Treatment of ophthalmic diseases

Abstract

The present invention relates to the use of antibodies that bind to VEGF and ANG2 for the treatment of ophthalmic diseases.

Description

[0001] This application is a divisional application of the invention patent application with application date of February 5, 2019, application number 201980011416.4, and invention name “Treatment of ophthalmic diseases”.

[0002] The present invention relates to the use of antibodies binding to VEGF and ANG2 for treating ophthalmic diseases. Background of the Invention

[0004] Angiogenesis has been implicated in the pathogenesis of a variety of disorders, including solid tumors, intraocular neovascular syndromes such as proliferative retinopathy or age-related macular degeneration, rheumatoid arthritis, and psoriasis (Folkman, J. et al., J. Biol. Chem. 267 (1992) 10931-10934; Klagsbrun, M. et al., Annu. Rev. Physiol. 53 (1991) 217-239; and Garner, A., Vascular diseases, in: Pathobiology of ocular disease, A dynamic approach, Garner, A. and Klintworth, GK (eds.), 2nd ed., Marcel Dekker, New York (1994), pp. 1625-1710)

[0005] Ranibizumab (trade name ) is with bevacizumab A monoclonal antibody fragment derived from the same parent murine antibody. However, it has been affinity matured to provide stronger binding to VEGF-A (WO98 / 45331). Systemic blockade of VEGF-A is known to be associated with an increased risk of certain adverse events, so ranibizumab lacks the Fc portion to reduce systemic exposure and the risk of systemic toxicity. It is an anti-angiogenic agent that has been approved for the treatment of the "wet" type of age-related macular degeneration (neovascular AMD), a common form of age-related vision loss.

[0006] Corneal angiogenesis assays have shown that both ANG-1 and ANG-2 have similar effects, acting synergistically with VEGF to promote the growth of new blood vessels. Asahara, T., et al., Circ. Res. 83 (1998) 233-40. The possibility of a dose-dependent endothelial response has been raised by the observation that ANG-2 can also be pro-angiogenic at high concentrations in vitro (Kim, I., et al., Oncogene 19 (2000) 4549-52). At high concentrations, ANG-2 acts as an apoptosis survival factor for endothelial cells during serum deprivation apoptosis via the PI-3 kinase and Akt pathways via activation of Tie2 (Kim, I., et al., Oncogene 19 (2000) 4549-52).

[0007] Ocular vascular diseases, such as "wet" age-related macular degeneration (AMD) and proliferative diabetic retinopathy (PDR), are due to abnormal choroidal or retinal neovascularization. Hemorrhage and leakage of these blood vessels can lead to retinal dysfunction and loss of vision. Other retinal vascular diseases, such as diabetic macular edema (DME) and macular edema secondary to retinal vein occlusion (RVO) are due to abnormal retinal leakage causing retinal swelling and damage to visual function. These conditions are the main causes of vision loss in industrialized countries. Since the retina is composed of well-defined layers of neuronal, glial and vascular elements, relatively small obstacles (such as obstacles seen in vascular proliferation or edema) can cause severe loss of visual function. Hereditary retinal degeneration, such as retinitis pigmentosa (RP), is also related to vascular abnormalities such as arteriolar narrowing and vascular atrophy. They affect as many as 1 in 3500 individuals and are characterized by progressive night blindness, visual field loss, optic nerve atrophy, arteriolar attenuation, and central visual loss that often progresses to complete blindness.

[0008] Ischemic retinopathy is characterized by the loss or dysfunction of the retinal vasculature, which results in reduced blood flow and hypoxia. The retina responds to hypoxia by generating signals to grow new blood vessels, but these new vessels are often fragile and disorganized. The growth of these abnormal new vessels poses the greatest threat to vision because they can leak, bleed, or cause scarring, which can ultimately lead to retinal detachment. Current treatments for ischemic retinopathy attempt to stop the growth of pathological blood vessels, but do not address the underlying ischemia that drives their growth. In addition, standard treatment for diabetic retinopathy, an ischemic retinopathy that affects millions, involves destroying part of the retina with a laser in an attempt to destroy the ischemic tissue to stop the growth of new blood vessels and preserve central vision. Strategies have been used to block the function of vascular endothelial growth factor (VEGF), a major promoter of abnormal blood vessel growth and leakage. In the short term, anti-VEGF therapy can improve vision, but does not address the underlying ischemia and may actually exacerbate the condition because it inhibits the growth of all blood vessels, including beneficial venation. There are also serious concerns about systemic exposure of these drugs in the elderly and / or diabetic patients, in whom new blood vessel growth may be required in the ischemic brain, heart, or limbs. Summary of the invention

[0009] According to one aspect of the present invention, there is provided a method, use, bispecific antibody (application), medicament or pharmaceutical preparation for treating a patient suffering from an ocular vascular disease, the method comprising administering to the patient an effective amount of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2),

[0010] wherein the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less; in one embodiment every 16 weeks or less).

[0011] One aspect of the invention is a method, use, bispecific antibody (application), medicament or pharmaceutical formulation (application) for treating a patient with an ocular vascular disease, comprising administering to the patient (intravitreally) an effective amount of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2), wherein the patient gains 12 or more BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart (in one embodiment 13 or more letters, in one embodiment 14 or more letters, in one embodiment 15 or more letters) compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered intravitreally every 8 weeks or less frequently. One embodiment of the invention is a method of treating a patient suffering from an ocular vascular disease, the method comprising administering to the patient (intravitreally) an effective amount of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiogenin, wherein the patient experiences an improvement in vision following administration of the bispecific VEGF / ANG2 antibody, the improvement being as measured by gaining 12 or more BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart (in one embodiment 13 or more letters, in one embodiment 14 or more letters, in one embodiment 15 or more letters) compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered intravitreally every 8 weeks or less frequently.

[0012] In one embodiment of the invention, the gain in letters in said BCVA / ETDRS letter score is measured at 4 weeks, and / or at 8 weeks, and / or at 12 weeks, and / or at 16 weeks, and / or at 20 weeks, and / or at 24 weeks after the start of treatment.

[0013] In one embodiment of the invention, the gain in letter in the BCVA / ETDRS letter score is at 24 weeks, and / or at 25 weeks, and / or at 26 weeks, and / or at 27 weeks, and / or at 28 weeks, and / or at 29 weeks, and / or at 30 weeks, and / or at 31 weeks, and / or at 32 weeks, and / or at 33 weeks, and / or at 34 weeks, and / or at 35 weeks, and / or at 36 weeks, and / or at 37 weeks, and / or at 38 weeks, and / or at 39 weeks, respectively, after the start of treatment. and / or measured at 40 weeks, and / or at 41 weeks, and / or at 42 weeks, and / or at 43 weeks, and / or at 44 weeks, and / or at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks. In one embodiment of the invention, the ocular vascular disease is selected from the group consisting of wet age-related macular degeneration (wet AMD), neovascular AMD, diabetic macular edema (DME), cystoid macular edema (CME), non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), macular edema secondary to central retinal vein occlusion, macular edema secondary to hemiretinal vein occlusion, or macular edema secondary to branch vein occlusion, retinitis, conjunctivitis, uveitis, choroiditis, choroidal neovascularization (CNV) secondary to ocular inflammation (including ocular histoplasmosis or presumed histoplasmosis or choroiditis); myopic choroidal neovascularization (mCNV). And choroidal neovascularization secondary to trauma, retinopathy of prematurity, and rubeosis iridis / rubeosis iridis glaucoma.

[0014] In one embodiment of the invention, the ocular vascular disease is diabetic macular edema (DME).

[0015] In one embodiment of the invention, the ocular vascular disease is diabetic macular edema (DME) and the gain in BCVA / ETDRS letter score is measured at about 9 to 15 months after initiation of treatment (in one embodiment at 9 to 14 months, and in one embodiment at 9 to 12 months).

[0016] In one embodiment of the invention, the ocular vascular disease is diabetic macular edema (DME) and the gain in letters in said BCVA / ETDRS is measured at 36 weeks, and / or at 37 weeks, and / or at 38 weeks, and / or at 39 weeks, and / or at 40 weeks, and / or at 41 weeks, and / or at 42 weeks, and / or at 43 weeks, and / or at 44 weeks, and / or at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks after the start of treatment, respectively.

[0017] These time points are very early, with maximal gains typically not achieved until approximately 6-9 months in nAMD and 9-12 months in DME.

[0018] In one embodiment of the invention, the ocular vascular disease is wet age-related macular degeneration (wet AMD) (, or neovascular age-related macular degeneration (nAMD).

[0019] In one embodiment of the invention, the ocular vascular disease is wet age-related macular degeneration (wet AMD) (or neovascular age-related macular degeneration (nAMD), and the gain in BCVA / ETDRS letter score is measured at about 9 to 15 months after initiation of treatment (in one embodiment at 6 to 9 months, and in one embodiment at 6 to 12 months).

[0020] In one embodiment of the invention, the ocular vascular disease is wet age-related macular degeneration (wet AMD) (or neovascular age-related macular degeneration (nAMD)), and the gain in BCVA / ETDRS letter score is at 24 weeks, and / or at 25 weeks, and / or at 26 weeks, and / or at 27 weeks, and / or at 28 weeks, and / or at 29 weeks, and / or at 30 weeks, and / or at 31 weeks, and / or at 32 weeks, and / or at 34 weeks, respectively, after initiation of treatment. Measured at 33 weeks, and / or at 34 weeks, and / or at 35 weeks, and / or at 36 weeks, and / or at 37 weeks, and / or at 38 weeks, and / or at 39 weeks, and / or at 40 weeks, and / or at 41 weeks, and / or at 42 weeks, and / or at 43 weeks, and / or at 44 weeks, and / or at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks.

[0021] In one embodiment of the present invention, the bispecific antibody that binds to human VEGF and human ANG2 is a bispecific, bivalent anti-VEGF / ANG2 antibody comprising a first antigen binding site that specifically binds to human VEGF and a second antigen binding site that specifically binds to human ANG-2, wherein

[0022] i) the first antigen-binding site that specifically binds to VEGF comprises a CDR3H region of SEQ ID NO: 1, a CDR2H region of SEQ ID NO: 2, and a CDR1H region of SEQ ID NO: 3 in the heavy chain variable domain, and a CDR3L region of SEQ ID NO: 4, a CDR2L region of SEQ ID NO: 5, and a CDR1L region of SEQ ID NO: 6 in the light chain variable domain; and

[0023] ii) said second antigen-binding site that specifically binds to ANG-2 comprises in the heavy chain variable domain a CDR3H region of SEQ ID NO: 9, a CDR2H region of SEQ ID NO: 10 and a CDR1H region of SEQ ID NO: 11, and in the light chain variable domain a CDR3L region of SEQ ID NO: 12, a CDR2L region of SEQ ID NO: 13 and a CDR1L region of SEQ ID NO: 14,

[0024] And among them

[0025] iii) the bispecific antibody comprises a constant heavy chain region of human IgG1 subclass comprising the mutations I253A, H310A and H435A and the mutations L234A, L235A and P329G (numbering according to EU index of Kabat).

[0026] In one embodiment of the invention, the patient suffering from an ocular vascular disease has not previously received anti-VEGF therapy (eg, monotherapy) (is treatment naive).

[0027] In one embodiment of the invention, the patient suffering from an ocular vascular disease has been previously treated with an anti-VEGF therapy (eg, monotherapy).

[0028] In one embodiment of the invention, the ocular vascular disease is DME and the treatment of patients suffering from DME comprises fixing a dosing schedule every 8th week (Q8W) after initiation of treatment.

[0029] In one embodiment of the invention, the ocular vascular disease is DME, and the treatment of patients suffering from DME comprises a fixed Q12W dosing schedule after initiation of treatment. In one embodiment of the invention, after initiation of treatment, a first dosing cycle of Q8W is performed prior to the fixed Q12W dosing regimen.

[0030] In one embodiment of the invention, the ocular vascular disease is DME, and treatment of a patient with DME comprises a dosing schedule after initiation of treatment that extends the dosing interval when the disease is stably absent, or shortens the dosing interval when disease activity is present. In one embodiment of the invention, such a dosing schedule comprises the patient receiving Q4W or Q8W or Q12W or Q16W dosing depending on their disease state. In one embodiment of the invention, the stable absence of disease is determined as

[0031] - Central subdomain thickness (CST) increased by <50 μm; and / or

[0032] - Best corrected visual acuity (BCVA / ETDRS) decreased by < 5 letters

[0033] and disease activity was determined to be

[0034] - Increase in central subdomain thickness (CST) by ≥50 μm; and / or

[0035] - A decrease in best-corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0036] In one embodiment of the invention, the ocular vascular disease is AMD, and treatment of a patient with AMD comprises a dosing schedule after initiation of treatment that extends the dosing interval when the disease is stably absent, or shortens the dosing interval when disease activity is present. In one embodiment of the invention, such a dosing schedule comprises the patient receiving Q4W or Q8W or Q12W or Q16W dosing depending on their disease state. In one embodiment of the invention, the stable absence of disease is determined as

[0037] - Central subdomain thickness (CST) increased by <50 μm; and / or

[0038] - Best corrected visual acuity (BCVA / ETDRS) decreased by < 5 letters

[0039] and disease activity was determined to be

[0040] - Increase in central subdomain thickness (CST) by ≥50 μm; and / or

[0041] - A decrease in best-corrected visual acuity (BCVA / ETDRS) of ≥5 letters. BRIEF DESCRIPTION OF THE DRAWINGS

[0042] Figure 1 : Change in BCVA of DME patients treated from baseline to week 24 (treatment-naive patients). VA2 refers to the bispecific anti-VEGF / ANG2 antibody RO6867461, which comprises the amino acid sequence of SEQ ID NO: 17, the amino acid sequence of SEQ ID NO: 18, the amino acid sequence of SEQ ID NO: 19 and the amino acid sequence of SEQ ID NO: 20 (administered intravitreally at a dose of 6.0 mg or 1.5 mg), RBZ refers to ranibizumab ((Administered intravitreally at a dose of 0.3 mg)).

[0043] Figure 2 =CST, central subfield thickness measured by SD OCT. Change in CST in time-treated DME patients from baseline to week 24 (treatment-naive patients). The bispecific anti-VEGF / ANG2 antibody RO6867461 (6.0 mg or 1.5 mg dose administered intravitreally) was combined with ranibizumab ((administered intravitreally at a dose of 0.3 mg)), the bispecific anti-VEGF / ANG2 antibody RO6867461 comprises the amino acid sequence of SEQ ID NO:17, the amino acid sequence of SEQ ID NO:18, the amino acid sequence of SEQ ID NO:19 and the amino acid sequence of SEQ ID NO:20.

[0044] Figure 3 : Time to necessary retreatment based on disease activity assessed by both: BCVA loss of ≥5 letters and CST increase of ≥50 μm after interruption of dosing (after 20 weeks or 6 monthly doses = time since last intravitreal (IVT) administration). The bispecific anti-VEGF / ANG2 antibody RO6867461 (6.0 mg or 1.5 mg intravitreally administered doses) was combined with ranibizumab ((administered intravitreally at a dose of 0.3 mg)), the bispecific anti-VEGF / ANG2 antibody RO6867461 comprises the amino acid sequence of SEQ ID NO:17, the amino acid sequence of SEQ ID NO:18, the amino acid sequence of SEQ ID NO:19 and the amino acid sequence of SEQ ID NO:20.

[0045] Figure 4 : Schematic comparison of DME with other treatment options based on published results (comparison of drug (Ranibizumab), (aflibercept), brolucizumab and VA2 (RO6867461 / RG7716).

[0046] Figure 5 : Overview of the study design evaluating the bispecific antibody RO6867461 administered at 12- and 16-week intervals in patients with neovascular age-related macular degeneration (nAMD).

[0047] Figure 6 : Comparison of bispecific antibody RO6867461 (comprising the amino acid sequence of SEQ ID NO: 17, the amino acid sequence of SEQ ID NO: 18, the amino acid sequence of SEQ ID NO: 19, and the amino acid sequence of SEQ ID NO: 20) (administered intravitreally at 6.0 mg) at 12-week and 16-week intervals with ranibizumab (administered intravitreally at a dose of 0.3 mg)) was administered at 4-week intervals to achieve baseline BCVA in patients with neovascular age-related macular degeneration (nAMD).

[0048] Figure 7 : Comparison of bispecific antibody RO6867461 (comprising the amino acid sequence of SEQ ID NO: 17, the amino acid sequence of SEQ ID NO: 18, the amino acid sequence of SEQ ID NO: 19, and the amino acid sequence of SEQ ID NO: 20) (administered intravitreally at 6.0 mg) at 12-week and 16-week intervals with ranibizumab (administered intravitreally at a dose of 0.3 mg)) at 4-week intervals, change from baseline CST (measured via OCT) in patients with neovascular age-related macular degeneration (nAMD). DETAILED DESCRIPTION OF THE INVENTION

[0050] According to one aspect of the present invention, there is provided a method for treating a patient suffering from an ocular vascular disease, the method comprising administering to the patient an effective amount of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2),

[0051] wherein the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0052] One embodiment of the present invention is a method of treating a patient suffering from an ocular vascular disease, the method comprising administering to the patient an effective amount of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin-2 (ANG-2), wherein the patient gains 12 or more BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart (in one embodiment 13 or more letters, in one embodiment 14 or more letters, in one embodiment 15 or more letters) compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered intravitreally (to be administered) every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0053] One embodiment of the invention is a method of treating a patient suffering from an ocular vascular disease, the method comprising administering to the patient an effective amount of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin-2 (ANG-2), wherein the patient experiences an improvement in vision following administration of the bispecific VEGF / ANG2 antibody as measured by gaining 12 or more BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart (in one embodiment 13 or more letters, in one embodiment 14 or more letters, in one embodiment 15 or more letters) as compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0054] In one embodiment of the invention, the gain in letters in said BCVA / ETDRS letter score is measured at 4 weeks, and / or at 8 weeks, and / or at 12 weeks, and / or at 16 weeks, and / or at 20 weeks, and / or at 24 weeks after the start of treatment.

[0055] In one embodiment of the invention, the gain in letter BCVA / ETDRS letter score is at 24 weeks, and / or at 25 weeks, and / or at 26 weeks, and / or at 27 weeks, and / or at 28 weeks, and / or at 29 weeks, and / or at 30 weeks, and / or at 31 weeks, and / or at 32 weeks, and / or at 33 weeks, and / or at 34 weeks, and / or at 35 weeks, and / or at 36 weeks, and / or at 37 weeks, and / or at 38 weeks, and / or at 39 weeks, and respectively after the start of treatment. and / or at 40 weeks, and / or at 41 weeks, and / or at 42 weeks, and / or at 43 weeks, and / or at 44 weeks, and / or at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks. In an embodiment of the invention, the gain in letter BCVA / ETDRS letter score is measured at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks after the start of treatment, respectively.

[0056] In one embodiment of the invention, the method is for prolonging the time to retreatment and / or prolonging the time to vision loss and, wherein retreatment with the bispecific antibody is administered when the disease activity is determined as:

[0057] An increase in central subdomain thickness (CST) of ≥50 μm (in one embodiment using spectraldomain optical coherence tomography (SD-OCT)); and / or

[0058] A decrease in best corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0059] One embodiment of the present invention is a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) for use in treating ocular vascular diseases.

[0060] wherein the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0061] One embodiment of the invention is a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) for use in treating a patient with an ocular vascular disease, wherein the patient gains 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, in one embodiment 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered intravitreally (to be administered) every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0062] One embodiment of the invention is a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) for use in treating a patient suffering from an ocular vascular disease, wherein the patient experiences an improvement in vision following (intravitreal) administration of the bispecific VEGF / ANG2 antibody, the improvement being as measured by gaining 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, in one embodiment 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart, compared to the patient's best corrected visual acuity (BCVA) letter score prior to dosing with the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0063] In one embodiment of the invention, the gain in letters in said BCVA / ETDRS letter score is measured at 4 weeks, and / or at 8 weeks, and / or at 12 weeks, and / or at 16 weeks, and / or at 20 weeks, and / or at 24 weeks after the start of treatment.

