID NO: 12 and SEQ ID NO: 8).

[0013] In another embodiment, the antibody is present at 0.1 nM ≤ K at pH 7.4 and 25°C. D Affinity dissociation constants (K) in the range of ≤1 nM D ) binds to human C5. In another embodiment, the antibody binds to human C5 at pH 6.0 and 25°C with a K D ≥10 nM binds to human C5. In yet another embodiment, the antibody has a K of [(the antibody or antigen-binding fragment thereof has a K of ≥10 nM for human C5 at pH 6.0 and 25°C] D ) / (K of the antibody or antigen-binding fragment thereof for human C5 at pH 7.4 and 25°C D )] is greater than 25.

[0014] In one aspect, a method is provided for subcutaneously administering an anti-C5 antibody or an antigen-binding fragment thereof (e.g., lavalizumab) at a dose of between 400 mg and 600 mg to a PNH patient. In one embodiment, a dose of between 450 and 550 mg of an anti-C5 antibody or an antigen-binding fragment thereof is subcutaneously administered to a PNH patient. In another embodiment, an anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously to a PNH patient at a dose of about 400, 405, 410, 420, 425, 430, 435, 440, 445, 450, 455, 460, 465, 470, 475, 480, 485, 490, 495, 500, 505, 510, 515, 520, 525, 530, 535, 540, 545, 550, 555, 560, 565, 570, 575, 580, 585, 590, 595, or 600 mg. In another embodiment, a dose of about 490 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously to a PNH patient.

[0015] In another embodiment, a dose of about 490 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously to a PNH patient once a week (e.g., for two weeks, three weeks, one month, two months, three months, four months, five months, six months, seven months, eight months, nine months, ten months, eleven months, one year, two years, three years, or long-term, e.g., for the rest of the patient's life).

[0016] In another aspect, a method for treating a PNH patient is provided, wherein an initial dose (e.g., a loading dose) of an anti-C5 antibody or an antigen-binding fragment thereof (e.g., lavalizumab) is administered intravenously to the patient, followed by subcutaneous administration of the anti-C5 antibody or antigen-binding fragment thereof (e.g., two weeks later). In one embodiment, the intravenous dose of the anti-C5 antibody or antigen-binding fragment thereof is based on the patient's weight. For example, in one embodiment, 2400 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered intravenously to a patient weighing ≥40 kg to <60 kg prior to subcutaneous treatment with the anti-C5 antibody or antigen-binding fragment thereof. In another embodiment, 2700 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered intravenously to a patient weighing ≥60 kg to <100 kg prior to subcutaneous treatment with the anti-C5 antibody or antigen-binding fragment thereof.

[0017] In another embodiment, on day 1 of the administration cycle, a dose (e.g., 2400 mg or 2700 mg) of an anti-C5 antibody or antigen-binding fragment thereof is administered intravenously to the patient, followed by subcutaneous administration of the anti-C5 antibody or antigen-binding fragment thereof (e.g., a 490 mg dose) on day 15 of the administration cycle and weekly thereafter (e.g., for two weeks, three weeks, one month, two months, three months, four months, five months, six months, seven months, eight months, nine months, ten months, eleven months, one year, two years, three years, or long-term administration, e.g., for the rest of the patient's life).

[0018] In another embodiment, a method of treating a human patient suffering from PNH is provided, the method comprising administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof during an administration cycle, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered by:

[0019] (a) Administer the following doses once intravenously on Day 1 of the administration cycle:

[0020] i. 2400 mg for patients weighing ≥40 kg to <60 kg, or

[0021] ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and

[0022] (b) 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0023] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a PNH patient weighing ≥40 kg to <60 kg as follows: (a) a 2400 mg dose administered intravenously once on day 1 of the administration cycle; and (b) a 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0024] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a PNH patient weighing ≥60 kg to <100 kg as follows: (a) a 2700 mg dose administered intravenously once on day 1 of the administration cycle; and (b) a 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0025] In another embodiment, a method of treating a human patient suffering from PNH is provided, the method comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof during an administration period, the antibody or antigen-binding fragment thereof comprising the CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and the CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered by:

[0026] (a) Administer the following doses once intravenously on Day 1 of the administration cycle:

[0027] i. 2400 mg for patients weighing ≥40 kg to <60 kg, or

[0028] ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and

[0029] (b) 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0030] In another embodiment, a method of treating a human patient with PNH is provided, the method comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof during an administration cycle, the antibody or antigen-binding fragment thereof comprising the CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively; the CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively; and a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each of which is numbered in EU, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered by:

[0031] (a) Administer the following doses intravenously on Day 1 of the administration cycle:

[0032] i. 2400 mg for patients weighing ≥40 kg to <60 kg, or

[0033] ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and

[0034] (b) 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0035] In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof (e.g., Lavalizumab) is formulated for intravenous administration (e.g., administration as an initial loading dose). For example, in one embodiment, the formulation for intravenous administration comprises 300 mg of Lavalizumab (10 mg / mL) in 10 mM sodium phosphate, 150 mM sodium chloride, 0.02% polysorbate 80, and water for injection. In another embodiment, the formulation for intravenous administration consists of 300 mg of Lavalizumab (10 mg / mL) in 10 mM sodium phosphate, 150 mM sodium chloride, 0.02% polysorbate 80, and water for injection. In another embodiment, Lavalizumab for intravenous administration is formulated in the form of a sterile, preservative-free concentrated aqueous solution (10 mg / mL) in a 30 mL single-use vial.

[0036] In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof (e.g., Lavalizumab) is formulated for subcutaneous administration. For example, in one embodiment, the formulation for subcutaneous administration comprises 262.5 mg Lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In another embodiment, the formulation for subcutaneous administration consists of 262.5 mg Lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In another embodiment, the formulation for subcutaneous administration comprises 245 mg Lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In another embodiment, the formulation for subcutaneous administration consists of 245 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In another embodiment, lavalizumab for subcutaneous administration is formulated at pH 7.4.

[0037] Subcutaneous administration of an anti-C5 antibody or antigen-binding fragment thereof (e.g., lavalizumab) according to the methods described herein can be achieved by any suitable means. In addition, the anti-C5 antibody or antigen-binding fragment thereof can be administered subcutaneously by a medical professional or by self-administration. In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously using an on-body delivery system (OBDS). In one embodiment, lavalizumab for subcutaneous administration is provided in a 3.5 mL single-use cartridge. In another embodiment, each cartridge containing lavalizumab for subcutaneous administration contains 262.5 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In another embodiment, each cartridge containing Lavalizumab for subcutaneous administration contains 245 mg of Lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In another embodiment, Lavalizumab for subcutaneous administration is formulated as a sterile and preservative-free concentrated aqueous solution (70 mg / mL) in a 3.5 mL single-use prefilled cartridge designed for a single-use wearable delivery system.

[0038] In one embodiment, the administration cycle is a total of 10 weeks of treatment. In another embodiment, after the administration cycle, a 490 mg dose of anti-C5 antibody or its antigen-binding fragment is subcutaneously administered once a week for up to 3 months, 6 months, 9 months, 12 months, 15 months, 18 months, 21 months, two years or long-term administration, such as for the rest of the patient's life. In some embodiments, patients treated according to the methods described herein have previously been treated with complement inhibitors. In one embodiment, the patient has previously been treated with eculizumab. In another embodiment, the patient has previously been treated with eculizumab for at least 1 month, at least 2 months, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 7 months, at least 8 months, at least 9 months, at least 10 months, at least 11 months, at least 12 months, at least 18 months or at least 24 months. In a specific embodiment, the patient has previously been treated with eculizumab for at least 6 months. In another embodiment, the patient has previously been treated with a 900 mg dose of eculizumab once every 2 weeks. In another embodiment, treatment is initiated at least two weeks after the patient received the last dose of eculizumab.

[0039] In some embodiments, patients treated according to the methods described herein are vaccinated against meningococcal infection within three years prior to or at the time of initiation of treatment. In one embodiment, patients treated less than 2 weeks after receiving a meningococcal vaccine are also treated with appropriate prophylactic antibiotics until 2 weeks after vaccination. In another embodiment, patients treated according to the methods described herein are vaccinated against meningococcal serotypes A, C, Y, W135, and / or B.

[0040] In another aspect, the treatment regimens described herein are sufficient to maintain a specific serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof. For example, in one embodiment, the treatment maintains a serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof at 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 200, 205 , 210, 215, 220, 225, 230, 240, 245, 250, 255, 260, 265, 270, 280, 290, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345, 350, 355, 360, 365, 370, 375, 380, 385, 390, 395 or 400 μg / ml or more. In another embodiment, the treatment maintains the serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 100 μg / ml or more. In another embodiment, the treatment maintains the serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 150 μg / ml or more. In another embodiment, the treatment maintains the serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 200 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at 250 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at 300 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at between 100 μg / ml and 200 μg / ml. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at about 175 μg / ml.

[0041] In some embodiments, to achieve an effective response, the amount and frequency of anti-C5 antibody administered to the patient is such as to maintain at least 50 μg, 55 μg, 60 μg, 65 μg, 70 μg, 75 μg, 80 μg, 85 μg, 90 μg, 95 μg, 100 μg, 105 μg, 110 μg, 115 μg, 120 μg, 125 μg, 130 μg, 135 μg, 140 μg, 150 μg, 160 μg, 170 μg, 180 μg, 190 μg, 200 μg, 210 μg, 220 μg, 230 μg, 240 μg, 250 μg, 260 μg, 270 μg, 280 μg, 290 μg, 300 μg, 310 μg, 320 μg, 330 μg, 340 μg, 350 μg, 360 μg, 370 μg, 380 μg, 390 μg, 400 μg, 410 μg, 420 μg, 430 μg, 440 μg, 450 μg, 460 μg, 470 μg, 480 μg, 490 μg, 500 μg, 510 μg, 520 μg, 530 μg, 540 μg, 550 μg, 560 μg, 570 μg, 580 μg, 590 μg In one embodiment, the amount and frequency of the anti-C5 antibody administered to the patient is such that between 50 μg and 250 μg of antibody is maintained per milliliter of the patient's blood. In another embodiment, the amount and frequency of the anti-C5 antibody administered to the patient is such that between 100 μg and 200 μg of antibody is maintained per milliliter of the patient's blood. In another embodiment, the amount and frequency of anti-C5 antibody administered to the patient is such as to maintain about 175 μg of antibody per mL of the patient's blood.

[0042] The efficacy of the treatment methods provided herein can be assessed using any suitable means. In one embodiment, for PNH patients, the treatment produces at least one therapeutic effect selected from the following group: fatigue, abdominal pain, dyspnea, anemia [hemoglobin <10 g / dL], dysphagia, chest pain, and erectile dysfunction are reduced or stopped.

[0043] In another embodiment, the treatment results in terminal complement inhibition.

[0044] In another embodiment, treatment results in a reduced need for blood transfusions.

[0045] In another embodiment, treatment increases hemoglobin stability relative to the patient's pre-treatment baseline.

[0046] In another embodiment, the treatment shifts toward normal levels a hemolysis-related blood biomarker selected from the group consisting of free hemoglobin, haptoglobin, reticulocyte count, PNH red blood cell (RBC) clone, and D-dimer.

[0047] In another embodiment, treatment reduces breakthrough hemolysis relative to eculizumab treatment. In another embodiment, treatment eliminates breakthrough hemolysis during treatment. In another embodiment, treatment reduces breakthrough hemolysis compared to the baseline amount of breakthrough hemolysis before treatment.

[0048] In another embodiment, treatment results in a reduction in major adverse vascular events (MAVE).In another embodiment, treatment results in a shift toward normal levels of chronic disease-associated biomarkers selected from the group consisting of estimated glomerular filtration rate (eGFR) and spot urine: albumin: creatinine and plasma brain natriuretic peptide (BNP).

[0049] In another embodiment, treatment results in a change from baseline in quality of life as assessed by the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale Version 4 and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 scale.

[0050] In a specific embodiment, lactate dehydrogenase (LDH) levels are used to assess responsiveness to therapy (e.g., reduced hemolysis assessed by lactate dehydrogenase (LDH) levels indicates improvement in at least one sign of PNH). For example, in one embodiment, the treatment described herein normalizes LDH levels.

[0051] In one embodiment, the LDH level of a patient treated according to the disclosed method is reduced to near normal levels or within a range of 10% or 20% higher than a value considered normal (e.g., within the range of 105-333 IU / L (international units / liter)). In another embodiment, the patient's LDH level is normalized throughout the treatment maintenance period. In another embodiment, the LDH level of the treated patient is normalized for at least 95% of the time during the treatment maintenance period. In another embodiment, the LDH level of the treated patient is normalized for at least 90%, 85%, or 80% of the time during the treatment maintenance period.

[0052] In one embodiment, LDH levels in a patient treated according to the disclosed methods are reduced to within the normal range or within a range of 10%, 20%, 30%, 40% or 50% below a value considered to be the upper limit of normal levels (e.g., within the range of 105-333 IU / L (International Units / L)).

[0053] In another aspect, an anti-C5 antibody or antigen-binding fragment thereof is provided, wherein the antibody or antigen-binding fragment thereof comprises the CDR1, CDR2 and CDR3 domains of the heavy chain variable region having the sequence shown in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the light chain variable region having the sequence shown in SEQ ID NO: 8, and is administered by:

[0054] (a) Administer the following doses intravenously on Day 1 of the administration cycle:

[0055] i. 2400 mg for patients weighing ≥40 kg to <60 kg, or

[0056] ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and

[0057] (b) 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0058] Also provided are kits comprising a pharmaceutical composition containing a therapeutically effective amount of an anti-C5 antibody or antigen-binding fragment thereof, such as lavalizumab, suitable for use in the methods described herein, and a pharmaceutically acceptable carrier. For example, in one embodiment, a kit for treating PNH in a human patient is provided, the kit comprising: (a) a dose of an anti-C5 antibody or antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising a heavy chain variable region having a sequence shown in SEQ ID NO: 12, CDR1, CDR2, and CDR3 domains, and a light chain variable region having a sequence shown in SEQ ID NO: 8, CDR1, CDR2, and CDR3 domains; and (b) instructions for using the anti-C5 antibody or antigen-binding fragment thereof in the methods described herein. In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥40 kg to <60 kg as follows: (a) a 2400 mg dose administered intravenously once on day 1 of an administration cycle; and (b) a 490 mg dose administered subcutaneously on day 15 of an administration cycle and weekly thereafter. In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to patients weighing ≥60 kg to <100 kg as follows: (a) a 2700 mg dose is administered intravenously once on day 1 of the administration cycle; and (b) a 490 mg dose is administered subcutaneously on day 15 of the administration cycle and weekly thereafter. In a specific embodiment, the anti-C5 antibody is lavazimab.

[0059] Also provided is a device comprising a pre-filled cartridge containing lavalizumab for subcutaneous administration co-packaged with a wearable injector. In one embodiment, the device is a sterile, single-use, disposable and / or electromechanical device. In another embodiment, the wearable injector comprises a 29-gauge needle. In another embodiment, the pre-filled cartridge is a 3.5 mL cartridge. In another embodiment, the lavalizumab for subcutaneous administration comprises 262.5 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, the lavalizumab for subcutaneous administration consists of 262.5 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, the lavalizumab for subcutaneous administration comprises 245 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, the lavalizumab for subcutaneous administration consists of 245 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, the lavalizumab for subcutaneous administration is formulated at about pH 7.4. BRIEF DESCRIPTION OF THE DRAWINGS

[0060] Figure 1 Schematic diagram depicting the design of a Phase III noninferiority study of subcutaneous versus intravenous lavalizumab in adult patients with PNH currently treated with eculizumab. DETAILED DESCRIPTION

[0061] I. definition

[0062] As used herein, the term "subject" or "patient" is a human patient (eg, a patient with paroxysmal nocturnal hemoglobinuria (PNH)).

[0063] Paroxysmal nocturnal hemoglobinuria is an acquired hemolytic disease that most commonly occurs in adults (Brodsky RA., Blood. 2015; 126: 2459-65). The disease begins with the clonal expansion of hematopoietic stem cells that acquire somatic mutations in the PIGA gene (Brodsky RA., Blood. 2014; 124: 2804-1). As a result, PNH blood cells lack glycophosphatidylinositol (GPI) anchors and lack membrane-bound complement inhibitory proteins CD55 and CD59. In the absence of CD55, the deposition of complement protein C3 cleavage products on the blood cell membrane surface increases, resulting in the cleavage of C5 into C5a and C5b. The pathology and clinical manifestations of PNH patients are caused by uncontrolled terminal complement activation.

[0064] C5a is a potent anaphylatoxin, chemokine, and cell-activating molecule that mediates a variety of pro-inflammatory and pro-thrombotic activities (Matis LA et al., Nat. Med. 1995; 1: 839-42; Prodinger et al., Complement. In: Paul WE, ed., Fundamental immunology (4th ed.). Philadelphia: Lippincott-Raven Publishers; 1999. pp. 967-95). C5b recruits the terminal complement components C6, C7, C8, and C9 to form the pro-inflammatory, pro-thrombotic cytolytic pore-forming molecule C5b-9, a process that would normally be blocked by CD59 on the red blood cell (RBC) membrane. However, in PNH patients, these final steps proceed unchecked, ultimately leading to hemolysis and release of free hemoglobin, as well as platelet activation (Hill et al. Blood 2013; 121: 4985-96). The signs and symptoms of PNH are attributable to chronic, uncontrolled complement C5 cleavage, and release of C5a and C5b-9 leading to RBC hemolysis, which together cause (Hill et al., Blood 2013;121:4985-96; Brodsky RA., Blood. 2014;124:2804-1): release of intracellular free hemoglobin and lactate dehydrogenase (LDH) into the circulation as a direct consequence of hemolysis, irreversible binding and inactivation of nitric oxide (NO) by hemoglobin, and inhibition of NO synthesis; vasoconstriction and tissue bed ischemia due to a lack of vasodilatory NO; and microthrombi that may manifest as abdominal pain, dysphagia, and erectile dysfunction; platelet activation; and a proinflammatory and prothrombotic state.

