Pharmaceutical formulations and dosing regimens for treatment of amyotrophic lateral sclerosis

Abstract

Pharmaceutical formulations and dosing regimens for the treatment of antibody-based amyotrophic lateral sclerosis (ALS) are provided.

Description

Technical Field

[0001] The present invention relates to therapies for amyotrophic lateral sclerosis (ALS), in particular to dosing regimens and formulations of antibodies for treating ALS that bind to misfolded forms of superoxide dismutase 1 (SOD1). Background Art

[0002] Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease that primarily affects motor neurons in the motor cortex and spinal cord tracts, leading to severe disability and ultimately death. Approximately 90% of ALS cases have a sporadic origin (sporadic ALS, sALS), while the remaining 10% develop due to inherited gene mutations (familial ALS, fALS). The clinical presentation of these two groups of ALS is indistinguishable, suggesting that different pathways converge to a clear outcome, with degeneration of motor neurons and loss of muscle function leading to varying degrees of weakness and spasticity in the limbs, bulbar, and respiratory muscles. In most patients, the limb onset (also called spinal onset) begins with asymmetric painless weakness of the limbs, but in approximately 20% of patients, the weakness may be bulbar in onset, presenting as dysarthria or dysphagia. Patients with bulbar onset have a poor prognosis. Patients develop progressive disability that limits walking, communication, feeding, and independence. Decreased respiratory function can lead to respiratory insufficiency and failure, which is usually the cause of death unless permanent mechanical ventilation is chosen (Paulukonis et al., PLoS One 10 (2015), e0131965.2015, Poulin-Brière et al., Front. Neurosci. 15 (2021), 790114).

[0003] Although some efforts have been made to explain the pathogenic mechanism of ALS, and various mechanisms and cellular targets have been proposed, its cause remains unclear. There is currently no cure for ALS. The only ALS treatments currently approved worldwide are riluzole, (an oral drug that can extend survival by 2 to 3 months) and edaravone (Miller et al., Cochrane Database Syst. Rev. 3 (2012), CD001447). These therapies have limited effects on survival and disease progression, demonstrating a slowing of the rate of decline in the ALS Functional Rating Scale (ALSFRS) in some patients. More recently, sodium phenylbutyrate and tauroursodeoxycholic acid (PB and TUDCA), Relyvrio TM and Tofersen, QALSODY TMA combination of drugs has been approved for the treatment of ALS. However, none of the available therapies targets wt-SOD1, but rather does not reverse SOD1 pathology.

[0004] Therefore, there is an urgent need for therapies for ALS, preferably therapeutic interventions with disease-modifying effects. Summary of the invention

[0005] The solution to the problem of providing a therapy for amyotrophic lateral sclerosis (ALS) is provided by the embodiments characterized in the claims and the description and illustrated in the examples.

[0006] Thus, in a first aspect, the present invention generally relates to a dosing regimen for treating ALS with a recombinant antibody that binds to superoxide dismutase 1 (SOD1), i.e., an anti-SOD1 antibody, wherein the antibody is administered to a subject, i.e., a human patient, at a high dose, preferably by intravenous administration. In a related aspect, the present invention relates to a pharmaceutical formulation of the antibody, which is particularly suitable for this treatment regimen, in particular for intravenous administration. More specifically, the present invention relates to a recombinant antibody that selectively binds to a misfolded and preferably aggregated form of SOD1, for treating ALS by administering a dose of 1000 mg to 10,000 mg, preferably 1000 mg to 5000 mg, and most preferably about 2500 mg of the antibody to a patient in need thereof. Preferably, the administration is once every 1 to 4 weeks, more preferably once every 2 to 4 weeks, and most preferably once every 3 weeks. The pharmaceutical formulation of the present invention is characterized by a stable liquid aqueous formulation of an anti-SOD1 antibody comprising the antibody at a concentration of about 10 to 50 mg / mL, preferably about 20 mg / mL, in an L-histidine / L-histidine monohydrochloride buffer at a pH of about 6.0.

[0007] Different therapeutic strategies and targets have been tested in animal models with encouraging results, such as kinase inhibitors, gene therapy, antisense oligonucleotides (ASOs), antibody-based interventions, and gene editing using CRISPR / Cas9 technology; see, for example, Poulin-Brière et al., (2021), supra. In this context, therapeutic interventions based on passive immunity have also attracted attention against ALS, and as summarized by Poulin-Brière et al., approximately 15 antibody targets are currently being studied.

[0008] The present invention is based on (i) selecting appropriate targets and antibody species, (ii) developing pharmaceutical formulations in which the antibodies are stable and can be tolerated by patients even at high doses of the antibodies, and (iii) establishing a treatment regimen that guarantees optimal therapeutic prospects while being well tolerated by patients, conditions that are usually not met by antibody-based approaches.

[0009] Regarding the first point, a recombinant human monoclonal antibody specific for human misfolded SOD1 (mSOD1), designated AP-101, originally disclosed in International Application WO 2012 / 080518A1 and characterized in Maier et al., Sci. Transl. Med. 10. (2018) doi: 10.1126 / scitranslmed.aah3924, has been used and studied. In addition to its disease-modifying properties, recent experiments have also shown that anti-SOD1 antibodies have high specificity for mSOD1 in vivo, as confirmed by PET imaging.

[0010] Second, a pharmaceutical formulation of the anti-SOD1 antibody was developed that provided sufficient antibody stability and was demonstrated to be suitable for long-term infusion of high-dose antibodies; see Examples 3 to 6.

[0011] Third, an appropriate dosing regimen was established based on a multicenter, open-label, single ascending dose study (SAD) in ALS patients, using an open-label oncology-style 3+3 design (clinical trial identifier: NCT03981536), in which AP-101 was administered to patients by intravenous infusion (IV) at ascending dose levels of 100, 500, or 2500 mg over 1 hour, where certain time points for readout appear to be critical for assessing the safety, tolerability, and pharmacokinetics (PK) of antibody AP-101; see Examples 1 and 2. The potential to administer AP-101 at high doses at intervals of several weeks without toxicity or adverse effects was evaluated in a 1-month study in cynomolgus monkeys (Study 8384444), which included 2 IV injections 2 weeks apart. Monkeys are a relevant toxicology species because AP-101 binds to human and monkey SOD-1; AP-101 does not bind to rodent SOD1. No AP-101-related effects on toxicology or safety pharmacology parameters were observed at doses up to and including 400 mg / kg (24,000 mg for a 60-kg human), the highest dose tested. In addition, the half-life of AP-101 in monkey toxicity studies was estimated to be 19.5 days. Based on the PK observed in cynomolgus monkeys and humans, a dosing regimen of 2500 mg, preferably a 500 mg loading dose, every three weeks was derived to help achieve the desired steady state more quickly; see Table 3 in Example 2.

[0012] Thus, in one aspect, the present invention relates to a dosing regimen in the treatment of ALS, i.e., a recombinant antibody that selectively binds to the misfolded and preferably aggregated form of SOD1, for treating ALS by administering a dose of about 2500 mg of the antibody to a subject in need thereof, preferably once every 3 weeks. In a preferred embodiment, the administration is performed intravenously.

[0013] It has also been found to be advantageous to administer a loading dose of 500 mg of the antibody one day prior to the administration of the first 2500 mg antibody dose. This dosing regimen ensures that the subject to be treated reaches a steady state as quickly as possible.

[0014] Thus, in one embodiment of the dosing regimen of the present invention, the subject to be treated receives a loading dose of about 500 mg of the antibody, a dose of about 2500 mg of the antibody the next day, and then the antibody is administered once every 3 weeks. This preferred dosing regimen is schematically depicted in Figure 1 middle.

[0015] In one embodiment, the treatment will be carried out for a period of at least 6 months. In a particularly preferred embodiment of the dosing regimen of the present invention, the antibody will be administered once every 3 weeks at a dose of 2500 mg for a period of at least 6 months, prior to which a loading dose of 500 mg of the antibody is administered the day before the first maintenance (effective) dose of 2500 mg of the antibody is administered.

[0016] As mentioned above, there are different forms of ALS, namely sporadic amyotrophic lateral sclerosis (sALS) and familial amyotrophic lateral sclerosis (fALS). Therefore, the subject to be treated may suffer from fALS, or alternatively, the subject to be treated has sALS. Diagnosis of fALS and sALS can be performed using a highly sensitive immunoassay disclosed in international application WO 2021 / 185961 A1, which includes an anti-SOD1 antibody as a capture antibody for determining the presence and level of misfolded SOD1 (mSOD1) in the subject's body fluids, respectively. The antibody is preferably an antibody further defined below. Therefore, in a preferred embodiment of the present invention, the subject to be treated has been diagnosed using the immunoassay disclosed in WO 2021 / 185961 A1.

[0017] Preferably, the anti-SOD1 antibody used in the dosing regimen and pharmaceutical formulation of the present invention is human IgG, and most preferably human IgG1. In a preferred embodiment, the antibody is human IgG1m3 allotype.

[0018] In a particularly preferred embodiment, the anti-SOD1 antibody used in the dosing regimen and pharmaceutical formulation of the present invention is AP-101 or an equivalent antibody derived from the human antibody NI-204.12G7, as characterized in WO 2012 / 080518A1 and Maier et al., Sci. Transl. Med. 10. (2018) doi: 10.1126 / scitranslmed.aah3924. As further explained below, antibody AP-101 is a fully human IgG1m3 allotype antibody and thus comprises a human constant heavy chain (HC) amino acid sequence present in SEQ ID NO: 12 and a corresponding human constant light chain (LC), here a lambda light chain illustrated in SEQ ID NO: 13. As further explained below, IgG antibodies are composed of tetramers consisting of HC and two light LC chains linked by disulfide bonds.

[0019] The antibody AP-101 is preferably produced in Chinese Hamster Ovary (CHO)-K1 cells. CHO cells are the most widely used mammalian cells for the production of recombinant monoclonal antibodies because they are capable of post-translational modifications (PTMs) of antibody molecules, which also normally occur in humans. Through genetic manipulation by mutagenesis, different CHO daughter cells with improved quality have been established. These variants include CHO-K1, CHO-S, CHO-DXB11 and CHO-DG44.

[0020] Thus, in one embodiment, the antibodies for use according to the invention are produced in CHO cells, preferably in the CHO-K1 cell line, and purified from the cell culture medium for further use.

[0021] As shown in Example 7, the major PTMs identified in antibody AP-101 are HC modification of glutamine at the N-terminus to pyroglutamic acid, deletion of C-terminal lysine, and N-glycosylation. In this context, an N-glycosylation site was identified at position 303 (HC N303).

[0022] Thus, in one embodiment, the anti-SOD1 antibody for use according to the invention has lost the C-terminal lysine, i.e., the antibody has undergone C-terminal lysine cleavage. In particular, the C-terminal lysine is cleaved from the heavy chain of the antibody, preferably from each heavy chain of the antibody. In addition, or alternatively, the glutamine at the N-terminus is modified to pyroglutamic acid, i.e., the antibody has undergone N-terminal glutamyl cyclization. In addition, or alternatively, the antibody is glycosylated, in particular N-glycosylated. More particularly, the heavy chain of the antibody is glycosylated, even more particularly N303 of the heavy chain is glycosylated.