[0064] In an embodiment of the invention, the gain in letter BCVA / ETDRS letter score is measured at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks after the start of treatment, respectively.

[0065] In one embodiment of the invention, (the use of) such a bispecific antibody is used to prolong the time to retreatment and / or to prolong the time to vision loss and, wherein retreatment with the bispecific antibody is administered if the disease activity is determined as:

[0066] An increase in central subdomain thickness (CST) of ≥50 μm (in one embodiment using spectral domain optical coherence tomography (SD-OCT)); and / or

[0067] A decrease in best corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0068] One embodiment of the present invention is a medicament or a pharmaceutical preparation comprising a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2), the medicament or the pharmaceutical preparation being useful for treating ocular vascular diseases,

[0069] wherein the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0070] One embodiment of the invention is a medicament or pharmaceutical formulation comprising a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2), the medicament or pharmaceutical formulation being used to treat a patient with an ocular vascular disease, wherein the patient gains 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, in one embodiment 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered intravitreally (to be administered) every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0071] One embodiment of the invention is a medicament or pharmaceutical formulation comprising a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2), the medicament or pharmaceutical formulation being useful for treating a patient suffering from an ocular vascular disease, wherein the patient experiences an improvement in vision following (intravitreal) administration of the bispecific VEGF / ANG2 antibody, the improvement being as measured by gaining 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, in one embodiment 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart, compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0072] In one embodiment of the invention, the gain in letters in said BCVA / ETDRS letter score is measured at 4 weeks, and / or at 8 weeks, and / or at 12 weeks, and / or at 16 weeks, and / or at 20 weeks, and / or at 24 weeks after the start of treatment.

[0073] In one embodiment of the invention, the gain in letter BCVA / ETDRS letter score is measured at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks after the start of treatment, respectively.

[0074] In one embodiment of the invention, this medicament or pharmaceutical formulation is for prolonging the time to retreatment and / or prolonging the time to vision loss and, wherein retreatment with the bispecific antibody is administered when the disease activity is determined as:

[0075] An increase in central subdomain thickness (CST) of ≥50 μm (in one embodiment using spectral domain optical coherence tomography (SD-OCT)); and / or

[0076] A decrease in best corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0077] One embodiment of the present invention is the use of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin-2 (ANG-2) in the preparation of a medicament for treating ocular vascular diseases.

[0078] wherein the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0079] One embodiment of the present invention is the use of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) in the preparation of a medicament for treating an ocular vascular disease, wherein the patient gains 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, in one embodiment 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered intravitreally (to be administered) every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0080] One embodiment of the invention is the use of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) in the preparation of a medicament for the treatment of an ocular vascular disease, wherein the patient experiences an improvement in vision following (intravitreal) administration of the bispecific VEGF / ANG2 antibody, the improvement being as measured by gaining 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, in one embodiment 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart, compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody. In one embodiment, the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0081] In one embodiment of the invention, the gain in letters in said BCVA / ETDRS letter score is measured at 4 weeks, and / or at 8 weeks, and / or at 12 weeks, and / or at 16 weeks, and / or at 20 weeks, and / or at 24 weeks after the start of treatment.

[0082] In an embodiment of the invention, the gain in letter BCVA / ETDRS letter score is measured at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks after the start of treatment, respectively.

[0083] In one embodiment of the invention the medicament is for prolonging the time to retreatment and / or prolonging the time to vision loss and, wherein retreatment with the bispecific antibody is administered if the disease activity is determined as:

[0084] An increase in central subdomain thickness (CST) of ≥50 μm (in one embodiment using spectral domain optical coherence tomography (SD-OCT)); and / or

[0085] A decrease in best corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0086] In one embodiment, the BCVA determination in this method, use, (application of) the bispecific antibody, medicament or pharmaceutical formulation is based on an eye chart adapted from the Early Treatment of Diabetic Retinopathy Study (ETDRS) protocol and is assessed at a starting distance of 4 meters.

[0087] Such methods, uses, (applications of) bispecific antibodies, drugs or pharmaceutical formulations may comprise sequential administration of an initial dose ("treatment initiation") (e.g., 3 to 7 monthly administrations; in one embodiment, treatment initiation comprises 3 to 4 monthly administrations, in one embodiment, treatment initiation comprises 4 to 5 monthly administrations; in one embodiment, treatment initiation comprises 4 to 6 monthly administrations; in one embodiment, treatment initiation comprises at least 4 monthly administrations; in one embodiment, treatment initiation comprises 5 to 7 monthly administrations; in one embodiment, treatment initiation comprises 6 monthly administrations), followed by one or more second doses of a therapeutically effective amount of the bispecific antibody, drug or pharmaceutical formulation.

[0088] In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered every 10 to 12 weeks (after initiation of treatment).

[0089] In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered every 11 to 13 weeks (after initiation of treatment).

[0090] In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered every 12 to 14 weeks (after initiation of treatment).

[0091] In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered every 13 to 15 weeks (after initiation of treatment).

[0092] In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered every 14 to 16 weeks (after initiation of treatment).

[0093] In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered every 10 to 11 weeks, or every 11 to 12 weeks, or every 12 to 13 weeks, or every 13 to 14 weeks, or every 14 to 15 weeks, or every 15 to 16 weeks (respectively after initiation of treatment).

[0094] In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered every 10 weeks, or every 11 weeks, or every 12 weeks, or every 13 weeks, or every 14 weeks, or every 15 weeks, or every 16 weeks (respectively after initiation of treatment).

[0095] In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered at a dose of about 5 to 7 mg (in each treatment). In one embodiment, the bispecific antibody is administered at a dose of 6 mg + / - 10% (in each treatment). In one embodiment, the bispecific antibody is administered at a dose of about 6 mg (in each treatment). (In one embodiment, at a dose of 6 mg (in each treatment)).

[0096] In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered at a concentration of about 30 mg / ml of the bispecific antibody. In one embodiment of the invention, the bispecific antibody, medicament or pharmaceutical formulation is administered at a concentration of about 120 mg / ml of the bispecific antibody.

[0097] The terms "ocular vascular disease" and "vascular eye disease" are used interchangeably herein and include, but are not limited to, intraocular neovascular syndromes such as diabetic retinopathy, diabetic macular edema, retinopathy of prematurity, neovascular glaucoma, (branch) retinal vein occlusion, central retinal vein occlusion, macular degeneration, age-related macular degeneration, retinitis pigmentosa, retinal angiomatous proliferation, macular telangiectasia, ischemic retinopathy, iris neovascularization, intraocular neovascularization, corneal neovascularization, retinal neovascularization, choroidal neovascularization and retinal degeneration. (Garner, A., Vascular diseases, In: Pathobiology of ocular disease, Adynamic approach, Garner, A., and Klintworth, GK, (eds.), 2nd edition, Marcel Dekker, New York (1994), pp. 1625-1710). As used herein, an ocular vascular disorder refers to any pathological condition characterized by altered or unregulated proliferation of new blood vessels and invasion into structures of ocular tissues such as the retina or cornea. In one embodiment, the ocular vascular disease is selected from the group consisting of: wet age-related macular degeneration (wet AMD), neovascular AMD (nAMD), diabetic macular edema (DME), cystoid macular edema (CME), non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), macular edema secondary to central retinal vein occlusion, macular edema secondary to retinal hemivenous occlusion, or macular edema secondary to branch vein occlusion, retinitis, conjunctivitis, uveitis, choroiditis, choroidal neovascularization (CNV) secondary to ocular inflammation (including ocular histoplasmosis or presumed histoplasmosis or choroiditis); myopic choroidal neovascularization (mCNV). and trauma, retinopathy of prematurity and iris rubeosis / iris rubeosis glaucoma secondary to choroidal neovascularization and other ophthalmic diseases, wherein the ocular disease or condition is associated with ocular neovascularization, vascular leakage and / or retinal edema. Therefore, the anti-VEGF / ANG2 bispecific antibodies for use and the methods described herein can be used to prevent and treat wet AMD, nAMD CME, DME, NPDR, PDR and uveitis, and preferably wet AMD, nAMD, also preferably DME, CME, NPDR and PDR, especially wet AMD. In some embodiments, the ocular vascular disease is selected from the group consisting of wet age-related macular degeneration (wet AMD), neovascular age-related macular degeneration (nAMD), (diabetic) macular edema, retinal vein occlusion, retinopathy of prematurity, and diabetic retinopathy.

[0098] Other diseases / conditions associated with (or that may be the cause of) corneal neovascularization include, but are not limited to, epidemic keratoconjunctivitis, vitamin A deficiency, contact lens overwear, atopic keratitis, superior limbal keratitis, pterygiumkeratitis sicca, Sjögren's syndrome, rosacea, uveomycosis, syphilis, mycobacterial infection, lipid degeneration, chemical burns, bacterial ulcers, fungal ulcers, herpes simplex infection, herpes zoster infection, protozoan infection, Kaposi's sarcoma, molar ulcer, Tryon's marginal corneal degeneration, marginal keratolysis, rheumatoid arthritis, systemic lupus erythematosus, polyarteritis, trauma, Wegener's sarcoidosis, scleritis, Steven Johnson disease, periphigoid radial keratotomy, keratotomy) and corneal transplant rejection (corneal graph rejection).

[0099] Diseases / conditions associated with (or that may be the cause of) retinal / choroidal neovascularization include, but are not limited to, diabetic retinopathy, macular degeneration, sickle cell anemia, sarcoidosis, syphilis, pseudoxanthoma elasticum, Paget's disease, venous occlusion, arterial occlusion, carotid occlusive disease, chronic uveitis / vitritis, mycobacterial infection, Lyme disease, systemic lupus erythematosus, retinopathy of prematurity, retinitis pigmentosa, retinal edema (including macular edema), Eales' disease, Bechets' disease, infections causing retinitis or choroiditis, presumed ocular histoplasmosis, Bechets' disease, myopia, optic (disc) fossa, Stargardt's disease, pars planitis, chronic retinal detachment, hyperviscosity syndrome, toxoplasmosis, trauma, and post-laser complications. Other diseases include, but are not limited to, diseases associated with iris rubeosis (neovascularization of the horn) and diseases caused by abnormal proliferation of fibrovascular or fibrous tissue, including all forms of proliferative vitreoretinopathy.

[0100] Retinopathy of prematurity (ROP) is an eye disease that affects babies who are born prematurely. It is thought to be caused by disturbed growth of blood vessels in the retina, which can lead to scarring and retinal detachment. ROP can be mild and may resolve spontaneously, but in severe cases it can lead to (complete) blindness. All premature babies are therefore at risk of developing ROP, with very low birth weight being an additional risk factor. Both oxygen toxicity and relative hypoxia can contribute to the development of ROP.

[0101] Macular degeneration is a medical condition mainly found in the elderly, in which the center of the inner layer of the eye (called the macula region of the retina) experiences thinning, atrophy, and in some cases, bleeding. This can lead to loss of central vision, which results in being unable to see fine details, unable to read or unable to recognize faces. According to the American Academy of Ophthalmology, it is the main cause of central vision loss (blindness) in people over fifty years old in the United States today. Although some macular dystrophies affecting young individuals are sometimes referred to as macular degeneration, the term generally refers to age-related macular degeneration (AMD or ARMD).

[0102] As used herein, "age-related macular degeneration (AMD)" refers to a serious eye disease when the small central part of the retina (called the macula) deteriorates. AMD includes wet AMD and neovascular AMD. The wet form of AMD (wet AMD, wAMD or also referred to as neovascular AMD, nAMD) is characterized by the growth of abnormal blood vessels from the choroid below the macula. This is called choroidal neovascularization. These blood vessels leak blood and fluid (below and) into the retina, resulting in (elevated retina) visual distortion, making straight lines look wavy, as well as blind spots and loss of central vision. These abnormal blood vessels will eventually leave scars, leading to permanent loss of central vision. Symptoms of AMD include dark, fuzzy areas in the center of vision; and weakened or altered color perception. AMD can be detected in routine eye examinations. One of the most common early signs of macular degeneration is the presence of drusen, which are tiny yellow deposits and pigment clumps under the retina.

[0103] There are two forms of advanced AMD that cause severe vision loss: dry and wet. Central geographic atrophy, the dry form of advanced AMD, is caused by atrophy of the retinal pigment epithelium, the layer beneath the retina, which causes vision loss through the loss of light-sensitive cells (rods and cones) in the central part of the eye. Although there is no treatment for this condition, the National Eye Institute and others have shown that vitamin supplements along with high doses of the antioxidants lutein and zeaxanthin can slow the progression of dry macular degeneration and improve vision in some patients.

[0104] Retinitis pigmentosa (RP) is a group of inherited eye conditions. In the development of RP symptoms, night blindness usually precedes tunnel vision by years or even decades. Many people with RP do not become legally blind until their 40s or 50s and retain some vision throughout their lives. Others lose their sight completely due to RP, in some cases even as early as childhood. The progression of RP is different in each case. RP is an inherited retinal dystrophy, a group of inherited disorders in which abnormalities of the photoreceptor cells (rods and cones) of the retina or the retinal pigment epithelium (RPE) lead to progressive vision loss. Affected individuals first experience defective dark adaptation or nyctalopia (night blindness), followed by reduced peripheral vision (called tunnel vision) and, sometimes, loss of central vision later in the course of the disease.

[0105] Macular edema occurs when fluid and protein deposits accumulate above or below the eye's macula (the central area of ​​the retina responsible for fine vision), causing it to thicken and swell. Since the macula is located near the center of the retina at the back of the eye, swelling may distort a person's central vision. This area has tightly packed cones that provide sharp, clear central vision, allowing a person to see shapes, colors, and details directly in their line of sight. Cystoid macular edema is a type of macular edema that includes cyst formation.

[0106] As used herein, "diabetic macular edema" (DME) refers to a serious eye condition that affects people with diabetes (type 1 or type 2). Macular edema occurs when blood vessels in the retina leak into the macula, and fluid and protein deposits accumulate on or under the macula of the eye and cause it to thicken and swell (edema). Since the macula is located near the center of the retina at the back of the eyeball, swelling may distort people's central vision. The main symptoms of DME include, but are not limited to, blurred vision, floaters, loss of contrast, diplopia, and eventual vision loss. The pathological characteristics of DME are the rupture of the internal blood-retinal barrier (which usually prevents the movement of fluid in the retina), so that fluid accumulates in the retinal tissue, and there is retinal thickening. DME is currently diagnosed during an eye examination consisting of a vision test, which determines the smallest letter a person can read on a standard chart, performs a dilated pupil examination to check for signs of the disease, imaging examinations (such as optical coherence tomography (OCT)) or fluorescein angiography (FA) and tonometer (an instrument for measuring intraocular pressure). The following studies have also been performed to determine treatment: optical coherence tomography (OCT), fluorescein angiography and color stereo fundus photography. DME can be roughly divided into two main categories - focal and diffuse. Focal DME is characterized by specific areas of separate and significant leakage in the macula with adequate macular blood flow. Diffuse DME is caused by leakage of the entire capillary bed surrounding the macula, and this leakage is caused by a breakdown of the internal blood-retinal barrier of the eye. In addition to focal and diffuse, DME is also divided into clinically significant macular edema (CSME), non-CSME and CSME with central involvement (CSME-CI), which involves the fovea, based on clinical examination findings. The present invention includes methods for treating the above-mentioned DME categories.

[0107] Best-corrected visual acuity (BCVA) was determined using a method adapted from the 4-meter Early Treatment Diabetic Retinopathy Study [ETDRS] protocol (using Early Treatment Diabetic Retinopathy Study (ETDRS)-like charts) and yielded respective letter scores.

[0108] Disease activity is determined, for example, by a decrease in BCVA / ETDR letter score and / or, for example, by macular thickening by spectral domain optical coherence tomography (SD-OCT), which involves the center of the macula as the central subfield thickness (CST) (also called central subfoveal thickness). In a preferred embodiment, the central subfield thickness (CST) is determined using spectral domain optical coherence tomography (SD-OCT): In a preferred embodiment, the CST is measured by spectral domain optical coherence tomography (SD-OCT) with a Spectralis TMThe CST is measured by spectral domain optical coherence tomography (SD-OCT) of the device; in a preferred embodiment, CST is measured by using a Cirrus TM The CST is measured by spectral domain optical coherence tomography (SD-OCT) of the device; in a preferred embodiment, the CST is measured by a Topcon TM The CST is measured by spectral domain optical coherence tomography (SD-OCT) with an Optovue TM The spectral domain optical coherence tomography (SD-OCT) of the device is measured. As used herein, the term "patient suffering from..." refers to a person who exhibits one or more symptoms or signs of an ocular vascular disease as described herein and / or has been diagnosed with an ocular vascular disease as described herein. The term "patient suffering from..." may also include, for example, a patient who exhibits (or has exhibited) one or more signs of a vascular eye disease such as, for example, retinal angiogenesis, neovascularization, vascular leakage, central retinal thickening of the fovea, a hard yellow exudate in the center of the fovea with adjacent retinal thickening, and at least 1 retinal thickened optic disc area, any portion of which is within 1 optic disc diameter of the center of the fovea, blurred vision, floaters, contrast loss, diplopia, and ultimately vision loss before treatment.

[0109] As used herein, the term "patient suffering from..." may include a subset of the population that is more susceptible to DME or AMD, or may show elevated levels of DME-related or AMD-related biomarkers. For example, a "subject in need thereof" may include a subject who has had diabetes for more than 10 years, has frequent high blood glucose levels or high fasting blood glucose levels. In certain embodiments, the term "patient suffering from" includes a subject who has or has been diagnosed with diabetes prior to or at the time of administration of the bispecific anti-VEGF / ANG2 antibody. In certain embodiments, the term "patient suffering from..." includes a subject who is older than 50 years of age prior to or at the time of administration of the anti-VEGF / ANG2 antibody. In some embodiments, the term "patient suffering from..." includes a subject who is a smoker, or a subject with high blood pressure or high cholesterol.

[0110] The present invention includes methods or (uses of) bispecific antibodies, medicaments or pharmaceutical formulations for treating, preventing or reducing the severity of ocular vascular diseases, comprising administering a therapeutically effective amount of a bispecific anti-VEGF / ANG2 antibody (or a medicament or pharmaceutical formulation comprising a bispecific anti-VEGF / ANG2 antibody) to a subject in need thereof, wherein the bispecific antibody, medicament or pharmaceutical formulation comprising such a bispecific anti-VEGF / ANG2 antibody is administered to the subject in multiple doses (intravitreally), e.g., as part of a specific therapeutic dosage regimen.

[0111] One embodiment of the invention is a method of treatment, a use, (application of) a bispecific antibody, a medicament or a pharmaceutical formulation as described herein, wherein the patient suffering from an ocular vascular disease has not previously received an anti-VEGF treatment (eg monotherapy) (is treatment naive).

[0112] One embodiment of the invention is a method of treatment, a use, (the use of) a bispecific antibody, a medicament or a pharmaceutical formulation as described herein, wherein the patient suffering from an ocular vascular disease has previously been treated with an anti-VEGF therapy (eg monotherapy).

[0113] One embodiment of the invention is a method of treatment, a use, a bispecific antibody (application), a medicament or a pharmaceutical formulation as described herein, wherein the ocular vascular disease is DME and the treatment of a patient suffering from DME comprises a fixed dosing schedule every 8 weeks (Q8W) after initiation of treatment (in one embodiment, initiation of treatment comprises 5 to 7 monthly administrations; in one embodiment, initiation of treatment comprises 6 monthly administrations).

[0114] One embodiment of the invention is a method of treatment, use, bispecific antibody (application), medicament or pharmaceutical formulation as described herein, wherein the ocular vascular disease is DME, and the treatment of patients with DME comprises a fixed Q12W dosing schedule after the start of treatment (in one embodiment, the start of treatment comprises 5 to 7 monthly administrations; in one embodiment, the start of treatment comprises 6 monthly administrations). In one embodiment, after the start of treatment, the first dosing cycle of Q8W is performed before the fixed Q12W dosing regimen.