[0065] Most PNH patients experience renal insufficiency and pulmonary hypertension (Hillmen et al., Am J Hematol. 2010; 85: 553-9. [Corrigendum found in Am J Hematol. 2010; 85: 911]; Hill et al., Br. J Haematol. 2012; 158: 409-14.; Hill et al., Blood 2013; 121: 4985-96). Patients also experience venous or arterial thrombosis at various sites including the abdomen or central nervous system (Brodsky RA., Blood. 2014; 124: 2804-1).

[0066] As used herein, "effective treatment" refers to treatment that produces a beneficial effect, such as an improvement in at least one symptom of a disease or condition. Effective treatment may refer to alleviation of at least one symptom of PNH (e.g., fatigue, abdominal pain, dyspnea, anemia, dysphagia, chest pain, or erectile dysfunction). The beneficial effect may be in the form of an improvement relative to a baseline, i.e., an improvement relative to a measurement or observation obtained prior to initiation of treatment according to the method.

[0067] The term "effective amount" refers to the amount of an agent that provides a desired biological, therapeutic and / or preventive result. The result can be a reduction, improvement, alleviation, reduction, delay and / or alleviation of one or more of the signs, symptoms or causes of the disease, or any other desired change in a biological system. In one embodiment, an "effective amount" is an amount of an anti-C5 antibody or antigen-binding fragment thereof that has been clinically shown to alleviate at least one symptom of PNH (e.g., fatigue, abdominal pain, dyspnea, anemia, dysphagia, chest pain or erectile dysfunction). The effective amount can be administered in one or more administrations.

[0068] As used herein, the terms "induction" and "induction phase" are used interchangeably and refer to the first phase of treatment.

[0069] As used herein, the terms "maintenance" and "maintenance phase" are used interchangeably and refer to the second phase of treatment. In certain embodiments, treatment will continue until clinical benefit is observed or until unmanageable toxicity or disease progression occurs.

[0070] As used herein, the term "loading dose" refers to the initial dose administered to a patient. For example, the loading amount can be 2400 mg or 2700 mg. The loading dose can be adjusted according to body weight. In one embodiment, the loading dose is administered to the patient intravenously. In another embodiment, the loading dose is administered to the patient subcutaneously.

[0071] As used herein, the term "maintenance dose" refers to the dose administered to a patient after a loading dose. For example, a maintenance dose can be about 400 mg, 405 mg, 410 mg, 420 mg, 425 mg, 430 mg, 435 mg, 440 mg, 445 mg, 450 mg, 455 mg, 460 mg, 465 mg, 470 mg, 475 mg, 480 mg, 485 mg, 490 mg, 495 mg, 500 mg, 505 mg, 510 mg, 515 mg, 520 mg, 525 mg, 530 mg, 535 mg, 540 mg, 545 mg, 550 mg, 555 mg, 560 mg, 565 mg, 570 mg, 575 mg, 580 mg, 585 mg, 590 mg, 595 mg, or 600 mg. In one embodiment, the maintenance dose of the anti-C5 antibody or antigen-binding fragment thereof is 490 mg. In one embodiment, the loading dose is administered to the patient subcutaneously.

[0072] As used herein, the term "serum trough level" refers to the lowest level of an agent (e.g., an anti-C5 antibody or antigen-binding fragment thereof) or drug present in serum. In contrast, a "peak serum level" refers to the highest level of an agent in serum. An "average serum level" refers to the average level of an agent in serum over time.

[0073] In one embodiment, the treatment regimen is sufficient to maintain a specific serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof. For example, in one embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195, 200, 205, 210 , 215, 220, 225, 230, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 295, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345, 350, 355, 360, 365, 370, 375, 380, 385, 390, 395 or 400 μg / ml or more. In one embodiment, the treatment maintains the serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 100 μg / ml or more. In another embodiment, the treatment maintains the serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 150 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at 200 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at 250 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at 300 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at between 100 μg / ml and 200 μg / ml. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at about 175 μg / ml.

[0074] In some embodiments, to achieve an effective response, the amount and frequency of anti-C5 antibody administered to the patient is such as to maintain at least 50 μg, 55 μg, 60 μg, 65 μg, 70 μg, 75 μg, 80 μg, 85 μg, 90 μg, 95 μg, 100 μg, 105 μg, 110 μg, 115 μg, 120 μg, 125 μg, 130 μg, 135 μg, 140 μg, 150 μg, 160 μg, 170 μg, 180 μg, 190 μg, 200 μg, 210 μg, 220 μg, 230 μg, 240 μg, 250 μg, 260 μg, 270 μg, 280 μg, 290 μg, 300 μg, 310 μg, 320 μg, 330 μg, 340 μg, 350 μg, 360 μg, 370 μg, 380 μg, 390 μg, 400 μg, 410 μg, 420 μg, 430 μg, 440 μg, 450 μg, 460 μg, 470 μg, 480 μg, 490 μg, 500 μg, 510 μg, 520 μg, 530 μg, 540 μg, 550 μg, 560 μg, 570 μg, 580 μg, 590 μg In one embodiment, the amount and frequency of the anti-C5 antibody administered to the patient is such that between 50 μg and 250 μg of antibody is maintained per milliliter of the patient's blood. In another embodiment, the amount and frequency of the anti-C5 antibody administered to the patient is such that between 100 μg and 200 μg of antibody is maintained per milliliter of the patient's blood. In another embodiment, the amount and frequency of anti-C5 antibody administered to the patient is such as to maintain about 175 μg of antibody per mL of the patient's blood.

[0075] In another embodiment, in order to obtain an effective response, the amount and frequency of the anti-C5 antibody administered to the patient is such that a minimum free C5 concentration is maintained. For example, in one embodiment, the amount and frequency of the anti-C5 antibody administered to the patient is such that a free C5 concentration of 0.2 μg / mL, 0.3 μg / mL, 0.4 μg / mL, 0.5 μg / mL or less is maintained. In another embodiment, the amount and frequency of the anti-C5 antibody administered to the patient is such that a free C5 concentration between 0.309 and 0.5 μg / mL is maintained. In another embodiment, the treatment described herein reduces the free C5 concentration by more than 99% throughout the treatment period. In another embodiment, the treatment reduces the free C5 concentration by more than 99.5% throughout the treatment period.

[0076] The term "antibody" describes a polypeptide comprising at least one antibody-derived antigen binding site (e.g., VH / VL region or Fv or CDR). Antibodies include known forms of antibodies. For example, antibodies can be human antibodies, humanized antibodies, bispecific antibodies, or chimeric antibodies. Antibodies can also be Fab, Fab'2, ScFv, SMIP, Nanobodies or domain antibodies. Antibodies can also be any of the following isotypes: IgG1, IgG2, IgG3, IgG4, IgM, IgA1, IgA2, IgAsec, IgD and IgE. Antibodies can be naturally occurring antibodies, or can be antibodies that have been altered by protein engineering techniques (e.g., by mutation, deletion, substitution, conjugation with non-antibody moieties). For example, an antibody can include one or more variant amino acids (compared to naturally occurring antibodies) that will alter the properties (e.g., functional properties) of the antibody. For example, many such changes are known in the art that can affect, for example, the half-life in patients, effector functions and / or immune responses to the antibody. The term antibody also includes artificial or engineered polypeptide constructs that include at least one antibody-derived antigen binding site.

[0077] II. Anti-C5 antibody

[0078] The anti-C5 antibodies described herein bind to complement component C5 (e.g., human C5) and inhibit the cleavage of C5 into fragments C5a and C5b. Anti-C5 antibodies suitable for use in the present invention (or VH / VL domains derived therefrom) can be produced using methods well known in the art. Alternatively, art-recognized anti-C5 antibodies can be used. Antibodies that compete with any of these art-recognized antibodies for binding to C5 can also be used.

[0079] Eculizumab (also known as ) is an anti-C5 antibody comprising a heavy chain and a light chain having the sequences shown in SEQ ID NOs: 10 and 11, respectively, or an antigen-binding fragment and variant thereof. Eculizumab is described in PCT / US1995 / 005688 and U.S. Pat. No. 6,355,245, the teachings of which are incorporated herein by reference. In one embodiment, the anti-C5 antibody comprises the CDR1, CDR2, and CDR3 domains of the VH region of eculizumab having the sequence shown in SEQ ID NO: 7, and the CDR1, CDR2, and CDR3 domains of the VL region of eculizumab having the sequence shown in SEQ ID NO: 8. In another embodiment, the antibody comprises the heavy chain CDR1, CDR2, and CDR3 domains having the sequences shown in SEQ ID NOs: 1, 2, and 3, respectively, and the light chain CDR1, CDR2, and CDR3 domains having the sequences shown in SEQ ID NOs: 4, 5, and 6, respectively. In another embodiment, the antibody comprises VH and VL regions having the amino acid sequences shown in SEQ ID NO: 7 and SEQ ID NO: 8, respectively.

[0080] An exemplary anti-C5 antibody is Lavalizumab or an antigen-binding fragment and variant thereof, which comprises a heavy chain and a light chain having the sequences shown in SEQ ID NOs: 14 and 11, respectively. Lavalizumab (also known as Ultomiris TM , BNJ441 and ALXN1210) are described in PCT / US2015 / 019225 and U.S. Patent No. 9,079,949, the teachings or cases of which are incorporated herein by reference. Throughout this document, the terms lavalizumab, Ultomiris TM , BNJ441, and ALXN1210 are used interchangeably but all refer to the same antibody. Lavalizumab selectively binds to the human complement protein C5, thereby inhibiting the cleavage of this complement protein into C5a and C5b during complement activation. This inhibition prevents the release of the proinflammatory mediator C5a and the formation of the cytolytic pore-forming membrane attack complex (MAC) C5b-9, while preserving the proximal or early components of complement activation (e.g., C3 and C3b), which are essential for microbial opsonization and immune complex clearance.

[0081] In other embodiments, the antibody comprises the heavy and light chain CDRs or variable regions of lavalizumab. For example, in one embodiment, the antibody comprises the CDR1, CDR2, and CDR3 domains of the lavalizumab VH region having the sequence shown in SEQ ID NO: 12, and the CDR1, CDR2, and CDR3 domains of the lavalizumab VL region having the sequence shown in SEQ ID NO: 8. In another embodiment, the antibody comprises the heavy chain CDR1, CDR2, and CDR3 domains having the sequences shown in SEQ ID NO: 19, 18, and 3, respectively, and the light chain CDR1, CDR2, and CDR3 domains having the sequences shown in SEQ ID NO: 4, 5, and 6, respectively. In another embodiment, the antibody comprises the VH and VL regions having the amino acid sequences shown in SEQ ID NO: 12 and SEQ ID NO: 8, respectively.

[0082] Another exemplary anti-C5 antibody is antibody BNJ421 or an antigen-binding fragment and variant thereof, which comprises a heavy chain and a light chain having the sequences shown in SEQ ID NOs: 20 and 11, respectively. BNJ421 (also known as ALXN1211) is described in PCT / US2015 / 019225 and U.S. Patent No. 9,079,949, the teachings or each of which are incorporated herein by reference.

[0083] In other embodiments, the antibody comprises the heavy and light chain CDRs or variable regions of BNJ421. For example, in one embodiment, the antibody comprises the CDR1, CDR2 and CDR3 domains of the BNJ421 VH region having the sequence shown in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the BNJ421 VL region having the sequence shown in SEQ ID NO: 8. In another embodiment, the antibody comprises the heavy chain CDR1, CDR2 and CDR3 domains having the sequences shown in SEQ ID NO: 19, 18 and 3, respectively, and the light chain CDR1, CDR2 and CDR3 domains having the sequences shown in SEQ ID NO: 4, 5 and 6, respectively. In another embodiment, the antibody comprises VH and VL regions having the amino acid sequences shown in SEQ ID NO: 12 and SEQ ID NO: 8, respectively.

[0084] The exact boundaries of the CDRs are defined in different ways according to different methods. In some embodiments, the positions of the CDRs or framework regions within the light chain or heavy chain variable domain may be as defined by Kabat et al. [(1991) "Sequences of Proteins of Immunological Interest", NIH Publication No. 91-3242, US Department of Health and Human Services, Bethesda, MD]. In this case, the CDR may be referred to as a "Kabat CDR" (e.g., "Kabat LCDR2" or "Kabat HCDR 1"). In some embodiments, the positions of the light chain or heavy chain variable region CDRs may be as defined by Chothia et al. (1989) Nature 557(5):115-123. 342 :877-883. Thus, these regions may be referred to as "Chothia CDRs" (e.g., "Chothia LCDR2" or "Chothia HCDR3"). In some embodiments, the positions of the light chain and heavy chain variable region CDRs may be defined as defined by the Kabat-Chothia combined definition. In such embodiments, these regions may be referred to as "combined Kabat-Chothia CDRs". Thomas et al. [(1996) Mol Immunol 33(17 / 18) : 1389-1401] illustrates the identification of CDR boundaries according to the Kabat and Chothia definitions.

[0085] In some embodiments, the anti-C5 antibodies described herein include a heavy chain CDR1 comprising or consisting of the following amino acid sequence: GHIFSNYWIQ (SEQ ID NO: 19). In some embodiments, the anti-C5 antibodies described herein include a heavy chain CDR2 comprising or consisting of the following amino acid sequence: EILPGSGHTEYTENFKD (SEQ ID NO: 18). In some embodiments, the anti-C5 antibodies described herein include a heavy chain variable region comprising the following amino acid sequence: QVQLVQSGAEVKKPGASVKVSCKASGHIFSNYWIQWVRQAPGQGLEWMGEILPGSGHTEYTENFKDRVTMTRDTSTSTVYMELSSLRSEDTAVYYCARYFFGSSPNWYFDVWGQGTLVTVSS (SEQ ID NO: 12).

[0086] In some embodiments, an anti-C5 antibody described herein comprises a light chain variable region comprising the following amino acid sequence:

[0087] DIQMTQSPSSSLSASVGDRVTITTCGASENIYGALNWYQQKPGK APKLLIYGATNLADGVPSRFSGSGSGTDFTLTISSLQPEDFATYYC QNVLNTPLTFGQGTKVEIK (SEQ ID NO: 8).

[0088] Another exemplary anti-C5 antibody is the 7086 antibody described in U.S. Pat. Nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 7086 antibody (see U.S. Pat. Nos. 8,241,628 and 8,883,158). In another embodiment, the antibody or antigen-binding fragment thereof comprises the heavy chain CDR1, CDR2 and CDR3 domains having the sequences shown in SEQ ID NOs: 21, 22 and 23, respectively, and the light chain CDR1, CDR2 and CDR3 domains having the sequences shown in SEQ ID NOs: 24, 25 and 26, respectively. In another embodiment, the antibody or antigen-binding fragment thereof comprises the 7086 antibody VH region having the sequence shown in SEQ ID NO: 27 and the 7086 antibody VL region having the sequence shown in SEQ ID NO: 28.

[0089] Another exemplary anti-C5 antibody is the 8110 antibody also described in U.S. Pat. Nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 8110 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises the heavy chain CDR1, CDR2, and CDR3 domains having the sequences shown in SEQ ID NOs: 29, 30, and 31, respectively, and the light chain CDR1, CDR2, and CDR3 domains having the sequences shown in SEQ ID NOs: 32, 33, and 34, respectively. In another embodiment, the antibody comprises the VH region of the 8110 antibody having the sequence shown in SEQ ID NO: 35 and the VL region of the 8110 antibody having the sequence shown in SEQ ID NO: 36.

[0090] Another exemplary anti-C5 antibody is the 305LO5 antibody described in US2016 / 0176954A1. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 305LO5 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises the heavy chain CDR1, CDR2, and CDR3 domains having the sequences shown in SEQ ID NOs: 37, 38, and 39, respectively, and the light chain CDR1, CDR2, and CDR3 domains having the sequences shown in SEQ ID NOs: 40, 41, and 42, respectively. In another embodiment, the antibody comprises the 305LI5 antibody VH region having the sequence shown in SEQ ID NO: 43 and the 305LI5 antibody VL region having the sequence shown in SEQ ID NO: 44.

[0091] Another exemplary anti-C5 antibody is the SKY59 antibody described in Fukuzawa T. et al., Rep. 2017 Apr 24;7(1):1080). In one embodiment, the antibody comprises the heavy chain and light chain CDRs or variable regions of the SKY59 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises a heavy chain comprising SEQ ID NO: 45 and a light chain comprising SEQ ID NO: 46.

[0092] Another exemplary anti-C5 antibody is the REGN3918 antibody (also known as H4H12166PP) described in US20170355757. In one embodiment, the antibody comprises a heavy chain variable region comprising SEQ ID NO: 47 and a light chain variable region comprising SEQ ID NO: 48. In some embodiments, the antibody comprises a heavy chain comprising SEQ ID NO: 49 and a light chain comprising SEQ ID NO: 50.

[0093] In another embodiment, the antibody competes for binding and / or binds to the same epitope on C5 as the above-mentioned antibodies (e.g., eculizumab, lavalizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In another embodiment, the antibody has at least about 90% variable region amino acid sequence identity (e.g., at least about 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% variable region identity) with the above-mentioned antibodies.

[0094] In some embodiments, the anti-C5 antibodies described herein may comprise a variant human Fc constant region that binds to a human neonatal Fc receptor (FcRn) with an affinity greater than the affinity of the native human Fc constant region from which the variant human Fc constant region is derived for FcRn. For example, relative to the native human Fc constant region from which the variant human Fc constant region is derived, the Fc constant region may comprise one or more (e.g., two, three, four, five, six, seven, or eight or more) amino acid substitutions. At a pH of 6.0, the substitutions may increase the binding affinity of an IgG antibody containing a variant Fc constant region to FcRn while maintaining the pH dependence of the interaction.