[0023] In a preferred embodiment, the anti-SOD1 antibody for use according to the present invention lacks a C-terminal cysteine, has a modified glutamine as pyroglutamic acid at the N-terminus, and includes at least one N-glycosylation site, or as used in a pharmaceutical formulation, preferably the majority of antibody species present in the formulation have the above modifications.

[0024] To evaluate the therapeutic effect of the antibody and the progression of ALS in human subjects, a pharmacodynamic evaluation can be performed as described in Example 2. In particular, the pharmacodynamic evaluation includes determining changes in the levels of total SOD1, misfolded SOD1 (mSOD1), phosphorylated neurofilament heavy chain (pNfH) and / or neurofilament light chain (NfL).

[0025] Therefore, in one embodiment of the treatment according to the present invention, the therapeutic effect of the antibody and the progression of ALS are monitored by evaluating one or more biomarkers, preferably any one of those mentioned above, more preferably selected from the group consisting of: phospho-neurofilament heavy chain (pNfH), neurofilament light chain (NfL) and misfolded SOD1 (mSOD1) or any combination thereof.

[0026] As mentioned above, riluzole and edaravone have been shown to prolong the survival of ALS patients, and therefore, in one embodiment, the invention relates to antibodies for use according to the invention, wherein the subject to be treated receives riluzole or edaravone. In another embodiment of the antibodies for use according to the invention, the subject to be treated receives a combination of sodium phenylbutyrate and tauroursodeoxycholic acid (PB and TUDCA) or tolfsin.

[0027] In general, concomitant medications should be avoided. However, over-the-counter medications, such as acetaminophen, may be administered for headache or for infusion reactions if observed. Alternatively, or in addition, antihistamines may be administered for infusion reactions if observed.

[0028] Thus, if headache or infusion reactions are observed during treatment according to the invention, in particular if infusion reactions are observed, acetaminophen or similar analgesics and antipyretics may be administered. Typically, 500 to 1000 mg of acetaminophen may be administered, and preferably 30 to 60 minutes before the start of administration of the antibody, in particular before the start of the infusion of the antibody (i.e., for subsequent doses). Administration of acetaminophen may be performed orally, or alternatively, intravenously.

[0029] In addition, or alternatively, if an infusion reaction is observed during treatment according to the invention, an antihistamine may be administered preferably 30 to 60 minutes before starting the infusion of the antibody (i.e., for subsequent dosing). Here too, the administration of the antihistamine may be carried out orally and intravenously, respectively.

[0030] In one embodiment of treatment according to the invention, if an infusion reaction is observed, both the above-mentioned doses of antihistamine and acetaminophen may be administered by the above-mentioned routes of administration.

[0031] In particularly preferred embodiments of all embodiments of the dosing regimens of the invention disclosed herein, the antibody is administered at a concentration of about 20 mg / mL, most preferably wherein the antibody is administered over a period of a minimum of 60 and a maximum of 120 minutes, with infusion rates of 500 mg (loading dose) and 2500 mg (maintenance or effective dose) over 60 minutes, respectively, being preferred.

[0032] In the event of a significant infusion reaction, the infusion rate should be reduced, preferably by 50%, and preferably the infusion should be completed at this lower rate. Thus, in one embodiment, administration of the antibody at the above 60 minute infusion rate is followed by, or interrupted to, an infusion rate that is about 50% lower, i.e., 120 minutes.

[0033] As highly complex proteins, antibodies are susceptible to a variety of physical and chemical degradation pathways. Antibodies are prone to aggregation during liquid storage, resulting in loss of biological activity and increased immunogenicity, which in turn leads to serious adverse reactions such as anaphylactic shock and other safety issues. In order to prevent the formation of aggregates that can cause undesirable immunogenicity or half-life changes, pharmaceutical antibody preparations usually contain one or more buffers to maintain a given pH range. Since aggregation is highly dependent on antibody concentration and the pH value of the preparation, selecting a suitable buffer system is a key step in obtaining a stable preparation. In addition, the desired preparation may depend on and should be suitable for and able to achieve the expected route of administration, so that patients can also tolerate treatment well.

[0034] As shown in the Examples, and demonstrated in the SAD study (Clinical Trials Government Identifier: NCT03981536) and monkey studies (Study 8384444), it is possible to establish a buffer system and develop a pharmaceutical formulation that provides adequate stability of the antibody in aqueous solution and also provides good tolerability when infused intravenously to a patient over 60 to 120 minutes. In particular, for the preferred dosing regimen of the present invention, in which the antibody is administered at a concentration of about 20 mg / mL, formulations in L-histidine / L-histidine monohydrochloride buffer at pH 6.0 have been found to be particularly suitable. Buffer system studies were conducted to determine the optimal buffer system for the antibody formulation, and based on the pH screening studies, L-histidine / L-histidine monohydrochloride buffer at pH 6.0 was selected as the final buffer system, which ensures that formulations including about 20 mg / ml of the antibody have long-term stability; see Examples 3 and 6 and Tables 14 to 17.

[0035] In addition, different types of excipients, including disaccharides (sucrose, trehalose, and sorbitol), amino acids (L-arginine-hydrochloride and L-methionine), and salts (NaCl) were evaluated through excipient studies to further enhance the stability of the antibody formulations. Thermal stability, formation of insoluble aggregates, and purity were monitored. Overall, sucrose and L-methionine at concentrations of 8% (w / v) and 0.1% (w / v), respectively, were selected as the best excipients for AP-101 formulations because they were shown to minimize the formation of low molecular weight and acidic species, thereby maintaining product purity; see Examples 3 and 6 and Tables 14 to 17.

[0036] In the surfactant type and strength screening study, four different polysorbate 80 (PS 80) concentrations (0.005%, 0.010%, 0.020% and 0.050% (w / v)) and two different poloxamer 188 concentrations (0.05% and 0.10% (w / v)) were tested. The number and purity of subvisible particles were evaluated. Polysorbate 80 at a concentration of 0.02% (w / v) was selected as the strength of the surfactant because the formation of subvisible particles was effectively inhibited and acceptable stability was shown; see Examples 3 and 6 and Tables 14 to 17.

[0037] Therefore, in another aspect, the present invention relates to a liquid aqueous pharmaceutical formulation (pharmaceutical formulation) of an anti-SOD1 antibody that selectively binds to a misfolded and / or aggregated form of SOD1, wherein the formulation comprises an antibody at a concentration of about 10-50 mg / mL in an L-histidine / L-histidine monohydrochloride buffer at a pH of about 6.0±1, wherein the antibody is stable at 5°C±2°C for at least 1 month, preferably up to 24 months; at 25°C±2°C for at least 1 month, preferably up to 6 months; and / or at 40°C±2°C for 1 week, as shown in Tables 14, 15, 16 and 17.

[0038] In principle, the antibody can be any anti-SOD1 antibody that preferably preferentially or exclusively recognizes the misfolded and preferably aggregated form of SOD1 over the physiological form of SOD1. In order to avoid the patient from producing "anti-drug antibodies" (ADA), the antibody is preferably a human antibody, typically human IgG, and most preferably human IgG1. In a preferred embodiment, the antibody is a human IgG1m3 allotype. Therefore, as described above, preferably, the anti-SOD1 antibody used in the dosing regimen and pharmaceutical formulation of the present invention is AP-101 or an equivalent antibody derived from the human antibody NI-204.12G7, as characterized in WO 2012 / 080518A1 and Maier et al., Sci. Transl. Med. 10. (2018) doi: 10.1126 / scitranslmed.aah3924; see also below.

[0039] As mentioned above, antibody AP-101 is preferably produced in Chinese Hamster Ovary (CHO)-K1 cells, and thus, in one embodiment, the antibody used in the pharmaceutical formulation of the present invention is produced in CHO cells, more particularly in the CHO-K1 cell line, and purified from the cell culture medium used for the formulation.

[0040] As also explained above, antibody AP-101 is a fully human IgG1m3 allotype antibody, and preferably comprises a heavy chain in which the glutamine at the N-terminus is modified to pyroglutamic acid, the C-terminal lysine is deleted, and / or is glycosylated, as explained in more detail above.

[0041] Therefore, in one embodiment, the formulation of the present invention comprises an anti-SOD1 antibody as defined above, wherein the antibody consists of two heavy chains having SEQ ID NO: 12 and two light chains having SEQ ID: 13, and wherein the glutamine at the N-terminus in the heavy chain is modified to pyroglutamic acid, the C-terminal lysine is deleted, and the heavy chain is N-glycosylated.

[0042] As shown in Example 7, about 99% to 100% of the antibodies present in a typical antibody preparation sample have an N-terminal pyroglutamic acid in the heavy chain, and about 94% of the antibodies have a deletion of the C-terminal lysine. Thus, in one embodiment, about 99% of the antibodies in the preparation of the invention have a heavy chain in which the N-terminal pyroglutamic acid is modified by an N-terminal glutamine, and / or about 94% of the antibodies have a deletion of the C-terminal lysine.

[0043] In one embodiment, the formulation of the invention comprises the antibody at a concentration of 20±5 mg / mL, preferably 20 mg / mL.

[0044] Additionally, or alternatively, the concentration of L-histidine / L-histidine monohydrochloride in the formulation of the present invention is 20±10 mM, preferably 20 mM.

[0045] Furthermore, in any of the aforementioned embodiments, the formulation of the present invention preferably further comprises an antioxidant, preferably L-methionine at a concentration of 0.1%±0.05% (w / v), most preferably L-methionine at a concentration of 0.1% (w / v).

[0046] Preferably, in addition or alternatively, any formulation of the invention further comprises a tonicity modifier, preferably sucrose at a concentration of 8% ± 1% (w / v), most preferably sucrose at a concentration of 8% (w / v).

[0047] In a further preferred embodiment, any formulation of the present invention further comprises a surfactant such as polysorbate, preferably polysorbate 80 at a concentration of 0.02% ± 0.01 (w / v), most preferably polysorbate 80 at a concentration of 0.02% (w / v).

[0048] The formulations of the present invention may have any of the above compositions, provided that the antibody remains stable at 5°C±2°C for at least 1 month, preferably up to 24 months; at 25°C±2°C for at least 1 month, preferably up to 6 months; and / or at 40°C±2°C for 1 week.

[0049] In particularly preferred embodiments, the formulations of the invention are substantially free of one or more excipients other than those specifically enumerated above.

[0050] As described above, the pharmaceutical formulation of the present invention is specifically developed for the dosage regimen of the present invention for treating ALS. Therefore, the dosage regimen of the present invention in the treatment of ALS is preferably carried out with the pharmaceutical formulation in the L-histidine / L-histidine monohydrochloride buffer of the present invention as described above, and is disclosed in more detail below and in the Examples. In this context, the pharmaceutical formulation that has been and is being used in clinical trials is the most preferred formulation of the present invention, which comprises or consists essentially of 20 mg / mL of an antibody, preferably AP-101, in 20 mM L-histidine / L-histidine monohydrochloride buffer at pH 6.0, 8% (w / v) sucrose, 0.1% (w / v) L-methionine and 0.02% (w / v) polysorbate 80.