[0115] One embodiment of the invention is a method of treatment, use, bispecific antibody (application), medicament or pharmaceutical formulation as described herein, wherein the ocular vascular disease is DME and the treatment of a patient suffering from DME comprises a dosing schedule after initiation of treatment that is as follows: the dosing interval is extended in the stable absence of disease, or the dosing interval is shortened in the presence of disease activity (in one embodiment, initiation of treatment comprises 3 to 7 monthly administrations; in one embodiment, initiation of treatment comprises 3 to 5 monthly administrations; in one embodiment, initiation of treatment comprises at least 4 monthly administrations; in one embodiment, initiation of treatment comprises 4 to 6 monthly administrations. In one embodiment, this dosing schedule comprises the patient receiving Q4W or Q8W or Q12W or Q16W dosing depending on their disease state. In one embodiment, the stable absence of disease is determined as

[0116] - Central subdomain thickness (CST) increased by <50μm

[0117] - Best corrected visual acuity (BCVA / ETDRS) decreased by < 5 letters

[0118] and disease activity was determined to be

[0119] - Central subdomain thickness (CST) increased by ≥50μm

[0120] - A decrease in best corrected visual acuity (BCVA / ETDRS) of ≥5 letters

[0121] In one embodiment, stable absence of disease is determined as

[0122] - Central subdomain thickness (CST) less than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using an Optovue TM The device’s spectral domain optical coherence tomography (SD-OCT) measures below 295μm),

[0123] and disease activity was determined to be

[0124] - Central subdomain thickness (CST) greater than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures above 315 μm; in one embodiment, by using an Optovue TM The device’s spectral domain optical coherence tomography (SD-OCT) measures above 295μm),

[0125] One embodiment of the invention is a method of treatment, use, bispecific antibody (application), medicament or pharmaceutical formulation as described herein, wherein the ocular vascular disease is AMD (in one embodiment, wet AMD) and the treatment of patients with AMD (in one embodiment, wet AMD) comprises a dosing schedule after initiation of treatment that extends the dosing interval when the disease is stably absent, or shortens the dosing interval when disease activity is present (in one embodiment, initiation of treatment comprises 3 to 7 monthly administrations; in one embodiment, initiation of treatment comprises 3 to 5 monthly administrations; in one embodiment, initiation of treatment comprises at least 4 monthly administrations; in one embodiment, initiation of treatment comprises 4 to 6 monthly administrations). In one embodiment, such a dosing schedule comprises patients receiving Q4W or Q8W or Q12W or Q16W dosing depending on their disease state. In one embodiment, the stable absence of disease is determined as

[0126] - Central subdomain thickness (CST) increased by <50 μm; and / or

[0127] - Best corrected visual acuity (BCVA / ETDRS) decreased by < 5 letters

[0128] and disease activity was determined to be

[0129] - Increase in central subdomain thickness (CST) by ≥50 μm; and / or

[0130] - A decrease in best-corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0131] In one embodiment, stable absence of disease is determined as

[0132] - Central subdomain thickness (CST) less than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using an Optovue TM The device’s spectral domain optical coherence tomography (SD-OCT) measures below 295μm),

[0133] and disease activity was determined to be

[0134] - Central subdomain thickness (CST) greater than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures above 315 μm; in one embodiment, by using an Optovue TM The device's spectral domain optical coherence tomography (SD-OCT) measurements were above 295 μm).

[0135] In one embodiment the vascular eye disease in this method, use, (application of) the bispecific antibody, medicament or pharmaceutical formulation is wet AMD (nAMD).

[0136] As used herein, "antibody" refers to a binding protein that contains an antigen binding site. As used herein, the term "binding site" or "antigen binding site" refers to the region of an antibody molecule to which a ligand actually binds. The term "antigen binding site" includes an antibody heavy chain variable domain (VH) and an antibody light chain variable domain (VL) (VH / VL pair).

[0137] Antibody specificity refers to the selective recognition of an antibody against a specific epitope of an antigen. For example, natural antibodies are monospecific.

[0138] A "bispecific antibody" according to the invention is an antibody with two different antigen binding specificities. The antibody of the invention has specificity for two different antigens, VEGF as the first antigen and ANG-2 as the second antigen.

[0139] As used herein, the term "monospecific" antibody refers to an antibody that has one or more binding sites that each bind to the same epitope of the same antigen.

[0140] The term "valency" as used in this application indicates the presence of a specified number of binding sites in an antibody molecule. Thus, the terms "bivalent", "tetravalent" and "hexavalent" indicate the presence of two binding sites, four binding sites and six binding sites in an antibody molecule, respectively. The bispecific antibodies according to the present invention are preferably "bivalent".

[0141] As used herein, the terms "bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin-2 (ANG-2)", "bispecific anti-VEGF / ANG2 antibody" and "bispecific <vegf ang2>"Antibody" is interchangeable and refers to an antibody that has at least two different antigen binding sites, the first binding to VEGF and the second binding to ANG2.

[0142] Bispecific anti-VEGF / ANG2 antibodies are described, for example, in WO2010040508, WO2011 / 117329, WO2012 / 131078, WO2015 / 083978, WO2017 / 197199 and WO2014 / 009465. WO2014 / 009465 describes bispecific anti-VEGF / ANG2 antibodies specifically designed for the treatment of ocular vascular diseases. The bispecific anti-VEGF / ANG2 antibodies of WO2014 / 009465 (incorporated herein in their entirety) are particularly useful in the treatment and therapeutic regimens for ocular vascular diseases as described herein.

[0143] In one embodiment, the bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin-2 (ANG-2) is a bispecific anti-VEGF / ANG2 antibody comprising a first antigen binding site that specifically binds to human VEGF and a second antigen binding site that specifically binds to human ANG-2, wherein

[0144] i) the first antigen binding site that specifically binds to VEGF comprises a CDR3H region of SEQ ID NO: 1, a CDR2H region of SEQ ID NO: 2, and a CDR1H region of SEQ ID NO: 3 in the heavy chain variable domain, and a CDR3L region of SEQ ID NO: 4, a CDR2L region of SEQ ID NO: 5, and a CDR1L region of SEQ ID NO: 6 in the light chain variable domain; and

[0145] ii) said second antigen-binding site that specifically binds to ANG-2 comprises in the heavy chain variable domain a CDR3H region of SEQ ID NO: 9, a CDR2H region of SEQ ID NO: 10 and a CDR1H region of SEQ ID NO: 11, and in the light chain variable domain a CDR3L region of SEQ ID NO: 12, a CDR2L region of SEQ ID NO: 13 and a CDR1L region of SEQ ID NO: 14,

[0146] And among them

[0147] iii) the bispecific antibody comprises a constant heavy chain region of human IgG1 subclass comprising the mutations I253A, H310A and H435A and the mutations L234A, L235A and P329G (numbering according to EU index of Kabat).

[0148] In one embodiment, the bispecific anti-VEGF / ANG2 antibody is bivalent.

[0149] In one embodiment, the bispecific anti-VEGF / ANG2 antibody is characterized in that

[0150] i) the first antigen binding site that specifically binds to VEGF comprises the amino acid sequence of SEQ ID NO: 7 as the heavy chain variable domain VH, and the amino acid sequence of SEQ ID NO: 8 as the light chain variable domain VL, and

[0151] ii) the second antigen-binding site that specifically binds to ANG-2 comprises the amino acid sequence of SEQ ID NO: 15 as the heavy chain variable domain VH, and the amino acid sequence of SEQ ID NO: 16 as the light chain variable domain VL.

[0152] In one aspect of the invention, this bispecific, bivalent antibody according to the invention is characterized in that it comprises

[0153] a) a heavy chain and a light chain of a first full-length antibody that specifically binds to VEGF;

[0154] b) A modified heavy chain and a modified light chain of a second full length antibody specifically binding to ANG-2, wherein the constant domains CL and CH1 are replaced with each other.

[0155] This bispecific bivalent antibody format (comprising a knob-into-hole modified CH3 domain) of a bispecific antibody specifically binding to human vascular endothelial growth factor (VEGF) and human angiopoietin-2 (ANG-2) is described in WO 2009 / 080253. Based on this bispecificity, the antibody in the bivalent antibody format is called CrossMAb.

[0156] In one embodiment, the bispecific, bivalent anti-VEGF / ANG2 antibody is characterized by comprising

[0157] a) the amino acid sequence of SEQ ID NO: 17 as the heavy chain of the first full-length antibody, and the amino acid sequence of SEQ ID NO: 18 as the light chain of the first full-length antibody, and

[0158] b) the amino acid sequence of SEQ ID NO: 19 as the modified heavy chain of the second full length antibody, and the amino acid sequence of SEQ ID NO: 20 as the modified light chain of the second full length antibody.

[0159] In one embodiment, the bispecific, bivalent anti-VEGF / ANG2 antibody is characterized by comprising the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19 and SEQ ID NO: 20. In a preferred embodiment, the bispecific, bivalent anti-VEGF / ANG2 antibody is faricimab.

[0160] Thus, one embodiment of the invention is a bispecific, bivalent antibody comprising a first antigen binding site that specifically binds to human VEGF and a second antigen binding site that specifically binds to human ANG-2, characterized by comprising the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19, and SEQ ID NO: 20. In a preferred embodiment, the bispecific, bivalent anti-VEGF / ANG2 antibody is faricimab.

[0161] In one embodiment, the CH3 domains of the bispecific bivalent antibody according to the invention are altered by the "knob-into-hole" technology, which is described in more detail with several examples in, for example, WO 96 / 027011, Ridgway JB et al., Protein Eng 9 (1996) 617-621; and Merchant, AM et al., Nat Biotechnol 16 (1998) 677-681. In this method, the interaction surfaces of the two CH3 domains are altered to increase the heterodimerization of the two heavy chains containing the two CH3 domains. Each of the two CH3 domains (of the two heavy chains) can be a "knob" and the other a "hole". The introduction of disulfide bridges stabilizes the heterodimer (Merchant, AM et al., Nature Biotech 16 (1998) 677-681; Atwell, S., et al. J. Mol. Biol. 270 (1997) 26-35) and increases the yield.

[0162] In a preferred aspect of the invention, the bispecific anti-VEGF / ANG2 antibody according to the invention is characterized in that

[0163] The CH3 domain of one heavy chain and the CH3 domain of the other heavy chain each meet at an interface that comprises the initial interface between antibody CH3 domains;

[0164] wherein the interface is altered to promote formation of a bispecific antibody, wherein the alteration is characterized by:

[0165] a) altering the CH3 domain of one heavy chain,

[0166] Thus, within the initial interface where the CH3 domain of one heavy chain meets the initial interface of the CH3 domain of the other heavy chain in the bispecific antibody,

[0167] The amino acid residue is replaced with an amino acid residue having a larger side chain volume, thereby generating a protrusion within the interface of the CH3 domain of one heavy chain, which protrusion can be located in a cavity within the interface of the CH3 domain of the other heavy chain,

[0168] and

[0169] b) changing the CH3 domain of the other heavy chain,

[0170] Thereby, within the initial interface of the second CH3 domain meeting the initial interface of the first CH3 domain in the bispecific antibody,

[0171] The amino acid residue is replaced with an amino acid residue having a smaller side chain volume, thereby creating a cavity within the interface of the second CH3 domain, within which the protrusion within the interface of the first CH3 domain can be located.

[0172] Therefore, preferably, the bispecific anti-VEGF / ANG2 antibodies described herein are characterized in that:

[0173] The CH3 domains of the heavy chains of the full length antibody of a) and the CH3 domains of the heavy chains of the full length antibody of b) each meet at an interface comprising an alteration in the original interface between the antibody CH3 domains;

[0174] i) in the CH3 domain of one heavy chain

[0175] The amino acid residue is replaced with an amino acid residue having a larger side chain volume, thereby generating a protrusion within the interface of the CH3 domain of one heavy chain, which protrusion can be located in a cavity within the interface of the CH3 domain of the other heavy chain,

[0176] And among them

[0177] ii) in the CH3 domain of the other heavy chain

[0178] The amino acid residue is replaced with an amino acid residue having a smaller side chain volume, thereby creating a cavity within the interface of the second CH3 domain, within which the protrusion within the interface of the first CH3 domain can be located.

[0179] Preferably, the amino acid residue with a larger side chain volume is selected from the following group: arginine (R), phenylalanine (F), tyrosine (Y), tryptophan (W).

[0180] Preferably, the amino acid residue with a smaller side chain volume is selected from the group consisting of alanine (A), serine (S), threonine (T), and valine (V).

[0181] In one aspect of the invention, the two CH3 domains are further altered by introducing cysteine ​​(C) as an amino acid in the corresponding position of each CH3 domain, enabling the formation of a disulfide bridge between the two CH3 domains.

[0182] In one embodiment, the bispecific antibody comprises a T366W mutation in the CH3 domain of the "knob chain" and T366S, L368A, Y407V mutations in the CH3 domain of the "hole chain". Additional interchain disulfide bridges between CH3 domains can also be used (Merchant, AM et al., Nature Biotech 16 (1998) 677-681), for example, by introducing an S354C mutation into one CH3 domain and a Y349C mutation into the other CH3 domain.

[0183] In another preferred embodiment, the bispecific antibody comprises S354C and T366W mutations in one of the two CH3 domains and Y349C, T366S, L368A, Y407V mutations in the other of the two CH3 domains. In another preferred embodiment, the bispecific antibody comprises Y349C, T366W mutations in one of the two CH3 domains and S354C, T366S, L368A, Y407V mutations in the other of the two CH3 domains (an additional Y349C or S354C mutation in one CH3 domain and an additional S354C or Y349C mutation in the other CH3 domain, forming an interchain disulfide bridge) (always numbered according to the EU index of Kabat (Kabat, EA et al., Sequences of Proteins of Immunological Interest, Fifth Edition, Public Health Service, National Institutes of Health, Bethesda, MD (1991)).

[0184] Other techniques for CH3 modification to force heterodimerization are contemplated as alternatives to the present invention and are described, for example, in WO 96 / 27011, WO 98 / 050431, EP 1870459, WO 2007 / 110205, WO 2007 / 147901, WO 2009 / 089004, WO 2010 / 129304, WO 2011 / 90754, WO 2011 / 143545, WO 2012 / 058768, WO 2013 / 157954 and WO 2013 / 096291.

[0185] In one embodiment, the heterodimerization method described in EP 1 870 459A1 can be used alternatively. The method is based on the substitution / mutation of charged amino acids with opposite charges at specific amino acid positions at the CH3 / CH3 domain interface between the two heavy chains. A preferred embodiment of the multispecific antibody is the amino acid R409D and K370E mutations in the CH3 domain of one heavy chain of the multispecific antibody and the amino acid D399K and E357K mutations in the CH3 domain of another heavy chain of the multispecific antibody (numbered according to the Kabat EU index).

[0186] In another embodiment, the multispecific antibody comprises an amino acid T366W mutation in the CH3 domain of the "knob chain" and amino acid T366S, L368A and Y407V mutations in the CH3 domain of the "hole chain"; and further comprises amino acid R409D and K370E mutations in the CH3 domain of the "knob chain" and amino acid D399K and E357K mutations in the CH3 domain of the "hole chain".

[0187] In one embodiment, the heterodimerization method described in WO2013 / 157953 can be used alternatively. In one embodiment, the CH3 domain of one heavy chain comprises an amino acid T366K mutation, and the CH3 domain of another heavy chain comprises an amino acid L351D mutation. In another embodiment, the CH3 domain of one heavy chain also comprises an amino acid L351K mutation. In another embodiment, the CH3 domain of another heavy chain also comprises an amino acid mutation selected from Y349E, Y349D and L368E (in one embodiment, L368E).

[0188] In one embodiment, the heterodimerization method described in WO2012 / 058768 can be used alternatively. In one embodiment, the CH3 domain of one heavy chain comprises amino acid L351Y and Y407A mutations, and the CH3 domain of the other heavy chain comprises amino acid T366A and K409F mutations. In another embodiment, the CH3 domain of the other heavy chain further comprises amino acid mutations at positions T411, D399, S400, F405, N390 or K392. In one embodiment, the amino acid mutations are selected from the group consisting of:

[0189] a) T411N, T411R, T411Q, T411K, T411D, T411E and T411W,

[0190] b)D399R, D399W, D399Y and D399K,

[0191] c) S400E, S400D, S400R and S400K,

[0192] d)F405I, F405M, F405T, F405S, F405V and F405W,

[0193] e) N390R, N390K and N390D,

[0194] f) K392V, K392M, K392R, K392L, K392F and K392E.

[0195] In another embodiment, the CH3 domain of one heavy chain comprises amino acid L351Y and Y407A mutations, and the CH3 domain of the other heavy chain comprises amino acid T366V and K409F mutations. In another embodiment, the CH3 domain of one heavy chain comprises amino acid Y407A mutations, and the CH3 domain of the other heavy chain comprises amino acid T366A and K409F mutations. In another embodiment, the CH3 domain of the other heavy chain further comprises amino acid K392E, T411E, D399R and S400R mutations.

[0196] In one embodiment the heterodimerization method described in WO2011 / 143545 may alternatively be used.In one embodiment the amino acid modification according to WO2011 / 143545 is introduced into a position selected from the group consisting of 368 and 409 in the CH3 domain of the heavy chain.

[0197] In one embodiment, the heterodimerization method described in WO2011 / 090762, which also uses the above-mentioned knob-into-hole technology, can be used alternatively. In one embodiment, the CH3 domain of one heavy chain comprises the amino acid T366W mutation and the CH3 domain of the other heavy chain comprises the amino acid Y407A mutation. In one embodiment, the CH3 domain of one heavy chain comprises the amino acid T366Y mutation and the CH3 domain of the other heavy chain comprises the amino acid Y407T mutation.

[0198] In one embodiment, the multispecific antibody is of IgG2 isotype and the heterodimerization approach described in WO2010 / 129304 may alternatively be used.

[0199] In one embodiment, the heterodimerization method described in WO2009 / 089004 may be used alternatively. In one embodiment, the CH3 domain of one heavy chain comprises an amino acid substitution of K392 or N392 with a negatively charged amino acid (in one embodiment, glutamic acid (E) or aspartic acid (D)) (in another embodiment, a K392D or N392D mutation), and the CH3 domain of the other heavy chain comprises a substitution of D399, E356, D356 or E357 with a positively charged amino acid (in one embodiment, lysine (K) or arginine (R)) (in another embodiment, a D399K, E356K, D356K or E357K substitution; and in another embodiment, a D399K or E356K mutation). In another embodiment, the CH3 domain of one heavy chain further comprises an amino acid substitution of K409 or R409 with a negatively charged amino acid ((in one embodiment glutamic acid (E) or aspartic acid (D); in another embodiment K409D or R409D mutation). In another embodiment, the CH3 domain of one heavy chain further or alternatively comprises an amino acid substitution of K439 and / or K370 with a negatively charged amino acid (in one embodiment glutamic acid (E) or aspartic acid (D)).

[0200] In one embodiment, the heterodimerization method described in WO2007 / 147901 may be used instead.In one embodiment, the CH3 domain of one heavy chain comprises amino acid K253E, D282K and K322D mutations and the CH3 domain of the other heavy chain comprises amino acid D239K, E240K and K292D mutations.

[0201] In one embodiment, the heterodimerization method described in WO2007 / 110205 may be used instead.

[0202] In one embodiment, the bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin-2 (ANG-2) is a bispecific anti-VEGF / ANG2 antibody comprising a first antigen binding site that specifically binds to human VEGF and a second antigen binding site that specifically binds to human ANG-2, wherein

[0203] i) the first antigen-binding site that specifically binds to VEGF comprises a CDR3H region of SEQ ID NO: 1, a CDR2H region of SEQ ID NO: 2, and a CDR1H region of SEQ ID NO: 3 in the heavy chain variable domain, and a CDR3L region of SEQ ID NO: 4, a CDR2L region of SEQ ID NO: 5, and a CDR1L region of SEQ ID NO: 6 in the light chain variable domain; and

[0204] ii) said second antigen-binding site that specifically binds to ANG-2 comprises in the heavy chain variable domain a CDR3H region of SEQ ID NO: 9, a CDR2H region of SEQ ID NO: 10 and a CDR1H region of SEQ ID NO: 11, and in the light chain variable domain a CDR3L region of SEQ ID NO: 12, a CDR2L region of SEQ ID NO: 13 and a CDR1L region of SEQ ID NO: 14,

[0205] And among them

[0206] iii) the bispecific antibody comprises a constant heavy chain region of human IgG1 subclass comprising the mutations I253A, H310A and H435A and the mutations L234A, L235A and P329G (numbering according to the EU index of Kabat; and wherein

[0207] iv) in the constant heavy chain region, one CH3 domain comprises a T366W mutation and the other CH3 domain comprises T366S, L368A, Y407V mutations (numbering according to EU index of Kabat).