[0095] Substitutions that enhance the binding affinity of an antibody Fc constant region for FcRn are known in the art and include, for example, (1) Dall'Acqua et al. (2006) J Biol Chem 281 :M252Y / S254T / T256E triple substitution described in 23514-23524; (2) Hinton et al. (2004) J Biol Chem 279 :6213-6216 and Hinton et al. (2006) J Immunol 176 :346-356; and (3) Petkova et al. (2006) Int Immunol 18(12) : 1759-69 described in N434A or T307 / E3 80A / N434A substitution. For example, in Datta-Mannan et al. (2007) J Biol Chem 282(3)Additional substitution pairs are described in: 1709-1717: P257I / Q311I, P257I / N434H and D376V / N434H, the disclosure of which is incorporated herein by reference in its entirety. Methods for testing whether one or more substitutions in an antibody Fc constant region increase the affinity of the Fc constant region to FcRn at pH 6.0 (while maintaining the pH dependence of the interaction) are known in the art and are illustrated in the working examples. See, for example, PCT / US2015 / 019225 and U.S. Patent No. 9,079,949, the disclosure of each case is incorporated herein by reference in its entirety.

[0096] In some embodiments, the variant constant region has a substitution of valine at EU amino acid residue 255. In some embodiments, the variant constant region has a substitution of asparagine at EU amino acid residue 309. In some embodiments, the variant constant region has a substitution of isoleucine at EU amino acid residue 312. In some embodiments, the variant constant region has a substitution at EU amino acid residue 386.

[0097] In some embodiments, the variant Fc constant region comprises no more than 30 (e.g., no more than 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, nine, eight, seven, six, five, four, three or two) amino acid substitutions, insertions or deletions relative to the native constant region from which it is derived. In some embodiments, the variant Fc constant region comprises one or more amino acid substitutions selected from the following groups: M252Y, S254T, T256E, N434S, M428L, V259I, T250I and V308F. In some embodiments, the variant human Fc constant region comprises a methionine at position 428 and an asparagine at position 434 in the native human IgG Fc constant region, each of the residues being numbered in EU. In some embodiments, the variant Fc constant region comprises a 428L / 434S double substitution as described, for example, in U.S. Pat. No. 8.088,376.

[0098] In some embodiments, the variant constant region comprises a substitution at amino acid position 237, 238, 239, 248, 250, 252, 254, 255, 256, 257, 258, 265, 270, 286, 289, 297, 298, 303, 305, 307, 308, 309, 311, 312, 314, 315, 317, 325, 332, 334, 360, 376, 380, 382, ​​384, 385, 386, 387, 389, 424, 428, 433, 434, or 436 (EU numbering) relative to a native human Fc constant region. In some embodiments, the substitution is selected from the following group: methionine for glycine at position 237; proline for alanine at position 238; lysine for serine at position 239; isoleucine for lysine at position 248; alanine, phenylalanine, isoleucine, methionine, glutamine, serine, valine, tryptophan, or tyrosine for threonine at position 250; phenylalanine, tryptophan, or tyrosine for methionine at position 252; threonine for serine at position 254; glutamic acid for arginine at position 255; aspartic acid, glutamic acid, or glutamine substituted threonine at position 256 with amine; substituted proline at position 257 with alanine, glycine, isoleucine, leucine, methionine, asparagine, serine, threonine or valine; substituted glutamic acid at position 258 with histidine; substituted aspartic acid at position 265 with alanine; substituted aspartic acid at position 270 with diphenylalanine; substituted asparagine at position 286 with alanine or glutamic acid; substituted threonine at position 289 with histidine; substituted asparagine at position 297 with alanine; substituted serine at position 298 with glycine; substituted valine at position 303 with alanine; substituted threonine at position 286 with asparagine or glutamic acid; substituted threonine at position 289 with histidine; substituted asparagine at position 297 with alanine; substituted serine at position 298 with glycine; substituted valine at position 303 with alanine; substituted threonine at position 305 with phenylalanine; substituted threonine at position 286 with asparagine or glutamic acid; substituted threonine at position 289 with histidine; substituted asparagine at position 297 with alanine; substituted threonine at position 298 with glycine; substituted valine at position 303 with alanine; substituted threonine at position 305 with phenylalanine valine; threonine at position 307 is substituted by alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, methionine, asparagine, proline, glutamine, arginine, serine, valine, tryptophan or tyrosine; valine at position 308 is substituted by alanine, phenylalanine, isoleucine, leucine, methionine, proline, glutamine or threonine; leucine or valine at position 309 is substituted by alanine, aspartic acid, glutamic acid, proline or arginine; glutamyl at position 311 is substituted by alanine, histidine or isoleucine amine; aspartic acid at position 312 is substituted by alanine or histidine; leucine at position 314 is substituted by lysine or arginine; asparagine at position 315 is substituted by alanine or histidine; lysine at position 317 is substituted by alanine; asparagine at position 325 is substituted by glycine; isoleucine at position 332 is substituted by valine; lysine at position 334 is substituted by leucine; lysine at position 360 is substituted by histidine; aspartic acid at position 376 is substituted by alanine; glutamic acid at position 380 is substituted by alanine; glutamic acid at position 382 is substituted by alanine; asparagine or serine at position 384 is substituted by alanine;Aspartic acid or histidine replaces glycine at position 385; proline replaces glutamine at position 386; glutamate replaces proline at position 387; alanine or serine replaces asparagine at position 389; alanine replaces serine at position 424; alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, asparagine, proline, glutamine, serine, threonine, valine, tryptophan or tyrosine replaces methionine at position 428; lysine replaces histidine at position 433; alanine, phenylalanine, histidine, serine, tryptophan or tyrosine replaces asparagine at position 434; and histidine replaces tyrosine or phenylalanine at position 436, all of which are EU numbering. ;

[0099] In some embodiments, due to antibody engineering, the precise positions of these mutations may deviate from the natural human Fc constant region positions. For example, when used for IgG2 / 4 chimeric Fc, the 428L / 434S double substitution may correspond to 429L and 435S in the M429L and N435S variants as found in BNJ441 (lavalizumab) and described in U.S. Pat. No. 9,079,949, the disclosure of which is incorporated herein by reference in its entirety.

[0100] In some embodiments, an anti-C5 antibody suitable for use in the methods described herein comprises a heavy chain polypeptide comprising the amino acid sequence shown in SEQ ID NO: 14 and / or a light chain polypeptide comprising the amino acid sequence shown in SEQ ID NO: 11. Alternatively, in some embodiments, an anti-C5 antibody suitable for use in the methods described herein comprises a heavy chain polypeptide comprising the amino acid sequence shown in SEQ ID NO: 20 and / or a light chain polypeptide comprising the amino acid sequence shown in SEQ ID NO: 11.

[0101] In one embodiment, the antibody binds to C5 with an affinity dissociation constant (K) of 0.04075 at 25° C. and pH 7.4 (and additionally, under physiological conditions). D ) is at least 0.1 nM (e.g., at least 0.15 nM, 0.175 nM, 0.2 nM, 0.25 nM, 0.275 nM, 0.3 nM, 0.325 nM, 0.35 nM, 0.375 nM, 0.4 nM, 0.425 nM, 0.45 nM, 0.475 nM, 0.5 nM, 0.525 nM, 0.55 nM). In some embodiments, the K of an anti-C5 antibody or antigen-binding fragment thereof is 0.575nM, 0.6nM, 0.625nM, 0.65nM, 0.675nM, 0.7nM, 0.725nM, 0.75nM, 0.775nM, 0.8nM, 0.825nM, 0.85nM, 0.875nM, 0.9nM, 0.925nM, 0.95nM, or 0.975nM.D No more than 1 nM (eg, no more than 0.9 nM, 0.8 nM, 0.7 nM, 0.6 nM, 0.5 nM, 0.4 nM, 0.3 nM or 0.2 nM).

[0102] In other embodiments, the dissociation quotient [(K of the antibody for C5 at pH 6.0 and 25°C) D ) / (K of antibody against C5 at pH 7.4 and 25°C D )] greater than 21 (e.g., greater than 22, 23, 24, 25, 26, 27, 28, 29, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300, 310, 320, 330, 340, 350, 360, 370, 380, 390, 400, 410, 420, 430, 440, 450, 460, 470, 480, 490, 500 40, 250, 260, 270, 280, 290, 300, 350, 400, 450, 500, 600, 700, 800, 900, 1000, 1500, 2000, 2500, 3000, 3500, 4000, 4500, 5000, 5500, 6000, 6500, 7000, 7500 or 8000).

[0103] Methods for determining whether an antibody binds to a protein antigen and / or the affinity of an antibody for a protein antigen are known in the art. For example, the binding of an antibody to a protein antigen can be detected and / or quantified using a variety of techniques, such as, but not limited to, Western blot, dot blot, surface plasmon resonance (SPR) method (e.g., BIAcore system; Pharmacia Biosensor AB, Uppsala, Sweden and Piscataway, NJ) or enzyme-linked immunosorbent assay (ELISA). See, for example, Benny KC Lo (2004) "Antibody Engineering: Methods and Protocols," Humana Press (ISBN: 1588290921); Johne et al. (1993) J Immunol Meth 160 :191-198; Jonsson et al. (1993) Ann Biol Clin 51 : 19-26; and Jonsson et al. (1991) Biotechniques 11 :620-627. In addition, methods for measuring affinity (e.g., dissociation constants and association constants) are described in the working examples.

[0104] As used herein, the term “k a” refers to the rate constant for the association of an antibody with an antigen. The term “k d ” refers to the rate constant for the dissociation of an antibody from an antibody / antigen complex. And the term “KD” refers to the equilibrium dissociation constant of the antibody-antigen interaction. The equilibrium dissociation constant is the ratio of the kinetic rate constant K D =k a / k d Such determinations are preferably measured at 25°C or 37°C (see the working examples). For example, the kinetics of antibody binding to human C5 can be determined by surface plasmon resonance (SPR) on a BIAcore 3000 instrument using an anti-Fc capture method to immobilize the antibody at pH 8.0, 7.4, 7.0, 6.5 and 6.0.

[0105] In one embodiment, the anti-C5 antibody or its antigen-binding fragment prevents the C5 protein (e.g., human C5 protein) from producing C5a and / or C5b active fragments or their activity. Through this blocking effect, the antibody inhibits, for example, the pro-inflammatory effects of C5a and the generation of C5b-9 membrane attack complex (MAC) at the cell surface.

[0106] Methods for determining whether a particular antibody described herein inhibits C5 cleavage are known in the art. Inhibition of human complement component C5 can reduce the cytolytic capacity of complement in a subject's body fluid. This reduction in the cytolytic capacity of complement present in a body fluid can be measured by methods well known in the art, such as by conventional hemolysis assays, such as Kabat and Mayer (eds.), "Experimental Immunochemistry, 2nd ed.," 135-240, Springfield, IL, CC Thomas (1961), pp. 135-139; or conventional variations of such assays, such as, for example, Hillmen et al. (2004) N Engl J Med. 350(6) Methods for determining whether a candidate compound inhibits the cleavage of human C5 into C5a and C5b forms are known in the art and are described in Evans et al. (1995) Mol Immunol 32(16) :1183-95. For example, the concentration and / or physiological activity of C5a and C5b in body fluids can be measured by methods well known in the art. For C5b, a hemolytic assay as discussed herein or an assay for soluble C5b-9 can be used. Other assays known in the art can also be used. Using these or other suitable types of assays, candidate agents that can inhibit human complement component C5 can be screened.

[0107] The ability of an anti-C5 antibody or antigen-binding fragment thereof to inhibit the conversion of C5 into a biologically active product can be determined by measuring the protein concentration of C5 and / or its cleavage products using immunological techniques, such as, but not limited to, ELISA. In some embodiments, the production of C5a is measured. In some embodiments, a C5b-9 neoepitope-specific antibody is used to detect terminal complement formation.

[0108] Hemolysis assays can be used to determine the inhibitory activity of anti-C5 antibodies or antigen-binding fragments thereof on complement activation. For example, the effect of anti-C5 antibodies or antigen-binding fragments thereof on hemolysis mediated by the classical complement pathway can be determined in an in vitro serum test solution using sheep erythrocytes coated with hemolysin or chicken erythrocytes sensitized with anti-chicken erythrocyte antibodies as target cells. The percentage of lysis is normalized by considering 100% lysis to be equal to lysis that occurs in the absence of an inhibitor. In some embodiments, the classical complement pathway is activated by human IgM antibodies, such as Classical Pathway Complement Kit ( COMPL CP310, Euro-Diagnostica, Sweden). Briefly, the test serum is incubated with an anti-C5 antibody or antigen-binding fragment thereof in the presence of human IgM antibodies. The amount of C5b-9 produced is measured by contacting the mixture with an enzyme-conjugated anti-C5b-9 antibody and a fluorescent substrate and measuring the absorbance at an appropriate wavelength. As a control, the test serum is incubated in the absence of an anti-C5 antibody or antigen-binding fragment thereof. In some embodiments, the test serum is a serum lacking C5 reconstituted with a C5 polypeptide.

[0109] Unsensitized rabbit or guinea pig erythrocytes can be used as target cells to determine the effect of anti-C5 antibodies or antigen-binding fragments thereof on alternative pathway-mediated hemolysis. In some embodiments, the serum test solution is serum lacking C5 reconstituted with C5 polypeptide. The percentage of lysis is normalized by considering 100% lysis to be equal to lysis occurring in the absence of inhibitor. In some embodiments, the alternative complement pathway is activated by lipopolysaccharide molecules, such as Alternative Pathway Complement Kit ( COMPL AP330, Euro-Diagnostica, Sweden). Briefly, the test serum is incubated with anti-C5 antibody or antigen-binding fragment thereof in the presence of lipopolysaccharide. The amount of C5b-9 produced is measured by contacting the mixture with enzyme-conjugated anti-C5b-9 antibody and a fluorescent substrate and measuring the fluorescence at an appropriate wavelength. As a control, the test serum is incubated in the absence of anti-C5 antibody or antigen-binding fragment thereof.

[0110] In some embodiments, C5 activity or its inhibition is quantified using the CH50eq assay. The CH50eq assay is a method for measuring total classical complement activity in serum. This is a lysis assay test that uses antibody-sensitized red blood cells as activators of the classical complement pathway and uses test serum of various dilutions to determine the amount required to achieve 50% lysis (CH50). The percentage of hemolysis can be determined, for example, using a spectrophotometer. The CH50eq assay can indirectly measure the formation of the terminal complement complex (TCC) because the TCC itself directly causes the measured hemolysis.

[0111] The assay is well known and commonly practiced by those skilled in the art. In short, in order to activate the classical complement pathway, an undiluted serum sample (e.g., a reconstructed human serum sample) is added to a microassay well containing antibody-sensitized red blood cells, thereby producing TCC. Next, the activated serum is diluted in a microassay well, which is coated with a capture reagent (e.g., an antibody bound to one or more components of TCC). The TCC present in the activated sample is bound to the monoclonal antibody coated on the surface of the microassay well. Each well is washed, and a detection reagent that can be detectably labeled and recognizes the bound TCC is added to each well. The detectable label can be, for example, a fluorescent label or an enzyme label. The result of the assay is expressed in CH50 unit equivalents per milliliter (CH50 U Eq / mL).

[0112] Inhibition, for example, when it comes to terminal complement activity, includes reducing the activity of terminal complement in, for example, a hemolytic assay or a CH50eq assay compared to the activity of a control antibody (or its antigen-binding fragment) under similar conditions and equimolar concentrations by at least 5% (e.g., at least 6%, 7%, 8%, 9%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55% or 60%). As used herein, substantial inhibition refers to at least 40% (e.g., at least 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90% or 95% or more) of a given activity (e.g., terminal complement activity). In some embodiments, the anti-C5 antibodies described herein contain one or more amino acid substitutions relative to the CDRs of eculizumab (i.e., SEQ ID NOs: 1-6), but retain at least 30% (e.g., at least 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90% or 95%) of the complement inhibition activity of eculizumab in a hemolytic assay or a CH50eq assay.

[0113] The serum half-life of the anti-C5 antibodies described herein in humans is at least 20 days (e.g., at least 21 days, 22 days, 23 days, 24, 25 days, 26 days, 27 days, 28 days, 29 days, 30 days, 31 days, 32 days, 33 days, 34 days, 35 days, 36 days, 37 days, 38 days, 39 days, 40 days, 41 days, 42 days, 43 days, 44 days, 45 days, 46 days, 47 days, 48 ​​days, 49 days, 50 days, 51 days, 52 days, 53 days, 54 days, or 55 days). In another embodiment, the serum half-life of the anti-C5 antibodies described herein in humans is at least 40 days. In another embodiment, the serum half-life of the anti-C5 antibodies described herein in humans is about 43 days. In another embodiment, the serum half-life of the anti-C5 antibodies described herein in humans is between 39-48 days. Methods for measuring the serum half-life of antibodies are known in the art. In some embodiments, the serum half-life of an anti-C5 antibody or antigen-binding fragment thereof described herein is at least 20% (e.g., at least 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 125%, 150%, 175%, 200%, 250%, 300%, 400%, 500%) longer than the serum half-life of eculizumab, e.g., as measured in one of the mouse model systems described in the working examples (e.g., a C5-deficient / NOD / scid mouse or a hFcRn transgenic mouse model system).

[0114] In one embodiment, the antibody competes with the antibodies described herein for binding and / or binding to the same epitope on C5. The term "binding to the same epitope" associated with two or more antibodies refers to the antibody binding to the same amino acid residue segment as determined by a given method. The techniques for determining whether an antibody binds to the "same epitope on C5" as the antibodies described herein include, for example, epitope mapping methods, such as x-ray analysis of crystals of antigen: antibody complexes, which provide atomic-level resolution of epitopes; and hydrogen / deuterium exchange mass spectrometry (HDX-MS). Other methods monitor the binding of antibodies to peptide antigen fragments of antigens or mutant variants of antigens, in which loss of binding due to modification of amino acid residues within the antigen sequence is generally considered to be an indication of epitope composition. In addition, epitope mapping can also be performed using computational combinatorial methods. These methods rely on the ability of the antibody of interest to affinity separate specific short peptides from a combinatorial phage display peptide library. Antibodies with the same VH and VL or the same CDR1, 2 and 3 sequences are expected to bind to the same epitope.

[0115] "An antibody that competes with another antibody for binding to a target" refers to an antibody that inhibits (partially or completely) the binding of another antibody to the target. Known competition experiments can be used to determine whether two antibodies compete with each other for binding to a target, i.e., whether and to what extent one antibody inhibits the binding of another antibody to a target. In certain embodiments, an antibody competes with another antibody for binding to a target and inhibits the binding of another antibody to a target by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% or 100%. The level of inhibition or competition may vary depending on which antibody is a "blocking antibody" (i.e., a cold antibody that is first cultivated with the target). Competitive antibodies bind to the same epitope, overlapping epitopes, or adjacent epitopes (e.g., confirmed by steric hindrance).