[0051] In addition, the compatibility of the antibody formulations with clinically used materials was evaluated. In particular, compatibility with polyvinyl chloride IV bags, polypropylene syringes, PVC infusion set components, etc. was evaluated. Both 20 mg / mL and 5 mg / mL concentrations were evaluated, and the data provided in Tables 11 to 13 in Example 5 show that the formulations are compatible with the evaluated clinically used materials.

[0052] The physical and chemical integrity of biopharmaceuticals must be maintained not only during long-term storage, but also during administration. While some biopharmaceuticals are formulated and delivered for clinical administration without further manipulation, many of these products require varying degrees of handling by healthcare professionals. During handling and administration, the physical and chemical stability of protein drugs must be maintained.

[0053] When delivering a biopharmaceutical product via the intravenous route, several factors must be considered such as protein properties, formulation composition, concentration of active pharmaceutical ingredients, choice of diluent, product contact surface and / or infusion time and rate. The last critical factor to be evaluated is environmental effects (e.g., area lighting and temperature). The contact surface is of particular interest because proteins tend to adsorb on interfaces due to their amphiphilic nature. With the widespread use of various plastic polymers in syringes and intravenous infusion containers and tubing, the risk of losing proteins through adsorption is considerable. Current drug regulations require that drugs delivered intravenously are always within 10% of the nominal concentration; see Morar-Mitrica et al., MAbs.7 (2015), 792–803 and references cited therein.

[0054] Thus, in generally preferred embodiments, the formulations of the invention are suitable for intravenous administration.

[0055] The present invention also relates to a medicament comprising the formulation of the present invention, wherein the medicament is for use in the treatment of ALS, most preferably for use in the dosage regimen of the present invention as defined above.

[0056] The invention also relates to a pharmaceutical container comprising the formulation and the medicament of the invention, respectively. In a preferred embodiment, the container is a disposable glass vial providing 100 mg of the antibody at a concentration of 20 mg / mL.

[0057] In one embodiment, the container, in particular the vial, of the present invention comprises an overfill of about 10% by volume.

[0058] Unless otherwise defined, all technical and scientific terms used herein have the same meanings as those generally understood by those of ordinary skill in the art to which the present invention belongs. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, exemplary methods and materials are described below. All publications, patent applications, patents and other references mentioned herein are incorporated herein by reference in their entirety. Materials, methods and embodiments are illustrative only and not restrictive.

[0059] Other features and advantages of the invention will become apparent from the following detailed description, and from the claims.

[0060] For the avoidance of any doubt, it is emphasized that the expressions "in some embodiments", "in certain embodiments", "in certain cases", "in certain cases", "in further embodiments", "in one embodiment" and the like are used and mean that when reading any embodiment described therein, each feature of those embodiments is to be considered combined and the disclosure must be treated in the same way as if the combination of features of those embodiments would be specified in one embodiment. The same is true for any combination of embodiments and features exemplified in the appended claims and examples, which are also intended to be combined with the features of the corresponding embodiments disclosed in the specification, where the features of the embodiments are subordinate only for reasons of consistency and simplicity, and in fact, each combination of embodiments and features, which may be interpreted due to the (multiple) dependencies, must be regarded as having been explicitly disclosed and not as a choice among different options. In this context, the skilled person will understand that the embodiments and features disclosed in the examples of antibody AP-101 are intended to be generalized to any anti-SOD1 antibody and equivalents having substantially the same properties. BRIEF DESCRIPTION OF THE DRAWINGS

[0061] Figure 1 : A schematic diagram of one embodiment of the dosage regimen of the present invention.

[0062] Figure 2 : Pharmacokinetic characteristics of antibody AP-101 in the serum of ALS patients after administration of 100 mg, 500 mg and 2500 mg of the antibody, respectively. DETAILED DESCRIPTION

[0063] The present invention relates to the embodiments characterized in the claims, disclosed in the specification and further characterized in the following examples and figures, namely, in a first aspect, to a dosing regimen for treating amyotrophic lateral sclerosis (ALS) with a recombinant antibody that binds to SOD1, and in a related aspect, to a pharmaceutical preparation of an anti-SOD1 antibody that is particularly suitable for the treatment regimen. In particular, the present invention relates to a recombinant antibody that selectively binds to a misfolded and / or aggregated form of SOD1 for treating ALS in a dosing regimen by administering a high dose of the antibody, such as 1000 mg to 10,000 mg, preferably 1000 mg to 5000 mg, most preferably 2500 mg, preferably once every 1 to 5 weeks, most preferably once every 3 weeks, to a subject in need thereof, or by administering another treatment regimen that delivers the antibody to the subject with substantially the same area under the curve. The pharmaceutical preparation of the present invention is more particularly characterized by a stable liquid aqueous preparation of an anti-SOD1 antibody, comprising an antibody at a concentration of about 10 to 50 mg / mL in an L-histidine / L-histidine monohydrochloride buffer at a pH of about 6.0. More particularly, the present invention relates to embodiments as characterized in the claims, disclosed in the description and further illustrated in the following examples and figures.

[0064] Unless otherwise indicated, definitions of terms used herein are provided in Oxford Dictionary of Biochemistry and Molecular Biology, Oxford University Press, 1997, revised 2000 and reprinted 2003, ISBN 0 19 850673 2; Second edition published 2006, ISBN 0-19-852917-1 978-0-19852917-0.

[0065] In addition, unless otherwise indicated, the terms and expressions used herein to characterize the present invention are given as defined in WO 2012 / 080518 A1, especially in the "I. Definitions" section on pages 10 to 30, the disclosure of which is expressly incorporated herein by reference. The same applies to the general embodiments of antibodies, etc. disclosed in WO 2012 / 080518 A1.

[0066] As used herein, the term "about" refers to a value of ±10% of the listed value; preferably ±5%.

[0067] As used herein, the term "subject" or "patient" is a human patient (eg, a patient suffering from ALS). As used herein, the terms "subject" and "patient" are used interchangeably.

[0068] In one embodiment, administration of an antibody according to the invention is performed according to a specific clinical administration regimen (eg, at a specific dose and / or according to a specific administration regimen).

[0069] In one embodiment of the dosing regimen of the present invention, the anti-SOD1 antibody is administered at a fixed dose, i.e., it is fixed and is independent of the patient's weight. The term "fixed dose" refers to a dose administered to a patient regardless of the patient's weight or body surface area (BSA). Thus, a fixed dose or flat dose is not provided as a mg / kg dose, but rather as an absolute amount of the antibody. In one embodiment, the antibody is administered to a subject in need thereof at a fixed dose of 1000 mg to 10,000 mg, preferably 1000 mg to 9000 mg, more preferably 1000 mg to 7500 mg, more preferably 1000 mg to 5000 mg, more preferably 2000 mg to 3000 mg, and in particular 1000 mg, 1500 mg, 2000 mg, 2500 mg, 3000 mg, 3500 mg, 4000 mg, 4500 mg, 5000 mg, 5500 mg, 6000 mg, 6500 mg, 7000 mg, 7500 mg, 8000 mg, 8500 mg, 9000 mg, 9500 mg or 10,000 mg and any range therebetween, preferably 2500 mg.

[0070] In one embodiment of the dosing regimen of the present invention, the anti-SOD1 antibody is administered at a dose of milligrams per kilogram (mg / kg). In one embodiment, the antibody is administered to a subject in need thereof at a dose of 17 mg / kg to 167 mg / kg, preferably 17 mg / kg to 150 mg / kg, more preferably 17 mg / kg to 125 mg / kg, more preferably 17 mg / kg to 83 mg / kg, more preferably 33 mg / kg to 50 mg / kg, particularly 17 mg / kg, 25 mg / kg, 33 mg / kg, 42 mg / kg, 50 mg / kg, 58 mg / kg, 67 mg / kg, 75 mg / kg, 83 mg / kg, 92 mg / kg, 100 mg / kg, 108 mg / kg, 117 mg / kg, 125 mg / kg, 133 mg / kg, 142 mg / kg, 150 mg / kg, 158 mg / kg or 167 mg / kg and any range therebetween, preferably 42 mg / kg.

[0071] In one embodiment of the dosing regimen of the present invention, the antibody is administered to a subject in need thereof once every 1 to 5 weeks, preferably once every 2 to 4 weeks, in particular once a week, once every 2 weeks, once every 3 weeks, once every 4 weeks, once every 5 weeks, and any time range therebetween, most preferably once every 3 weeks.

[0072] In particular, in one embodiment of the dosing regimen of the present invention, the antibody is administered to a subject in need thereof once a week, once every 2 weeks, once every 3 weeks, once every 4 weeks, once every 5 weeks, and any time range therebetween, preferably once every 3 weeks, at a fixed dose of 1000 mg, 1500 mg, 2000 mg, 2500 mg, 3000 mg, 3500 mg, 4000 mg, 4500 mg, 5000 mg, 5500 mg, 6000 mg, 6500 mg, 7000 mg, 7500 mg, 8000 mg, 8500 mg, 9000 mg, 9500 mg or 10,000 mg, and any range therebetween, preferably 2500 mg.Thus, the dosage regimens of the invention include administration of the antibody at a dose of 1000 mg per week, 1000 mg every 2 weeks, 1000 mg every 3 weeks, 1000 mg every 4 weeks, 1000 mg every 5 weeks, 1500 mg per week, 1500 mg every 2 weeks, 1500 mg every 3 weeks, 1500 mg every 4 weeks, 1500 mg every 5 weeks, 2000 mg per week, 2000 mg every 2 weeks, 2000 mg every 3 weeks, 2000 mg every 4 weeks, 2000 mg every 5 weeks, 2500 mg per week, 2500 mg every 2 weeks, 2500 mg every 3 weeks, 2500 mg every 4 weeks, 2500 mg every 5 weeks, 3000 mg per week, 3000 mg every 2 weeks, 3000 mg every 3 weeks. 0mg, 3000mg every 4 weeks, 3000mg every 5 weeks, 3500mg every week, 3500mg every 2 weeks, 3500mg every 3 weeks, 3500mg every 4 weeks, 3500mg every 5 weeks, 4000mg every week, 4000mg every 2 weeks, 4000mg every 3 weeks, 4000mg every 4 weeks, 4000mg every 5 weeks, 4500mg every week, 4500mg every 2 weeks, 4500mg every 3 weeks, 4500mg every 4 weeks, 4500mg every 5 weeks, 5000mg every week, 5000mg every 2 weeks, 5000mg every 3 weeks, 5000mg every 4 weeks, 5000mg every 5 weeks, 5500mg every week, 5500mg every 2 weeks, 5500mg every 3 weeks 500mg, 5500mg every 4 weeks, 5500mg every 5 weeks, 6000mg every week, 6000mg every 2 weeks, 6000mg every 3 weeks, 6000mg every 4 weeks, 6000mg every 5 weeks, 6500mg every week, 6500mg every 2 weeks, 6500mg every 3 weeks, 6500mg every 4 weeks, 6500mg every 5 weeks, 7000mg every week, 7000mg every 2 weeks, 7000mg every 3 weeks, 7000mg every 4 weeks, 7000mg every 5 weeks, 7500mg every week, 7500mg every 2 weeks, 7500mg every 3 weeks, 7500mg every 4 weeks, 7500mg every 5 weeks, 8000mg every week, 8000mg every 2 weeks, 3 8000 mg per week, 8000 mg every 4 weeks, 8000 mg every 5 weeks, 8500 mg per week, 8500 mg every 2 weeks, 8500 mg every 3 weeks, 8500 mg every 4 weeks, 8500 mg every 5 weeks, 9000 mg per week, 9000 mg every 2 weeks, 9000 mg every 3 weeks, 9000 mg every 4 weeks, 9000 mg every 5 weeks, 9500 mg per week, 9500 mg every 2 weeks, 9500 mg every 3 weeks, 9500 mg every 4 weeks, 9500 mg every 5 weeks, 10000 mg per week, 10000 mg every 2 weeks, 10000 mg every 3 weeks, 10000 mg every 4 weeks, 10000 mg every 5 weeks, and preferably 2500 mg every 3 weeks.