[0208] In one embodiment, the bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin-2 (ANG-2) is a bispecific anti-VEGF / ANG2 antibody comprising a first antigen binding site that specifically binds to human VEGF and a second antigen binding site that specifically binds to human ANG-2, wherein

[0209] i) the first antigen-binding site that specifically binds to VEGF comprises a CDR3H region of SEQ ID NO: 1, a CDR2H region of SEQ ID NO: 2, and a CDR1H region of SEQ ID NO: 3 in the heavy chain variable domain, and a CDR3L region of SEQ ID NO: 4, a CDR2L region of SEQ ID NO: 5, and a CDR1L region of SEQ ID NO: 6 in the light chain variable domain; and

[0210] ii) said second antigen-binding site that specifically binds to ANG-2 comprises in the heavy chain variable domain a CDR3H region of SEQ ID NO: 9, a CDR2H region of SEQ ID NO: 10 and a CDR1H region of SEQ ID NO: 11, and in the light chain variable domain a CDR3L region of SEQ ID NO: 12, a CDR2L region of SEQ ID NO: 13 and a CDR1L region of SEQ ID NO: 14,

[0211] And among them

[0212] iii) the bispecific antibody comprises a constant heavy chain region of human IgG1 subclass comprising the mutations I253A, H310A and H435A and the mutations L234A, L235A and P329G (numbering according to the EU index of Kabat; and wherein

[0213] iv) in the constant heavy chain region, one CH3 domain comprises S354C and T366W mutations and the other CH3 domain comprises Y349C, T366S, L368A and Y407V mutations (numbering according to EU index of Kabat).

[0214] In one embodiment, the bispecific anti-VEGF / ANG2 antibody is bivalent.

[0215] In one embodiment, the bispecific anti-VEGF / ANG2 antibody is characterized in that

[0216] i) the first antigen binding site that specifically binds to VEGF comprises the amino acid sequence of SEQ ID NO: 7 as the heavy chain variable domain VH, and the amino acid sequence of SEQ ID NO: 8 as the light chain variable domain VL, and

[0217] ii) the second antigen-binding site that specifically binds to ANG-2 comprises the amino acid sequence of SEQ ID NO: 15 as the heavy chain variable domain VH, and the amino acid sequence of SEQ ID NO: 16 as the light chain variable domain VL.

[0218] In one aspect of the invention, this bispecific, bivalent antibody according to the invention is characterized in that it comprises

[0219] a) a heavy chain and a light chain of a first full-length antibody that specifically binds to VEGF;

[0220] b) A modified heavy chain and a modified light chain of a second full length antibody specifically binding to ANG-2, wherein the constant domains CL and CH1 are replaced with each other.

[0221] As used herein, the term "VEGF" refers to human vascular endothelial growth factor (VEGF / VEGF-A), the 165 amino acid human vascular endothelial cell growth factor (amino acids 27-191 of the precursor sequence of human VEGF165: SEQ ID NO: 24, amino acids 1-26 represent the signal peptide), and the related 121, 189 and 206 vascular endothelial cell growth factor isoforms, as described in, e.g., Leung, DW, et al., Science 246 (1989) 1306-9; Houck et al., Mol. Endocrin. 5 (1991) 1806-1814; Keck, PJ, et al., Science 246 (1989) 1309-12 and Connolly, DT, et al., J. Biol. Chem. 264 (1989) 20017-24; as well as naturally occurring alleles and processed forms of these growth factors. VEGF is involved in the regulation of normal and abnormal angiogenesis and neovascularization associated with tumors and intraocular diseases (Ferrara, N., et al., Endocr. Rev. 18 (1997) 4-25; Berkman, RA, et al., J. Clin. Invest. 91 (1993) 153-159; Brown, LF, et al., Human Pathol. 26 (1995) 86-91; Brown, LF, et al., Cancer Res. 53 (1993) 4727-4735; Mattern, J., et al., Brit. J. Cancer. 73 (1996) 931-934; and Dvorak, HF, et al., Am. J. Pathol. 146 (1995) 1029-1039). VEGF is a homodimeric glycoprotein that has been isolated from a variety of sources and includes multiple isoforms. VEGF exhibits highly specific mitogenic activity on endothelial cells. VEGF antagonists / inhibitors inhibit the binding of VEGF to its receptor VEGFR. Known VEGF antagonists / inhibitors include bispecific anti-VEGF / ANG2 antibodies as described in WO2014 / 009465.

[0222] As used herein, the term "ANG-2" refers to human angiopoietin-2 (ANG-2) (alternatively abbreviated as ANGPT2 or ANG2) (SEQ ID NO: 25), which is described, for example, in Maisonpierre, PC, et al., Science 277 (1997) 55-60 and Cheung, AH, et al., Genomics 48 (1998) 389-91. Angiopoietin-1 (SEQ ID NO: 26) and -2 were found to be ligands for Ties, a family of tyrosine kinases selectively expressed in the vascular endothelium (Yancopoulos, GD, et al., Nature 407 (2000) 242-48). There are now four well-defined members of the angiopoietin family. Angiopoietin-3 and -4 (Ang-3 and Ang-4) may represent widely diverged counterparts of the same gene locus in mice and humans (Kim, I., et al., FEBS Let, 443 (1999) 353-56; Kim, I., et al., J Biol Chem 274 (1999) 26523-28). ANG-1 and ANG-2 were originally identified as agonists and antagonists, respectively, in tissue culture experiments (see, for ANG-1: Davis, S., et al., Cell 87 (1996) 1161-69; and for ANG-2: Maisonpierre, PC, et al., Science 277 (1997) 55-60). All known angiopoietins bind primarily to their receptor TIE2 (SEQ ID NO: 27), and both Ang-1 and -2 bind to TIE2 with an affinity of 3 nM (Kd) (Maisonpierre, PC, et al., Science 277 (1997) 55-60). ANG2 antagonists / inhibitors inhibit the binding of ANG2 to its receptor TIE2. Known ANG2 antagonists / inhibitors include bispecific anti-VEGF / ANG2 antibodies as described in WO2014 / 009465.

[0223] The antigen binding site of the bispecific antibody of the present invention comprises six complementary determining regions (CDRs), which contribute to the affinity of the binding site for the antigen to varying degrees. There are three heavy chain variable domain CDRs (CDRH1, CDRH2 and CDRH3) and three light chain variable domain CDRs (CDRL1, CDRL2 and CDRL3). The extent of the CDRs and framework regions (FRs) is determined by comparison with a compiled database of amino acid sequences, in which these regions have been defined based on the variability between sequences.

[0224] The antibodies of the invention comprise immunoglobulin constant regions derived from one or more immunoglobulin classes of human origin, wherein such immunoglobulin classes include IgG, IgM, IgA, IgD and IgE classes, and in the case of IgG and IgA, subclasses thereof, particularly IgG1 and IgG4.

[0225] As used herein, the terms "monoclonal antibody" or "monoclonal antibody composition" refer to a preparation of antibody molecules of a single amino acid composition.

[0226] The term "chimeric antibody" refers to an antibody comprising a variable region, i.e., a binding region, from one source or species and at least a portion of a constant region derived from a different source or species, which is usually prepared by recombinant DNA technology. Chimeric antibodies comprising a murine variable region and a human constant region are preferred. Other preferred forms of "chimeric antibodies" encompassed by the present invention are those in which the constant region has been modified or altered from that of the original antibody to generate the properties according to the present invention (particularly with respect to C1q binding / or Fc receptor (FcR) binding). Such chimeric antibodies are also referred to as "class-switched antibodies". Chimeric antibodies are the expression product of immunoglobulin genes comprising a DNA segment encoding an immunoglobulin variable region and a DNA segment encoding an immunoglobulin constant region. Methods for producing chimeric antibodies involve conventional recombinant DNA and gene transfection techniques, which are well known in the art. See, for example, Morrison, SL, et al., Proc. Natl. Acad. Sci. USA 81 (1984) 6851-6855; US 5,202,238 and US 5,204,244.

[0227] The term "humanized antibody" refers to an antibody in which the framework or "complementarity determining regions" (CDRs) have been modified to contain immunoglobulin CDRs of a different specificity than that of the parent immunoglobulin. In a preferred embodiment, murine CDRs are grafted into the framework regions of a human antibody to prepare a "humanized antibody". See, e.g., Riechmann, L., et al., Nature 332 (1988) 323-327; and Neuberger, MS, et al., Nature 314 (1985) 268-270. Particularly preferred CDRs correspond to those sequences representing recognition of the antigens noted above for chimeric antibodies. Other forms of "humanized antibodies" encompassed by the present invention are those in which the constant regions have been additionally modified or altered from those of the original antibody to generate the properties according to the present invention, particularly with respect to C1q binding and / or Fc receptor (FcR) binding.

[0228] As used herein, the term "human antibody" is intended to include antibodies having variable and constant regions derived from human germline immunoglobulin sequences. Human antibodies are well known in the art (van Dijk, MA and van de Winkel, JG, Curr. Opin. Chem. Biol. 5 (2001) 368-374). Human antibodies can also be produced in transgenic animals (e.g., mice) that are capable of producing a complete repertoire or portions of human antibodies after immunization in the absence of endogenous immunoglobulin production. Transfer of the human germline immunoglobulin gene array in such germline mutant mice results in the production of human antibodies upon antigen challenge (see, e.g., Jakobovits, A. et al., Proc. Natl. Acad. Sci. USA 90 (1993) 2551-2555; Jakobovits, A. et al., Nature 362 (1993) 255-258; Brueggemann, M. et al., Year Immunol. 7 (1993) 33-40). Human antibodies can also be produced in phage display libraries (Hoogenboom, HR, and Winter, GJ, Mol. Biol. 227 (1992) 381-388; Marks, JD et al., J. Mol. Biol. 222 (1991) 581-597). The techniques of Cole, A. et al. and Boerner, P. et al. can also be used to prepare human monoclonal antibodies (Cole, A. et al., Monoclonal Antibodies and Cancer Therapy, Liss, AL, p. 77 (1985); and Boerner, P. et al., J. Immunol. 147 (1991) 86-95). As already mentioned with respect to chimeric and humanized antibodies according to the invention, as used herein, the term "human antibody" also encompasses such antibodies which have been modified in the constant region to generate the properties according to the invention (particularly with respect to C1q binding / or FcR binding), for example by "class switching", i.e. a change or mutation of the Fc part (e.g. from IgG1 to IgG4 and / or IgG1 / IgG4 mutation).

[0229] As used herein, the term "recombinant antibody" is intended to include all human antibodies prepared, expressed, created or separated by recombinant means, such as antibodies isolated from host cells such as NS0 or CHO cells or from transgenic animals (e.g., mice) of human immunoglobulin genes or antibodies expressed using recombinant expression vectors transfected into host cells. Such recombinant antibodies have variable regions and constant regions in rearranged form. Recombinant antibodies according to the present invention have undergone in vivo somatic hypermutation. Therefore, the amino acid sequence of the VH and VL regions of the recombinant antibodies is a sequence that, although derived from and associated with human germline VH and VL sequences, may not exist naturally in the human antibody germline repertoire in vivo.

[0230] As used herein, "variable domain" (light chain variable domain (VL), heavy chain variable domain (VH)) refers to each pair of light and heavy chains that are directly involved in the binding of an antibody to an antigen. Human light and heavy chain variable domains have the same general structure, and each domain contains four widely conserved framework (FR) regions connected by three "hypervariable regions" (or complementarity determining regions, CDRs). The framework regions adopt a β-sheet conformation, while the CDRs can form loops connecting the β-sheet structures. The CDRs in each chain maintain their three-dimensional structure through the framework regions, and together with the CDRs from the other chain form an antigen binding site. The antibody heavy and light chain CDR3 regions play a particularly important role in the binding specificity / affinity of the antibodies according to the present invention, and therefore provide a further object of the present invention.

[0231] The term "antigen-binding portion of an antibody" or "hypervariable region" as used herein refers to the amino acid residues in an antibody that are responsible for antigen binding. The hypervariable region comprises amino acid residues from the "complementarity determining region" or "CDR". The "framework" or "FR" regions are those variable domain regions that differ from the hypervariable region residues as defined herein. Thus, the light and heavy chains of an antibody comprise, from N-terminus to C-terminus, the domains FR1, CDR1, FR2, CDR2, FR3, CDR3, and FR4. The CDRs on each chain are separated by such framework amino acids. In particular, CDR3 of the heavy chain is the region that is most conducive to antigen binding. CDR and FR regions are determined according to the standard definitions of Kabat, EA et al., Sequences of Proteins of Immunological Interest, 5th ed., Public Health Service, National Institutes of Health, Bethesda, MD (1991).

[0232] The term "full-length antibody" refers to an antibody consisting of two "full-length antibody heavy chains" and two "full-length antibody light chains". A "full-length antibody heavy chain" is a polypeptide consisting of an antibody heavy chain variable domain (VH), an antibody heavy chain constant domain 1 (CH1), an antibody hinge region (HR), an antibody heavy chain constant domain 2 (CH2), and an antibody heavy chain constant domain 3 (CH3) (abbreviated as VH-CH1-HR-CH2-CH3); and optionally, an antibody heavy chain constant domain 4 (CH4) (in the case of antibodies of subclass IgE). Preferably, a "full-length antibody heavy chain" is a polypeptide consisting of VH, CH1, HR, CH2 and CH3 in the N-terminal to C-terminal direction. A "full-length antibody light chain" is a polypeptide consisting of an antibody light chain variable domain (VL) and an antibody light chain constant domain (CL) (abbreviated as VL-CL) in the N-terminal to C-terminal direction. The antibody light chain constant domain (CL) can be κ (kappa) or λ (lambda). The two full-length antibody chains are linked together via inter-polypeptide disulfide bonds between the CL domain and the CH1 domain and between the hinge regions of the heavy chains of the full-length antibodies. Typical examples of full-length antibodies are natural antibodies, such as IgG (e.g., IgG 1 and IgG2), IgM, IgA, IgD, and IgE. The full-length antibodies according to the present invention may be from a single species, such as humans, or they may be chimeric or humanized antibodies. The full-length antibodies according to the present invention comprise two antigen binding sites, each formed by a pair of VH and VL, which both specifically bind to the same antigen. The C-terminus of the heavy or light chain of the full-length antibody refers to the last amino acid at the C-terminus of the heavy or light chain. The N-terminus of the heavy or light chain of the full-length antibody refers to the last amino acid at the N-terminus of the heavy or light chain.

[0233] As used in the present application, the term "constant region" represents the sum of the domains different from the variable region in the antibody. Constant region does not directly involve the combination of antigens, but exhibits a variety of effector functions. According to the amino acid sequence of its heavy chain constant region, antibodies are divided into categories: IgA, IgD, IgE, IgG and IgM, and several of these can be further divided into subclasses, such as IgG1, IgG2, IgG3 and IgG4, IgA1 and IgA2. The heavy chain constant region corresponding to the antibody of different classes is referred to as α, δ, ε, γ and μ respectively. The constant region of light chain that can be found in all 5 kinds of antibody classifications is referred to as κ (Kappa) and λ (Lambda).

[0234] As used in this application, the term "constant region derived from human origin" or "human constant region" refers to the heavy chain constant region and / or the light chain kappa or lambda constant region of a human antibody of subclass IgG1, IgG2, IgG3, or IgG4. Such constant regions are well known in the art, for example, as described in Kabat, EA, et al., Sequences of Proteins of Immunological Interest, Fifth Edition, Public Health Service, National Institutes of Health, Bethesda, MD (1991) (see also, for example, Johnson, G., and Wu, TT, Nucleic Acids Res. 28 (2000) 214-218; Kabat, EA, et al., Proc. Natl. Acad. Sci. USA 72 (1975) 2785-2788). In this application, for the numbering of positions and mutations, the index numbering according to Kabat, EA, et al., Sequences of Proteins of Immunological Interest, 5th ed., Public Health Service, National Institutes of Health, Bethesda, MD (1991) is used and is referred to as "EU index numbering according to Kabat".

[0235] In one embodiment, the bispecific antibody according to the present invention has a constant region of human IgG1 subclass (derived from human IgG1 subclass). However, the C-terminal lysine (Lys447) or the C-terminal glycine (Gly446) and the C-terminal lysine (Lys447) of the Fc region may be present or absent.

[0236] In one embodiment, the bispecific antibody described herein is of IgG1 isotype / subclass and comprises a constant heavy chain domain of SEQ ID NO: 23 or a heavy chain amino acid sequence of SEQ ID NO: 17 and a constant portion of an amino acid sequence of SEQ ID NO: 18. In one embodiment, a C-terminal glycine (Gly446) is additionally present. In one embodiment, a C-terminal glycine (Gly446) and a C-terminal lysine (Lys447) are additionally present.

[0237] Unless otherwise specified herein, the numbering of amino acid residues in the constant region is according to the EU numbering system, also known as the EU index of Kabat, as described in Kabat et al., Sequences of Proteins of Immunological Interest, Fifth Edition, Public Health Service, National Institutes of Health, Bethesda, MD (1991), NIH Publication 91-3242.

[0238] In one embodiment, the bispecific antibody according to the invention is of human IgG1 subclass with the mutations L234A (Leu235Ala), L235A (Leu234Ala) and P329G (Pro329Gly). Such antibodies have reduced FcR binding (in particular, they no longer show binding to FcRγI, FcRγII and FcRγIII). This is particularly useful for reducing potential side effects (e.g., thrombosis (Meyer, T., et al., J. Thromb. Haemost. 7 (2009) 171-81).

[0239] Although the Pro329Ala mutation already described only removes two thirds of the FcγRIIIa sandwich interaction, Pro329Gly in the antibodies according to the invention completely confer binding of the Fc part to FcγRIII. This is particularly useful because binding to FcγRIII is involved in ADCC (antibody-dependent cellular cytotoxicity), which leads to cell death, which may help treat cancer diseases but may lead to severe side effects in antibody-based treatments of other vascular or immune diseases. Therefore, the antibodies of the invention of the IgG1 subclass with the mutations L234A, L235A and P329G and the antibodies of the invention of the IgG4 subclass with the mutations S228P, L235E and P329G are particularly useful because they all show no more binding to FcRγI, FcRgγII and FcRγIII.

[0240] An "effective amount" of an agent, e.g., a pharmaceutical agent or a bispecific anti-VEGF / ANG2 antibody, refers to an amount effective, at dosages and for periods of time necessary, to achieve the desired therapeutic or prophylactic result.

[0241] In one embodiment of the invention, the bispecific antibodies, drugs or pharmaceutical formulations described herein are administered by intravitreal application, for example via intravitreal injection ("intravitreal" administration). This can be performed according to standard procedures known in the art. See, e.g., Ritter et al., J. Clin. Invest. 116 (2006) 3266-76; Russelakis-Carneiro et al., Neuropathol. Appl. Neurobiol. 25 (1999) 196-206; and Wray et al., Arch. Neurol. 33 (1976) 183-5.

[0242] In some embodiments, the therapeutic kit of the present invention may include one or more doses of a bispecific antibody present in a drug or drug formulation, a suitable device for intravitreal injection of the drug or drug formulation, and instructions detailing the subject and protocol for performing the injection. In these embodiments, the drug or drug formulation is typically administered to a subject in need of treatment by intravitreal injection. This can be performed according to standard procedures known in the art. See, for example, Ritter et al., J. Clin. Invest. 116 (2006) 3266-76; Russelakis-Carneiro et al., Neuropathol. Appl. Neurobiol. 25 (1999) 196-206; and Wray et al., Arch. Neurol. 33 (1976) 183-5.