[0116] The anti-C5 antibodies or antigen-binding fragments thereof described herein for use in the methods described herein can be produced using a variety of art-recognized techniques. Monoclonal antibodies can be obtained by a variety of techniques familiar to those skilled in the art. Briefly, spleen cells from an animal immunized with the desired antigen are typically immortalized by fusion with myeloma cells (see Kohler and Milstein, Eur. J. Immunol. 6:511-519 (1976)). Alternative immortalization methods include transformation with Epstein Barr Virus, oncogenes or retroviruses, or other methods well known in the art. Colonies derived from single immortalized cells are screened for the production of antibodies with the desired specificity and affinity for the antigen, and the yield of monoclonal antibodies produced by such cells can be increased by a variety of techniques, including injection into the peritoneal cavity of a vertebrate host. Alternatively, DNA sequences encoding monoclonal antibodies or binding fragments thereof can be isolated by screening a DNA library from human B cells according to the general protocol outlined in Huse et al., Science 246:1275-1281 (1989).

[0117] III. Composition

[0118] In addition, provided herein are compositions (e.g., formulations) for use in the methods of treatment described herein, comprising an anti-C5 antibody or an antigen-binding fragment thereof. In one embodiment, the composition comprises an anti-C5 antibody comprising CDR1, CDR2, and CDR3 domains in a heavy chain variable region having a sequence as shown in SEQ ID NO: 12, and comprising CDR1, CDR2, and CDR3 domains in a light chain variable region having a sequence as shown in SEQ ID NO: 8. In another embodiment, the anti-C5 antibody comprises a heavy chain and a light chain having the sequences as shown in SEQ ID NO: 14 and 11, respectively. In another embodiment, the anti-C5 antibody comprises a heavy chain and a light chain having the sequences as shown in SEQ ID NO: 20 and 11, respectively.

[0119] The composition can be formulated into a pharmaceutical solution, for example, to be administered to a subject for the treatment or prevention of PNH. The pharmaceutical composition will generally include a pharmaceutically acceptable carrier. As used herein, "pharmaceutically acceptable carrier" refers to and includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, etc. that are physiologically compatible. The composition may include a pharmaceutically acceptable salt, such as an acid addition salt or a base addition salt; a sugar; a carbohydrate; a polyol; and / or a tension modifier.

[0120] These compositions can be formulated according to standard methods. Pharmaceutical formulation is a well-known technique and is further described in, for example, Gennaro (2000) "Remington: The Science and Practice of Pharmacy," 20th edition, Lippincott, Williams & Wilkins (ISBN: 0683306472); Ansel et al. (1999) "Pharmaceutical Dosage Forms and Drug Delivery Systems," 7th edition, Lippincott Williams & Wilkins Publishers (ISBN: 0683305727); and Kibbe (2000) "Handbook of Pharmaceutical Excipients American Pharmaceutical Association," 3rd edition (ISBN: 091733096X). In some embodiments, the composition can be formulated, for example, in the form of a buffer solution having a suitable concentration and suitable for storage at 2-8°C (e.g., 4°C). In some embodiments, the composition can be formulated to be suitable for storage at a temperature below 0°C (e.g., at -20°C or -80°C). In some embodiments, the composition can be formulated for storage at 2-8°C (e.g., at 4°C) for up to 2 years (e.g., one month, two months, three months, four months, five months, six months, seven months, eight months, nine months, 10 months, 11 months, 1 year ... month, 1 month, 1 month, 1 month, 1 month, 1 month, 1 month, 1 month, 1 month, 1 year, 1 year, 1 year, 1 month, 1 month, 1 month, 1 month, 1 month, 1 year, 1 / 2 years or 2 years). Thus, in some embodiments, the compositions described herein are storage stable at 2-8°C (eg, at 4°C) for at least 1 year.

[0121] Pharmaceutical compositions can be in various forms. These forms include, for example, liquid, semisolid and solid dosage forms, such as liquid solutions (e.g., injection solutions and infusion solutions), dispersions or suspensions, tablets, pills, powders, liposomes and suppositories. The preferred form depends in part on the predetermined mode of administration and therapeutic application. For example, compositions containing compositions intended for systemic or local delivery can be in the form of injection solutions or infusion solutions. Therefore, compositions can be formulated to be administered by parenteral means (e.g., by intravenous, subcutaneous, intraperitoneal intramuscular injection). As used herein, "parenteral administration," "administered parenterally," and other grammatically equivalent phrases refer to modes of administration other than enteral and topical administration, usually by injection, and include, but are not limited to, intravenous, intranasal, intraocular, pulmonary, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intrapulmonary, intraperitoneal, transtracheal, subcutaneous, subcutaneous, intraarticular, subcapsular, subarachnoid, intraspinal, epidural, intracerebral, intracranial, intracarotid, and intrasternal injection and infusion.

[0122] In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof (e.g., Lavalizumab) is formulated for intravenous administration. For example, in one embodiment, the formulation for intravenous administration comprises 300 mg of Lavalizumab (10 mg / mL) in 10 mM sodium phosphate, 150 mM sodium chloride, 0.02% polysorbate 80, and water for injection. In one embodiment, the formulation for intravenous administration consists of 300 mg of Lavalizumab (10 mg / mL) in 10 mM sodium phosphate, 150 mM sodium chloride, 0.02% polysorbate 80, and water for injection. In another embodiment, Lavalizumab for intravenous administration is formulated in the form of a sterile and preservative-free concentrated aqueous solution (10 mg / mL) in a 30 mL single-use vial.

[0123] In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof (e.g., Lavalizumab) is formulated for subcutaneous administration. For example, in one embodiment, the formulation for subcutaneous administration comprises 262.5 mg Lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In another embodiment, the formulation for subcutaneous administration consists of 262.5 mg Lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In another embodiment, the formulation for subcutaneous administration comprises 245 mg Lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In one embodiment, the formulation for subcutaneous administration consists of 245mg lavalizumab (70mg / mL) in 50mM sodium phosphate, 25mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, the lavalizumab for subcutaneous administration is formulated at pH 7.4. In another embodiment, the lavalizumab for subcutaneous administration is provided in a single-use cartridge of 3.5mL. In another embodiment, each cartridge containing the lavalizumab for subcutaneous administration contains 262.5mg lavalizumab (70mg / mL) in 50mM sodium phosphate, 25mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, each cartridge containing Lavalizumab for subcutaneous administration contains 245 mg of Lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection. In another embodiment, Lavalizumab for subcutaneous administration is formulated as a sterile and preservative-free concentrated aqueous solution (70 mg / mL) in a 3.5 mL single-use prefilled cartridge designed for use in a single-use wearable delivery system.

[0124] IV. method

[0125] Provided herein are compositions and methods for treating PNH in a human patient, the methods comprising administering to the patient an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously (or for subcutaneous administration) according to a specific clinical dosing regimen (i.e., at a specific dose and according to a specific dosing schedule). In one embodiment, the patient has previously been treated with eculizumab. treat.

[0126] In one aspect, a method is provided for subcutaneously administering an anti-C5 antibody or an antigen-binding fragment thereof (e.g., lavalizumab) at a dose of between 400 mg and 600 mg to a PNH patient. In one embodiment, a dose of between 450 and 550 mg of an anti-C5 antibody or an antigen-binding fragment thereof is subcutaneously administered to a PNH patient. In another embodiment, an anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously to a PNH patient at a dose of about 400, 405, 410, 420, 425, 430, 435, 440, 445, 450, 455, 460, 465, 470, 475, 480, 485, 490, 495, 500, 505, 510, 515, 520, 525, 530, 535, 540, 545, 550, 555, 560, 565, 570, 575, 580, 585, 590, 595, or 600 mg. In another embodiment, a dose of about 490 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously to a PNH patient.

[0127] In another embodiment, a dose of about 490 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously to a PNH patient once a week (e.g., for two weeks, three weeks, one month, two months, three months, four months, five months, six months, seven months, eight months, nine months, ten months, eleven months, one year, two years, three years, or long-term, e.g., for the rest of the patient's life).

[0128] In another aspect, a method for treating a PNH patient is provided, wherein an initial dose (e.g., a loading dose) of an anti-C5 antibody or an antigen-binding fragment thereof (e.g., lavalizumab) is administered intravenously to the patient, followed by subcutaneous administration of the anti-C5 antibody or antigen-binding fragment thereof (e.g., two weeks later). In one embodiment, the intravenous dose of the anti-C5 antibody or antigen-binding fragment thereof is based on the patient's weight. For example, in one embodiment, 2400 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered intravenously to a patient weighing ≥40 kg to <60 kg prior to subcutaneous treatment with the anti-C5 antibody or antigen-binding fragment thereof. In another embodiment, 2700 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered intravenously to a patient weighing ≥60 kg to <100 kg prior to subcutaneous treatment with the anti-C5 antibody or antigen-binding fragment thereof.

[0129] In another embodiment, on day 1 of the administration cycle, a dose (e.g., 2400 mg or 2700 mg) of an anti-C5 antibody or antigen-binding fragment thereof is administered intravenously to the patient, followed by subcutaneous administration of the anti-C5 antibody or antigen-binding fragment thereof (e.g., a 490 mg dose) on day 15 of the administration cycle and weekly thereafter (e.g., for two weeks, three weeks, one month, two months, three months, four months, five months, six months, seven months, eight months, nine months, ten months, eleven months, one year, two years, three years, or long-term administration, e.g., for the rest of the patient's life).

[0130] In another embodiment, a method of treating a human patient suffering from PNH is provided, the method comprising administering to the patient an effective amount of an anti-C5 antibody or an antigen-binding fragment thereof during an administration cycle, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered by:

[0131] (a) Administer the following doses once intravenously on Day 1 of the administration cycle:

[0132] i. 2400 mg for patients weighing ≥40 kg to <60 kg, or

[0133] ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and

[0134] (b) 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0135] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a PNH patient weighing ≥40 kg to <60 kg as follows: (a) a 2400 mg dose administered intravenously once on day 1 of the administration cycle; and (b) a 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0136] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a PNH patient weighing ≥60 kg to <100 kg as follows: (a) a 2700 mg dose administered intravenously once on day 1 of the administration cycle; and (b) a 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0137] In another embodiment, a method of treating a human patient suffering from PNH is provided, the method comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof during an administration period, the antibody or antigen-binding fragment thereof comprising the CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively, and the CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered by:

[0138] (a) Administer the following doses once intravenously on Day 1 of the administration cycle:

[0139] i. 2400 mg for patients weighing ≥40 kg to <60 kg, or

[0140] ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and

[0141] (b) 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0142] In another embodiment, a method of treating a human patient with PNH is provided, the method comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof during an administration cycle, the antibody or antigen-binding fragment thereof comprising the CDR1, CDR2 and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18 and 3, respectively; the CDR1, CDR2 and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5 and 6, respectively; and a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each of which is numbered in EU, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered by:

[0143] (a) Administer the following doses intravenously on Day 1 of the administration cycle:

[0144] i. 2400 mg for patients weighing ≥40 kg to <60 kg, or

[0145] ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and

[0146] (b) 490 mg dose administered subcutaneously on day 15 of the administration cycle and weekly thereafter.

[0147] In one embodiment, the administration cycle is a total of 10 weeks of treatment. In another embodiment, a 490 mg dose of an anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously once a week for up to 3 months, 6 months, 9 months, 12 months, 15 months, 18 months, 21 months, two years, or long-term administration after the administration cycle, for example, for the rest of the patient's life.

[0148] In some embodiments, the patient treated according to the methods described herein has previously been treated with a complement inhibitor. In one embodiment, the patient has previously been treated with eculizumab. In another embodiment, the patient has previously been treated with eculizumab for at least 1 month, at least 2 months, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 7 months, at least 8 months, at least 9 months, at least 10 months, at least 11 months, at least 12 months, at least 18 months, or at least 24 months. In a specific embodiment, the patient has previously been treated with eculizumab for at least 6 months. In another embodiment, an anti-C5 antibody or its antigen-binding fragment (e.g., lavalizumab) is administered to the patient, wherein the patient has been treated with eculizumab for at least about 1 month, at least about 2 months before the first day of the administration cycle. At least about 3 months, at least about 4 months, at least about 5 months, at least about 6 months, at least about 7 months, at least about 8 months, at least about 9 months, at least about 10 months, at least about 11 months, or at least about 12 months. In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient, wherein the patient has been treated with eculizumab for at least about 1 year prior to day 1 of the administration cycle. In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient, wherein the patient has been treated with eculizumab for at least about 6 months prior to day 1 of the administration cycle.

[0149] In some embodiments, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient, wherein the patient has previously been treated with eculizumab at a dose of about 600 mg, about 700 mg, about 800 mg, or about 900 mg once every 2 weeks. In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient, wherein the patient has previously been treated with eculizumab at a dose of about 900 mg once every 2 weeks ([q2w]).

[0150] In some embodiments, an anti-C5 antibody or antigen-binding fragment thereof (e.g., lavalizumab) is administered to a patient, wherein the administration period begins at least about two weeks, at least about three weeks, at least about four weeks, at least about six weeks, at least about seven weeks, or at least about eight weeks after the patient's last dose of eculizumab was administered. In another embodiment, an anti-C5 antibody or antigen-binding fragment thereof (e.g., lavalizumab) is administered to a patient, wherein the administration period begins at least two weeks after the patient's last dose of eculizumab was administered.

[0151] In some embodiments, patients treated according to the methods described herein are vaccinated against meningococcal infection within three years prior to or at the time of initiation of treatment. In one embodiment, patients treated less than 2 weeks after receiving a meningococcal vaccine are also treated with appropriate prophylactic antibiotics until 2 weeks after vaccination. In another embodiment, patients treated according to the methods described herein are vaccinated against meningococcal serotypes A, C, Y, W1 35, and / or B.

[0152] In another aspect, the treatment regimen is sufficient to maintain a specific serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof. For example, in one embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195, 200, 205, 210, 225, 230, 240, 250, 260, 270, 280, 290, 300, 310, 325, 330, 340, 350, 360, 370, 380, 390, 400, 410, 420, 430, 440, 450 15, 220, 225, 230, 235, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 295, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345, 350, 355, 360, 365, 370, 375, 380, 385, 390, 395 or 400 μg / ml or more. In one embodiment, the treatment maintains the serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 100 μg / ml or more. In another embodiment, the treatment maintains the serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 150 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at 200 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at 250 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at 300 μg / ml or more. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at between 100 μg / ml and 200 μg / ml. In another embodiment, treatment maintains a serum trough concentration of an anti-C5 antibody, or antigen-binding fragment thereof, at about 175 μg / ml.

[0153] In some embodiments, to achieve an effective response, the amount and frequency of anti-C5 antibody administered to the patient is such as to maintain at least 50 μg, 55 μg, 60 μg, 65 μg, 70 μg, 75 μg, 80 μg, 85 μg, 90 μg, 95 μg, 100 μg, 105 μg, 110 μg, 115 μg, 120 μg, 125 μg, 130 μg, 135 μg, 140 μg, 150 μg, 160 μg, 170 μg, 180 μg, 190 μg, 200 μg, 210 μg, 220 μg, 230 μg, 240 μg, 250 μg, 260 μg, 270 μg, 280 μg, 290 μg, 300 μg, 310 μg, 320 μg, 330 μg, 340 μg, 350 μg, 360 μg, 370 μg, 380 μg, 390 μg, 400 μg, 410 μg, 420 μg, 430 μg, 440 μg, 450 μg, 460 μg, 470 μg, 480 μg, 490 μg, 500 μg, 510 μg, 520 μg, 530 μg, 540 μg, 550 μg, 560 μg, 570 μg, 580 μg, 590 μg In one embodiment, the amount and frequency of the anti-C5 antibody administered to the patient is such that between 50 μg and 250 μg of antibody is maintained per milliliter of the patient's blood. In another embodiment, the amount and frequency of the anti-C5 antibody administered to the patient is such that between 100 μg and 200 μg of antibody is maintained per milliliter of the patient's blood. In another embodiment, the amount and frequency of anti-C5 antibody administered to the patient is such as to maintain about 175 μg of antibody per mL of the patient's blood.

[0154] V. result

[0155] Symptoms of PNH include, but are not limited to, fatigue (e.g., tiredness, difficulty with daily activities, difficulty concentrating, dizziness, weakness), pain (e.g., stomach pain, leg pain or swelling, chest pain, back pain), dark urine, shortness of breath, anemia, difficulty swallowing, yellowing of the skin and / or eyes, erectile dysfunction, blood clots, kidney disease, organ damage, stroke, or heart attack. Patients treated according to the methods disclosed herein preferably experience improvement in at least one sign of PNH. For example, treatment can produce at least one therapeutic effect selected from the group consisting of reduction or cessation of fatigue, abdominal pain, difficulty breathing, difficulty swallowing, chest pain, and erectile dysfunction.

[0156] LDH is a marker for intravascular hemolysis (Hill, A. et al., Br. J Haematol., 149:414-25, 2010; Hillmen, P. et al., N. Engl. J. Med., 350:552-9, 2004; Parker, C. et al., Blood, 106:3699-709, 2005). Red blood cells contain a large amount of LDH, and a correlation between cell-free hemoglobin and LDH concentration has been reported in vitro (Van Lente, F. et al., Clin. Chem., 27:1453-5, 1981) and in vivo (Kato, G. et al., Blood, 107:2279-85, 2006). The consequences of hemolysis are independent of anemia (Hill, A. et al., Haematologica, 93(s1):359Abs.0903, 2008; Kanakura, Y. et al., Int. J. Hematol., 93:36-46, 2011). LDH concentrations obtained at baseline and subsequently continuously throughout the treatment period are important measures of hemolysis. PNH patients whose LDH is ≥1.5 times the upper limit of normal (LDH>1.5×ULN) have significantly elevated baseline levels of cell-free plasma hemoglobin, and there is a significant correlation between LDH and cell-free plasma hemoglobin (Hillmen, P. et al., N. Engl. J. Med., 355:1233-43, 2006). Normal LDH values ​​range from 105-333 IU / L (international units / liter).