[0073] The above dosage regimen is in principle applicable to any subject to be treated, regardless of its weight. As can be seen from Example 1, the weight of patients treated with 2500 mg of the antibody was between 60 kg and 120.9 kg. Of course, in the case where the weight of the subject to be treated is significantly greater than 121 kg or less than 60 kg, dosage adjustment may be beneficial to the treatment effect.

[0074] In one embodiment of the dosage regimen of the present invention, 17 mg / kg to 167 mg / kg, preferably 17 mg / kg to 150 mg / kg, more preferably 17 mg / kg to 125 mg / kg, more preferably 17 mg / kg to 83 mg / kg, more preferably 33 mg / kg to 50 mg / kg, and in particular 17 mg / kg, 25 mg / kg, 25 mg / kg, 42 mg / kg, 50 mg / kg, 58 mg / kg, 67 mg / kg, 75 mg / kg The antibody is administered to a subject in need thereof once a week, once every 2 weeks, once every 3 weeks, once every 4 weeks, once every 5 weeks, and any time range therebetween, preferably once every 3 weeks, at a dose of 1,000 mg / kg, 2,000 mg / kg, 4,000 mg / kg, 5,000 mg / kg, 6,000 mg / kg, 7,000 mg / kg, 8,000 mg / kg, 9,000 mg / kg, 10,000 mg / kg, 11,000 mg / kg, 12,000 mg / kg, 13,000 mg / kg, 14,000 mg / kg, 15,000 mg / kg, or 16,000 mg / kg, and any range therebetween, preferably once every 3 weeks. Thus, the dosing regimens of the invention include administration of the antibody at a dose of 17 mg / kg per week, 17 mg / kg every 2 weeks, 17 mg / kg every 3 weeks, 17 mg / kg every 4 weeks, 17 mg / kg every 5 weeks, 25 mg / kg per week, 25 mg / kg every 2 weeks, 25 mg / kg every 3 weeks, 25 mg / kg every 4 weeks, 25 mg / kg every 5 weeks, 25 mg / kg per week, 25 mg / kg every 2 weeks, 25 mg / kg every 3 weeks, 25 mg / kg every 4 weeks, 25 mg / kg every 5 weeks, 42mg / kg per week, 42mg / kg every 2 weeks, 42mg / kg every 3 weeks, 42mg / kg every 4 weeks, 42mg / kg every 5 weeks, 50mg / kg per week, 50mg / kg every 2 weeks, 50mg / kg every 3 weeks, 50mg / kg every 4 weeks, 50mg / kg every 5 weeks, 58mg / kg per week, 58mg / kg every 2 weeks, 58mg / kg every 3 weeks, 58mg / kg every 4 weeks, 58mg / kg every 5 weeks, 67mg / kg per week, 67mg / kg every 2 weeks,67mg / kg every 3 weeks, 67mg / kg every 4 weeks, 67mg / kg every 5 weeks, 75mg / kg every week, 75mg / kg every 2 weeks, 75mg / kg every 3 weeks, 75mg / kg every 4 weeks, 75mg / kg every 5 weeks, 83mg / kg every week, 83mg / kg every 2 weeks, 83mg / kg every 3 weeks, 83mg / kg every 4 weeks, 83mg / kg every 5 weeks, 92mg / kg every week, 92mg / kg every 2 weeks, 92mg / kg every 3 weeks, 92mg / kg every 4 weeks, 92mg / kg for 5 weeks, 100mg / kg per week, 100mg / kg every 2 weeks, 100mg / kg every 3 weeks, 100mg / kg every 4 weeks, 100mg / kg every 5 weeks, 108mg / kg per week, 108mg / kg every 2 weeks, 108mg / kg every 3 weeks, 108mg / kg every 4 weeks, 108mg / kg every 5 weeks, 117mg / kg per week, 117mg / kg every 2 weeks, 117mg / kg every 3 weeks, 117mg / kg every 4 weeks, 117mg / kg every 5 weeks g, 125mg / kg per week, 125mg / kg every 2 weeks, 125mg / kg every 3 weeks, 125mg / kg every 4 weeks, 125mg / kg every 5 weeks, 133mg / kg per week, 133mg / kg every 2 weeks, 133mg / kg every 3 weeks, 133mg / kg every 4 weeks, 133mg / kg every 5 weeks, 142mg / kg per week, 142mg / kg every 2 weeks, 142mg / kg every 3 weeks, 142mg / kg every 4 weeks, 142mg / kg every 5 weeks, 150mg / kg per week g / kg, 150mg / kg every 2 weeks, 150mg / kg every 3 weeks, 150mg / kg every 4 weeks, 150mg / kg every 5 weeks, 158mg / kg every week, 158mg / kg every 2 weeks, 158mg / kg every 3 weeks, 158mg / kg every 4 weeks, 158mg / kg every 5 weeks, 167mg / kg every week, 167mg / kg every 2 weeks, 167mg / kg every 3 weeks, 167mg / kg every 4 weeks, 167mg / kg every 5 weeks, and preferably 42mg / kg every 3 weeks. ,

[0075] In one embodiment of the dosing regimen of the present invention, the subject to be treated receives a loading dose of the antibody on day 1, followed by a different maintenance dose on day 2 and every 1 to 5 weeks, preferably 2 to 4 weeks, and most preferably 3 weeks thereafter. In a preferred embodiment, the subject to be treated receives a loading dose of the antibody on day 1, followed by a different maintenance dose on day 2, day 22 ± 3 days, day 43 ± 3 days, day 64 ± 3 days, day 85 ± 3 days, day 106 ± 3 days, day 127 ± 3 days, day 148 ± 3 days, and day 169 ± 3 days. The maintenance dose is preferably any of the above doses, but preferably 2500 mg and 42 mg / kg, respectively, and most preferably 2500 mg. The loading dose is preferably 200 to 800 mg and 3 to 13 mg / kg, respectively, more preferably 300 to 700 mg and 5 to 11 mg / kg, respectively, more preferably 400 to 600 mg and 7 and 10 mg / kg, respectively, and most preferably 500 mg and 8 mg / kg, respectively, and in particular 500 mg.

[0076] In one embodiment of the dosage regimen, the treatment is maintained for at least 4 months, preferably at least 5 months, more preferably at least 6 months (maintenance phase). However, in general, there is no restriction on the duration of treatment, and in one embodiment of the dosage regimen of the present invention, the treatment is carried out for one year, two years, three years or several years. In one embodiment, as long as clinical benefit is observed, the treatment is continued throughout the patient's life until the disease is cured, unless uncontrollable toxicity and / or disease progression occur.

[0077] The term "loading dose" refers to the initial dose administered to a patient. The term "maintenance phase" refers to the second phase of the dosing regimen, which, in a preferred embodiment, begins on Day 2. The term "maintenance dose" (or effective dose) refers to the dose administered to a patient after the loading dose and is administered during the maintenance phase.

[0078] In one embodiment of the dosing regimen of the invention, the antibody is administered at a concentration of about 10 mg / mL to 50 mg / mL, preferably about 10 mg / mL to 40 mg / mL, preferably about 20 mg / mL to 30 mg / mL, and most preferably about 20 mg / mL.

[0079] Administration of the antibody can be achieved in different ways, for example, by intravenous, intraperitoneal, subcutaneous, intramuscular, intranasal, oral, topical or intradermal administration or spinal or brain delivery. Aerosol formulations such as nasal spray formulations include purified aqueous solutions or other solutions of the active agent with preservatives and isotonic agents. Such formulations are preferably adjusted to a pH and isotonic state compatible with the nasal mucosa. Preparations for rectal or vaginal administration can be presented as suppositories with suitable carriers. In a preferred embodiment of the invention, the antibody is administered intravenously.

[0080] In this context, as described above, a pharmaceutical formulation in L-histidine / L-histidine monohydrochloride buffer at a pH of about 6.0 has been developed that is particularly suitable for intravenous administration of an anti-SOD1 antibody at a concentration of 20 mg / mL, as described in another aspect of the invention and in the Examples below. Thus, in the most preferred embodiment of the dosing regimen of the invention, the antibody is administered in a pharmaceutical formulation according to the invention by any of the embodiments disclosed herein.

[0081] In one embodiment of the dosing regimen of the present invention, 500 mg (loading dose) and 2500 mg (maintenance or effective dose) of the antibody are administered in a minimum time period of 60 and a maximum time period of 120 minutes, respectively, preferably in a 60-minute time period. In one embodiment, the antibody is administered over at least 60 minutes, wherein the infusion duration can be increased, or the infusion can be stopped if deemed necessary or if an infusion reaction is observed. However, intravenous administration needs to be preferably completed within no more than 120 minutes after the start of the infusion. When administering a higher or lower dose of the antibody, the infusion time can be appropriately increased or decreased.

[0082] Hypersensitivity reactions may occur after administration of any monoclonal antibody. Acute hypersensitivity reactions, including infusion reactions or severe allergic reactions, may occur during the infusion process or within a few hours of infusion. Subjects should be monitored for hypotension, fever, chills, bronchospasm, angioedema and other severe allergic reaction symptoms or signs. The infusion should be slowed down or stopped, and the reaction should be managed. In particular, in the case of a significant infusion reaction, the infusion rate should be reduced, preferably by 50%. In one embodiment, if the infusion rate has been reduced, the infusion is completed at a lower rate. In one embodiment, if the infusion rate has been reduced, for example, when the infusion reaction is alleviated, the infusion rate is increased to its previous rate (before reduction) again. Therefore, in one embodiment, after the antibody is administered at the above-mentioned infusion rate, it is performed, or interrupted to perform an infusion rate of about 50% lower, preferably wherein the required amount of antibody is administered in a time period of at least 120 minutes and at most 240 minutes, for example 500 mg (loading dose) and 2500 mg (maintenance or effective dose) are administered respectively.