[0243] Regardless of the route of administration chosen, the bispecific antibodies described herein are formulated into pharmaceutically acceptable dosage forms by conventional methods known to those skilled in the art.

[0244] Amino acid sequence description

[0245]

[0246]

[0247] In the following, embodiments of the present invention are listed:

[0248] 1. A bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) for use in treating ocular vascular diseases,

[0249] wherein the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0250] 2A. A bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) for use in treating a patient with an ocular vascular disease, wherein the patient gains 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart as compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody.

[0251] 2B. A bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) for use in treating a patient with an ocular vascular disease, wherein the patient experiences an improvement in vision following administration of the bispecific VEGF / ANG2 antibody, the improvement being as measured by gaining 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, in one embodiment 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart, compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody.

[0252] 3. (the use of) the bispecific antibody according to any one of embodiments 2A to 2B,

[0253] wherein the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0254] 4. The bispecific antibody (for use) according to any one of embodiments 1-3, wherein the gain in letters in BCVA / ETDRS is measured at 4 weeks, and / or 8 weeks, and / or 12 weeks, and / or 16 weeks, and / or 20 weeks, and / or 24 weeks after the start of treatment, respectively.

[0255] 5. (The use of) the bispecific antibody according to any one of embodiments 1 to 3, wherein the gain in letters in BCVA / ETDRS is measured at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks after the start of treatment, respectively.

[0256] 6. The bispecific antibody (use) according to any one of embodiments 1 to 5, wherein the bispecific antibody is used to prolong the time to retreatment and / or prolong the time to vision loss (e.g., best corrected visual acuity (BCVA) BCVA / ETDRS), wherein retreatment is considered necessary when disease activity is determined to be:

[0257] An increase in central subdomain thickness (CST) of ≥50 μm (in one embodiment using spectral domain optical coherence tomography (SD-OCT)); and / or

[0258] A decrease in best-corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0259] 7. The bispecific antibody according to any one of embodiments 1 to 6, wherein the bispecific antibody is administered after 3 to 7 monthly administrations of treatment initiation (in one embodiment, the treatment initiation comprises 3 to 5 monthly administrations; in one embodiment, the treatment initiation comprises 4 monthly administrations; in one embodiment, the treatment initiation comprises 5 to 7 monthly administrations; in one embodiment, the treatment initiation comprises 6 monthly administrations).

[0260] 8. (The use of) the bispecific antibody according to any one of embodiments 1 to 7, wherein the ocular vascular disease is selected from the group consisting of wet age-related macular degeneration (wet AMD), neovascular AMD, diabetic macular edema (DME), cystoid macular edema (CME), non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), macular edema secondary to central retinal vein occlusion, macular edema secondary to hemiretinal vein occlusion, or macular edema secondary to branch vein occlusion, retinitis, conjunctivitis, uveitis, choroiditis, choroidal neovascularization (CNV) secondary to ocular inflammation (including ocular histoplasmosis or presumed histoplasmosis or choroiditis); myopic choroidal neovascularization (mCNV), and choroidal neovascularization secondary to trauma, retinopathy of prematurity, and rubeosis iridis / rubeosis iridis glaucoma.

[0261] 9. (Use of) the bispecific antibody according to any one of embodiments 1 to 7, wherein the ocular vascular disease is diabetic macular edema (DME).

[0262] 10. (The use of) the bispecific antibody according to any one of embodiments 1 to 7, wherein the ocular vascular disease is wet age-related macular degeneration (wet AMD) or neovascular age-related macular degeneration (nAMD).

[0263] 11. (Use of) the bispecific antibody according to any one of embodiments 1 to 10, wherein the bispecific antibody that binds to VEGF and human ANG-2 is a VEGF antagonist / inhibitor and an ANG2 antagonist / inhibitor or inhibits the binding of VEGF to its receptor VEGFR and inhibits the binding of ANG2 to its receptor TIE2.

[0264] 12. (The use of) the bispecific antibody according to any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 10 to 12 weeks.

[0265] 13. (The use of) the bispecific antibody according to any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 11 to 13 weeks.

[0266] 14. (The use of) the bispecific antibody according to any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 12 to 14 weeks.

[0267] 15. (The use of) the bispecific antibody according to any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 13 to 15 weeks.

[0268] 16. (The use of) the bispecific antibody according to any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 14 to 16 weeks.

[0269] 17. (Use of) the bispecific antibody according to any one of embodiments 1 to 16, wherein the bispecific antibody that binds to human VEGF and human ANG2 is a bispecific, bivalent anti-VEGF / ANG2 antibody comprising a first antigen binding site that specifically binds to human VEGF and a second antigen binding site that specifically binds to human ANG-2, wherein

[0270] i) the first antigen-binding site that specifically binds to VEGF comprises a CDR3H region of SEQ ID NO: 1, a CDR2H region of SEQ ID NO: 2, and a CDR1H region of SEQ ID NO: 3 in the heavy chain variable domain, and a CDR3L region of SEQ ID NO: 4, a CDR2L region of SEQ ID NO: 5, and a CDR1L region of SEQ ID NO: 6 in the light chain variable domain; and

[0271] ii) said second antigen-binding site that specifically binds to ANG-2 comprises in the heavy chain variable domain a CDR3H region of SEQ ID NO: 9, a CDR2H region of SEQ ID NO: 10 and a CDR1H region of SEQ ID NO: 11, and in the light chain variable domain a CDR3L region of SEQ ID NO: 12, a CDR2L region of SEQ ID NO: 13 and a CDR1L region of SEQ ID NO: 14,

[0272] And among them

[0273] iii) the bispecific antibody comprises a constant heavy chain region of human IgG1 subclass comprising the mutations I253A, H310A and H435A and the mutations L234A, L235A and P329G (numbering according to EU index of Kabat).

[0274] 18. (The use of) the bispecific antibody according to embodiment 17, wherein

[0275] i) the first antigen binding site that specifically binds to VEGF comprises the amino acid sequence of SEQ ID NO: 7 as the heavy chain variable domain VH, and the amino acid sequence of SEQ ID NO: 8 as the light chain variable domain VL, and

[0276] ii) the second antigen-binding site that specifically binds to ANG-2 comprises the amino acid sequence of SEQ ID NO: 15 as the heavy chain variable domain VH, and the amino acid sequence of SEQ ID NO: 16 as the light chain variable domain VL.

[0277] 19. The bispecific antibody (use) according to embodiment 18, wherein the bispecific antibody that binds to human VEGF and human ANG2 comprises the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19 and SEQ ID NO: 20.

[0278] 20. (The use of) the bispecific antibody according to any one of embodiments 17 to 19, wherein the bispecific antibody is administered at a dose of about 5 to 7 mg (per treatment).

[0279] 21. The bispecific antibody of any one of embodiments 17 to 19, wherein the bispecific antibody is administered at a dose of about 6 mg (per treatment) (in one embodiment at a dose of 6 mg + / - 10% (in one embodiment at a dose of 6 mg (per treatment)).

[0280] 22. The bispecific antibody according to any one of embodiments 20 to 21, wherein the bispecific antibody is administered at a concentration of about 30 mg / ml.

[0281] 23. The bispecific antibody according to any one of embodiments 20 to 21, wherein the bispecific antibody is administered at a concentration of about 120 mg / ml.

[0282] 24. (The use of) the bispecific antibody according to any one of the preceding embodiments, wherein the patient suffering from an ocular vascular disease has not been previously treated with (is treatment naive) anti-VEGF therapy (eg monotherapy).

[0283] 25. (The use of) the bispecific antibody according to any one of the preceding embodiments, wherein the patient suffering from an ocular vascular disease has previously been treated with an anti-VEGF therapy (eg monotherapy).

[0284] 26. The bispecific antibody according to the preceding embodiments, wherein the ocular vascular disease is DME and the treatment of patients suffering from DME comprises a fixed dosing schedule every 8 weeks (Q8W) after initiation of treatment (in one embodiment, initiation of treatment comprises 5 to 7 monthly administrations; in one embodiment, initiation of treatment comprises 6 monthly administrations).

[0285] 27. The bispecific antibody according to the preceding embodiments, wherein the ocular vascular disease is DME and the treatment of patients suffering from DME comprises a fixed dosing schedule of Q12W after initiation of treatment (in one embodiment, initiation of treatment comprises 5 to 7 monthly administrations; in one embodiment, initiation of treatment comprises 6 monthly administrations).

[0286] 28. The bispecific antibody (use) according to embodiment 27, wherein, after initiation of treatment, a first dosing cycle of Q8W is performed prior to a fixed Q12W dosing regimen.

[0287] 29. The bispecific antibody (use) according to the preceding embodiments, wherein the ocular vascular disease is DME, and treatment of patients suffering from DME comprises a dosing schedule after treatment initiation that extends the dosing interval when the disease is stably absent, or shortens the dosing interval when disease activity is present (in one embodiment, treatment initiation comprises 3 to 7 monthly administrations; in one embodiment, treatment initiation comprises 4 to 6 monthly administrations).

[0288] 30. (The use of) the bispecific antibody according to embodiment 29, wherein the dosing schedule comprises the patient receiving Q8W or Q12W or Q16W dosing depending on their disease state (in one embodiment, Q4W or Q8W or Q12W or Q16W dosing depending on their disease state).

[0289] 31. (The use of) the bispecific antibody according to embodiment 29 or 30, wherein the stable absence of disease is determined to be

[0290] - Central subdomain thickness (CST) increased by <50 μm; and / or

[0291] - Best corrected visual acuity (BCVA / ETDRS) decreased by < 5 letters

[0292] and disease activity was determined to be

[0293] - Increase in central subdomain thickness (CST) by ≥50 μm; and / or

[0294] - A decrease in best corrected visual acuity (BCVA / ETDRS) of ≥5 letters

[0295] 32. The method of embodiment 29 or 30, wherein the stable absence of disease is determined to be

[0296] - Central subdomain thickness (CST) less than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using an Optovue TM The device’s spectral domain optical coherence tomography (SD-OCT) measures below 295μm),

[0297] and disease activity was determined to be

[0298] - Central subdomain thickness (CST) greater than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures above 315 μm; in one embodiment, by using an Optovue TM The device's spectral domain optical coherence tomography (SD-OCT) measurements were above 295 μm).

[0299] 33. (The use of) the bispecific antibody according to the preceding embodiments, wherein the ocular vascular disease is AMD (in one embodiment, wet AMD), and the treatment of patients with AMD (in one embodiment, wet AMD) comprises a dosing schedule after treatment initiation (in one embodiment, treatment initiation comprises 3 to 7 monthly administrations; in one embodiment, treatment initiation comprises 4 to 6 monthly administrations) that extends the dosing interval when the disease is stably absent, or shortens the dosing interval when disease activity is present.

[0300] 34. (The use of) the bispecific antibody according to embodiment 33, wherein the dosing schedule comprises the patient receiving Q8W or Q12W or Q16W dosing depending on their disease state (in one embodiment, Q4W or Q8W or Q12W or Q16W dosing depending on their disease state).

[0301] 35. (The use of) the bispecific antibody according to embodiment 33 or 34, wherein the stable absence of disease is determined to be

[0302] - Central subdomain thickness (CST) increased by <50 μm; and / or

[0303] - Best corrected visual acuity (BCVA / ETDRS) decreased by < 5 letters

[0304] and disease activity was determined to be

[0305] - Increase in central subdomain thickness (CST) by ≥50 μm; and / or

[0306] - A decrease in best-corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0307] 36. (The use of) the bispecific antibody according to embodiment 33 or 34, wherein the stable absence of disease is determined to be

[0308] - Central subdomain thickness (CST) less than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using an Optovue TM The device’s spectral domain optical coherence tomography (SD-OCT) measures below 295μm),

[0309] and disease activity was determined to be

[0310] - Central subdomain thickness (CST) greater than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures above 315 μm; in one embodiment, by using an Optovue TM The device's spectral domain optical coherence tomography (SD-OCT) measurements were above 295 μm).

[0311] In the following, embodiments of the present invention are listed:

[0312] 1. A method for treating a patient suffering from an ocular vascular disease, the method comprising administering to the patient an effective amount of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2),

[0313] wherein the bispecific antibody is administered intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0314] 2A. A method of treating a patient having an ocular vascular disease, the method comprising administering to the patient an effective amount of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiogenin, wherein the patient gains 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, in one embodiment 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart as compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody.

[0315] 2B. A method of treating a patient suffering from an ocular vascular disease, the method comprising administering to the patient an effective amount of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiogenin, wherein the patient experiences an improvement in vision following administration of the bispecific VEGF / ANG2 antibody, the improvement being as measured by gaining 12 or more (in one embodiment 13 or more, in one embodiment 14 or more, in one embodiment 15 or more) BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart as compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific VEGF / ANG2 antibody.

[0316] 3. The method according to any one of embodiments 2A to 2B,

[0317] wherein the bispecific antibody is administered (to be administered) intravitreally every 8 weeks or less (in one embodiment every 9 weeks or less; in one embodiment every 10 weeks or less; in one embodiment every 11 weeks or less; in one embodiment every 12 weeks or less; in one embodiment every 13 weeks or less; in one embodiment every 14 weeks or less; in one embodiment every 15 weeks or less).

[0318] 4. A method according to any one of embodiments 1 to 3, wherein the gain in letters in the BCVA / ETDRS letter score is measured at 4 weeks, and / or 8 weeks, and / or 12 weeks, and / or 16 weeks, and / or 20 weeks, and / or 24 weeks after the start of treatment, respectively.

[0319] 5. The method of any one of embodiments 1 to 3, wherein the gain of a letter in the BCVA / ETDRS letter score is measured at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks after start of treatment, respectively.

[0320] 6. The method according to any one of embodiments 1 to 5, wherein the bispecific antibody is used to prolong the time to retreatment and / or prolong the time to vision loss and, wherein retreatment with the bispecific antibody is administered when disease activity is determined to be:

[0321] An increase in central subdomain thickness (CST) of ≥50 μm (in one embodiment using spectral domain optical coherence tomography (SD-OCT)); and / or

[0322] A decrease in best-corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0323] 7. The method of any one of embodiments 1 to 6, wherein the bispecific antibody is administered after 3 to 7 monthly administrations of treatment initiation (in one embodiment, the treatment initiation comprises 3 to 5 monthly administrations; in one embodiment, the treatment initiation comprises 4 monthly administrations; in one embodiment, the treatment initiation comprises 5 to 7 monthly administrations; in one embodiment, the treatment initiation comprises 6 monthly administrations).

[0324] 8. A method according to any one of embodiments 1 to 7, wherein the ocular vascular disease is selected from the group consisting of wet age-related macular degeneration (wet AMD), neovascular AMD, diabetic macular edema (DME), cystoid macular edema (CME), non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), macular edema secondary to central retinal vein occlusion, macular edema secondary to retinal hemivenous occlusion, or macular edema secondary to branch vein occlusion, retinitis, conjunctivitis, uveitis, choroiditis, choroidal neovascularization (CNV) secondary to ocular inflammation (including ocular histoplasmosis or presumed histoplasmosis or choroiditis); myopic choroidal neovascularization (mCNV), and choroidal neovascularization secondary to trauma, retinopathy of prematurity, and rubeosis iridis / rubeosis iridis glaucoma.

[0325] 9. The method of any one of embodiments 1 to 7, wherein the ocular vascular disease is diabetic macular edema (DME).

[0326] 10. The method of any one of embodiments 1 to 7, wherein the ocular vascular disease is wet age-related macular degeneration (wet AMD) or neovascular age-related macular degeneration (nAMD).

[0327] 11. The method according to any one of embodiments 1 to 10, wherein the bispecific antibody that binds to VEGF and human ANG-2 is a VEGF antagonist / inhibitor and an ANG2 antagonist / inhibitor or inhibits the binding of VEGF to its receptor VEGFR and inhibits the binding of ANG2 to its receptor TIE2.

[0328] 12. The method according to any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 10 to 12 weeks.

[0329] 13. The method according to any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 11 to 13 weeks

[0330] 14. The method of any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 12 to 14 weeks.

[0331] 15. The method of any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 13 to 15 weeks.

[0332] 16. The method of any one of embodiments 1 to 11, wherein the bispecific antibody is administered every 14 to 16 weeks.

[0333] 17. The method according to any one of embodiments 1 to 16, wherein the bispecific antibody that binds to human VEGF and human ANG2 is a bispecific, bivalent anti-VEGF / ANG2 antibody comprising a first antigen binding site that specifically binds to human VEGF and a second antigen binding site that specifically binds to human ANG-2, wherein

[0334] i) the first antigen-binding site that specifically binds to VEGF comprises a CDR3H region of SEQ ID NO: 1, a CDR2H region of SEQ ID NO: 2, and a CDR1H region of SEQ ID NO: 3 in the heavy chain variable domain, and a CDR3L region of SEQ ID NO: 4, a CDR2L region of SEQ ID NO: 5, and a CDR1L region of SEQ ID NO: 6 in the light chain variable domain; and

[0335] ii) said second antigen-binding site that specifically binds to ANG-2 comprises in the heavy chain variable domain a CDR3H region of SEQ ID NO: 9, a CDR2H region of SEQ ID NO: 10 and a CDR1H region of SEQ ID NO: 11, and in the light chain variable domain a CDR3L region of SEQ ID NO: 12, a CDR2L region of SEQ ID NO: 13 and a CDR1L region of SEQ ID NO: 14,

[0336] And among them

[0337] iii) the bispecific antibody comprises a constant heavy chain region of human IgG1 subclass comprising the mutations I253A, H310A and H435A and the mutations L234A, L235A and P329G (numbering according to EU index of Kabat).

[0338] 18. The method according to embodiment 17, wherein

[0339] i) the first antigen binding site that specifically binds to VEGF comprises the amino acid sequence of SEQ ID NO: 7 as the heavy chain variable domain VH, and the amino acid sequence of SEQ ID NO: 8 as the light chain variable domain VL, and

[0340] ii) the second antigen-binding site that specifically binds to ANG-2 comprises the amino acid sequence of SEQ ID NO: 15 as the heavy chain variable domain VH, and the amino acid sequence of SEQ ID NO: 16 as the light chain variable domain VL.

[0341] 19. The method of embodiment 18, wherein the bispecific antibody that binds to human VEGF and human ANG2 comprises the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19, and SEQ ID NO: 20.

[0342] 20. The method of any one of embodiments 17 to 19, wherein the bispecific antibody is administered at a dose of about 5 to 7 mg (per treatment).

[0343] 21. The method of any one of embodiments 17 to 19, wherein the bispecific antibody is administered at a dose of about 6 mg (per treatment) (in one embodiment at a dose of 6 mg + / - 10% (per treatment) (in one embodiment, at a dose of 6 mg (per treatment)).

[0344] 22. The method of any one of embodiments 20 to 21, wherein the bispecific antibody is administered at a concentration of about 30 mg / ml.

[0345] 23. The method of any one of embodiments 20 to 21, wherein the bispecific antibody is administered at a concentration of about 120 mg / ml.

[0346] 24. The method according to any one of the preceding embodiments, wherein the patient suffering from an ocular vascular disease has not been previously treated with (is treatment naive) anti-VEGF therapy (eg, monotherapy).

[0347] 25. The method according to any one of the preceding embodiments, wherein the patient suffering from the ocular vascular disease has been previously treated with anti-VEGF therapy (eg, monotherapy).

[0348] 26. A method according to the preceding embodiments, wherein the ocular vascular disease is DME and treatment of patients suffering from DME comprises a fixed dosing schedule every 8 weeks (Q8W) after initiation of treatment (in one embodiment, initiation of treatment comprises 5 to 7 monthly administrations; in one embodiment, initiation of treatment comprises 6 monthly administrations).

[0349] 27. A method according to the preceding embodiments, wherein the ocular vascular disease is DME and treatment of patients suffering from DME comprises a fixed Q12W dosing schedule after initiation of treatment (in one embodiment, initiation of treatment comprises 5 to 7 monthly administrations; in one embodiment, initiation of treatment comprises 6 monthly administrations).