[0157] Published data support LDH as a reliable, objective, and direct measure of intravascular hemolysis in PNH patients and is considered by experts to be the best measure of complement-mediated hemolysis, which is a marker of PNH disease activity (Dale J. et al., Acta Med Scand., 191(1-2): 133-136, 1972; Parker C. et al., Blood. 106(12): 3699-3709, 2005; Canalejo K et al., Int J Lab Hemat., 36(2): 1213-1221, 2013). Results from the eculizumab clinical program showed that LDH concentrations in untreated (placebo) patients remained significantly elevated and unchanged, whereas serum LDH in eculizumab-treated patients decreased immediately (within 1 week of treatment initiation) to normal or near-normal levels (Brodsky RA et al., Blood, 111(4):1840-1847, 2008; Hillmen P et al., Am J Hematol., 85(8):553-559, 2010. Erratumin Am J Hematol. 2010;85(11):911). This decrease was reflected in rapid symptom relief and improvement in fatigue (Hillmen P et al., Am J Hematol., 85(8):553-559, 2010; Brodsky RA et al., Blood, 111(4):1840-1847, 2008).

[0158] LDH levels can be measured using any suitable test or assay, such as those described in Ferri's Clinical Advisor 2014. Philadelphia: Pa: Elsevier Mosby, edited by Ferri FF; 2014: Section IV-Laboratory tests and interpretation of results. LDH concentrations can be measured in various samples obtained from patients, particularly serum samples. As used herein, the term "sample" refers to biological material from a subject. Although serum LDH concentrations are of great interest, samples can also be from other sources, including, for example, single cells, multiple cells, tissues, tumors, biological fluids, biomolecules, or supernatants or extracts of any of the foregoing. Examples include tissue removed for biopsy, tissue removed during resection, blood, urine, lymphatic tissue, lymph fluid, cerebrospinal fluid, mucus, and stool samples. The samples used will vary depending on the format of the assay, the detection method, and the nature of the tumor, tissue, cell, or extract to be assayed. Methods for preparing samples are known in the art and can be readily modified to obtain samples that are compatible with the method being used.

[0159] In one embodiment, LDH levels are used to evaluate responsiveness to therapy (e.g., hemolysis reduced by LDH level assessment indicates improvement of at least one PNH sign). For example, in one embodiment, the treatment described herein normalizes LDH levels. In another embodiment, the LDH levels of patients treated according to the disclosed method are reduced to near normal levels or reduced to a range of 10% or 20% higher than the value considered normal (e.g., within the range of 105-333IU / L (international units / liter)). In another embodiment, before initiating treatment, the patient's LDH level is ≥1.5 times higher than the upper limit of normal (LDH≥1.5×ULN). In another embodiment, throughout the treatment maintenance period, the patient's LDH level is normalized. In another embodiment, the LDH level of the treated patient is normalized for at least 95% of the time during the treatment maintenance period. In another embodiment, the LDH level of the treated patient is normalized for at least 90%, 85% or 80% of the time during the treatment maintenance period. In one embodiment, before initiating treatment, the patient's LDH level is ≥1.5 times higher than the upper limit of normal (LDH≥1.5×ULN).

[0160] In another embodiment, treatment reduces breakthrough hemolysis relative to eculizumab treatment. In another embodiment, treatment eliminates breakthrough hemolysis during treatment. In another embodiment, treatment reduces breakthrough hemolysis compared to the baseline amount of breakthrough hemolysis before treatment.

[0161] In another embodiment, treatment reduces the need for transfusion. In another embodiment, treatment increases the chance of avoiding transfusion. In another embodiment, treatment increases the chance of avoiding transfusion by at least 50%. In another embodiment, treatment increases the chance of avoiding transfusion by at least 60%. In another embodiment, treatment increases the chance of avoiding transfusion by more than 70%. In all cases, the chance of avoiding transfusion is measured relative to the frequency of needing to receive transfusion before treatment.

[0162] In another embodiment, treatment results in a reduction in major adverse vascular events (MAVE) (e.g., thrombophlebitis / deep vein thrombosis, pulmonary embolism, myocardial infarction, transient ischemic attack, unstable angina, renal vein thrombosis / renal artery thrombosis / glomerular thrombosis, renal infarction, acute peripheral vascular occlusion, mesenteric / visceral vein / artery thrombosis or infarction, hepatic / portal vein thrombosis, cerebral artery occlusion / cerebrovascular accident, cerebral vein occlusion, renal artery thrombosis, or multi-infarct dementia), which are further described in the Examples.

[0163] In another embodiment, the treatment shifts hemolysis-related blood biomarkers toward normal levels, the hemolysis-related blood biomarkers selected from the group consisting of free hemoglobin, haptoglobin, reticulocyte count, PNH red blood cell (RBC) clones, and D-dimers. In another embodiment, the treatment increases hemoglobin stability relative to the patient's pre-treatment baseline.

[0164] In another embodiment, treatment results in a shift toward normal levels of a chronic disease associated biomarker selected from the group consisting of estimated glomerular filtration rate (eGFR) and spot urine: albumin: creatinine and plasma brain natriuretic peptide (BNP).

[0165] In another embodiment, treatment results in a change in quality of life from baseline as assessed by the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale Version 4 and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 scale and as further detailed in the Examples. In another embodiment, treatment results in a change in quality of life from baseline as assessed by a change of at least 7 points on the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale Version 4 and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 scale relative to the patient's untreated baseline score.

[0166] VI. Reagent test kit

[0167] Also provided herein is a kit comprising a pharmaceutical composition containing a therapeutically effective amount of an anti-C5 antibody or antigen-binding fragment thereof suitable for use in the aforementioned method, such as lavalizumab, and a pharmaceutically acceptable carrier. The kit may optionally further include instructions, such as an administration schedule, to allow a practitioner (e.g., a physician, a nurse, or a patient) to administer the composition contained therein, thereby administering the composition to a patient suffering from PNH. The kit may also include a syringe or a wearable delivery system (OBDS).

[0168] In one embodiment, a kit for treating PNH in a human patient is provided, the kit comprising: (a) a dose of an anti-C5 antibody or antigen-binding fragment thereof, the antibody or antigen-binding fragment thereof comprising a heavy chain variable region having a sequence shown in SEQ ID NO: 12, CDR1, CDR2, and CDR3 domains, and a light chain variable region having a sequence shown in SEQ ID NO: 8, CDR1, CDR2, and CDR3 domains; and (b) instructions for using the anti-C5 antibody or antigen-binding fragment thereof in the methods described herein. In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥40 kg to <60 kg as follows: (a) a 2400 mg dose is administered intravenously once on day 1 of an administration cycle; and (b) a 490 mg dose is administered subcutaneously on day 15 of an administration cycle and weekly thereafter. In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to patients weighing ≥60 kg to <100 kg as follows: (a) a 2700 mg dose is administered intravenously once on day 1 of the administration cycle; and (b) a 490 mg dose is administered subcutaneously on day 15 of the administration cycle and weekly thereafter. In a specific embodiment, the anti-C5 antibody is lavazimab.

[0169] VII. instrument

[0170] Also provided is a device (e.g., a wearable delivery system (OBDS)) comprising a pre-filled cartridge containing lavalizumab for subcutaneous administration co-packaged with a wearable injector. In one embodiment, the device is a sterile, single-use, disposable and / or electromechanical device. In another embodiment, the wearable injector comprises a 29-gauge needle. In another embodiment, the pre-filled cartridge is a 3.5 mL cartridge. In another embodiment, the lavalizumab for subcutaneous administration comprises 262.5 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, the lavalizumab for subcutaneous administration consists of 262.5 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, the lavalizumab for subcutaneous administration comprises 245 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, the lavalizumab for subcutaneous administration consists of 245 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. In another embodiment, the lavalizumab for subcutaneous administration is formulated at about pH 7.4.

[0171] An exemplary device for use in combination with the lavalizumab described herein for subcutaneous administration is the Wearable Delivery System (OBDS) manufactured by West Pharmaceuticals, Inc., which is currently approved in the United States for use with eculizumab. The device is a compact, sterile, single-use, disposable electromechanical (battery powered, microprocessor controlled), research medical device with an integrated 29-gauge needle (manufactured by West Pharmaceuticals Ltd.) designed to be used with a piston-capped prefilled Crystal For use with Telescopic Screw Assembly (TSA).

[0172] The following examples are merely illustrative and should not be construed in any way as limiting the scope of the present disclosure, as numerous variations and equivalents will be apparent to those skilled in the art upon reading this disclosure.

[0173] The contents of all references, Genbank entries, patents, and published patent applications cited throughout this application are expressly incorporated herein by reference.

[0174] Example

[0175] Example 1: Phase 3 clinical trial

[0176] A phase 3 randomized, parallel-group, multicenter, open-label, pharmacokinetic, noninferiority study of subcutaneously versus intravenously administered lavalizumab was conducted in adult patients with paroxysmal nocturnal hemoglobinuria (PNH) currently treated with eculizumab.

[0177] 1. Target

[0178] The primary objective was to compare the pharmacokinetics (PK) of lavalizumab administered subcutaneously (SC) versus intravenously (IV) via a wearable delivery system (OBDS) in patients with paroxysmal nocturnal hemoglobinuria (PNH) who were clinically stable prior to study entry and had been previously treated with eculizumab for at least 6 months. Based on the established relationship between PK exposure and clinical efficacy of lavalizumab IV, the PK noninferiority of lavalizumab SC versus lavalizumab IV enabled the efficacy and safety data obtained with lavalizumab IV to be correlated with lavalizumab SC. This study hypothesized that serum C levels of lavalizumab SC on day 71 would be 谷 Non-inferior to lavalizumab IV serum C at day 71 谷 This study also aims to demonstrate the safety and tolerability of lavalizumab SC and lavalizumab OBDS, a drug-device combination product.

[0179] The primary and secondary objectives and their endpoints are summarized in Table 1 below.

[0180] Table 1: Objectives and endpoints

[0181]

[0182]

[0183] Abbreviations: ADA = anti-drug antibody; C5 = complement component 5; 谷 = predose concentration; EORTC = European Organisation for Research and Treatment of Cancer; FACIT = Functional Assessment of Chronic Condition Therapy; HRQoL = health-related quality of life; IV = intravenous; LDH = lactate dehydrogenase; OBDS = wearable delivery system; PD = pharmacodynamics; PK = pharmacokinetic; QLQ-C30 = Quality of Life Questionnaire-Core 30; SC = subcutaneous; TASQ = Treatment Satisfaction Questionnaire.

[0184] 2. Overall Design

[0185] This is a phase 3 randomized, open-label, parallel-group, multicenter study designed to evaluate the PK non-inferiority of lavalizumab administered subcutaneously (SC) versus intravenously (IV) via OBDS in adult patients with PNH who were clinically stable prior to study entry and had been previously treated with eculizumab for at least 6 months. An overview of this study is described in Figure 1 middle.

[0186] The study consisted of a 4-week screening period, a 10-week randomized treatment period, and a 42-week extension period. Entry into the study was defined as the date of providing informed consent. Patients were divided into groups based on body weight (≥40 kg to <60 kg and ≥60 kg to <100 kg) and then randomly assigned in a 2:1 ratio to receive lavalizumab SC or lavalizumab IV.

[0187] All doses during the randomized treatment period, including the SC dose, were administered in the clinic by trained members of the site research team. Day 1 of study treatment occurred 12 to 16 days after the patient received the last dose of eculizumab. The timing of study drug administration and predose PK sample collection was critical to ensure that a sufficient number of patients had evaluable PK data.

[0188] The study includes at least 105 patients (70 patients in the lavalizumab SC group; 35 patients in the lavalizumab IV group). An interim analysis is performed for sample size re-estimate and the sample size may be increased to a maximum of 144 patients. The lavalizumab IV and SC formulations are described in Table 2 below.

[0189] Table 2: Study Drug Formulations

[0190]

[0191] Abbreviations: IV = intravenous; OBDS = wearable delivery system; SC = subcutaneous.

[0192] Lavalizumab OBDS is provided in a kit containing 245 mg of Lavalizumab SC in a sterile, single-use prefilled cartridge assembly packaged with a single-use syringe. Two kits were used to deliver the total 490 mg dose of Lavalizumab SC.

[0193] The loading and maintenance doses of lavalizumab IV were based on the patient's body weight before dosing at each dosing visit.

[0194] Patients randomized to the lavalizumab SC group received a loading dose of lavalizumab IV on day 1, followed by a maintenance dose of lavalizumab SC on day 15 and qw thereafter for a total of 10 weeks of study treatment. All maintenance doses of lavalizumab SC were delivered using two lavalizumab OBDS kits. Patients randomized to the lavalizumab IV group received a loading dose of lavalizumab IV on day 1, followed by a maintenance dose of lavalizumab IV on day 15. Doses during the 26 weeks of randomized treatment are set forth in Table 3 below.

[0195] Table 3: Dosages during the 26-week randomized treatment period

[0196]

[0197]

[0198] a Weight group ≥40kg to <60kg.

[0199] b Weight group ≥60kg to <100kg.

[0200] c It is administered in the clinic by trained members of the field research team.

[0201] d Self-administered by the patient.

[0202] Abbreviations: IV = intravenous; OBDS = wearable delivery system; qw = weekly; SC = subcutaneous.

[0203] Day 71 was the end of the randomized treatment period and the beginning of the extension period. All Day 71 assessments completed before dosing were considered part of the randomized treatment period. Dosing on Day 71 was the beginning of the extension period. During the extension period, (1) patients randomized to the SC lavalizumab group continued to receive 490 mg of SC lavalizumab administered using 2 OBDS kits on Day 71 and weekly thereafter until the end of the extension period (Day 365); and (2) patients randomized to the IV lavalizumab group switched to 490 mg of SC lavalizumab administered using 2 OBDS kits on Day 71 and weekly thereafter until the end of the extension period (Day 365).

[0204] Lavalizumab SC doses during the extension period were self-administered by patients at home, with the following exceptions where lavalizumab SC had to be administered in the clinic: (1) the 490 mg dose of lavalizumab SC on Day 71 was self-administered by patients in the clinic as part of a required training program for home self-administration; (2) doses coinciding with study visits were self-administered by patients in the clinic; and (3) in regions / countries where home administration was not possible, lavalizumab SC could be administered in the clinic during the extension period.

[0205] 3. Event Schedule

[0206] The schedule of activities (SoA) for the screening and randomized treatment periods for the lavalizumab SC group is provided in Table 4 and the lavalizumab IV group is provided in Table 5. Day 71 is the end of the randomized treatment period. All assessments on Day 71 are performed before dosing. Dosing on Day 71 is the beginning of the extension period. The SoA for the extension period is provided in Table 6. The first dose of lavalizumab SC in the extension period was self-administered in the clinic as part of a training program required for self-administration at home.

[0207] Table 4: Subcutaneous Lavalizumab Treatment Group: Study Visit and Activity Schedule - Screening to End of Randomized Treatment Period (Continued)

[0208]

[0209]

[0210]

[0211] a Doses were given on designated visit days during the randomized treatment period.

[0212] b The Day 71 assessment during the randomized treatment period was performed prior to dosing on Day 71.

[0213] c All patients had been vaccinated against meningococcal infection within 3 years before or at the time of starting study drug.

[0214] d The sizes of leukocyte (granulocytes and monocytes) and erythrocyte clones were measured by high-sensitivity flow cytometry at screening and day 1; only the size of erythrocyte clones was measured at day 71.

[0215] e Female patients of childbearing potential only: Serum pregnancy test at Screening and Day 71; urine pregnancy test at all other required time points. Urine test results must be negative on designated visit days prior to administration of lavalizumab to female patients of childbearing potential.

[0216] f Following the assessment on Day 1, a weight-based lavalizumab IV dose was administered on Day 1 (2400 mg for patients ≥40 kg to <60 kg and 2700 mg for patients ≥60 kg to <100 kg).

[0217] g A maintenance dose of 490 mg of lavalizumab SC was administered on day 15 and weekly thereafter.

[0218] h New or worsening abnormalities are reported as AEs

[0219] i Serum samples for PK / PD / ADA analysis were collected as early as possible but within 30 minutes prior to dosing. Samples were collected from the arm contralateral to that used for IV dosing. Samples were not collected from heparinized lines.

[0220] j At screening, patients completed the TASQ-IV within 24 hours of receiving a dose of eculizumab.

[0221] k Patients randomly assigned to the SC lavalizumab group completed the TASQ-IV at screening, on days 1 and 15, and then on days 43 and 71.

[0222] l On dosing days, vital signs were obtained prior to administration of study drug.

[0223] m Follicle-stimulating hormone levels were measured only during the screening period to confirm postmenopausal status.

[0224] n The brief physical examination consists of an examination of relevant body systems based on the investigator's (or designee's) judgment and the patient's symptoms. At least 1 body system will be examined in the brief physical examination.

[0225] o If a breakthrough hemolytic event was suspected, blood samples were collected for LDH, PK, PD, and ADA parameters and sent to a central laboratory for analysis. If a suspected breakthrough event did not occur at the scheduled visit, an unscheduled visit was performed to evaluate the patient and collect the required blood samples.

[0226] Abbreviations: ADA = antidrug antibodies; ECG = electrocardiogram; EORTC QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; FACIT-Fatigue = Functional Assessment of Chronic Illness Therapy-Fatigue scale; HIV = human immunodeficiency virus; IV = intravenous; LDH = lactate dehydrogenase; PD = pharmacodynamics; PK = pharmacokinetic; PNH = paroxysmal nocturnal hemoglobinuria; qw = weekly; SC = subcutaneous; TASQ = Treatment Satisfaction Questionnaire.

[0227] Table 5: Intravenous Lavalizumab Group: Schedule of Study Visits and Activities - Screening to End of Randomized Treatment Period (Continued)

[0228]

[0229]

[0230]

[0231] aAdministered on designated visit days during the randomized treatment period.

[0232] b The Day 71 assessment during the randomized treatment period was performed prior to dosing on Day 71.