[0083] Generally, according to the present invention, a prodrug should not be administered prior to administration of the antibody. However, if an infusion reaction occurs, appropriate medications may be used at the discretion of one or more of the investigators of the study. If an infusion reaction is observed, acetaminophen (500 to 1000 mg) and / or an antihistamine may be administered orally or intravenously 30 to 60 minutes prior to the start of the infusion for subsequent dosing. In addition, acetaminophen may be used to treat headaches.

[0084] Thus, if headache or infusion reactions are observed during the treatment according to the invention, but in particular if infusion reactions are observed, paracetamol, preferably 500 to 1000 mg, may be administered, and preferably before the start of administration of the antibody, in particular 30 to 60 minutes before the start of the infusion of the antibody (i.e. for subsequent dosing). Administration of paracetamol may be performed orally or intravenously. In addition to paracetamol, other antipyretic analgesics may be administered, such as acidic (non-steroidal anti-inflammatory drugs, NSAIDs) and non-acidic (paracetamol, pyrazolones) drugs, and selective cyclooxygenase-2 (COX-2) inhibitors, such as those reviewed in Hinz and Brune, Handb. Exp. Pharmacol. 177 (2007), 65-93.

[0085] Additionally, or alternatively, if infusion reactions are observed during treatment according to the invention, an antihistamine may be administered, preferably 30 to 60 minutes prior to starting the antibody infusion (ie, for subsequent dosing), wherein the antihistamine may be administered orally or intravenously.

[0086] In one embodiment of treatment according to the invention, if an infusion reaction is observed, both the above-mentioned doses of antihistamine and acetaminophen may be administered by the above-mentioned routes of administration.

[0087] In one embodiment, during treatment according to the invention, the antibody is administered with one or more additional drugs or therapeutic agents for treating ALS. The additional agent can be, for example, a therapeutic agent recognized in the art for treating ALS. The combination can also include more than one additional agent, such as two or three additional agents. In one embodiment, a patient treated according to the invention is treated with riluzole, which is approved by the US Food and Drug Administration for treating ALS. Edaravone Treatment, or treatment with both riluzole and edaravone. Preferably, the patient takes a stable dose of riluzole and / or edaravone before treatment according to the invention is started. In one embodiment, treatment with riluzole and / or edaravone is started simultaneously with treatment with an antibody according to the invention.

[0088] In one embodiment, the additional therapeutic agent is an agent that reduces SOD1 levels, such as pyrimethamine (Lange et al. Ann. Neurol. 81 (2017), 837-848), a therapeutic agent for gene silencing, such as morpholino oligonucleotides (MO) or a therapeutic agent for non-specific treatment, such as rapamycin. In addition, the additional therapeutic agent can be an agent for some specific symptoms of ALS, such as, analgesics or muscle relaxants. Therefore, the additional therapeutic agent is preferably baclofen ( ) or diazepam It can help relieve spasticity. Accumulation of saliva in the mouth due to difficulty swallowing is also a symptom of ALS and can be treated with different drugs, which are additional therapeutic agents according to the present invention. Preferably, the therapeutic agent is (amitriptyline), trihexyphenidyl, (scopolamine patch) or (Glycopyrrolate).

[0089] In one embodiment, the additional therapeutic agent is another antibody for treating ALS, such as a C5 antibody, such as ravulizumab or eculizumab. WO 2015 / 134894A1 describes ravulizumab (also known as BNJ441, ALXN1210 or ). Eculizumab (also known as (Soliris)).

[0090] As mentioned above, two forms of ALS are known, i.e., familial ALS (fALS) and sporadic ALS (sALS), and there is strong evidence that both genetic and non-genetic drivers of SOD1 misfolding lead to the formation of toxic conformers that initiate and drive the pathogenesis of ALS, i.e., fALS and sALS are driven by pathogenic SOD1 accumulation. Importantly and in support of this hypothesis, recent evidence suggests that misfolded SOD1 aggregates can also be detected in the spinal cord of sALS patients, indicating common elements in the disease pathology between familial and sporadic ALS (Li and Cashman, Prion 8 (2014), 33-41; Bosco et al., Nat. Neurosci. 13 (2010), 1396-403; Forsberg et al. Acta Neuropathol. 121 (2011), 623-34; Forsberg et al., PLos One 5 (2010), e11552).

[0091] Thus, a subject to be treated according to the present invention may be suffering from fALS or sALS.

[0092] Diagnosis of fALS and sALS can be performed using a highly sensitive immunoassay disclosed in WO 2021 / 185961 A1, which includes an anti-SOD1 antibody as a capture antibody for determining the presence and level of misfolded SOD1 (mSOD1) in a subject's body fluid, respectively. The antibody is preferably an antibody further defined below. The assay is particularly capable of identifying patients with sALS with a high degree of certainty. Therefore, in one embodiment of the invention, the subject to be treated has been diagnosed using the immunoassay disclosed in WO 2021 / 185961 A1, the contents of which are hereby incorporated by reference herein.

[0093] In one embodiment, ALS is defined in a subject to be treated according to the present invention using the King's ALS clinical staging system (Roche et al., Brain 135 (Part 3) (2012), 847-8S2). The King's ALS system classifies the degree of ALS progression in a patient or subject according to the occurrence of discrete milestones, defined as the first appearance of ALS symptoms (e.g., a central nervous system region (defined as the medulla, upper limbs, lower limbs, or diaphragm) is functionally affected by weakness, weight loss, spasticity, dysarthria, or dysphagia), diagnosis, secondary region functional involvement, tertiary region functional involvement, and the need for gastrostomy and non-invasive ventilation. Based on these observable and measurable events, the King's system classifies ALS progression according to the following four stages: Stage 1—onset of symptoms, primary region involvement; Stage 2A—diagnosis; Stage 2B—second region involvement; Stage 3—third region involvement; Stage 4A—need for gastrostomy; and Stage 4B—need for non-invasive ventilation.

[0094] In one embodiment, ALS is defined as meeting the possible, laboratory-supported possible, probable, or definite criteria for a diagnosis of ALS in a subject to be treated according to the present invention according to the revised World Federation of Neurology El Escorial criteria.

[0095] Thus, in one embodiment, a subject to be treated in accordance with the present invention has possible, clinically probable, clinically probable-laboratory supported, or definite fALS or sALS according to the El-Escorial criteria, or has been diagnosed with ALS as defined by the Gold Coast criteria; progressive movement disorders documented by history or repeated clinical examinations, previously normal motor development, the presence of upper and lower motor neuron dysfunction in at least one body site, or the presence of lower motor neuron dysfunction in at least two body sites, and investigations to exclude other conditions.

[0096] In one embodiment, the subject to be treated according to the invention is diagnosed with an ALS onset, defined as the time of first onset of muscle weakness (e.g., limb weakness, dysarthria, dysphagia and / or shortness of breath) no more than 24 to 60 months, preferably no more than 48 months, and most preferably within the past 24 months prior to evaluation for treatment with the antibody.

[0097] In one embodiment, a subject to be treated according to the invention has an upright slow vital capacity (SVC) of at least 50% at the time of evaluation for treatment with the antibody.

[0098] It is well known that further neurodegenerative diseases such as Alzheimer's disease (AD) and Parkinson's disease (PD) are associated with superoxide dismutase (SOD1) accumulation, and it is therefore prudent to expect that these diseases are also treatable when the dosage regimen of the present invention is applied to patients suffering from AD and PD. Therefore, the present invention also relates to a recombinant antibody that selectively binds to misfolded and / or aggregated forms of SOD1 for use in the treatment of neurodegenerative diseases associated with SOD1 accumulation, such as AD or PD, by administering to a patient in need thereof a dose of 1000 mg to 10,000 mg, preferably 1000 mg to 5000 mg, preferably 2000 mg to 3000 mg, and most preferably 2500 mg of the antibody once every 1 to 5 weeks, preferably once every 2 to 4 weeks, and most preferably once every 3 weeks.

[0099] The antibodies and pharmaceutical products used in the dosing regimen, i.e. the liquid aqueous pharmaceutical formulations of the invention may in principle be any anti-SOD1 antibody that selectively binds, preferably preferentially or exclusively, to misfolded and / or aggregated forms of SOD1 over the physiological form of SOD1.

[0100] In principle, the antibody can be any form that recognizes misfolded SOD1, including, for example, chimeric antibodies, single-chain antibodies, Fab fragments, bispecific antibodies, fusion antibodies, labeled antibodies, or analogs of any of these antibodies. Corresponding methods for generating such variants are known to those skilled in the art and are described, for example, in: Harlow and Lane "Antibodies, A Laboratory Manual", CSH Press, Cold Spring Harbor (1988) First edition; Second edition by Edward A. Greenfield, Dana-Farber Cancer Institute 2014, ISBN 978-1-936113-81-1. For example, Fab and F(ab')2 fragments can be produced recombinantly or by proteolytic cleavage of immunoglobulin molecules using enzymes such as papain (to produce Fab fragments) or pepsin (to produce F(ab')2 fragments). The F(ab')2 fragment contains the variable region, the light chain constant region, and the heavy chain CH1 domain.

[0101] In one embodiment, the antibodies used in the dosing regimens and pharmaceutical preparations of the present invention may be provided in a form selected from the group consisting of single-chain Fv fragments (scFv), F(ab') fragments, F(ab) fragments and F(ab')2 fragments, Fd, Fv, single-chain antibodies and disulfide-linked Fv (sdFv) and / or the antibodies are chimeric mouse-human or humanized antibodies. Preferably, the anti-SOD1 antibodies employed include human constant domains.

[0102] The antibody AP-101, which corresponds to the antibody NI-204.12G7 characterized in WO 2012 / 080518 A1 and Maier et al., Sci. Transl. Med. 10. (2018) doi: 10.1126 / scitranslmed.aah3924, is particularly preferred and is a fully human IgG1m3 allotype antibody that binds to misfolded SOD1 protein with selective high affinity. In two ALS mouse models, intravenous or intrathecal administration of a chimeric version of AP-101 (chα-miSOD1) alleviated the loss of spinal motor neurons and improved motor function and prolonged overall survival (Welt et al., Sci. Transl. Med. 10 (2018), eaah3924, WO 2012 / 080518 A1). The therapeutic effect of AP-101 treatment may be mediated by different non-exclusive mechanisms. These include direct neutralization of extracellular toxic SOD1 conformers (Zhao et al., Glia 58 (2010), 231-243), and interference with prion-like spread of SOD1 aggregates released from dead or living cells through exosome-dependent or -independent pathways (Basso and Bonetto, Front. Neurosci. 10 (2016), 127; Silverman et al., Cell. Mol. Life Sci 70 (2016), 377-381), transsynaptic transmission (Ayers et al., Acta Neuropathol. 131 (2016), 103-114), and / or macropinocytotic uptake of aggregates (Grad and Cashman, Prion 8 (2014), 33-41; Bidhendi, J Clin. Invest. 126 (2016), 2249-2253; and Sundaramoorthy et al., Cell. Mol. Life Sci. 70 (2013), 4181-4195). The functional glycosylated fragment crystallizable (Fc) region of antibody AP-101 has comprehensive therapeutic efficacy, indicating that Fcγ receptor (FcγR)-mediated effects are related to in vivo activity. Therefore, recruiting microglia and engulfing toxic SOD1 aggregates may be a credible potential mechanism of action (Welt et al., 2018, supra).