[0350] 28. The method of embodiment 27, wherein, after initiation of treatment, a first dosing cycle of Q8W is performed prior to a fixed Q12W dosing schedule.

[0351] 29. A method according to the preceding embodiments, wherein the ocular vascular disease is DME, and treatment of patients suffering from DME comprises a dosing schedule after treatment initiation that extends the dosing interval when the disease is stably absent, or shortens the dosing interval when disease activity is present (in one embodiment, treatment initiation comprises 3 to 7 monthly administrations; in one embodiment, treatment initiation comprises 4 to 6 monthly administrations).

[0352] 30. The method of embodiment 29, wherein the dosing schedule comprises the patient receiving Q8W or Q12W or Q16W dosing depending on their disease state (in one embodiment, Q4W or Q8W or Q12W or Q16W dosing depending on their disease state).

[0353] 31. The method of embodiment 28 or 29, wherein the stable absence of disease is determined to be

[0354] - Central subdomain thickness (CST) increased by <50 μm; and / or

[0355] - Best corrected visual acuity (BCVA / ETDRS) decreased by < 5 letters

[0356] and disease activity was determined to be

[0357] - Increase in central subdomain thickness (CST) by ≥50 μm; and / or

[0358] - A decrease in best-corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0359] 32. The method of embodiment 28 or 29, wherein the stable absence of disease is determined to be

[0360] - Central subdomain thickness (CST) less than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using an Optovue TM The device’s spectral domain optical coherence tomography (SD-OCT) measures below 295μm),

[0361] and disease activity was determined to be

[0362] - Central subdomain thickness (CST) greater than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures above 315 μm; in one embodiment, by using an Optovue TM The device's spectral domain optical coherence tomography (SD-OCT) measurements were above 295 μm).

[0363] 33. A method according to the preceding embodiment, wherein treatment of a patient with AMD (in one embodiment, wet AMD) comprises a dosing schedule after treatment initiation (in one embodiment, treatment initiation comprises 3 to 7 monthly administrations; in one embodiment, treatment initiation comprises 4 to 6 monthly administrations) that extends the dosing interval when the disease is stably absent, or shortens the dosing interval when disease activity is present.

[0364] 34. A method according to embodiment 33, wherein the dosing schedule includes the patient receiving Q8W or Q12W or Q16W dosing depending on their disease state (in one embodiment, Q4W or Q8W or Q12W or Q16W dosing depending on their disease state).

[0365] 35. The method of embodiment 33 or 34, wherein the stable absence of disease is determined to be

[0366] - Central subdomain thickness (CST) increased by <50 μm; and / or

[0367] - Best corrected visual acuity (BCVA / ETDRS) decreased by < 5 letters

[0368] and disease activity was determined to be

[0369] - Increase in central subdomain thickness (CST) by ≥50 μm; and / or

[0370] - A decrease in best-corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

[0371] 36. The method of embodiment 33 or 34, wherein the stable absence of disease is determined to be

[0372] - Central subdomain thickness (CST) less than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures less than 315 μm; in one embodiment, by using an Optovue TM The device’s spectral domain optical coherence tomography (SD-OCT) measures below 295μm),

[0373] and disease activity was determined to be

[0374] - Central subdomain thickness (CST) greater than about 300 μm (in one embodiment, by using a Spectralis TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 325 μm; in one embodiment, by using a Cirrus TM The device's spectral domain optical coherence tomography (SD-OCT) measures greater than 315 μm; in one embodiment, by using a Topcon TM The device's spectral domain optical coherence tomography (SD-OCT) measures above 315 μm; in one embodiment, by using an Optovue TM The device's spectral domain optical coherence tomography (SD-OCT) measurements were above 295 μm). Example

[0375] Treatment of patients with vascular ocular diseases with bispecific antibodies that bind to human VEGF and human ANG2

[0376] Example 1A: Efficacy and Durability in Treating Patients with Diabetic Macular Edema (DME)

[0377] Purpose

[0378] Main Purpose

[0379] The main aims of this study are to:

[0380] To evaluate the efficacy of a bispecific antibody that binds human VEGF and human ANG2, comprising the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19 and SEQ ID NO: 20 (this antibody VEGFang2-0016 and its production are also described in detail in WO2014 / 009465, which is incorporated herein by reference) compared to an effective comparator in patients with center-involving diabetic macular edema (CI-DME) who are treatment naive. This bispecific anti-VEGF / ANG2 antibody is designated herein as RO6867461 or RG7716 or VEGFang2-0016 or fasitumab. Vials of a sterile, colorless to brown, preservative-free solution of RO6867461 administered IVT at a dose of 1.5 mg or 6 mg every 4 weeks were used. The concentration of the bispecific antibody was about 120 mg / ml.

[0381] Secondary Purpose

[0382] The secondary objectives of this study are as follows:

[0383] To investigate the pharmacodynamics and anatomical findings to inform the mechanism of action of RO6867461.

[0384] To study the formation of plasma anti-RO6867461 antibodies.

[0385] To explore the duration of action of RO6867461.

[0386] Purpose of exploration

[0387] The exploratory objectives of this study are as follows:

[0388] To explore the predictive role of previous IVT anti-VEGF treatment on the efficacy of RO6867461.

[0389] To evaluate the efficacy and safety of RO6867461 compared with an active comparator in patients with CIDME with prior IVT anti-VEGF therapy.

[0390] To evaluate the effect of RO6867461 on the levels of plasma markers of angiogenesis and inflammation.

[0391] To investigate the concentration of RO6867461 in aqueous humor samples (optional) and vitreous samples (optional) and biomarkers of angiogenesis and inflammation if sample quantity permits.

[0392] To evaluate the improvement in diabetic retinopathy (DR) severity scores.

[0393] Study Design

[0394] This was a multicenter, multiple-dose, randomized, active comparator-controlled, double-blind, three-parallel-group, 36-week study in patients with CI-DME.

[0395] The three groups in this study are as follows:

[0396] Group A: 0.3 mg ranibizumab IVT

[0397] Group B: 1.5 mng RO6867461 IVT

[0398] Group C: 6 mg RO6867461 IVT

[0399] Only one eye will be selected as the study eye. If both eyes meet all eligibility criteria, the eye with worse BCVA will be defined as the study eye. If both eyes meet all eligibility criteria and have the same BCVA letter score on Day 1, the study eye will be selected at the discretion of the investigator.

[0400] Number of patients

[0401] Up to 210 patients were randomized.

[0402] Approximately 150 treatment-naive patients and approximately 60 patients previously treated with IVT anti-VEGF were enrolled in the study.

[0403] Approximately 50 treatment-naive patients were randomized in each group (1:1:1 randomization scheme), and approximately 30 patients previously treated with IVT anti-VEGF were randomized into groups A and C.

[0404] Target Audience

[0405] Male and female patients aged ≥18 years with CI-DME.

[0406] Inclusion / Exclusion Criteria

[0407] Inclusion Criteria

[0408] Patients must meet the following criteria to enter the study:

[0409] Eye Criteria for Study Eyes:

[0410] Macular edema associated with DR is defined as macular thickening by spectral domain optical coherence tomography (SD-OCT) involving the center of the macula: Screening with Spectralis TM Central subdomain thickness (CST) ≥ 325 μm (Heidelberg) (Where Spectralis is not available, the following devices and CST thresholds are acceptable: For Cirrus TM CST ≥ 315 μm for Topcon CST ≥ 315 μm for Optovue TM CST ≥ 295 μm).

[0411] Visual acuity decline was primarily attributable to DME, with best-corrected visual acuity (BCVA) letter scores of 73-24 letters, inclusive, on Early Treatment Diabetic Retinopathy Study (ETDRS)-like charts (20 / 40-20 / 320 Snellen equivalents) on Day 1.

[0412] Transparent ocular media and adequate pupil dilation to allow acquisition of high-quality retinal images to confirm the diagnosis

[0413] General criteria:

[0414] Diagnosis of diabetes mellitus (DM; type 1 or type 2) as defined by the World Health Organization and / or the American Diabetes Association

[0415] Able and willing to provide written informed consent and comply with the study protocol in accordance with the International Conference on Harmonization (ICH) and local regulations. Alternatively, a legally authorized representative must be able to consent to the patient in accordance with ICH and local regulations.

[0416] Age ≥ 18 years

[0417] For non-postmenopausal women (i.e., non-treatment-induced amenorrhea confirmed by FSH for ≥12 months if not taking hormone replacement) or surgically infertile (ovarian and / or uterine)) who agree to remain abstinent or use a combined contraceptive method that results in a failure rate of <1% per year during treatment and for at least 4 weeks after the last dose.

[0418] Abstinence is acceptable only if it is consistent with the patient's preference and usual lifestyle. Periodic abstinence (eg, calendar, ovulation, symptothermal, or postovulation methods) and withdrawal are not acceptable methods of contraception;

[0419] Examples of contraceptive methods with an expected failure rate of <1% per year include male sterilization, hormonal implants, the correct combination of oral or injectable hormonal contraceptives, and certain intrauterine devices. Alternatively, two methods can be used in combination (e.g., two barrier methods such as condoms and cervical caps) to achieve a failure rate of <1% per year, and spermicide must always be used to supplement the barrier method.

[0420] For males: Agree to use a barrier method of contraception during the treatment period of at least 4 weeks after the last dose of study drug

[0421] Patients must be willing not to participate in any other clinical trials, including investigational medicinal products (IMPs) or devices, until completion of the current study.

[0422] Exclusion criteria

[0423] Patients who met any of the following criteria were excluded from the study:

[0424] Eye Criteria for Study Eyes:

[0425] Any sign of high-risk PDR was defined as:

[0426] Any vitreous or preretinal hemorrhage

[0427] NVE ≥ 1 / 2 of the optic disc area in an area equivalent to the standard dilated ETDRS 7 visual field on clinical examination

[0428] Clinical examination: NVD ≥ 1 / 3 of the optic disc area

[0429] Any IVT anti-VEGF therapy within 3 months prior to Day 1

[0430] Any panretinal photocoagulation (PRP) treatment before Day 1

[0431] Any macular laser photocoagulation within 3 months before Day 1

[0432] History of vitreoretinal surgery

[0433] Any IVT or periocular corticosteroid therapy within 3 months prior to Day 1. or Any history of implants will not be permitted

[0434] Use of steroids for any cataract surgery or treatment of complications of cataract surgery within 3 months prior to Day 1

[0435] History of incisional glaucoma surgery

[0436] Uncontrolled glaucoma (eg, progressive loss of visual field or defined as intraocular pressure [IOP] ≥ 25 mmHg despite treatment with antiglaucoma medications)

[0437] Concurrent ocular conditions in the study eye:

[0438] History of rubeosis

[0439] Current or history of any ocular disease other than DME that may confound macular assessment or affect central vision (eg, age-related macular degeneration, retinal vein occlusion, uveitis, angioid streaks, histoplasmosis, active or inactive cytomegalovirus, pathological myopia, retinal detachment, macular traction, macular hole, severe cataract)

[0440] Any current ocular condition for which, in the investigator's opinion, visual loss would not improve with resolution of macular edema (e.g., foveal atrophy, pigmentary abnormalities, dense subfoveal hard exudates, non-retinal pathology)

[0441] Any active eye infection on day 1

[0442] Any active intraocular inflammation (grade trace or above) on day 1

[0443] Characteristics of the fellow eye:

[0444] Any anti-VEGF therapy within 7 days before Day 1

[0445] Any retinal condition that the investigators believe may require anti-VEGF therapy within 7 days from day 1

[0446] General criteria:

[0447] Any systemic anti-VEGF within 6 months before Day 1

[0448] Any major illness or major surgical procedure within 1 month before Day 1

[0449] Any high fever during the week before Day 1

[0450] Any stroke or myocardial infarction within 12 months before Day 1

[0451] Uncontrolled blood pressure (BP; defined as systolic BP >180 mmHg and / or diastolic BP >100 mmHg when the patient is at rest). If the patient's initial reading exceeds these values, a second reading may be obtained 30 minutes or more later on the same day or another day during the screening period. If the patient's BP needs to be controlled with antihypertensive medication, the patient should have been taking the same medication continuously for at least 1 month prior to Day 1.

[0452] Patients with HbA1c>12% at screening

[0453] Untreated diabetes or initiation of oral antidiabetic medication or insulin within 4 months prior to Day 1, or anticipated change in antidiabetic medication during the study period

[0454] Renal failure requiring kidney transplantation, hemodialysis, or peritoneal dialysis within 6 months prior to Day 1, or anticipated need for hemodialysis or peritoneal dialysis at any time during the study

[0455] History of other medical conditions, metabolic dysfunction, physical examination findings, or clinical laboratory findings that reasonably suspect a condition that contraindicates the use of an IMP or that could affect the interpretation of the study results or place the patient at high risk for treatment complications in the investigator's opinion

[0456] For women of childbearing potential, a positive blood pregnancy test

[0457] Breastfeeding women

[0458] Use of systemic corticosteroids within 1 month before Day 1

[0459] Any known hypersensitivity reaction to the active comparator, fluorescein, any component of the preparation used, dilution eye drops or any anesthetic and microbial drops used

[0460] Any other restrictions on the use of valid comparators

[0461] Any treatment with IMP within 3 months before Day 1

[0462] Duration of the study

[0463] The total study duration for each enrolled patient was up to 40 weeks (from screening to study completion) as follows:

[0464] Screening: Up to 4 weeks

[0465] Baseline: Day 1

[0466] Study treatment administration period: from day 1 to week 20

[0467] Observation period: from week 20 to week 36

[0468] Safety follow-up calls: During the observation period and 7 days after ranibizumab administration

[0469] End of the study

[0470] The end of the study was defined as the date on which the last patient's last observation (LPLO) occurred. The LPLO was expected to occur 36 weeks after the last patient was enrolled.

[0471] Efficacy and Pharmacodynamic Outcome Measures

[0472] The primary analysis population was treatment-naive patients. Additional analyses could be performed on the overall population and patients previously treated with IVT anti-VEGF.

[0473] The primary efficacy outcome measure of this study was the mean change in BCVA (ETDRS letters) from baseline at Week 24 in treatment-naive patients.

[0474] Anatomical outcome measures by SD-OCT:

[0475] Mean change from baseline in central foveal thickness at week 24

[0476] Mean change from baseline in mean CST (1 mm diameter) at Week 24

[0477] Proportion of patients with resolution of subretinal and intraretinal fluid at week 24

[0478] Anatomical outcome measurements by fundus fluorescein angiography (FFA)

[0479] Proportion of patients with resolution of macular exudates at week 24

[0480] Change from baseline in the size of the foveal avascular zone at week 24

[0481] Exploratory outcome measures

[0482] Exploratory outcome measures for this study included, but were not limited to, the following:

[0483] BCVA:

[0484] Difference in mean BCVA change from baseline between treatment-naive patients and patients previously treated with IVT anti-VEGF (differential effect of RO6867461)

[0485] Exploratory outcome measures related to persistence:

[0486] Time to CST increase ≥50 μm and / or loss of BCVA ≥5 letters due to DME compared with week 20 values

[0487] Time to retreatment with 0.3 mg ranibizumab after week 20

[0488] result

[0489] The primary efficacy analysis included all randomized patients and divided patients according to the randomized treatment group.

[0490] The primary efficacy variable was the change in BCVA from baseline to Week 24. The primary efficacy analysis was performed using a mixed model for repeated measures (MMRM) model.

[0491] Best corrected visual acuity

[0492] BCVA was measured at a starting test distance of 4 meters before mydriasis by a trained and certified VA examiner who was blinded to the study medication group assignment.

[0493] BCVA is achieved by using three Precision Vision TM The visual acuity was measured using a set of VA distance visual acuity charts (modified ETDRS charts 1, 2, and R). VA manuals were provided to the investigators. VA examiner and VA examination room credentials were obtained prior to any VA examination.

[0494] The BCVA examiner is blinded to the study eye and treatment assignment and will only perform refraction and BCVA assessments (e.g., vision specification manuals). The BCVA examiner has also been blinded to the BCVA letter score of the patient's previous visit and only knows the patient's previous visit refraction data. The BCVA examiner is not allowed to perform any other direct patient care tasks.

[0495] Table: Baseline ocular characteristics of study eyes

[0496]

[0497] The main efficacy outcome measures were Figure 1 shown. Figure 1 The primary efficacy endpoint is shown: change in BCVA from baseline over time to Week 24 for patients who have been treated for the first time so far. VA2 refers to the bispecific anti-VEGF / ANG2 antibody RO6867461, which comprises the amino acid sequence of SEQ ID NO: 17, the amino acid sequence of SEQ ID NO: 18, the amino acid sequence of SEQ ID NO: 19 and the amino acid sequence of SEQ ID NO: 20 (administered intravitreally at a dose of 6.0 mg or 1.5 mg), and RBZ refers to ranibizumab (administered intravitreally at a dose of 0.3 mg)).

[0498] Change from Baseline in Central Subfield Thickness (CST) (Study Eye)

[0499] A key secondary endpoint was the change from baseline in CST (central subfield thickness). Figure 2 The bispecific anti-VEGF / ANG2 antibody RO6867461 comprising the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19 and SEQ ID NO: 20 (administered intravitreally at a dose of 6.0 mg or 1.5 mg) was combined with ranibizumab (administered intravitreally at a dose of 0.3 mg). This secondary anatomical endpoint was directional in support of the primary outcome of BCVA.

[0500] Durability / re-treatment time

[0501] Criteria for the use of ranibizumab during the observation period

[0502] BCVA was assessed and SD-OCT imaging was performed at each visit after the last dose of study treatment (Week 20 visit) (except the Week 26 visit).

[0503] The BCVA and CST values ​​obtained at week 24 were compared with those obtained at visit week 20. The BCVA and CST values ​​at weeks 28, 32, and 36 were compared with those at week 24.

[0504] Patients will receive a single dose of 0.3 mg of ranibizumab and exit the study if they meet both of the following criteria:

[0505] CST increased by ≥50μm,

[0506] BCVA decreased by ≥5 letters due to DME

[0507] The results are as follows Figure 3 As shown: Figure 3 The time to retreatment after dosing interruption (after 20 weeks or 6 monthly dosing = time after last intravitreal (IVT) administration) is shown, based on disease activity assessed by both: BCVA decrease of ≥5 letters and CST increase of ≥50 μm. The bispecific anti-VEGF / ANG2 antibody RO6867461 comprising the amino acid sequence of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19 and SEQ ID NO: 20 (administered intravitreally at a dose of 6.0 mg or 1.5 mg) was administered with ranibizumab (administered intravitreally at a dose of 0.3 mg) for comparison.

[0508] As an overview, Figure 4 A schematic comparison based on published results with other treatment options for DME is presented (the following drugs are compared: (Ranibizumab), (aflibercept), brolucizumab and VA2 (RO6867461 / RG7716).

[0509] Example 1B: Efficacy and Durability in Treating Patients with Diabetic Macular Edema (DME)

[0510] In a further study similar to the study in Example 1A above, patients with DME (e.g., centrally involved diabetic macular edema (CI-DME)) are treated with a bispecific antibody that binds to human VEGF and human ANG2, comprising the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19, and SEQ ID NO: 20. As an effective comparator in treatment, e.g., aflibercept and / or ranibizumab and / or brolicuzimab will be used. Patients include anti-VEGF treatment naive patients (those not previously treated with anti-VEGF monotherapy, e.g., aflibercept and / or ranibizumab and / or brolicuzimab)), as well as a group of patients who have been previously treated with anti-VEGF monotherapy. The respective bispecific antibodies that bind to human VEGF and human ANG2 are designated RO6867461 or RG7716. Vials of a sterile, colorless to brown, preservative-free solution of RO6867461 administered IVT at 1.5 mg or 6 mg doses were used.

[0511] Use one or more of the following dosing schedules:

[0512] a) Patients with DME will be treated with a fixed Q8W dosing schedule after treatment initiation (e.g., 6 initial monthly injections)

[0513] b) Patients with DME will be treated with fixed Q12W dosing (on a schedule that begins with a cycle of Q8W) after treatment initiation (e.g., initial 6-month injections)

[0514] c) Patients with DME will be treated at the start of treatment (e.g., with 3-7 monthly initial injections) with a dosing schedule that extends the injection interval when the disease is stable and absent, or shortens the injection interval when disease activity is present. Such a schedule includes, for example, the patient receiving Q4W / Q8W / Q12W / Q16W dosing, depending on the patient's condition.