[0233] c All patients had been vaccinated against meningococcal infection within 3 years before or at the time of initiation of study drug.

[0234] d The sizes of leukocyte (granulocytes and monocytes) and erythrocyte clones were measured by high-sensitivity flow cytometry at screening and day 1; only the size of erythrocyte clones was measured at day 71.

[0235] e Female patients of childbearing potential only. Serum pregnancy test at Screening and Day 71; urine pregnancy test at all other required time points. Urine test results must be negative on designated visit days prior to administration of lavalizumab to female patients of childbearing potential.

[0236] f Following the assessment on Day 1, a weight-based lavalizumab IV dose was administered on Day 1 (2400 mg for patients ≥40 kg to <60 kg and 2700 mg for patients ≥60 kg to <100 kg).

[0237] gThe maintenance dose of lavazimab was administered on Day 15 based on weight: 3000 mg for patients weighing ≥40 kg to <60 kg and 3300 mg for patients weighing ≥60 kg to <100 kg.

[0238] h New or worsening abnormalities are reported as AEs

[0239] i Serum samples for PK / PD / ADA analysis were collected as early as possible but within 30 minutes prior to dosing. Samples were collected from the arm contralateral to that used for IV dosing. Samples were not collected from heparinized lines.

[0240] j No lavalizumab dose was administered on Day 57; samples were collected at any time during the Day 57 assessment period.

[0241] k During screening, patients completed the TASQ-IV within 24 hours of receiving a dose of eculizumab.

[0242] l On dosing days, vital signs were obtained prior to administration of study drug.

[0243] m Follicle-stimulating hormone levels were measured only during the screening period to confirm postmenopausal status.

[0244] n The brief physical examination consists of an examination of relevant body systems based on the investigator's (or designee's) judgment and the patient's symptoms. At least 1 body system will be examined in the brief physical examination.

[0245] o If a breakthrough hemolytic event was suspected, blood samples were collected for LDH, PK, PD, and ADA parameters and sent to the central laboratory. If a suspected breakthrough event did not occur at the scheduled visit, an unscheduled visit was performed to evaluate the patient and collect the required blood samples.

[0246] Abbreviations: ADA = antidrug antibodies; AE = adverse event; ECG = electrocardiogram; EORTCQLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; FACIT-Fatigue = Functional Assessment of Chronic Illness Therapy-Fatigue scale; HIV = human immunodeficiency virus; IV = intravenous; LDH = lactate dehydrogenase; PD = pharmacodynamics; PK = pharmacokinetics; PNH = paroxysmal nocturnal hemoglobinuria; TASQ = Treatment Satisfaction Questionnaire.

[0247] Table 6: Schedule of Study Visits and Activities - Extension Period

[0248]

[0249]

[0250]

[0251] aDosing on Day 71 was the start of the extension period. The 490 mg dose of lavalizumab SC on Day 71 was self-administered in the clinic as part of a required training program.

[0252] b Non-visit days: Patients were contacted by telephone on the first home dosing day to ensure that they were asked about the dose of study medication administered, completion of the patient's electronic diary, and device status.

[0253] c Patients who switched to alternative PNH therapy could do so after completing all study assessments at Day 365 or the ET visit.

[0254] d A qualified member of the on-site study team provided initial (and, when appropriate, ongoing) demonstrative training on how to properly self-administer lavalizumab SC using the 2 required OBDS kits. Doses coinciding with study visit days were self-administered in the clinic.

[0255] e Serum samples were collected prior to dosing for PK / PD / ADA analysis. Samples were not collected from heparinized lines.

[0256] f Vital signs were obtained prior to administration of study medication.

[0257] g For female patients of childbearing potential only. Serum pregnancy test only at ET; urine pregnancy test at all other time points. Urine test results must be negative on a given visit day prior to administration of lavalizumab to female patients of childbearing potential.

[0258] h The brief physical examination consists of an examination of relevant body systems based on the investigator's (or designee's) judgment and the patient's symptoms. At least 1 body system must be examined in the brief physical examination.

[0259] i If a breakthrough hemolytic event was suspected, blood samples were collected for LDH, PK, PD, and ADA parameters and sent to a central laboratory for analysis. If a suspected breakthrough event did not occur at the scheduled visit, an unscheduled visit was performed to evaluate the patient and collect the required blood samples.

[0260] j Follow-up telephone calls were conducted 30 days after the last dose of study drug and were limited to monitoring of adverse events and concomitant medications.

[0261] k New or worsening abnormalities are reported as AEs

[0262] Abbreviations: ADA = antidrug antibodies; ECG = electrocardiogram; EORTC QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; ET = early termination; FACIT-Fatigue = Functional Assessment of Chronic Illness Therapy-Fatigue scale; LDH = lactate dehydrogenase; NA = not applicable; OBDS = wearable delivery system; PD = pharmacodynamics; PK = pharmacokinetics; PNH = paroxysmal nocturnal hemoglobinuria; SC = subcutaneous; TASQ = Treatment Satisfaction Questionnaire.

[0263] 4. Inclusion criteria

[0264] Patients must meet all inclusion criteria and not meet exclusion criteria. Patient eligibility is reviewed and confirmed prior to randomization. Patients who fail any eligibility criteria may be rescreened once. Patients are eligible to participate in the study if they meet all of the following criteria:

[0265] 1. Patients must be at least 18 years old when signing the informed consent form.

[0266] 2. Prior to entering the study, the patient had been treated with eculizumab (900 mg, every 14 days ± 2 days) according to the labeled PNH recommended dose for at least 6 months, and had not missed a dose within 2 months prior to entering the study and had not taken more than 2 doses outside the visit window.

[0267] 3. Lactate dehydrogenase level ≤1.5×ULN (upper limit of normal) at screening as determined by a central laboratory. The specimen must be obtained within 24 hours of the scheduled eculizumab dose or immediately prior to administration (ie, at the eculizumab trough level).

[0268] 4. Confirm the diagnosis of PNH by high-sensitivity flow cytometry evaluation (Borowitz MJ et al., Cytometry B. Clin Cytom. 2010; 78(4): 211-230).

[0269] 5. Vaccination against meningococci to reduce the risk of meningococcal infection (Neisseria meningitidis) within 3 years before or at the time of starting study drug.

[0270] 6. Body weight ≥40kg to <100kg, and the investigator believes that the patient is likely to remain within this weight range during the duration of the study.

[0271] 7. Female patients of childbearing age and male patients with female partners of childbearing age must follow the contraceptive instructions specified in the protocol during treatment and for at least 8 months after the last dose of study drug.

[0272] 8. Patients (or their legally authorized representatives) must be willing and able to provide written informed consent and comply with all study visits and procedures, including self-administration of lavalizumab SC doses and direct recording of patient data using any data collection devices.

[0273] 5. Exclusion criteria

[0274] Patients were excluded from the study if they met any of the following criteria:

[0275] 1. LDH value > 2×ULN more than once in the 6 months before entering the study.

[0276] 2. Major adverse vascular events (MAVE) within 6 months before entering the study.

[0277] 3. Platelet count <30,000 / mm at screening 3 (30×10 9 / L).

[0278] 4. Absolute neutrophil count <500 / μL (0.5×10 9 / L).

[0279] 5. Have a history of bone marrow transplantation.

[0280] 6. History of Neisseria meningitidis infection.

[0281] 7. Have an unexplained history of infection.

[0282] 8. Active systemic bacterial, viral or fungal infection within 14 days prior to administration of study drug on Day 1.

[0283] 9. Fever ≥38°C (100.4°F) within 7 days prior to administration of study drug on Day 1.

[0284] 10. Human immunodeficiency virus (HIV) infection (demonstrated by HIV-1 or HIV-2 antibody titer).

[0285] 11. Have a history of malignant disease within 5 years of screening, except for non-melanoma skin cancer or cervical carcinoma in situ that has been treated and has no signs of recurrence.

[0286] 12. History or ongoing disease of severe heart, lung, kidney, endocrine or liver disease (e.g., active hepatitis) that prevents the patient from participating in clinical studies.

[0287] 13. An unstable medical condition that makes the patient unlikely to tolerate the requirements of the regimen (e.g., myocardial ischemia, active gastrointestinal bleeding, severe congestive heart failure, anticipated need for major surgery within 6 months of Day 1, concurrent chronic anemia not related to PNH).

[0288] 14. History of allergy to any ingredient in the study drug, including allergy to mouse protein.

[0289] 15. Female patients who are planning to become pregnant or are currently pregnant or breastfeeding.

[0290] 16. Female patients with a positive pregnancy test result at screening or on Day 1.

[0291] 17. Medical or psychological conditions or risk factors that are known to interfere with the patient's full participation in the study, impose additional risks on the patient, or confound the study results.

[0292] 18. Known or suspected history of drug or alcohol abuse or dependence within 1 year prior to screening.

[0293] 19. Unable to complete the requirements for SC self-administration.

[0294] 20. Unable to attend the clinic weekly during the randomized treatment period or unable to meet the logistical requirements of the study drug.

[0295] 21. Concomitant use of anticoagulants is prohibited if a stabilization regimen has not been implemented for at least 2 weeks prior to study entry.

[0296] 22. Participation in another study or use of any experimental therapy (except participation in observational studies [e.g., PNH registries]) within 30 days prior to initiation of study drug on Day 1 of this study or within 5 half-lives of the investigational product, whichever is longer.

[0297] 23. Have received any other experimental C5 antagonists at any time.

[0298] 6. Research drugs and medical devices

[0299] a. Lavalizumab

[0300] Lavalizumab SC is formulated at pH 7.4 and is provided in a single-use cartridge of 3.5 mL. Each Lavalizumab SC cartridge contains 245 mg or 262.5 mg Lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection. Lavalizumab IV is formulated at pH 7.0 and is provided in a single-use vial of 30 mL. Each Lavalizumab IV vial contains 300 mg Lavalizumab (10 mg / mL) in 10 mM sodium phosphate, 150 mM sodium chloride, 0.02% polysorbate 80 and water for injection.

[0301] Both Lavalizumab SC and Lavalizumab IV formulations are suitable for human use and are manufactured in accordance with current good manufacturing practices. Detailed information on Lavalizumab SC and Lavalizumab IV formulations is presented in Table 7. Tables 8 and 9 present the dosage reference tables for Lavalizumab SC and Lavalizumab IV groups, respectively.

[0302] Table 7: Study Drugs Administered

[0303]

[0304]

[0305] aLavalizumab OBDS is a drug-device combination product in a prefilled cartridge containing lavalizumab and the West SmartDose device, co-packaged for SC administration.

[0306] Abbreviations: IV = intravenous; OBDS = wearable delivery system; SC = subcutaneous.

[0307] Table 8: Dose reference table for subcutaneous lavalizumab group

[0308]

[0309]

[0310] NOTE: Additional dosage preparation instructions are provided in the pharmacy leaflet.

[0311] aLavalizumab IV dose.

[0312] b The SC infusion rate is pre-programmed into the device. According to the instructions for use, it is approximately nine minutes. Abbreviations: IV = intravenous; NA = not applicable; SC = subcutaneous.

[0313] Table 9: Dose reference table for intravenous lavalizumab group

[0314]

[0315]

[0316] NOTE: Additional dosage preparation instructions are provided in the pharmacy leaflet.

[0317] aDosage regimen was based on last recorded study visit body weight.

[0318] Abbreviations: IV = intravenous; NA = not applicable; SC = subcutaneous.

[0319] During the randomized treatment period, trained members of the on-site research team administered lavalizumab SC to patients weekly in the clinic. During the extension period, and after completion of the required training, patients self-administered weekly infusions at home unless otherwise specified in the assessment schedule.

[0320] Patients followed the written instructions for use ("IFU"). If the wearable delivery system (OBDS) malfunctioned resulting in no dose or partial dose being delivered, the patient used a new OBDS to ensure that the patient received at least 490 mg lavalizumab SC.

[0321] Lavalizumab IV should not be administered as an IV push or bolus. Lavalizumab IV infusion solutions are prepared using aseptic technique. The lavalizumab dose required by the patient should be further diluted as shown in Tables 8 and 9. After the dosing solution for one patient is prepared, the solution should be administered only to that patient. The drug is administered via an infusion pump using an IV line. A 0.2 micron filter is required during the infusion of lavalizumab IV. Study drug vials are for single use only, and any drug product remaining in the vial must not be administered to another patient.

[0322] The shelf life of the dosing solution after opening is 6 hours at ambient temperature. The shelf life and time of the dosing solution are calculated from the time the first vial is broken. The dose should be administered within the shelf life and time.

[0323] b. Wearable Delivery System (OBDS)

[0324] The Lavalizumab OBDS drug-device combination product consists of a prefilled cartridge containing Lavalizumab SC and a wearable injector. Lavalizumab OBD S is a compact, sterile, single-use, wearable electromechanical infusion device that administers a fixed dose of Lavalizumab from the prefilled cartridge assembly into the SC tissue at a fixed rate through a stainless steel 29-gauge needle. The device is a sterile, single-use, surgically invasive active medical device for temporary use as defined in the Medical Device Directive 93 / 42 / EEC. The device contains a non-removable battery and includes a biocompatible adhesive patch. After administration is completed, the device with adhesive is removed from the skin.

[0325] The primary container closure (cartridge) consists of a 5 mL CZ cartridge with a chlorobutyl elastomer septum, a chlorobutyl elastomer piston, and a TSA that screws into the piston. The prefilled CZ cartridge is packaged with the wearable syringe in a two-compartment blister tray. The prefilled cartridge assembly is loaded into the device immediately prior to patient use. The device is designed to be used only with the provided 3.5 mL prefilled cartridge.

[0326] After loading the device with a cartridge, adhering it to the skin and activating it, a 3.5 mL dose can be delivered in less than 10 minutes.

[0327] All patients self-administered lavalizumab SC doses according to the instructions in the SoA during the randomized treatment period and after completion of training on device use by qualified members of the site research team.

[0328] The Lavalizumab OBDS drug-device combination product consists of 2 components: a prefilled cartridge containing Lavalizumab and a wearable injector. The prefilled cartridge and device components are packaged together in a thermoformed blister pack with a Tyvek cap over the compartment containing the device to provide a sterile barrier. The secondary packaging consists of an empty carton containing the blister pack and a booklet label with relevant instructions. The identification traceability label is affixed to the Tyvek cap blister, the serial number label is affixed to the side of the device, and a panel label is affixed to each cartridge.

[0329] c. Handling, storage management and application

[0330] Detailed information regarding the preparation, handling, storage, administration, and administration of study medication (Lavalizumab IV and Lavalizumab SC as part of the Lavalizumab OBDS kit), whether administered in the clinic or self-administered at home, is discussed below.

[0331] For clinical administration of lavalizumab IV and lavalizumab SC, study drug kits were distributed to each site after receipt of all required documentation, in accordance with applicable regulations. When the study drug kits arrived at the study site, the pharmacist or designee immediately removed the study drug kits from the shipping refrigerated container and stored them in the original carton under refrigeration at 2°C to 8°C (35°F to 47°F) and protected from light. Prior to administration, the lavalizumab IV mixed drug product and the lavalizumab OBDS kit were kept at ambient temperature. The material should not be heated (e.g., by using a microwave or other heat source). Only authorized site personnel may provide or administer study medication. Patients were trained by qualified members of the site study team to self-administer the lavalizumab OBDS on Day 71 and to self-administer at designated times. All study medications should be stored in a secure, environmentally controlled, and monitored (manual or automated) area according to labeled storage conditions and accessible only to study personnel and authorized site personnel. The investigator, institution, pharmacist, or medical facility director, as applicable, is responsible for the count, reconciliation, and record maintenance (i.e., receipt, reconciliation, and final disposition records) of study medication. A count will be performed on both used and unused IV study medication vials, unless institutional procedures require immediate destruction of used lavalizumab IV study medication. The lavalizumab OBDS is a single-use device that is placed in a biological waste container immediately after medication administration. A count will be performed on both used and unused cartridges and devices. At the end of the study, a final reconciliation will be performed on the amounts of study medication kits supplied, dispensed, and subsequently destroyed or returned.

[0332] For home administration of lavalizumab SC, patients should be provided with a lavalizumab OBDS kit for weekly self-administration during the extension period, based on regional and local requirements. Upon receipt of the lavalizumab OBDS kit, patients should immediately store it according to the instructions for use. Patients should follow the training instructions and instructions for use on each dosing day to ensure appropriate administration of their lavalizumab dose and use an electronic diary to record self-administration and results.

[0333] d. Previous and concomitant therapy

[0334] Prior medications (including vitamins and herbal preparations) taken or received by the patient within 28 days prior to the start of screening and up to the time of the first dose of study drug, including those discussed in the exclusion criteria and procedures (any therapeutic interventions such as surgery / biopsy or physical therapy), should be recorded in the patient's electronic case report form (eCRF). In addition, meningococcal vaccination history within 3 years prior to the first dose of study drug was collected. Transfusions of packed red blood cells received within 1 year prior to the first dose of study drug should be recorded in the patient's eCRF.

[0335] All medication use and procedures experienced during the study should be recorded in the patient's original file / medical record and eCRF. This record includes all prescription drugs, herbal products, vitamins, minerals, over-the-counter drugs, and current medications for PNH. Unless the patient switches to an alternative treatment for PNH, concomitant medications should be recorded from the first infusion of study drug to 30 days after the patient's last dose of study drug. Any changes in concomitant medications should also be recorded in the patient's original file / medical record and eCRF. The researcher may, at his or her discretion, administer any concomitant medication that is considered necessary for the patient's standard of care during the study or for the treatment of any adverse events, as well as the following permitted medications. However, it is the researcher's responsibility to ensure that the details of all medications are fully recorded in the patient's original file / medical record and eCRF.

[0336] Concomitant use of anticoagulants was prohibited if a stable dose regimen had not been implemented for at least 2 weeks prior to study entry. Use of complement inhibitors other than the patient's assigned study treatment was prohibited.

[0337] e. Dose or treatment group changes

[0338] Patients who received lavalizumab IV during the randomized treatment period switched to lavalizumab SC 490 mg qw at the start of the extension phase and continued this treatment for the duration of the study.