[0103] Therefore, in one embodiment, the antibody for use according to the present invention, i.e., the antibody used in the dosage regimen and pharmaceutical formulation of the present invention, is an anti-SOD1 antibody that recognizes an epitope comprising the amino acid sequence 73-GGPKDEERHVG-83 (SEQ ID NO: 11).

[0104] In a particularly preferred embodiment, the antibody for use according to the present invention is AP-101 and is derived from the human antibody NI-204.12G7, characterized in that it comprises in its variable region, i.e. the binding domain, a residue having the residues in WO 2012 / 080518 A1. Figure 1 The variable weight (V H ) and variable lightness (V L ) chain or its equivalent antibody, wherein one or more of the CDRs may differ in their amino acid sequence from that in WO 2012 / 080518 A1 Figure 1 B, in the case of CDR2 and CDR3, there are one, two, three or even more amino acids that differ, and wherein the antibody exhibits immunological characteristics that are substantially equivalent or identical to those of the anti-SOD1 antibody NI-204.12G7 shown in the Examples of WO 2012 / 080518 A1. The positions of the CDRs are as in WO 2012 / 080518 A1. Figure 1 B, and Figure 1 The corresponding nucleotide sequences are listed in Table II on page 54 of WO 2012 / 080518 A1. In addition, or alternatively, the framework region or the complete V H and / or V L Chain and WO 2012 / 080518 Al Figure 1 The framework region described in B is 80% identical to that in WO 2012 / 080518 A1. Figure 1 B respectively described framework region and V H and / or V L The chains are 85%, 90%, 95%, 96%, 97%, 98%, 99% or 100% identical. In addition, the cloning and expression of antibody NI-204.B have been carried out as described in the "Materials and Methods" section on pages 84 to 88 of WO 2012 / 080518A1, which are incorporated herein by reference.

[0105] In a particularly preferred embodiment, the antibody is characterized by Figure 1 V described in B H and / or V L chain.

[0106] Therefore, the antibody preferably comprises

[0107] (i) a variable heavy (VH) chain comprising VH complementarity determining regions (CDRs) 1, 2 and 3, and / or a variable light (VL) chain comprising VL CDRs 1, 2 and 3, wherein

[0108] (a) VH-CDR1 comprises the amino acid sequence of SEQ ID NO: 3 or a variant thereof, wherein,

[0109] The variants include one or two amino acid substitutions,

[0110] (b) VH-CDR2 comprises the amino acid sequence of SEQ ID NO: 4 or a variant thereof, wherein,

[0111] The variants include one or two amino acid substitutions,

[0112] (c) VH-CDR3 comprises the amino acid sequence of SEQ ID NO: 5 or a variant thereof, wherein,

[0113] The variants include one or two amino acid substitutions,

[0114] (d) VL-CDR1 comprises the amino acid sequence of SEQ ID NO: 8 or a variant thereof, wherein,

[0115] The variants include one or two amino acid substitutions,

[0116] (e) VL-CDR2 comprises the amino acid sequence of SEQ ID NO: 9 or a variant thereof, wherein,

[0117] The variant includes one or two amino acid substitutions, and

[0118] (f) VL-CDR3 comprises the amino acid sequence of SEQ ID NO: 10 or a variant thereof, wherein,

[0119] The variant comprises one or two amino acid substitutions; and / or

[0120] (ii) a VH chain and / or a VL chain, wherein

[0121] (a) the VH chain comprises the amino acid sequence described in SEQ ID NO: 1 or 2, or a variant thereof, wherein the variant comprises one or more amino acid substitutions; and

[0122] (b) the VL chain comprises the amino acid sequence described in SEQ ID NO: 6 or 7, or a variant thereof, wherein the variant comprises one or more amino acid substitutions;

[0123] Preferably, the VH and VL chain amino acid sequences are at least 90% identical to SEQ ID NO: 1 or 2 and 6 or 7, respectively.

[0124] Therefore, most preferably, the anti-SOD1 antibody used in the dosing regimen and pharmaceutical formulation of the present invention is AP-101 or an equivalent antibody derived from the human antibody NI-204.12G7, as characterized in WO 2012 / 080518A1 and Maier et al., Sci. Transl. Med. 10. (2018) doi: 10.1126 / scitranslmed.aah3924.

[0125] The five main classes of immunoglobulins are IgG, IgM, IgA, IgD, and IgE. These are distinguished by the type of heavy chain in the molecule. The heavy chain of an IgG molecule is called a gamma chain; IgM has a μ chain; IgA has an alpha chain; IgE has an epsilon chain; and IgD has a delta chain; see reviews, e.g., Schroeder et al., J. Allergy Clin. Immunol. 125 (2010), S41-S52. In addition, there are different subclasses, with IgA being further divided into IgA1 and IgA2 subclasses, and IgG being further divided into IgG1, IgG2, IgG3, and IgG4 subclasses. In addition, there are two types of light chains, kappa (κ) and lambda (λ).

[0126] In principle, the antibodies used according to the present invention may be of any kind of class and subclass, respectively, and may comprise any kind of light chain, as long as the antibody binds to the misfolded and preferably aggregated form of SOD1, and preferably as long as the binding specificity of the antibody NI-204.12G7 to SOD1 remains unaffected in kind as shown in the examples of WO 2012 / 080518 A1, and as long as no adverse factors occur when the antibody is administered to a patient, wherein adverse reactions can be determined as described in Examples 1 and 2. However, it is preferred to use complete IgG antibodies, wherein the antibody comprises constant domains. Thus, in one embodiment, the immunoglobulin heavy and / or light chain constant domains present in the antibodies used according to the present invention are of the IgG type, IgM type, IgA type, IgD type or IgE type, preferably of the IgG type. In one embodiment, the immunoglobulin heavy and / or light chain constant domains present in the antibodies used according to the invention are of the IgA1, IgA1, IgG1, IgG2, IgG3 or IgG4 subclass, preferably of the IgG1, IgG2, IgG3 or IgG4 subclass, and most preferably of the IgG1 subclass.

[0127] The recombinant expression of complete human IgG1 antibody with human or mouse constant domain can be carried out substantially according to the description in the embodiment of WO 2012 / 080518A1.Preferably, antibody is a monoclonal antibody or is derived from a monoclonal antibody.As shown in Table V in the 105th page embodiment 10 of WO2012 / 080518A1, by comparing the nucleotide sequence of the original antibody with the human germline sequence in the database Vbase (http: / / vbase.mrc-cpe.cam.ac.uk / ) managed by MRC Protein Engineering Center (MRC Centre for Protein Engineering) (Cambridge, UK), the IgG germline family classification is described, germline is specified by their heavy chain locus and their light chain Vbase entry number, based on this, antibody NI-204.12G7 is classified as 3a.119B4 / V2-11+ and L-λ type (NI-204.12G7L), i.e. including λ chain.

[0128] In addition to the four subclasses of IgG mentioned above, human heavy and light chain genes also exhibit one or more extensive structural polymorphisms, and because they are closely linked, they can be inherited as haplotypes. Allotypic variants can be immunogenic and induce antibody responses after allogeneic immunization. Therefore, switching allotypes may be of particular importance for providing non-immunogenic antibody therapies. To date, a large number of allotypes (polymorphisms) have been known, but the focus is on serologically defined allotypes. The allotype of an IgG protein is defined by the expression of one or more unique epitopes recognized by one or more unique serum reagents. The allotype expressed in the constant region of the IgG heavy chain is called Gm (genetic marker) and is represented together with the subclass (e.g., G1m) and the allotype number (or letter), such as G1m1 [(or G1m(a)], G3m5 [or G3m(b1)]. Human immunoglobulin allotypes are listed in Table 1 of Jefferis and Lefrance, mAbs 1 (2009), 1-7 and in Table 1 of Irani et al., Molecular Immunology 67 (2015), 171-182. Figure 1A, the contents of which are incorporated herein by reference. Therefore, in one embodiment, the antibodies used according to the present invention belong to any of the following allotypes, but are not limited thereto: G1m1, G1m2, G1m3, G1m17, G2m23, G3m21, G3m28, G3m11, G3m5, G3m13, G3m14, G3m10, G3m15, G3m16, G3m6, G3m24, G3m26, G3m27, A2m1, A2m2, A2m3, Em1, Km1, Km2 and Km3, but preferably G1m2, G1m3 or G1m17, and most preferably G1m3.

[0129] As explained above, antibody AP-101 is a fully human IgG1m3 allotype antibody and consists of two identical heavy chains of the IgG1 subclass and IgG1m3 allotype. In addition, as described above, the original human antibody NI-204.12G7 belongs to the L-λ type, and therefore AP-101 consists of two identical light chains of the λ subclass. The sequences of the variable heavy chain (VH) and variable light chain (VL) of AP-101 are listed in SEQ ID NOs: 1 and 2 and 6 and 7, respectively, and the sequences of the corresponding human constant regions are known in the art. For example, each isotype and, for example, the IgG1m3 isotype has a unique amino acid sequence of the constant region of its heavy chain; see Jefferis and Lefrance (2009), supra. Thus, in one embodiment, the antibody used according to the present invention is characterized by two heavy chains and two light chains, wherein each heavy chain comprises the amino acid sequence listed in SEQ ID NO: 12 and each light chain comprises the amino acid sequence listed in SEQ ID NO: 13. Each heavy chain consists of 453 amino acid residues, and each light chain consists of 213 amino acid residues. The four chains are stabilized by twelve intrachain disulfide bonds and four interchain disulfide bonds. Each heavy chain contains a single N-linked glycosylation site at Asn303. The N-linked glycosylation structure is mainly a fucosylated complex biantennary glycan with 0 galactose residues (G0F) or 1 galactose residue (G1F).

[0130] In addition, in the formulations of the present invention, and when used in the dosing regimens described herein, it may be found that certain antibody species have undergone other post-translational modifications (PTMs) such as partial cleavage, oxidation, deamidation, succinimide or pyroglutamate formation and isomerization, but to a lesser extent, preferably negligible. The PTMs identified as present in AP-101 are shown in Example 7 and Table 18.

[0131] In a preferred embodiment, the antibody for use according to the invention has a heavy chain that does not include a C-terminal lysine. For example, in this embodiment, the C-terminal lysine included in SEQ ID NO: 12 is deleted.

[0132] Additionally, or alternatively, the antibodies for use according to the invention have a heavy chain in which the N-terminal glutamine is replaced by pyroglutamic acid. This pyroglutamic acid formation is also known as N-terminal cyclization.