[0515] Disease stability assessment will be based on best corrected visual acuity (BCVA) and CST, and retinal thickness based on optical coherence tomography (OCT). Outcome measures and results will be evaluated as described, e.g., in Example 1. The primary endpoint will be between 45 and 60 weeks.

[0516] In one embodiment, the patient with DME is treatment naive (not previously treated with anti-VEGF monotherapy, e.g., aflibercept and / or ranibizumab and / or brolucizumab).

[0517] In one embodiment, the patient with DME was previously treated with anti-VEGF monotherapy, e.g., aflibercept and / or ranibizumab and / or brolucizumab).

[0518] In one embodiment, patients with DME will be treated with a fixed Q8W dosing schedule after initiation of treatment (eg, initial 6 monthly injections).

[0519] In one embodiment, patients with DME will be treated with fixed Q12W dosing (in one embodiment initially with a cycle of Q8W) after initiation of treatment (eg, initial 6 monthly injections).

[0520] In one embodiment, patients with DME will be treated with the following dosing regimen at the start of treatment (e.g., with 3-7 initial monthly injections): the injection interval is extended when the disease is stable, or the injection interval is shortened when there is disease activity. In one embodiment, such a regimen includes patients receiving Q4w / Q8w / Q12w / Q16w dosing depending on the patient's condition.

[0521] In one embodiment, patients suffering from AMD will be treated with the following dosing regimen at the start of treatment (e.g., with 3-4 initial monthly injections): extend the injection interval when the disease is not stable, or shorten the injection interval when there is disease activity. In one embodiment, such a regimen includes that the patient receives Q4W / Q8W / Q12W / Q16W dosing depending on the patient's condition.

[0522] Example 2A: Efficacy and Durability in Treating Patients with Age-Related Macular Degeneration (AMD)

[0523] Purpose and End Point

[0524] This study has evaluated the efficacy, safety and pharmacokinetics of RO6867461 administered at 12 and 16 week intervals in patients with neovascular age-related macular degeneration (nAMD). RO6867461 is a bispecific antibody that binds to human VEGF and human ANG2, comprising the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19 and SEQ ID NO: 20 (this antibody VEGFang2-0016 and its generation are also described in detail in WO2014 / 009465, which is incorporated herein by reference). This bispecific anti-VEGF / ANG2 antibody is designated herein as RO6867461 or RG7716 or VEGFang2-0016 or faricimab.

[0525] The specific objectives of the studies and corresponding endpoints are outlined below.

[0526] Purpose and corresponding endpoints

[0527] Main efficacy and purpose

[0528] To evaluate the efficacy of RO6867461 on visual acuity when administered at 2-week and 16-week intervals

[0529] The corresponding end point

[0530] Mean change from baseline BCVA at week 40 using an ETDRS-like graph Secondary efficacy objectives:

[0531] 1) To evaluate the efficacy of RO6867461 on additional visual outcomes

[0532] The corresponding end point

[0533] Mean change from baseline BCVA over time using an ETDRS-like graph

[0534] Proportion of patients gaining ≥15, ≥10, ≥5, or ≥0 letters of BCVA over time relative to baseline

[0535] Proportion of patients who avoid BCVA loss of ≥15, ≥10, ≥5, or ≥0 letters relative to baseline over time

[0536] Proportion of patients with BCVA of 20 / 40 or better over time

[0537] Proportion of patients with BCVA 20 / 200 or worse over time

[0538] 2) To evaluate the efficacy of RO6867461 in anatomical outcome measures using SD-OCT

[0539] The corresponding end point

[0540] Mean change from baseline in CFT over time

[0541] Mean change from baseline in mean CST (1 mm diameter) over time

[0542] Proportion of patients with intraretinal fluid, subretinal fluid, cysts, or pigment epithelial detachment over time

[0543] 3) To evaluate the efficacy of RO6867461 in anatomical outcome measures using FFA

[0544] The corresponding end point

[0545] Mean change from baseline in total CNV area at Week 40 and Week 52

[0546] Mean change from baseline in total area of ​​CNV components at Week 40 and Week 52

[0547] Mean change from baseline in total area of ​​leakage at Week 40 and Week 52

[0548] Exploratory efficacy objectives

[0549] Investigate the incidence of disease activity at week 24

[0550] The corresponding end point

[0551] Proportion of patients with disease activity at week 24

[0552] Security purpose

[0553] To evaluate the safety of multiple IVT doses of RO6867461 at 12- and 16-week intervals

[0554] The corresponding end point

[0555] Incidence and severity of ocular adverse events

[0556] Incidence and severity of non-ocular adverse events

[0557] Other safety data, including but not limited to reasons for study withdrawal, laboratory data, concomitant medications, vital signs, and physical examination results, will be listed and summarized descriptively

[0558] Exploratory pharmacokinetic / pharmacodynamic objectives

[0559] 1) To evaluate the systemic PK profile of RO6867461

[0560] The corresponding end point

[0561] Plasma concentrations of RO6867461 at specified times

[0562] 2) To evaluate the profiles of RO6867461, ranibizumab, free VEGF-A and Ang-2 in aqueous humor.

[0563] Relationship between aqueous humor RO6867461 concentration or PK parameters and free VEGF-A and Ang-2 concentrations

[0564] The corresponding end point

[0565] Relationship between ranibizumab concentration or PK parameters and free VEGF-A and Ang-2 concentrations in aqueous solution

[0566] Time course of free VEGF-A and Ang-2 concentrations in aqueous humor

[0567] Immunogenicity purpose

[0568] To study the formation of plasma anti-RO6867461 antibodies

[0569] The corresponding end point

[0570] The incidence of ADA during the study period

[0571] Exploratory biomarker objectives

[0572] Explore levels of potential biomarkers of angiogenesis and inflammation in aqueous humor at baseline and additional time points to assess response to RO6867461

[0573] The corresponding end point

[0574] Relationship between aqueous humor concentrations of potential biomarkers and primary and secondary endpoints

[0575] Abbreviations used above:

[0576] ADA = antidrug antibodies; Ang-2 = angiopoietin-2; BCVA = best-corrected visual acuity; CFT = foveal thickness; CNV = choroidal neovascularization; CST = central subfield thickness; ETDRS = Early Treatment Diabetic Retinopathy Study; FFA = fundus fluorescein angiography; IVT = intravitreal; PK = pharmacokinetics; SD-OCT = spectral-domain optical coherence tomography; VEGF-A = vascular endothelial growth factor A.

[0577] Study Design Figure 5 An overview of the study design is given)

[0578] Study Description

[0579] This is a Phase II, multicenter, randomized, active comparator-controlled, subject- and outcome assessor-blinded, parallel-group, 52-week study to investigate the efficacy, safety, and pharmacokinetics of RO6867461 administered at 12- and 16-week intervals in patients with nAMD who are treatment-naive.

[0580] Approximately 75 patients were enrolled and randomized in a 2:2:1 ratio to one of three treatment groups:

[0581] Arm A (Q12W): 6 mg RO6867461 intravitreally (IVT) every 4 weeks until Week 12 (4 injections), then 6 mg RO6867461 IVT every 12 weeks until Week 48 (injections at Weeks 24, 36, and 48; 3 injections)

[0582] · Arm B (Q16W): IVT 6 mg RO6867461 every 4 weeks until Week 12 (4 injections), then IVT 6 mg RO6867461 every 16 weeks until Week 48 (injections at Weeks 28 and 44; 2 injections). The protocol-defined Week 24 disease activity assessment required that Arm B patients with active disease (see criteria below) be switched to a 12-week dosing schedule of 6 mg RO6867461, starting at Week 24 and repeated at Weeks 36 and 48, for the remainder of the study.

[0583] Group C (comparator group): IVT 0.5 mg of ranibizumab every 4 weeks for 48 weeks (13 injections), with only one eye selected as the study eye. The total duration of the study for each patient will be up to 56 weeks, divided as follows:

[0584] Screening: Up to 4 weeks before or on the day of randomization

[0585] Randomization: Day 1

[0586] Study treatment administration: From day 1 to week 48

[0587] Final visit: Week 52

[0588] Patients had undergone a screening examination within 4 weeks of study treatment administration. Screening and Week 1 / Day 1 (randomization) visits may occur as a combined visit if all assessments (except informed consent) are completed within 48 hours. During Screening (or combined Screening / Day 1 visit), patient eligibility was assessed, including primary review of fundus photography (FP), spectral domain optical coherence tomography (SD-OCT), and fundus fluorescein angiography (FFA) to ensure that CNV secondary to AMD met the predetermined ocular criteria for the study. Patients who are deemed ineligible based on screening results for any of the following reasons may be rescreened:

[0589] Uncontrolled blood pressure

[0590] Administrative reasons (e.g., unable to schedule Day 1 within 28 days of screening visit)

[0591] Does not meet the eligibility criteria for the study eye (if the patient may be eligible to have a second eye enrolled after the initial screening period)

[0592] At the time of rescreening, all screening visit assessments were performed (except for FFA imaging), provided that the FFA images meeting the central reading center requirements were obtained within the 4 weeks prior to the new Day 1 visit (randomization).

[0593] On Day 1, eligible patients received their first IVT administration of either RO6867461 or ranibizumab according to the randomization schedule described above and following the established standard administration procedures. Patients returned to the ophthalmology clinic 7 days after the first IVT administration and then every 4 weeks for study treatment administration and assessments as outlined in the active schedule in the protocol. Sham IVT administration allocations were delivered to patients randomized to Arms A and B to maintain blinding throughout the study.

[0594] All patients were assessed for disease activity at Week 24. Patients randomized to Group B with active disease at Week 24 (see criteria below) were switched to a Q12W dosing regimen of 6 mg RO6867461 for the remainder of the study, starting injections at Week 24 and repeated at Weeks 36 and 48.

[0595] Active disease is defined as any of the following criteria:

[0596] Increase in thickness of the central subdomain ( CST>50 μm on OCT compared with the average CST of the two most recent visits (weeks 16 and 20)

[0597] or

[0598] An increase in CST of ≥75 μm compared with the lowest CST recorded at week 16 or week 20

[0599] or

[0600] A decrease in best-corrected visual acuity (BCVA) of at least 5 letters compared to the mean BCVA at the two most recent visits (weeks 16 and 20) due to nAMD disease activity

[0601] or

[0602] A decrease in BCVA of ≥10 letters compared with the highest BCVA recorded at Week 16 or Week 20 due to nAMD disease activity or

[0603] Presence of new macular hemorrhage due to nAMD activity

[0604] Patients will return for a final visit at Week 52. Following the final visit, follow-up for adverse events should be conducted as outlined in the protocol. If an unscheduled visit occurs, it should be assessed at the discretion of the investigator.

[0605] Patient Population: Approximately 75 treatment-naive patients with nAMD in the United States are expected to be enrolled and randomized in this study.

[0606] Target Audience

[0607] Inclusion Criteria

[0608] Patients met the following criteria for entry into the study: Eye Study Criteria

[0609] First-time treatment CNV secondary to AMD (nAMD)

[0610] Subfoveal CNV or juxtafoveal CNV with a subfoveal component (such as subretinal fluid, subretinal hyperreflective material, evidence of leakage, or hemorrhage) that correlates with CNV activity by FFA or SD-OCT

[0611] All types of CNV lesions (primarily classic, minimally classic, or occult CNV lesions) with: total lesion size (including blood, atrophy, fibrosis, and neovascularization) (by FFA) ≤ 6 disc areas, and CNV-constituting areas accounting for ≥ 50% of the total lesion size (by FFA) and effective CNV (evidence of leakage) confirmed by FFA and CNV extravasation (presence of fluid) confirmed by SD-OCT

[0612] Transparent ocular media and adequate pupil dilation to allow acquisition of high-quality retinal images to confirm general diagnostic criteria

[0613] Sign the informed consent form

[0614] Age on the first day ≥ 50 years old

[0615] ·Able to comply with the study protocol, in the investigator's judgment

[0616] For women of childbearing potential: agree to remain abstinent (avoid heterosexual intercourse) or use a contraceptive method with a failure rate of < 1% per year during treatment and for at least 28 days after the last dose of study treatment

[0617] • Patients must be willing not to participate in any other clinical trials, including investigational medicinal products (IMPs) or devices, until completion of the current study.

[0618] Exclusion criteria

[0619] Patients who met any of the following criteria were excluded from the study:

[0620] Eye Standards for Studying Eyes

[0621] The CNV is caused by a cause other than AMD, such as ocular histoplasmosis, trauma, pathological myopia, angioid streaks, choroidal rupture, or uveitis

[0622] Screening for central serous chorioretinopathy

[0623] Retinal pigment epithelial tear involving the macula

[0624] FFA subretinal hemorrhage greater than 50% of the total lesion area and / or foveal fibrosis or atrophy involving greater than 50% of the total lesion area and / or involving the fovea

[0625] Any prior or concomitant treatment for CNV, including (but not limited to) IVT therapy (steroids, anti-vascular endothelial growth factor [VEGF], tissue plasminogen activator, ocriplasmin, C3F8 gas, air), periocular medical intervention, argon laser photocoagulation, Verteporfin photodynamic therapy, diode laser, transpupillary thermotherapy, or surgical intervention Cataract surgery within 3 months of baseline assessment (Day 1)

[0626] Any other intraocular surgery (pars plana vitrectomy, glaucoma surgery, corneal transplant, radiotherapy)

[0627] · Previous IVT treatment (including anti-VEGF drug therapy) other than steroid IVT treatment to control complications of cataract · Previous periocular pharmacological intervention for ocular conditions concurrent with other retinal diseases

[0628] Any concurrent intraocular condition in the study eye (e.g., amblyopia, aphakia, retinal detachment, cataract, diabetic retinopathy or maculopathy, or epiretinal membrane with traction) that, in the investigator's opinion, could reduce the likelihood of visual improvement or require medical or surgical intervention during the study

[0629] Active intraocular inflammation (grade trace or above) in the study eye on Day 1 (prior to randomization) BCVA letter score of 73 to 24 letters (inclusive) on the Early Treatment Diabetic Retinopathy Study (ETDRS)-class chart (20 / 40 to 20 / 320 Snellen equivalent) on Day 1

[0630] Current vitreous hemorrhage in the study eye

[0631] Uncontrolled glaucoma in the study eye (e.g., progressive loss of visual field or defined as intraocular pressure [IOP] ≥ 25 mmHg despite treatment with antiglaucoma medications)

[0632] · Spherical lens equivalent of refractive error, indicating that the myopia of the study eye exceeded 8 diopters

[0633] History of primary or autoimmune uveitis in either eye

[0634] Active infectious conjunctivitis, keratitis, scleritis, or endophthalmitis in any eye on Day 1 (prior to randomization)

[0635] General Standards

[0636] Any major illness or major surgical operation within 1 month before screening

[0637] Uncontrolled blood pressure ([BP] defined as systolic BP >180 mmHg and / or diastolic BP >100 mmHg when the patient is at rest). If the patient's initial reading exceeds these values, a second reading may be taken later on the same day or another day during the screening period. If the patient's BP is controlled by antihypertensive medication, the patient should have been taking the same medication continuously for at least 30 consecutive days prior to Day 1.

[0638] · Stroke or myocardial infarction within 3 months before Day 1

[0639] History of other medical conditions, metabolic dysfunction, physical examination findings or clinical laboratory findings, reasonable suspicion of a condition that contraindicates the use of the investigational drug or that could affect the interpretation of the study results or place the patient at high risk for treatment complications in the opinion of the investigator

[0640] Women of childbearing potential who are pregnant or breastfeeding, or intend to become pregnant during the study, must have a negative urine pregnancy test result within 28 days prior to the start of study treatment. If the urine pregnancy test is positive, it must be confirmed by a serum pregnancy test.

[0641] Known hypersensitivity to ranibizumab, fluorescein, any component of the formulation, mydriatic solution, or any anesthetic or antimicrobial solution used

[0642] Treatment with investigational therapy within 3 months prior to initiation of study treatment

[0643] End of study

[0644] The end of the study is defined as the date of the last patient's last visit (LPLV). LPLV is expected to occur 52 weeks after the last patient is enrolled.

[0645] Duration of the study

[0646] The total duration of the study, from screening of the first patient to completion of the study, is expected to be approximately 18-19 months.

[0647] Pharmaceutical product testing products for research and study

[0648] RO6867461 drug product (120 mg / mL) is provided as a sterile, colorless to brown liquid, without preservatives. A vial of a sterile, colorless to brown, preservative-free solution of RO6867461 administered IVT at a 6 mg dose is used. The concentration of the bispecific antibody is approximately 120 mg / ml.

[0649] Dosage and administration,

[0650] RO6867461, ranibizumab and counterfeits

[0651] Patients were given 50 μL of IVT injection of RO6867461 or ranibizumab into the study eye, or sham administration according to the randomization schedule described below.

[0652] Arm A (Q12W): IVT 6 mg RO6867461 every 4 weeks until Week 12 (4 injections), then IVT 6 mg RO6867461 every 12 weeks until Week 48 (injections at Weeks 24, 36, and 48; 3 injections)

[0653] Arm B (Q16W): IVT 6 mg RO6867461 every 4 weeks until Week 12 (4 injections), then IVT 6 mg RO6867461 every 16 weeks until Week 48 (injections at Weeks 28 and 44; 2 injections)

[0654] Group C (comparative group): 0.5 mg of ranibizumab IVT every 4 weeks for 48 weeks (13 injections)

[0655] Select only one eye as the study eye.

[0656] Learning Assessment

[0657] At several consistent time points for assessment, the following sequence is suggested at the discretion of the investigator. The sequence may be adjusted to optimize time management for site personnel and patients unless explicitly stated as mandatory (i.e., italicized text):

[0658] Vital signs

[0659] Blood sampling: At the visit for FFA, blood sampling and angiography can be performed from the same venous cannula. The blood sample must be collected before the angiography.

[0660] Eye assessment and imaging

[0661] BCVA: BCVA must be obtained before pupil dilation. At the Screening and Day 1 visits, BCVA can be obtained before vital signs and blood sampling to avoid unnecessary scientific studies in patients who would have failed the screening based on the results of the BCVA letter score.

[0662] Slit lamp examination

[0663] Dilated pupils

[0664] SD-OCT

[0665] FP (+ infrared reflectivity)

[0666] FFA

[0667] Dilated binocular indirect high-power ophthalmoscopy

[0668] IOP: must be performed after all imaging assessments and should be performed using the same method throughout the study

[0669] Aqueous humor sampling (optional)

[0670] Disease-Specific Assessments

[0671] All ocular assessments were performed on both eyes unless otherwise stated in the activity schedule (Appendix 1).

[0672] Best corrected visual acuity

[0673] BCVA was measured at a starting test distance of 4 meters before dilation of the eyes by a trained and certified visual acuity (VA) examiner who was blinded to the study eye treatment assignment.

[0674] BCVA was measured using a set of three Precision Vision TM or Lighthouse distance visual acuity charts (modified ETDRS charts 1, 2, and R). The VA operation manual was provided to the investigators. VA examiner and VA examination room credentials were obtained prior to any VA examination.

[0675] The BCVA examiner is blinded to the study eye and treatment assignment and will perform both refraction and BCVA assessments (e.g., VA specification manual). The BCVA examiner is also blinded to the patient's previous visit BCVA letter score and may only know the patient's previous visit refraction data.

[0676] Additional eye assessment

[0677] Other eye assessments performed during the study included the following:

[0678] Slit lamp examination (the scale used to grade flare / cell and vitreous hemorrhage density is described in detail in Appendix 2)

[0679] Dilated binocular indirect high-power ophthalmoscopy

[0680] IOP

[0681] The IOP measurement method used for patients remained consistent throughout the study. IOP measurements were performed in both eyes after all imaging.

[0682] At the study treatment visit, IOP pressure was measured in the study eye before and 30 (± 15) minutes after study treatment administration; if IOP was ≥ 30 mmHg, IOP was reassessed after 30 (± 15) minutes. If IOP continued to increase, treatment was administered at the discretion of the investigator.