[0339] If any patient receiving lavalizumab IV weighs ≥100 kg before Day 71 during the randomized treatment period, the patient's data will be excluded from the primary endpoint analysis and the patient will be withdrawn from the study. If a patient's weight is ≥100 kg on Day 71, the patient's data will be included in the primary analysis. After completing the pre-dose assessment on Day 71, the patient will be withdrawn from the study. If any patient receiving lavalizumab SC weighs ≥100 kg during the randomized treatment period, the patient will discontinue treatment. The patient's data will not be included in the primary endpoint analysis unless this weight is first observed for the patient at the Day 71 assessment. If any patient receiving lavalizumab SC weighs ≥100 kg, the patient will discontinue treatment. No other dose or treatment group changes were allowed in this study.

[0340] 7. Research Assessment and Procedures

[0341] The study procedures and their timing are summarized in Tables 4 to 6. No waivers or exemptions from the protocol were permitted.

[0342] Blood and urine samples were collected at the time points specified in Tables 4 to 6. The following disease-related laboratory parameters were measured during the study: lactate dehydrogenase, reticulocyte count, paroxysmal nocturnal hemoglobinuria RBC clone size assessed by high-sensitivity flow cytometry (Borowitz MJ et al., Cytometry B Clin Cytom. 2010; 78(4): 211-230), and estimated glomerular filtration rate (calculated using the Modification of Diet in Renal Disease formula).

[0343] Achieving transfusion freedom was defined as patients remaining transfusion-free and not requiring transfusion after the first dose of study drug.

[0344] Breakthrough hemolysis was defined as at least 1 new or worsening symptom or sign of intravascular hemolysis (fatigue, hemoglobinuria, abdominal pain, shortness of breath [dyspnea], anemia [hemoglobin <10 g / dL], MAVE including thrombosis, dysphagia, or erectile dysfunction) in the presence of elevated LDH >2×ULN as assessed by a central laboratory.

[0345] Stable hemoglobin was defined as the avoidance of a decrease in hemoglobin level of ≥2 g / dL from baseline to the end of the period of interest in the absence of transfusions.

[0346] The investigator or designee assesses each patient for signs and symptoms of PNH, which may include the following: fatigue, chest pain, abdominal pain, dyspnea, dysphagia, erectile dysfunction, and red / dark urine or hemoglobinuria.

[0347] Two validated HRQoL scales were administered to patients prior to study drug administration and at the time points specified in Tables 4-6. The Functional Assessment of Chronic Condition Therapy (FACIT)-Fatigue Scale version 4.0 is a battery of HRQoL questionnaires that addresses the management of fatigue symptoms caused by chronic conditions. FACIT-Fatigue is a 13-item questionnaire that assesses self-reported fatigue and its impact on daily activities and function over the previous 7 days. Patients rate each item on a 5-point scale: 0 (not at all) to 4 (very much). Total scores range from 0 to 52, with higher scores indicating better HRQoL.

[0348] The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 30 Scale (QLQ-C30) version 3.0 is a questionnaire developed to assess HRQoL in cancer patients. The questionnaire includes the following subscales: overall health status, functional scale (physical function, role function, emotional function, cognitive function, and social activity), symptom scale (fatigue, nausea and vomiting, and pain), and single items (dyspnea, insomnia, loss of appetite, constipation, diarrhea, and financial difficulties). There are thirty questions related to HRQoL, of which the first 28 questions are scored on a 4-point scale (1 point = not at all to 4 points = very much), while the last 2 questions explore the patient's overall health status and HRQoL scores are 1 point (very poor) to 7 points (excellent). Each subscale ranges from 0% to 100%, with high scores indicating higher levels of response. Therefore, high scores on the functional scale represent high levels of functioning, but high scores on the symptom scale represent high levels of symptoms / problems.

[0349] Patients were also given a treatment satisfaction and patient preference questionnaire (PPQ) at the time points specified in Tables 4-6. The Treatment Satisfaction Questionnaire (TASQ) is a validated questionnaire that assesses patients' perceptions and satisfaction with treatment with eculizumab IV, lavalizumab IV, or lavalizumab SC (Theodore-Oklota C et al., Validation of a treatment satisfaction questionnaire in non-Hodgkin lymphoma: assessing the change from intravenous to subcutaneous administration of rituximab. Patient Preference and Adherence. 2016; 10: 1767-1776). The TASQ scores treatment satisfaction using 5 domains: physical impact, psychological impact, impact on ADL, convenience, and satisfaction. Each domain provides up to 5 response options, with lower scores indicating a more positive response. Scoring is completed by adding up the scores for each of the 5 domains.

[0350] The Patient Preference Questionnaire (PPQ) assessed patients' overall preference for SC lavalizumab over IV eculizumab. The PPQ recorded preference as 'IV.', 'SC.', or 'no preference' and rated preference on a 3-point scale as 'very strong', 'fairly strong', or 'not very strong'. Along with the rating, patients were asked to provide 2 main reasons for their treatment preference. Options included 'feeling less emotional distress', 'required less time in the clinic', 'less pain at the infusion site', 'feeling more comfortable during administration', or 'other reason'.

[0351] 8. Safety Assessment

[0352] The investigator or designee met with the patient to discuss the potential safety risk of major adverse vascular events (MAVEs). Descriptions of MAVEs, including diagnostic method (e.g., magnetic resonance imaging, ultrasound, angiography), date of diagnosis, and date of resolution (or ongoing), were collected in the eCRF as part of the patient's medical history (before baseline) and throughout the study. MAVEs were defined as follows: thrombophlebitis / deep vein thrombosis, pulmonary embolism, myocardial infarction, transient ischemic attack, unstable angina, renal vein thrombosis, acute peripheral vascular occlusion, mesenteric / visceral vein thrombosis or infarction, mesenteric / visceral artery thrombosis or infarction, hepatic / portal vein thrombosis (Budd-Chiari syndrome), cerebral artery occlusion / cerebrovascular accident, cerebral vein occlusion, renal artery thrombosis, gangrene (nontraumatic; nondiabetic), amputation (nontraumatic; nondiabetic), and / or dermal thrombosis.

[0353] The physical examination included an assessment of the following: general appearance; skin; head, ears, eyes, nose, and throat; neck; lymph nodes; chest; heart; abdomen; extremities; central nervous system; and musculoskeletal system. The brief physical examination consisted of relevant examinations of body systems based on the judgment of the investigator (or designee) and the patient's symptoms. Vital sign measurements were taken after the patient had rested for at least 5 minutes and included systolic and diastolic blood pressure (BP; mm Hg), heart rate (beats / minute), respiratory rate (breaths / minute), and temperature (°C or °F).

[0354] As outlined in Tables 4-6, a single 12-lead electrocardiogram (ECG) was obtained using an ECG machine that automatically calculated heart rate and measured PR, QRS, QT, and QTc intervals. The patient was required to lie supine for approximately 5 to 10 minutes prior to ECG collection and remained supine but awake during ECG collection. The investigator or designee was responsible for reviewing the ECG to assess whether the ECG was within normal limits and to determine the clinical significance of the results. These assessments were noted on the eCRF.

[0355] Laboratory assessments are performed at a central laboratory facility. Any clinically significant abnormal results are followed until resolved or stabilized. If a breakthrough hemolytic event is suspected, an unscheduled visit must be performed, at which time the central laboratory will collect samples for analysis of LDH, PK, PD, and ADA. Clinically significant abnormal laboratory test results will not be considered AEs unless the investigator judges that they are more severe than expected for the patient's condition and are related to the underlying disease.

[0356] The urine sample is analyzed. If the results of the visual analysis are abnormal, a microscopic examination of the urine sample is performed. In addition, the urine sample is analyzed to measure protein and creatinine, from which the urine protein:creatinine ratio is calculated.

[0357] Prior to enrollment, all patients were required to undergo human immunodeficiency virus testing for HIV-1 and HIV-2. HIV-positive patients were not allowed to enroll.

[0358] Prior to administration of study drug, blood samples were collected to test for the presence of ADA against Lavalizumab in the serum. Further characterization of the antibody response, including binding and neutralizing antibodies, PK / PD, safety, and activity of Lavalizumab, may be performed as appropriate. Antibodies against Lavalizumab were evaluated in serum samples collected from all patients according to Tables 4-6. Serum samples were screened for antibodies that bind to Lavalizumab and the titers of samples determined to be positive were reported. The trial sponsor performed or supervised a validated assay to detect and characterize antibodies against Lavalizumab.

[0359] Patients (or, as appropriate, caregivers, surrogates, or legally authorized representatives of patients) report adverse events (AEs) and serious adverse events (SAEs) to the investigator or qualified designated personnel. Device adverse events (ADEs) are AEs associated with the use of an investigational medical device. ADEs and serious ADEs (SADEs) are determined by the investigator or qualified designated personnel.

[0360] An adverse event is any unexpected medical occurrence in a patient to whom a medicinal product is administered that is not necessarily causally related to treatment. Thus, an adverse event can be any untoward or undesirable sign (e.g., abnormal laboratory test result), symptom, or illness temporally associated with the use of a medicinal product, whether or not considered to be related to the medicinal product. Events that meet the definition of an adverse event include: (1) any abnormal laboratory test result (hematology, clinical chemistry, or urinalysis) or other safety assessment (e.g., ECG, radiographic scan, vital sign measurement), including those that are worsening from baseline or considered, in the medical and scientific judgment of the investigator, to be clinically significant (i.e., not related to the progression of the underlying disease); (2) an exacerbation of a chronic or intermittent pre-existing condition, including an increase in the frequency and / or intensity of the condition; (3) the detection or diagnosis of a new condition after administration of the study drug, even if the condition may have existed before the start of the study; and (4) signs, symptoms, or clinical sequelae of a suspected drug interaction. “Lack of efficacy” or “failure of the expected pharmacological action” is not reported as an adverse event or serious adverse event in itself. Such conditions are recorded in the efficacy evaluation. However, signs, symptoms, and / or clinical sequelae resulting from lack of efficacy will be reported as adverse events or serious adverse events, even if these meet the definition.

[0361] Events that do not meet the definition of an adverse event include: (1) a medical or surgical procedure (e.g., endoscopy, appendectomy): the condition leading to the procedure is an AE. Conditions in which no adverse medical event occurs (e.g., hospitalization for elective surgery planned before signing the ICF, admission for social reasons, or for convenience); (2) expected daily fluctuations in pre-existing illness or condition that was present or detected at the start of the study and has not worsened; (3) lack of drug effect is not an AE in clinical studies, as the purpose of clinical studies is to determine drug effects; or (4) medication errors (including intentional misuse, abuse, and overdose of the product) or uses other than those defined in the protocol are not considered adverse events unless they result in unintended medical consequences.

[0362] If an event is not an adverse event as defined above, it is not considered a serious adverse event even if the event meets the criteria for seriousness (e.g., hospitalization due to signs / symptoms of the disease under study, death due to disease progression). A serious adverse event is defined as any unfavorable medical occurrence that meets one of the following criteria at any dose.

[0363] 1. Cause death.

[0364] 2. Life-threatening. In the definition of 'serious', the term 'life-threatening' refers to an event where the patient is at risk of death at the time of the event. It does not refer to an event that, if more severe, could result in death.

[0365] 3. Requirement for hospitalization or prolongation of an existing hospitalization. Generally speaking, hospitalization means that the patient has been kept in a hospital or emergency room (usually at least overnight) for observation and / or treatment that is not appropriate in the physician's office or outpatient setting. Complications that occur during hospitalization are adverse events. If the complication prolongs the hospital stay or meets any other severity criteria, the event is serious. When there is doubt as to whether a "hospitalization" occurred or was necessary, the adverse event should be considered a serious event. Elective hospitalization for a pre-existing condition without worsening relative to baseline is not considered an AE.

[0366] 4. Resulting in permanent disability / incapacity. The term disability refers to a substantial impairment of an individual’s ability to perform normal life functions.

[0367] 5. Congenital malformations / birth defects.

[0368] This definition is not intended to include experiences of relatively minor medical significance, such as uncomplicated headaches, nausea, vomiting, diarrhea, influenza, and accidental trauma (e.g., a sprained ankle), which may interfere with or prevent daily functioning but do not constitute a major disruption.

[0369] Suspected and unexpected serious adverse reactions (SUSAR) are serious events that are not listed in the IB but that the investigator identifies as being related to the investigational product or procedure. Reporting of SUSAR is required by Title 21 of the Code of Federal Regulations (CFR) 312.32 of the United States and the European Clinical Trials Directive 2001 / 20 / EC and related detailed guidance documents or national regulatory requirements of member states.

[0370] Adverse events associated with the use of investigational medical devices include any adverse events caused by inadequacies or inappropriateness in the instructions for use, deployment, installation, operation, or any malfunction of the investigational medical device.

[0371] An adverse device event (ADE) includes any event caused by a use error or intentional misuse. A use error is an operation or operating error that causes the device to react differently than the manufacturer or user intended. An unexpected physiological reaction in a subject does not, in itself, constitute a use error.

[0372] A serious adverse device effect (SADE) is an ADE resulting in any consequence that is typical of a SAE.

[0373] An unexpected serious adverse device effect (USADE) is a SADE that, based on its nature, incidence, severity, or outcome, is not identified as an expected event in the current version of the lavalizumab OBDS IB.

[0374] A device defect is a deficiency related to the properties, quality, durability, reliability, safety or performance of an investigational medical device. This may be caused by malfunction, misuse, user error, improper labeling or insufficient information provided by the manufacturer.

[0375] As with any terminal complement antagonist, use of lavalizumab increases a patient's susceptibility to meningococcal infection (Neisseria meningitidis). To reduce the risk of meningococcal infection, all patients must have received a meningococcal vaccine within 3 years prior to or at the time of initiation of study drug. Patients who start study drug therapy less than 2 weeks after receiving a meningococcal vaccine should receive appropriate prophylactic antibiotics within 2 weeks of vaccination.

[0376] When available, vaccines against serotypes A, C, Y, W135, and B are recommended to protect against common pathogenic meningococcal serotypes. Patients must be vaccinated or revaccinated with a complement inhibitor (e.g., eculizumab) according to current national vaccination guidelines or local vaccination practices.

[0377] Vaccination may not be sufficient to prevent meningococcal infection. Appropriate use of antibacterial agents may be considered in accordance with official guidance and local practice. All patients should be monitored for early signs of meningococcal infection and, if infection is suspected, promptly evaluated and treated with appropriate antibiotics if necessary. To increase risk awareness and facilitate rapid disclosure of any potential signs or symptoms of infection experienced by patients during the study, patients should be provided with a safety card to carry with them at all times. Additional discussion and explanation of potential risks, signs and symptoms should occur at each visit.

[0378] Infusion site reactions are reactions localized to the site of SC or IV drug administration and may include reactions such as erythema, pruritus, and bruising. Infusion-related reactions are systemic reactions that may be immune or non-immune mediated and generally occur within a few hours of drug administration. Immune-mediated reactions may include allergic reactions (e.g., anaphylaxis), while non-immune mediated reactions are non-specific (e.g., headache, dizziness, nausea). Monitoring for these reactions is part of the routine safety assessments of this study.

[0379] Infusion-related reactions were defined as systemic AEs that occurred during or within 24 hours of starting an IV or SC infusion and were assessed by the investigator as possibly, probably, or definitely related to study drug (e.g., fever, chills, flushing, changes in heart rate and BP, dyspnea, nausea, vomiting, diarrhea, and generalized rash).

[0380] As required in the IFU, device performance was assessed using the results of reported full-dose administration attempts, including device failures / malfunctions.

[0381] 9. Pharmacokinetic evaluation

[0382] The timing of PK sample collection is critical to the primary endpoint of this study. The time of dosing on Day 1 is the nominal time for all subsequent doses and related samples. Samples obtained outside the assigned PK visit window are considered protocol deviations. The time of the next sample collection is still relative to the nominal time of dosing on Day 1. Blood samples were collected before administration of study drug to determine serum drug concentrations at the time points and windows indicated in Tables 4-6. Post-dose blood samples were collected within 30 minutes after the end of infusion on Day 1 in the SC group and Days 1 and 15 in the IV group. On Day 57 in the IV group, blood samples were collected during a site visit; no dose was administered on Day 57. The date and time (24-hour format) of each sample collection were recorded.

[0383] If breakthrough hemolysis occurs, additional PK samples will be required. Unused samples may be retained for up to 5 years to perform other lavalizumab-related assessments as needed.

[0384] Serum lavalizumab concentrations were evaluated over time, with the primary endpoint (C 谷 ) as the primary PK parameter of interest. Other PK parameters may also be explored.

[0385] 10. Pharmacodynamics

[0386] Free C5 concentrations were evaluated over time. Blood samples were collected prior to administration of study drug at the time points and windows indicated in Tables 4-6. Post-dose blood samples were collected within 30 minutes after the end of infusion on Day 1 in the SC group and Days 1 and 15 in the IV group. On Day 57 in the IV group, blood samples were collected during a site visit; no dose was administered on Day 57. Samples obtained outside of the assigned visit window were considered protocol deviations. If breakthrough hemolysis occurs, an additional PD sample is required. Unused samples may be retained for up to 5 years to perform additional assessments as needed.

[0387] 11. Statistical methods and planned analyses

[0388] The statistical hypothesis was that patients treated with lavalizumab SC by OBDS would have a C 谷 Concentrations were non-inferior to those seen in patients treated with lavalizumab IV.

[0389] Assumption C 谷The ratio of the geometric means of (SC / IV) was 1.03 and the coefficient of variation was 0.4, then using a one-sided test, at an alpha level of 0.05 and a PK non-inferiority margin (NIB) of 0.8, 62 patients in the lavalizumab SC group and 31 patients in the lavalizumab IV comparison group would have a 90% probability of detecting non-inferiority. The alpha level and NIB were based on the recommendations in the guidance documents "Standard Approaches to Establishing Bioequivalence" and "Guideline on the Investigation of Bioequivalence" of the US Food and Drug Administration and the European Medicines Agency, respectively. This sample size was increased to 105 patients (70 patients in the lavalizumab SC group and 35 patients in the lavalizumab IV group) to account for the possibility that up to 10% of patients would not meet the inclusion criteria in the PK analysis set. An interim analysis was performed to evaluate futility and perform a sample size re-estimate. This sample size reestimate allowed an increase to up to 144 patients (up to 96 patients in the lavalizumab SC group and 48 patients in the lavalizumab IV comparator group).