[0133] Additionally, or alternatively, the antibody for use according to the invention has an N-glycosylated heavy chain, preferably wherein the N-linked glycosylation site is Asn303.

[0134] Most preferably, the antibody for use according to the invention has a heavy chain which does not include a C-terminal lysine, i.e. the C-terminal lysine has undergone C-terminal lysine cleavage, wherein the glutamine at the N-terminus is replaced by pyroglutamic acid, i.e. the N-terminal glutamine is cyclized, and which is N-glycosylated.

[0135] The amino acid sequences of the heavy and light chains are shown below:

[0136]

[0137] (SEQ ID NO: 12, AP-101, heavy chain amino acid sequence, wherein the amino acids of the constant region are underlined, and wherein the C-terminal lysine (K) is optional, and / or the N-terminal glutamine (Q) undergoes intramolecular cyclization, resulting in the formation of pyroglutamic acid)

[0138]

[0139] (SEQ ID NO: 13, AP-101, light chain amino acid sequence, wherein the amino acids of the constant region are underlined).

[0140] In one embodiment, the treatment of ALS according to the present invention comprises alleviating or ameliorating one or more symptoms associated with ALS. Symptoms associated with ALS include progressive loss of motor neurons, resulting in varying degrees of weakness and spasticity in the limbs, medulla oblongata, and respiratory muscles.

[0141] In one embodiment, treatment of ALS comprises improving at least one clinical marker and biomarker, respectively, for progression of ALS. The revised ALSFRS-R is a recognized clinical endpoint for functional effects on ALS disease progression (FDA 2019 (Guidance for Industry: Amyotrophic Lateral Sclerosis: Developing Therapeutic Drugs. September 2019); EMA 2015 (European Medicines Agency. Committee for Medicinal Products for Human Use (CHMP). Guidance for clinical investigations of medicinal products intended to treat amyotrophic lateral sclerosis (ALS)). Recent data further suggest that several neurofilament proteins may have a clinical role in the prognosis and treatment response of ALS. Preclinical models initially suggested that phospho-neurofilament heavy chain (pNfH) and neurofilament light chain (NfL) could serve as biomarkers for monitoring axonal degeneration during ALS (Brettschneider et al., Neurology 66 (2006), 852-856; Boylan et al.. J. Neurochem. 111 (2009), 1182-1191; Gaiottino et al., PLoS One 8 (2013), e75091). These studies are supported by more recent publications describing increases in neurofilament markers with disease onset and correlations between levels of these proteins and the overall rate of ALS progression (Benatar et al., Neurology 95 (2020), e59-e69). In addition, there is now emerging evidence that neurofilament levels in serum and CSF have the potential to be early markers of treatment efficacy (Miller et al., N. Engl. J. Med. 383 (2020), 109-119. However, other markers may be suitable, and non-limiting examples of those markers for ALS progression include:

[0142] The change from baseline in the ALSFRS-R total score, ie, a measure of the clinical effect of treatment on the rate of functional decline as measured by the ALSFRS-R;

[0143] The change from baseline in percent predicted SVC, i.e., a measure of the clinical effect of treatment on lung function (SVC);

[0144] ·Measurement of the clinical effect of treatment on pulse oximetry;

[0145] The percentage change from baseline in the combined muscle composite score (Megascore) assessed by handheld dynamometer (HHD), i.e., a measure of the clinical effect of treatment on muscle strength (HHD);

[0146] The time during the randomized controlled period to the earliest occurrence of one of the following ventilation-free survival (VAFS) events: all-cause mortality; first use of non-invasive ventilation (NIV), ~22 hours per day for ~10 consecutive days; and first use of permanent assisted ventilation (PAV), ~22 hours per day for ~7 consecutive days, i.e., a composite time-to-event measure including death, tracheostomy for ventilation purposes, or time to 22-24 hours per day of non-invasive ventilation;

[0147] Change from baseline in ALSAQ-40 score;

[0148] Change from baseline in the European Quality of Life 5-item Questionnaire (EQ 5D 5L);

[0149] Change from baseline in the Short Form 36 Health Survey (SF 36);

[0150] Change from baseline in the Total Satisfaction with Medication Questionnaire (TSQM) score;

[0151] · Shift from baseline in the Columbia-Suicide Severity Rating Scale (C-SSRS);

[0152] Changes from baseline in vital signs, electrocardiogram (ECG) parameters, and clinical laboratory assessments;

[0153] Changes from baseline in levels of biomarkers of complement dysregulation, neuroinflammation, and neurodegeneration;

[0154] Any decrease from baseline stage in the King's staging system, i.e., a measure of the clinical effect of treatment on disease stage (King's staging tool);

[0155] The clinical impact of treatment on quality of life as measured by the Amyotrophic Lateral Sclerosis Specific Quality of Life Scale-Short Form (ALSSQOL-SF);

[0156] Change from baseline in NfL concentrations in serum, CSF and / or plasma, i.e., measurement of NfL levels in serum, cerebrospinal fluid and / or plasma;

[0157] a change from a baseline in the concentration of pNfH in any body fluid, preferably serum, CSF and / or plasma, i.e. a measurement of the level of pNfH in any body fluid, preferably serum, CSF and / or plasma;

[0158] - a change from a baseline in the total SOD1 concentration in any body fluid, preferably CSF, i.e. a measurement of the total SOD1 level in any body fluid, preferably CSF;

[0159] a change from a baseline in the concentration of mSOD1 in any body fluid, preferably CSF, ie a measurement of the level of mSOD1 in any body fluid, preferably CSF; and / or

[0160] Measurement of other biomarkers of disease activity, including creatinine and transcriptional markers.

[0161] Preferably, markers are assessed at several time points throughout the study, but at least at the end point, ie, week 24 (6 months) after starting treatment here. Of course, longer or shorter time periods may also be observed, for example, until week 50.

[0162] Therefore, the therapeutic effect of the antibodies used according to the present invention and the administration regimen of the present invention, as well as the progression of ALS, are monitored by evaluating one or more markers, preferably selected from the above-mentioned markers, respectively.

[0163] In a preferred embodiment of the treatment according to the invention, the therapeutic effect of the antibody and the progression of ALS are monitored by evaluating one or more markers selected from the group consisting of:

[0164] · A measure of the clinical effect of treatment on the rate of functional decline as measured by the ALSFRS-R;

[0165] Measures of clinical effect of treatment on lung function (SVC);

[0166] ·Measurement of the clinical effect of treatment on pulse oximetry;

[0167] ·Measurement of the clinical effect of treatment on muscle strength (HHD);

[0168] A composite time-to-event measure including time to death, tracheostomy for ventilation purposes, or use of non-invasive ventilation 22-24 hours per day;

[0169] ·Measurement of the clinical effect of treatment on disease stage (King staging tool);

[0170] ·Measurement of the clinical effect of treatment on quality of life as measured by the ALSSQOL-SF;

[0171] Measurement of NfL levels in any body fluid, preferably serum, CSF and / or plasma, preferably CSF and plasma;

[0172] Measurement of pNfH levels in any body fluid, preferably serum, CSF and / or plasma, preferably CSF and plasma;

[0173] · Measurement of total SOD1 levels in any body fluid, preferably CSF;

[0174] · Measurement of mSOD1 levels in any body fluid, preferably CSF; and

[0175] Measurement of other biomarkers of disease activity, including creatinine and transcriptional markers, or any of those disclosed in Table 2 of Vijayakumar et al., Front. Neurol. 10 (2019), 400, and / or Tables 1 to 5 disclosed in Vu and Bowser, Neurotherapeutics 14 (2017), 119–134.

[0176] In other preferred embodiments of the treatment according to the invention, the therapeutic effect of the antibody and the progression of ALS are monitored by evaluating one or more markers selected from the group consisting of:

[0177] Measurement of NfL levels in any body fluid, preferably serum, CSF and / or plasma, more preferably in CSF and plasma;

[0178] Measurement of pNfH levels in any body fluid, preferably serum, CSF and / or plasma, more preferably in CSF and plasma;

[0179] Measurement of total SOD1 levels in any body fluid, preferably CSF; and

[0180] - Measurement of mSOD1 levels in any body fluid, preferably CSF.

[0181] In an even more preferred embodiment of the treatment according to the invention, the therapeutic effect of the antibody and the progression of ALS are monitored by assessing one or more markers selected from the group consisting of:

[0182] Measurement of NfL levels in any body fluid, preferably serum, CSF and / or plasma, more preferably in CSF and plasma;

[0183] Measurement of pNfH levels in any body fluid, preferably serum, CSF and / or plasma, more preferably CSF and plasma; and

[0184] - Measurement of mSOD1 levels in any body fluid, preferably CSF.

[0185] As already mentioned above, the measurement of SOD1 levels, in particular the measurement of mSOD1 levels, can be performed using the immunoassay disclosed in WO 2021 / 185961 A1.

[0186] In other aspects, but related to the dosing regimen described herein, the present invention relates to a liquid aqueous pharmaceutical formulation (drug product) of an anti-SOD1 antibody that selectively binds to the misfolded and preferably aggregated form of SOD1, wherein the formulation is characterized by an L-histidine / L-histidine monohydrochloride buffer having a pH of about 6.0±1, preferably a pH of about 6.0±0.5. As previously described, this formulation has been shown to be particularly suitable for intravenous injection and for use in the dosing regimen of the present invention.

[0187] In a preferred embodiment, the formulation of the present invention comprises an antibody as defined above. In one embodiment, the antibody is characterized in that it comprises the six CDRs and constant regions of the VH and VL chains described above in its variable region, preferably a human Ig constant region, and / or comprises the VH chain and VL chain described above and a constant region, preferably a human Ig constant region, in its variable region. The antibody included in the formulation of the present invention is preferably characterized in that it binds to the epitope of SOD1 in the amino acid sequence 73-GGPKDEERHVGD-84 listed in SEQ ID NO: 11. In one embodiment, the antibody included in the formulation of the present invention is a human IgG, preferably a human IgG1, and more preferably a human IgG1m3 allotype. Preferably, the antibody is defined by its heavy chain and light chain as described above, wherein the light chain is preferably a lambda (λ) light chain. Most preferably, the antibody is antibody AP-101, and is characterized by two heavy chains, each of which comprises the amino acid sequence listed in SEQ ID NO: 12; and two light chains, each of which comprises the amino acid sequence listed in SEQ ID NO: 13.

[0188] In one embodiment, the antibody in the formulation of the invention has a heavy chain that does not include a C-terminal lysine. For example, in this embodiment, the C-terminal lysine of SEQ ID NO: 12 is missing. Therefore, in a preferred embodiment, the formulation of the invention comprises an antibody as defined above, characterized in that it has two heavy chains, each of which comprises the amino acid sequence set forth in SEQ ID NO: 12, wherein in one heavy chain, preferably in both heavy chains, the C-terminal lysine included in SEQ ID NO: 12 is missing; and two light chains, each of which comprises the amino acid sequence set forth in SEQ ID NO: 13.