[0683] Finger count visual assessment

[0684] Post-treatment optic nerve head perfusion was assessed for each patient immediately following study treatment administration (within a maximum of 15 minutes after treatment administration) by testing finger count visual acuity, hand movement, or light perception, as appropriate, in the study eye.

[0685] Eye Imaging

[0686] The Central Reading Center provides sites with a Central Reading Center Manual and training materials for study-ordered eye imaging. Site personnel and imaging systems (if applicable) are certified by the Reading Center prior to obtaining study images as specified in the Central Reading Center Manual. All study subject eye images are obtained at the study site on certified / registered equipment only by trained and Central Reading Center-certified personnel. Copies of all study subject eye images are transferred to the Central Reading Center for storage and independent analysis, including confirmation of qualifications for defined image-related criteria.

[0687] Disease activity assessment at week 24

[0688] All patients were assessed for disease activity at Week 24. Patients randomized to Group B with active disease at Week 24 (see criteria below) were switched to a Q12W dosing regimen of 6 mg RO6867461 for the remainder of the study, starting injections at Week 24 and repeated at Weeks 36 and 48.

[0689] Active disease is defined as any of the following criteria:

[0690] Compared with the mean CST at the two most recent visits (weeks 16 and 20), Increase of CST on OCT CST>50μm,

[0691] or

[0692] An increase in CST of ≥75 μm compared with the lowest CST recorded at week 16 or week 20

[0693] or

[0694] A decrease in BCVA of at least 5 letters compared to the mean BCVA at the two most recent visits (weeks 16 and 20) due to nAMD disease activity

[0695] or

[0696] A decrease in BCVA of ≥10 letters compared with the highest BCVA recorded at Week 16 or Week 20 due to nAMD disease activity

[0697] or

[0698] New macular hemorrhages due to nAMD activity

[0699] result

[0700] Best corrected visual acuity (BCVA) and durability of BCVA gain (time to retreatment to maintain BCVA gain) between)

[0701] The main efficacy outcome measures were Figure 6 shown. Figure 6 The primary efficacy endpoint is shown: change in BCVA from baseline over time to Week 40. RO6867461 refers to the bispecific anti-VEGF / ANG2 antibody RO6867461 comprising the amino acid sequence of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19 and SEQ ID NO: 20 (administered intravitreally at a dose of 6.0 mg Q12W or Q16W), ranibizumab The initial BCVA gain in the RO6867461Q12W or Q16W groups was completely unchanged, comparable to that of ranibizumab. The range was similar in the Q4W group.

[0702] Change from Baseline in Central Subfield Thickness (CST) (Study Eye)

[0703] A key secondary endpoint was the change from baseline in CST (central subfield thickness). Figure 7 The bispecific anti-VEGF / ANG2 antibody RO6867461 comprising the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19 and SEQ ID NO: 20 (administered intravitreally at a dose of 6.0 mg Q12W or Q16W) was combined with ranibizumab (administered intravitreally at a dose of 0.3 mg Q4W). This secondary anatomical endpoint directly supports the primary outcome of BCVA. There was a greater reduction in CST with the bispecific anti-VEGF / ANG2 antibody RO6867461 than with ranibizumab at the start of treatment.

[0704] Example 2B: Efficacy and Durability in Treating Patients with Age-Related Macular Degeneration (AMD)

[0705] In a further study similar to the study in Example 2A above, patients with AMD (e.g., wet age-related macular degeneration (wAMD), in particular neovascular AMD)) are treated with a bispecific antibody that binds to human VEGF and human ANG2, the bispecific antibody comprising the amino acid sequences of SEQ ID NO: 17, SEQ ID NO: 18, SEQ ID NO: 19 and SEQ ID NO: 20. As an effective comparator in treatment, for example, aflibercept and / or ranibizumab and / or bromocriptine will be used. Patients include anti-VEGF treatment naive patients (those not previously treated with anti-VEGF monotherapy, such as aflibercept and / or ranibizumab and / or bromocriptine)), as well as a group of patients who have been previously treated with anti-VEGF monotherapy, such as aflibercept and / or ranibizumab and / or bromocriptine. The respective bispecific antibodies that bind to human VEGF and human ANG2 are designated RO6867461 or RG7716. Vials of a sterile, colorless to brown, preservative-free solution of RO6867461 administered IVT at 1.5 mg or 6 mg doses were used.

[0706] For example, use the following dosing schedule:

[0707] Patients with ADM will be treated with the following dosing regimen after treatment initiation (e.g., with 2-7 initial monthly injections): the injection interval is extended when the disease is stable, or the injection interval is shortened when the disease is active. Such a regimen includes, for example, depending on the patient's condition, the patient receives Q4W / Q8W / Q12W / Q16W dosing.

[0708] Disease stability assessment will be based on best corrected visual acuity (BCVA) and CST, and retinal thickness based on optical coherence tomography (OCT). Outcome measures and results will be evaluated as described, e.g., in Example 1. The primary endpoint will be between 45 and 60 weeks.

[0709] Example 3

[0710] Binding of anti-VEGF / ANG2 antibodies to VEGF, Ang2, FcγR, and FcRn

[0711] VEGF isoform kinetic affinity, including species cross-reactivity assessment

[0712] Approximately 12,000 resonance units (RU) of the capture system (10 μg / ml goat anti-human F(ab)'2; order number: 28958325; GE Healthcare Bio-Sciences AB, Sweden) were coupled to a CM5 chip (GE Healthcare BR-1005-30) at pH 5.0 using an amine coupling kit supplied by GE Healthcare. The sample and system buffers were PBS-T (10 mM phosphate-buffered saline, including 0.05% 20) pH 7.4. The flow cell was set to 25°C - the sample block was set to 12°C and primed twice with running buffer. The bispecific antibodies were captured by injecting a 50 nM solution for 30 seconds at a flow rate of 5 μl / min. The association was measured by injecting human hVEGF121, mouse mVEGF120 or rat rVEGF164 solutions at different concentrations in solution for 300 seconds starting from 300 nM (diluted 1:3) at a flow rate of 30 μl / min. The dissociation phase was monitored for up to 1200 seconds and triggered by switching from the sample solution to the running buffer. The surface was regenerated by washing with a glycine pH 2.1 solution for 60 seconds at a flow rate of 30 μl / min. The overall refractive index difference was corrected by subtracting the response obtained from the goat anti-human F(ab')2 surface. The blank injection (= double reference) was also subtracted. In order to calculate the apparent K D For other kinetic parameters, the Langmuir 1:1 model was used. The results are shown in Table 5.

[0713] Ang2 protocol affinity, including species cross-reactivity assessment

[0714] Solution affinity determines the affinity of an interaction by determining the concentration of the free interaction partner in an equilibrium mixture. Solution affinity assays involve <vegf-ang-2>The bispecific antibody was mixed with varying concentrations of the ligand (=Ang2). The maximum possible resonance units of the antibody (e.g. 17000 resonance units (RU)) were immobilized on the surface of a CM5 chip (GE Healthcare BR-1005-30) at pH 5.0 using an amine coupling kit supplied by GE Healthcare. The sample and system buffer was HBS-P pH 7.4. The flow cell was set to 25°C and the sample block was set to 12°C and primed twice with running buffer. To generate a calibration curve, increasing concentrations of Ang2 were injected into a BIAcore containing the immobilized VEGF-ANG-2> bispecific antibody. TM flow cell. The amount of bound Ang2 was determined as resonance units (RU) and plotted against concentration. Solutions of each ligand (11 concentrations from 0 to 200 nM for VEGF-ANG-2>bispecific antibody) were incubated with 10 nM Ang2 and allowed to reach equilibrium at room temperature. The free Ang2 concentration was determined based on a calibration curve generated before and after measuring the response of solutions with known amounts of Ang2. Using model 201, a 4-parameter fit was set up using XLfit4 (IDBS software) using the free Ang2 concentration as the y-axis and the antibody concentration for inhibition as the x-axis. The affinity was calculated by determining the inflection point of the curve. The surface was regenerated by washing once with a 0.85% H3PO4 solution at a flow rate of 30 μl / min for 30 seconds. The overall refractive index difference was corrected by subtracting the response obtained from the blank coupled surface. The results are shown in Table 6.

[0715] FcRn steady-state affinity

[0716] For FcRn measurements, the bispecific antibodies were compared to each other using steady-state affinity. Human FcRn was diluted into coupling buffer (10 μg / ml, sodium acetate pH 5.0) and quantified using BIAcore TM The guide was immobilized onto a C1-Chip (GE Healthcare BR-1005-35) by a targeted immobilization procedure to a final reaction of 200 RU. The flow cell was set to 25°C and the sample block was set to 12°C and primed twice with running buffer. The sample and system buffers were PBS-T (10 mM phosphate buffered saline, including 0.05% 20) pH 6.0. To evaluate different IgG concentrations for each antibody, concentrations of 62.5 nM, 125 nM and 250 nM, 500 nM were prepared. The flow rate was set to 30 μl / min and an association time of 180 s was chosen to continuously inject the different samples onto the chip surface. The surface was regenerated by injecting PBS-T pH 8 for 60 s at a flow rate of 30 μl / min. The overall refractive index difference was corrected by subtracting the response obtained from the blank surface. The buffer injection was also subtracted (= double reference). To calculate the steady-state affinity, the method from the Bia-Evaluation software was used. In short, the RU values ​​(RU max) were plotted against the analyzed concentrations to obtain a dose-response curve. Based on a 2-parameter fit, the upper asymptote was calculated, so that the half-maximal RU value and thus the affinity could be determined. The results are shown in Figure 5 and as shown in Table 7. Similarly, the affinity to cynomolgus monkey, mouse and rabbit FcRn can be determined.

[0717] FcγRIIIa measurement

[0718] For the measurement of FcγRIIIa, a direct binding assay was used. By using an amine coupling kit supplied by GE Healthcare, a capture system (1 μg / ml Penta-His; Qiagen) of about 3000 resonance units (RU) was coupled to a CM5 chip (GE Healthcare BR-1005-30) at pH 5.0. The sample and system buffer were HBS-P+pH 7.4. The flow cell was set to 25°C- and the sample block was set to 12°C- and triggered twice with running buffer. The FcγRIIIa-His-receptor was captured by injecting 100nM solution at a flow rate of 5μl / min for 60 seconds. Combination was measured by injecting 100nM bispecific antibodies or monospecific control antibodies (anti-Dig of IgG1 subclass and antibodies of IgG4 subclass) for 180 seconds with a flow rate of 30μl / . The surface was regenerated by washing with a glycine pH 2.5 solution at a flow rate of 30μl / min for 120 seconds. Because the binding of FcγRIIIa is different from the Langmuir 1:1 model, this assay only determines binding / no binding. Binding of FcγRIIa can be determined in a similar manner to FcγRIa. Results are shown in Figure 6 It was concluded that by introducing the mutation P329G LALA, binding to FcγRIIIa was no longer detectable.

[0719] Evaluation of independent VEGF and Ang2 <vegf-ang-2>Binding of bispecific antibodies

[0720] Approximately 3500 resonance units (RU) of the capture system (10 μg / ml goat anti-human IgG; GE Healthcare Bio-Sciences AB, Sweden) were coupled to a CM4 chip (GE Healthcare BR-1005-34) at pH 5.0 using an amine coupling kit supplied by GE Healthcare. The sample and system buffers were PBS-T (10 mM phosphate buffered saline including 0.05% 20) pH 7.4. The temperature of the flow cell was set to 25° C. and the temperature of the sample block was set to 12° C. Prior to capture, the flow cell was primed twice with running buffer.

[0721] The bispecific antibody was captured by injecting a 10 nM solution for 60 seconds at a flow rate of 5 μl / min. The independent binding of each ligand to the bispecific antibody was analyzed by determining the active binding capacity of each ligand, which was added sequentially or simultaneously (flow rate of 30 μl / min):

[0722] 1. Human VEGF was injected at a concentration of 200 nM for 180 seconds (to determine single binding of the antigen).

[0723] 2. Human Ang2 was injected at a concentration of 100 nM for 180 seconds (to determine single binding of the antigen).

[0724] 3. Human VEGF was injected at a concentration of 200 nM for 180 seconds, followed by an additional injection of human Ang2 at a concentration of 100 nM for 180 seconds (to determine the binding of Ang2 in the presence of VEGF).

[0725] 4. Human Ang2 was injected at a concentration of 100 nM for 180 seconds, followed by an additional injection of human VEGF at a concentration of 200 nM (to determine the binding of VEGF in the presence of Ang2).

[0726] 5. Human VEGF at a concentration of 200 nM and human Ang2 at a concentration of 100 nM were co-injected for 180 seconds (binding of VEGF and Ang2 was determined simultaneously).

[0727] The surface was regenerated by washing with 3 mM MgCl2 solution at a flow rate of 30 μl / min for 60 sec. The overall refractive index difference was corrected by subtracting the response obtained from the goat anti-human IgG surface.

[0728] The bispecific antibody is able to bind to both antigens independently of each other if the resulting final signals of methods 3, 4 and 5 are equal or similar to the sum of the respective final signals of methods 1 and 2. The results are shown in the table below, where VEGFang2-0016 (=RO6867461) was shown to be able to bind to VEGF and ANG2 independently of each other.

[0729] Evaluation of simultaneous VEGF and Ang2 expression <vegf-ang-2>Binding of bispecific antibodies

[0730] First, approximately 1600 resonance units (RU) of VEGF (20 μg / ml) were coupled to a CM4 chip (GE Healthcare BR-1005-34) at pH 5.0 using an amine coupling kit supplied by GE Healthcare. The sample and system buffers were PBS-T (10 mM phosphate buffered saline including 0.05% 20) pH 7.4. The flow cell was set to 25°C and the sample block was set to 12°C and primed twice with running buffer. Second, a solution of 50 nM bispecific antibody was injected at a flow rate of 30 μl / min for 180 seconds. Third, hAng-2 was injected at a flow rate of 30 μl / min for 180 seconds. The binding response of hAng-2 depended on the amount of bispecific antibody bound to VEGF and showed simultaneous binding. The surface was regenerated by washing with 0.85% H3PO4 solution at a flow rate of 30 μl / min for 60 seconds. Simultaneous binding was achieved by the hAng2 binding to the previously bound VEGF. <vegf-ang-2>Additional specific binding signals of the bispecific antibodies are shown.

[0731] Table: Results: Kinetic affinity of VEGF isoforms from different species

[0732] VEGFang2-0016-apparent affinity Human VEGF 121 ≤1pM (beyond Biacore manual) Mouse VEGF 120 No combination Rat VEGF 164 14nM

[0733] Table: Results Solution affinity for Ang2

[0734] VEGFang2-0016 KD[nM] Ang2 20 Cynomolgus monkey Ang2 13 Mouse Ang2 13 Rat Ang2 11

[0735] Table: Results: <vegf-ang-2>Affinity of bispecific antibodies for FcRn

[0736]

[0737]

[0738] Table: Results of binding to FcγRI-IIIa

[0739] VEGFang2-0016 FcγRIa No combination FcγRIIa No combination FcγRIIIa No combination

[0740] Table: Results: VEGF- and Ang2 <vegf-ang-2>Independent binding of bispecific antibodies

[0741] < / vegf>

Claims

1. Use of a bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) in the preparation of a medicament for treating an ocular vascular disease or a patient suffering from an ocular vascular disease, wherein the ocular vascular disease is macular edema secondary to central retinal vein occlusion, and the bispecific antibody is administered intravitreally every 12 weeks or less frequently, and The bispecific antibody that binds to human vascular endothelial growth factor (VEGF) and human angiopoietin 2 (ANG-2) is faricimab.

2. The use according to claim 1, wherein the patient gains 12 or more BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart compared to the patient's best corrected visual acuity (BCVA) letter score before administration of the bispecific antibody.

3. The use of claim 1, wherein the patient experiences an improvement in vision after administration of the bispecific antibody, as measured by gaining 12 or more BCVA letters measured using an Early Treatment Diabetic Retinopathy Study (ETDRS)-like chart compared to the patient's best corrected visual acuity (BCVA) letter score prior to administration of the bispecific antibody.

4. The use according to any one of claims 1 to 3, wherein the gain of letters in the BCVA BCVA / ETDRS is measured at 4 weeks, and / or at 8 weeks, and / or at 12 weeks, and / or at 16 weeks, and / or at 20 weeks, and / or at 24 weeks after the start of treatment.

5. The use according to any one of claims 1 to 3, wherein the gain of letters in the BCVA BCVA / ETDRS is measured after the start of treatment at 45 weeks, and / or at 46 weeks, and / or at 47 weeks, and / or at 48 weeks, and / or at 49 weeks, and / or at 50 weeks, and / or at 51 weeks, and / or at 52 weeks, and / or at 53 weeks, and / or at 54 weeks, and / or at 55 weeks, and / or at 56 weeks, and / or at 57 weeks, and / or at 58 weeks, and / or at 59 weeks, and / or at 60 weeks, respectively.

6. The use according to any one of claims 1 to 3, wherein the bispecific antibody is used to prolong the time to retreatment and / or prolong the time to vision loss (e.g., best corrected visual acuity (BCVA)) BCVA / ETDRS), and wherein retreatment is considered necessary when disease activity is determined to be: An increase in central subfield thickness (CST) of ≥50 μm (in one claim using spectral domain optical coherence tomography (SD-OCT)); and / or a decrease in best corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

7. The method according to any one of claims 1 to 3), wherein the bispecific antibody is administered after 3 to 7 treatment initiations of monthly administration.

8. The use according to any one of claims 1 to 3, wherein the bispecific antibody is administered every 12 weeks.

9. The use according to any one of claims 1 to 3, wherein the bispecific antibody is administered every 12 to 13 weeks.

10. The use according to any one of claims 1 to 3, wherein the bispecific antibody is administered every 12 to 14 weeks.

11. The use according to any one of claims 1 to 3, wherein the bispecific antibody is administered every 13 to 15 weeks.

12. The use according to any one of claims 1 to 3, wherein the bispecific antibody is administered every 14 to 16 weeks.

13. The use according to any one of claims 1 to 3, wherein the bispecific antibody is administered at a dose of about 5 to 7 mg per treatment.

14. The use according to any one of claims 1 to 3, wherein the bispecific antibody is administered at a dose of about 6 mg per treatment.

15. The use according to any one of claims 1 to 3, wherein the bispecific antibody is administered at a concentration of about 30 mg / ml.

16. The use according to any one of claims 1 to 3, wherein the bispecific antibody is administered at a concentration of about 120 mg / ml.

17. The use according to any one of claims 1 to 3, wherein the patient suffering from an ocular vascular disease has not been previously treated with an anti-VEGF therapy (eg monotherapy).

18. Use according to any one of claims 1 to 3, wherein the patient suffering from an ocular vascular disease has previously been treated with an anti-VEGF therapy (eg monotherapy).

19. The use according to any one of claims 1 to 3, wherein the treatment of the patient comprises a fixed dosing schedule of Q12W after initiation of treatment.

20. The use according to claim 19, wherein After treatment initiation, the first dosing cycle was Q8W prior to the fixed Q12W dosing schedule.

21. The use according to claims 1 to 3, wherein the treatment of the patient comprises a dosing schedule after the initiation of treatment which has a longer dosing interval in the stable absence of disease or a shorter dosing interval in the presence of disease activity.

22. The use according to claim 21, wherein the dosing schedule comprises the patient receiving Q12W or Q16W dosing depending on their disease state.

23. The use according to claim 21, wherein the stable absence of disease is determined as - an increase in central subdomain thickness (CST) of <50 μm; and / or - Best corrected visual acuity (BCVA / ETDRS) decreased by < 5 letters and disease activity is determined as - an increase in central subdomain thickness (CST) of ≥50 μm; and / or - A decrease in best-corrected visual acuity (BCVA / ETDRS) of ≥5 letters.

24. The use according to claim 21, wherein the stable absence of disease is determined as - a central subdomain thickness (CST) of less than about 300 μm, And disease activity was determined as - central subdomain thickness (CST) above about 300 μm.

Images