[0390] For ease of analysis, the groups are defined in Table 10 .

[0391] Table 10: Groups

[0392]

[0393]

[0394] Abbreviations: ICF = informed consent form; PD = pharmacodynamics; PK = pharmacokinetics.

[0395] Evaluable PK data are defined as non-missing results generated from samples that meet sample integrity requirements during sample collection, storage, transport, and bioanalysis.

[0396] The primary analysis was performed after all patients completed all protocol-required assessments during the randomized treatment period to evaluate the serum C level of lavalizumab SC compared with lavalizumab IV. 谷 The primary analysis was performed based on the PK analysis set.

[0397] The primary endpoint was serum lavalizumab C at day 71. 谷 The geometric mean C obtained from the lavalizumab SC group was calculated with a two-sided 90% CI. 谷Compared with the geometric mean C obtained from the lavalizumab IV group 谷 If the lower limit of the 90% CI for the ratio of the geometric means (lavalizumab SC / lavalizumab IV) was greater than the NIB of 80%, lavalizumab SC treatment was considered non-inferior to lavalizumab IV treatment.

[0398] To obtain the 90% CI for the above references, ANOVA was used to analyze the C 谷 Data. In addition to formulation (SC or IV), the statistical analysis model also takes into account body weight. Before analysis, data were transformed using logarithmic transformation. Point estimates and CIs for the mean difference of logarithmic transformed parameters were calculated and constructed. Then, they were inversely transformed to be presented on a ratio scale. Sensitivity analysis was performed by repeating the primary analysis of the full analysis set (FAS) patients and the protocol-compliant set (PP S) with evaluable PK data.

[0399] Secondary analyses were performed on the full analysis set (FAS). If applicable, results from the randomized treatment period will be presented in parallel by treatment group without formal comparison. The summary of data over time for patients receiving SC lavalizumab is based on the time since the first exposure to SC lavalizumab. The start of the extension period was 56 days from the first dose of SC lavalizumab for patients randomized to the SC group, while at the same time, patients initially randomized to the IV group received the first dose of SC lavalizumab. This difference in exposure was taken into account, and for example, the summary for Day 183 (from the first dose of SC lavalizumab) used data obtained on study Day 183 for patients randomized to the SC group and on study Day 239 for patients randomized to the IV group.

[0400] Pharmacokinetic analyses were performed on all patients with evaluable PK data from the full analysis set (FAS). Because this was a multicenter patient study, censoring of PK or PD data could be considered when inferring sample collection or handling errors.

[0401] Quality of life was assessed using the FACIT-Fatigue version 4 questionnaire and the EORTC QLQ-C30 version 3.0 questionnaire. Data from these questionnaires were summarized at baseline and day 183, and at each applicable post-baseline time point, using descriptive statistics for continuous variables observed and changes from baseline. Patient satisfaction with treatment was assessed using TASQ scores. These data were summarized at baseline and day 183, and at each applicable post-baseline time point, using descriptive statistics for continuous variables observed and changes from baseline.

[0402] Lactate dehydrogenase data at baseline and at each applicable postbaseline time point were summarized using descriptive statistics for continuous variables regarding observed values ​​and changes from baseline.

[0403] The number and proportion of patients with breakthrough hemolysis were summarized over time by providing the number and proportion of patients with breakthrough hemolysis at each applicable post-baseline time point, along with two-sided 95% CIs. The number and proportion of patients who did not require a transfusion and the number and proportion of patients with stable hemoglobin were summarized in a similar manner.

[0404] All safety analyses were performed on the Safety Set, which was defined as all patients who received at least 1 dose of lavalizumab. The following definitions were used for adverse events and adverse device events (ADEs). A treatment-emergent adverse event was defined as any adverse event that began after informed consent but before the first infusion of study drug. A treatment-emergent AE (TEAE) was defined as any adverse event that began during or after the first infusion of study drug. All ADEs occurred during or after the start of the first infusion, by definition.

[0405] The incidence of treatment-emergent adverse events (TEAEs) was summarized overall by system organ class (SOC) and preferred term, severity, and relationship to treatment. The incidence of SAEs was also summarized. The incidence of ADEs and serious adverse device events (SADEs) was summarized in a similar manner, by SOC and preferred term, and severity. All AEs and ADEs were coded using the Medical Dictionary for Regulatory Activities, 18th edition or later. Undesirable changes from baseline in physical examination results were classified as AEs and analyzed accordingly.

[0406] Observed values ​​and changes from baseline (last assessment before lavalizumab administration) in electrocardiograms, vital signs, and laboratory assessments were summarized across all applicable study visits. For laboratory results that were categorized as normal, low, or high based on normal range values, shifts from baseline in the categorization were summarized across all applicable study visits.

[0407] Changes from baseline in ECG intervals (PR, RR, QT, and QTcF) were summarized for all applicable study visits. QT intervals were corrected for heart rate using the Fridericia formula (QTcF).

[0408] For immunogenicity data, the number and proportion of patients who developed ADA to lavalizumab were summarized, as well as the titer values. The proportion of patients with at least 1 positive ADA result (ever positive) and the proportion of patients who were always negative could be studied over time.

[0409] An interim analysis was performed when 50% of the planned patients (n=105) had been assessed for the primary endpoint (i.e., 34 patients in the lavalizumab SC group and 17 patients in the lavalizumab IV comparator group). This was expected to result in at least 45 patients meeting the inclusion criteria for the PK analysis set. The initial part of the analysis was to assess futility in order to allow the trial sponsor to stop the study early if it was unlikely to result in a significant final result. This would save resources and not expose additional patients to study drug if non-inferiority was not possible.

[0410] After the futility assessment, but using the same patients and data sets, an interim sample size re-estimation analysis was performed to re-estimate the required sample size for the study based on the estimate of the primary endpoint. An unconstrained futility margin based on a conditional power for noninferiority (CPni) of 20% was used, so that if the trial sponsor decided to continue the study, even if the futility margin was exceeded, it would not affect the type I error rate of the primary analysis.

[0411] The sample size recalculation (SSR) analysis was also based on the CPni calculated using the results obtained at this interim analysis. The CPni was calculated assuming the 'observed effect' value; that is, the population mean C 谷 Equal to the sample mean C at the time of sample size reestimation 谷 The maximum total number of patients is 144. The sample size must not be lower than the planned sample size of 105 patients. If the CPni of the planned total sample size of 105 patients is at least 90%, the sample size does not need to be increased. Decisions based on this sample size re-estimation analysis follow the following principles:

[0412] If CPmin≤CPni<0.9, the sample size is increased appropriately by the upper limit of 144 patients to increase CPni to 90%. The range CPmin≤CPni<0.9 is called the hope region for non-inferiority. Specifically, if CPni is within its hope region, this decision principle increases the sample size to the lesser of 144 patients or the number required to raise CPni to 90%.

[0413] Table 11: Criteria for futility analysis and sample size re-estimation

[0414]

[0415]

[0416] Abbreviations: CPmin=CPni=conditional power for non-inferiority; N=number of [patients].

[0417] The lower limit of the hope region, CPmin, was determined according to the method explained in Mehta and Pocock (Mehta, 2011) and is not explicitly stated here to avoid possible study bias after any decision is made based on this sample size re-estimation analysis.

[0418] Sequence Overview

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Claims

1. An on-wearable delivery system (OBDS) containing 245 mg of lavalizumab in a sterile, single-use, pre-filled cartridge assembly packaged with a single-use syringe.

2. The OBDS of claim 1, wherein the OBDS is an electromechanical device.

3. The OBDS of any preceding claim, wherein the syringe comprises a 29 gauge needle.

4. The OBDS according to any preceding claim, wherein the pre-filled cartridge is a 3.5 mL cartridge.

5. The OBDS according to any preceding claim, comprising 245 mg of lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80 and water for injection for subcutaneous administration.

6. The OBDS according to any one of the preceding claims, wherein the lavalizumab is formulated at about pH 7.

4.

7. An OBDS according to any preceding claim, wherein the OBDS is configured to be self-administered.

8. Lavalizumab for use in a method of treating PNH, wherein the lavalizumab is administered subcutaneously using the OBDS of any one of claims 1 to 7.

9. Lavalizumab for use in a method of treating PNH according to claim 8, wherein each subcutaneous dose of lavalizumab is subcutaneously administered at a dose of about 490 mg using two OBDS according to any one of claims 1 to 7.

10. A method for treating a human patient with paroxysmal nocturnal hemoglobinuria (PNH), the method comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof during an administration period, the antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5, and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered by: (a) Administer the following dose once intravenously on day 1 of the administration cycle: i. 2400 mg for patients weighing ≥40 kg to <60 kg, or ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and (b) 490 mg subcutaneously on day 15 of the administration cycle and weekly thereafter.

11. A method for treating a human patient with paroxysmal nocturnal hemoglobinuria (PNH), the method comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof during an administration cycle, the antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 heavy chain sequences as shown in SEQ ID NOs: 19, 18, and 3, respectively; the CDR1, CDR2, and CDR3 light chain sequences as shown in SEQ ID NOs: 4, 5, and 6, respectively; and a variant human Fc constant region that binds to a human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of a native human IgG Fc constant region, each of which is numbered in EU, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered by: (a) administering intravenously on day 1 of the administration cycle the following dose: i. 2400 mg for patients weighing ≥40 kg to <60 kg, or ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and (b) 490 mg subcutaneously on day 15 of the administration cycle and weekly thereafter.

12. The method of claim 10 or 11, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥40 kg to <60 kg by: (a) a single intravenous dose of 2400 mg on day 1 of the administration cycle; and (b) 490 mg subcutaneously on day 15 of the administration cycle and weekly thereafter.

13. The method according to any one of claims 10 to 12, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥60 kg to <100 kg by: (a) a single intravenous dose of 2700 mg on day 1 of the administration cycle; and (b) 490 mg subcutaneously on day 15 of the administration cycle and weekly thereafter.

14. The method of any one of claims 10 to 13, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of 490 mg on day 15 of the administration cycle and seven weeks thereafter.

15. The method according to any one of claims 10 to 14, wherein the administration period is a total of 10 weeks of treatment.

16. The method of any one of claims 10 to 15, wherein after the administration period, a dose of 490 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously once a week for up to 3 months, 6 months, 9 months, 12 months, 15 months, 18 months, 21 months, two years, or long-term for the rest of the patient's life.

17. The method of any one of claims 10 to 16, wherein the patient has been previously treated with eculizumab.

18. The method of claim 17, wherein the administration cycle begins at least two weeks after the patient's last dose of eculizumab.

19. The method of claim 17 or 18, wherein the patient has been treated with eculizumab for at least 6 months prior to day 1 of the administration cycle.

20. The method of any one of claims 17, 18 or 19, wherein the patient has previously been treated with eculizumab at a dose of 900 mg every 2 weeks.

21. The method of any one of claims 10 to 20, wherein the anti-C5 antibody or antigen-binding fragment thereof comprises the heavy chain variable region shown in SEQ ID NO: 12 and the light chain variable region shown in SEQ ID NO:

8.

22. The method of any one of claims 10 to 21, wherein the anti-C5 antibody or antigen-binding fragment thereof further comprises a heavy chain constant region shown in SEQ ID NO:

13.

23. The method according to any one of claims 10 to 22, wherein the antibody or antigen-binding fragment thereof comprises a heavy chain polypeptide comprising the amino acid sequence shown in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence shown in SEQ ID NO:

11.

24. The method according to any one of claims 10 to 23, wherein the anti-C5 antibody or antigen-binding fragment thereof is at a concentration of 0.1 nM ≤ K at pH 7.4 and 25°C. D Affinity dissociation constants (K) in the range of ≤1 nM D ) binds to human C5.

25. The method of any one of claims 10 to 24, wherein the anti-C5 antibody or antigen-binding fragment thereof is at a pH of 6.0 and 25°C with a K D ≥10 nM binding to human C5.

26. The method of any one of claims 10 to 25, wherein the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof of 100 μg / ml or greater during the administration cycle.

27. The method of any one of claims 10 to 26, wherein the treatment results in terminal complement inhibition.

28. The method of any one of claims 10 to 27, wherein the treatment results in reduced hemolysis as assessed by lactate dehydrogenase (LDH) levels.

29. The method of any one of claims 10 to 28, wherein the treatment produces at least one therapeutic effect selected from the group consisting of: reduction or cessation of fatigue, abdominal pain, dyspnea, anemia, dysphagia, chest pain, and erectile dysfunction.

30. The method of any one of claims 10 to 29, wherein the treatment shifts hemolysis-related blood biomarkers toward normal levels: free hemoglobin, haptoglobin, reticulocyte count, PNH red blood cell (RBC) clone, and D-dimer.

31. The method of any one of claims 10 to 30, wherein the treatment shifts chronic disease-associated biomarkers toward normal levels: estimated glomerular filtration rate (eGFR) and spot urine: albumin: creatinine and plasma brain natriuretic peptide (BNP).

32. The method of any one of claims 10 to 31, wherein the treatment results in a reduction in the need for blood transfusions and / or major adverse vascular events (MAVE).

33. The method of any one of claims 10 to 32, wherein the treatment results in a change from baseline in quality of life as assessed by the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale Version 4 and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 scale.

34. The method of any one of claims 10 to 33, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered subcutaneously using an on-wearable delivery system (OBDS).

35. The method of any one of claims 10 to 34, wherein the anti-C5 antibody or antigen-binding fragment thereof is self-administered to the patient subcutaneously.

36. The method of any one of claims 10 to 35, wherein the antibody is lavalizumab.

37. The method of claim 36, wherein the lavalizumab for subcutaneous administration comprises 262.5 mg lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection.

38. The method of claim 36, wherein the lavalizumab for subcutaneous administration comprises 245 mg lavalizumab (70 mg / mL) in 50 mM sodium phosphate, 25 mM arginine, 5% sucrose, 0.05% polysorbate 80, and water for injection.

39. An anti-C5 antibody for use in a method of treating paroxysmal nocturnal hemoglobinuria (PNH) in a human patient, wherein the anti-C5 antibody comprises a heavy chain polypeptide as shown in SEQ ID NO: 14 and a light chain polypeptide as shown in SEQ ID NO: 11, and is administered subcutaneously at a dose of 400 mg to 600 mg.

40. The anti-C5 antibody for use in a method of treating paroxysmal nocturnal hemoglobinuria (PNH) in a human patient according to claim 39, wherein the antibody is lavalizumab.

41. An anti-C5 antibody for use in a method of treating paroxysmal nocturnal hemoglobinuria (PNH) in a human patient according to claim 39 or 40, wherein the method comprises administering the anti-C5 antibody subcutaneously weekly at a dose of 490 mg.

42. An anti-C5 antibody for use in a method of treating paroxysmal nocturnal hemoglobinuria (PNH) in a human patient according to any one of claims 39 to 41, wherein the method comprises subcutaneous administration of a 490 mg dose of the anti-C5 antibody once a week for up to 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, 2 years, 3 years, or long-term administration for the rest of the patient's life.

43. An anti-C5 antibody for use in a method of treating paroxysmal nocturnal hemoglobinuria (PNH) in a human patient according to any one of claims 39 to 42, wherein the method further comprises administering an initial dose of the anti-C5 antibody intravenously prior to subcutaneous administration of the anti-C5 antibody.

44. A kit for treating paroxysmal nocturnal hemoglobinuria (PNH) in a human patient by subcutaneously administering a pharmaceutical composition comprising an anti-C5 antibody or an antigen-binding fragment thereof at a dose of 400 mg to 600 mg, the kit comprising: (a) a dose of an anti-C5 antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises the CDR1, CDR2 and CDR3 domains of the heavy chain variable region having the sequence shown in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the light chain variable region having the sequence shown in SEQ ID NO: 8; and (b) instructions for using the anti-C5 antibody or antigen-binding fragment thereof in the method of any one of claims 10 to 43.

45. The kit of claim 44, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥40 kg to <60 kg by: (a) a single intravenous dose of 2400 mg on day 1 of the administration cycle; and (b) 490 mg subcutaneously on day 15 of the administration cycle and weekly thereafter.

46. ​​The kit of claim 44, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥60 kg to <100 kg by: (a) a single intravenous dose of 2700 mg on day 1 of the administration cycle; and (b) 490 mg subcutaneously on day 15 of the administration cycle and weekly thereafter.

47. The kit of any one of claims 44 to 46, wherein the anti-C5 antibody is lavalizumab.

48. A kit suitable for treating paroxysmal nocturnal hemoglobinuria (PNH) in a human patient by subcutaneously administering a pharmaceutical composition comprising an anti-C5 antibody at a dose of 400 mg to 600 mg, the kit comprising: (a) a pharmaceutical composition comprising an anti-C5 antibody, wherein the anti-C5 antibody comprises a heavy chain polypeptide as shown in SEQ ID NO: 14 and a light chain polypeptide as shown in SEQ ID NO: 11; (b) a pharmaceutically acceptable carrier; and (c) Injector or wearable delivery system (OBDS).

49. The kit of claim 48, wherein the anti-C5 antibody is lavalizumab.

50. An anti-C5 antibody or antigen-binding fragment thereof for administration in a treatment cycle, the antibody or antigen-binding fragment thereof comprising the CDR1, CDR2 and CDR3 domains of the heavy chain variable region having the sequence shown in SEQ ID NO: 12, and the CDR1, CDR2 and CDR3 domains of the light chain variable region having the sequence shown in SEQ ID NO: 8, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered by: (a) Administer the following doses intravenously on Day 1 of the administration cycle: i. 2400 mg for patients weighing ≥40 kg to <60 kg, or ii. 2700 mg for patients weighing ≥60 kg to <100 kg; and (b) 490 mg subcutaneously on day 15 of the administration cycle and weekly thereafter.

51. The antibody of claim 50, wherein the patient has been previously treated with eculizumab.

52. The antibody of claim 50 or 51, wherein the antibody is determined to be safe, tolerable, effective and sufficiently non-immunogenic following multiple subcutaneous doses in PNH patients.

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