[0189] In addition, or alternatively, the antibody in the formulation according to the invention has a heavy chain in which the glutamine at the N-terminus is replaced by pyroglutamic acid. This pyroglutamic acid formation is also referred to as N-terminal cyclization. Therefore, in a preferred embodiment, the formulation of the invention comprises an antibody as defined above, characterized in that it comprises two heavy chains, each of which comprises the amino acid sequence set forth in SEQ ID NO: 12, wherein in one heavy chain, preferably in both heavy chains, the glutamine at the N-terminus is replaced by pyroglutamic acid; and two light chains, each of which comprises the amino acid sequence set forth in SEQ ID NO: 13.

[0190] Additionally, or alternatively, the antibody in the formulation of the invention has an N-glycosylated heavy chain, preferably wherein the N-linked glycosylation site is Asn 303. Thus, in a preferred embodiment, the formulation of the invention comprises an antibody as defined above, characterized in that two heavy chains, wherein each heavy chain comprises the amino acid sequence set forth in SEQ ID NO: 12, wherein one heavy chain, preferably both heavy chains are N-glycosylated, preferably wherein Asn at position 303 of the heavy chain is glycosylated; and two light chains, wherein each light chain comprises the amino acid sequence set forth in SEQ ID NO: 13.

[0191] Most preferably, the antibody in the formulation of the invention has a heavy chain that does not include a C-terminal lysine, i.e., the C-terminal lysine has undergone C-terminal lysine cleavage, wherein the glutamine at the N-terminus is replaced by pyroglutamic acid, i.e., the N-terminal glutamine is cyclized, and it is N-glycosylated.

[0192] As shown in Example 7, about 99% to 100% of the antibodies in the sample of the antibody preparation of the present invention have N-terminal pyroglutamic acid, and about 94% of the antibodies have a loss of C-terminal lysine. Therefore, in one embodiment, at least 90% to 100%, preferably 95% to 100% of the antibodies in the preparation have N-terminal pyroglutamic acid modified by N-terminal glutamine. In one embodiment, at least about 90%, preferably 91%, more preferably 92%, more preferably 93%, more preferably 94%, more preferably 95%, more preferably 96%, more preferably 97%, more preferably 98%, more preferably 99%, and most preferably 99.5% of the antibodies in the preparation have N-terminal pyroglutamic acid modified by N-terminal glutamine. In one embodiment, at least 85% to 100%, preferably 90% to 97% of the antibodies in the preparation have a loss of C-terminal lysine. In one embodiment, at least about 85%, preferably 86%, more preferably 87%, more preferably 88%, more preferably 89%, more preferably 90%, more preferably 91%, more preferably 92%, more preferably 93%, and most preferably 94% of the antibodies in the formulation have a lack of the C-terminal lysine.

[0193] In a preferred embodiment, the formulation of the invention comprises a therapeutically effective amount of an antibody, preferably at a concentration of about 10 to 50 mg / mL, wherein the antibody is stable at 5°C±2°C for at least 1 month, preferably up to 24 months, more preferably up to 53 months; or at 25°C±2°C for at least 1 month, preferably up to 6 months, or at 40°C±2°C for 1 week; or at 5°C±2°C for at least 1 month, preferably up to 24 months, more preferably up to 53 months, and at 25°C±2°C for at least 1 month, preferably up to 6 months. Up to 6 months; or at least 1 month at 5°C±2°C, preferably up to 24 months, more preferably up to 53 months, and at 40°C±2°C for 1 week; or at least 1 month at 25°C±2°C, preferably up to 6 months, and at 40°C±2°C for 1 week; or at least 1 month at 5°C±2°C, preferably up to 24 months, more preferably up to 53 months, and at least 1 month at 25°C±2°C, preferably up to 6 months, and at 40°C±2°C for 1 week.

[0194] In some embodiments, the antibody concentration can be 10mg / mL, 15mg / mL, 20mg / mL, 25mg / mL, 30mg / mL, 35mg / mL, 40mg / mL, 45mg / mL or 50mg / mL, or any range between 10mg / mL and 50mg / mL. In a preferred embodiment, the preparation of the present invention comprises an antibody having a concentration of 20 ± 5mg / mL, preferably 20mg / mL. The antibody is an antibody defined according to the present invention, and the preparation of the present invention is particularly suitable for realizing the dosage regimen of the present invention.

[0195] In the context of the present invention, a "therapeutically effective amount" of an antibody refers to an amount effective for preventing or treating a condition for which the antibody is effective, in this case ALS or a related disease. The "pharmaceutical formulation" referred to in the present invention is prepared in a form that enables the active ingredient to be effective, and includes only pharmaceutically acceptable excipients, diluents and other additives deemed safe by regulatory agencies, and does not contain additional ingredients that are toxic to the subject to which the formulation is administered. The "liquid aqueous pharmaceutical formulation" used herein refers to a pharmaceutical formulation defined above in a liquid state using water as a solvent, and includes a pharmaceutically active drug in combination with one or more excipients. In this case, the term "pharmaceutical formulation" used in accordance with the present invention to define a pharmaceutical formulation (alternatively referred to as a "drug product" and a drug product, respectively) may not be confused with a "test formulation" proposed as a "pharmaceutical formulation" only on the basis of hypothetical considerations, and its tolerance and / or efficacy in humans has not yet been confirmed at least in recognized animal models. In one embodiment, such a "test formulation" is excluded from the scope of the present invention. In other embodiments, the liquid aqueous pharmaceutical formulation of the present invention is a pharmaceutical formulation as defined above that maintains stability (e.g., chemical and / or physical stability and / or biological activity) during storage without the need for lyophilization, spray drying and / or freezing.

[0196] As used herein, the term "buffer" or "buffer solution" refers to an aqueous solution composed of a mixture of a weak acid and its conjugate base or a weak base and its conjugate acid, which can resist changes in pH. It is well known that the type and concentration of the buffer can have an impact on the stability of the protein. Therefore, the choice of buffer is crucial for achieving pH control and desired stability of antibody preparations. In terms of antibody aggregation, the selection of a suitable buffer system and pH plays a vital role because it determines the net charge of the protein / antibody structure and the subsequent electrostatic interactions caused by the increase in acidity or alkalinity of the solution (Chi et al., Pharmaceutical Research 20 (2003), 1325-1336). The charge repulsion between the charged groups inside the antibody in the solution continues to increase, which can make its folding or native state unstable (Vermeer and Norde, Biophys. J. 76 (2000), 394-404). In the context of the present invention, we find that the L-histidine / L-histidine monohydrochloride buffer with a pH of about 6.0 ± 1 is particularly suitable for antibody preparations.

[0197] In one embodiment, the concentration of L-histidine / L-histidine monohydrochloride in the formulation of the present invention is 20±10 mM, preferably 20 mM.

[0198] In other embodiments, any formulation of the present invention comprises an osmotic pressure of 310 ± 50 mOsmol / kg. In a preferred embodiment, the osmotic pressure of the formulation of the present invention is between 290 and 320 mOsmol / kg, more preferably between 300 and 310 mOsmol / kg, and most preferably about 307 mOsmol / kg.

[0199] The formulations of the invention allow for intravenous, intraperitoneal, subcutaneous, intramuscular, intranasal, oral, topical or intradermal administration, or spinal or brain delivery of the antibody. In a preferred embodiment, the formulations of the invention are designed for intravenous administration.

[0200] In one embodiment, the formulation of the present invention further comprises other excipients, such as antioxidants, tonicity modifiers and / or surfactants in any combination of two or all three excipients. On the other hand, compared to the most preferred pharmaceutical formulations described in the examples, one or more excipients can be omitted from the solution or replaced with another excipient because they have known properties.

[0201] As used herein, the term "excipient" includes therapeutically inactive ingredients in the pharmaceutical preparations of the present invention. Depending on the respective characteristics of the excipient, the excipient may be included in the pharmaceutical preparation for a variety of purposes, for example, a buffer for controlling pH, a carbohydrate used as a bulking agent for freeze drying, a polymer for increasing solution viscosity, a salt or sugar for stabilizing proteins and as a tension agent to obtain physiological tension and osmotic pressure (osmolality), a surfactant for inhibiting protein adsorption to the interface, a preservative, an antioxidant, a cryoprotectant or a diluent for preventing microbial growth. A variety of formulation excipients have been shown to stabilize antibodies under different processing conditions and during storage, including sugars such as sucrose, lactose or dextrose, polyols (also referred to as sugar alcohols) such as mannitol or sorbitol, salts such as sodium chloride, amino acids such as arginine, histidine, lysine, aspartic acid or glutamic acid, surfactants and water as a solvent (Paborji et al., Pharm. Res. 11 (1994), 764–771).

[0202] "Antioxidant" or free radical scavenger is a molecule that can reduce or prevent the oxidation of other molecules. The term "tonicity agent" or "isotonicity agent" or "tonicity modifier" or "tonifier" or "tonicifying agent" used herein refers to an agent whose function is to make the osmotic properties of liquid aqueous preparations similar to those of physiological fluids. In other words, such isotonic pharmaceutical preparations have an osmotic pressure substantially the same as human blood. Commonly used tonicity agents include dextrose, mannitol, sodium chloride, potassium chloride and glycerol. Isotonic or physiological preparations will generally have an osmotic pressure of about 275-325mOsm. The "surfactant" used in the present invention can be nonionic and ionic surfactants. These surfactants reduce the surface tension of protein solutions, as well as reduce the driving force for protein adsorption and or aggregation on hydrophobic surfaces. Nonionic surfactants are generally preferred in protein stabilization. Since the "critical micelle concentration" (CMC) of nonionic surfactants is relatively low (Bam et al., Pharm Res. 12 (1995), 2-11), low concentrations of nonionic surfactants are usually sufficient to prevent or reduce surface adsorption and / or aggregation of proteins. Therefore, the term "surfactant" used in the present invention refers in particular to nonionic surfactants, which are widely used to stabilize proteins, inhibit aggregation and help protein refolding (Chi et al. 2003, supra). The surfactant is preferably polysorbate, which is an emulsifier formed by esterification of PEGylated sorbitan (a derivative of sorbitol) with fatty acids. Polysorbate 80 and polysorbate 20 (also known as and ) has been widely used in protein drugs on the market, ranging from 0.0003-0.3%.

[0203] In one embodiment, the formulation of the present invention includes an antioxidant. In one embodiment, the antioxidant is an amino acid or an amino acid derivative, such as L-methionine, L-arginine-hydrochloride or N-acetyl-l-cysteine, or a vitamin, such as ascorbic acid or a thiol. In a preferred embodiment, the antioxidant is an amino acid, and most preferably L-methionine. Therefore, in a preferred embodiment, the formulation of the present invention includes L-methionine, preferably at a concentration of 0.1% ± 0.05% (w / v), and most preferably at a concentration of 0.1% (w / v).

[0204] In one embodiment, the formulation of the present invention includes a tonicity adjuster. In one embodiment, the tonicity adjuster is selected from the group consisting of sucrose, trehalose, sorbitol, dextrose, mannitol, sodium chloride, potassium chloride and glycerol, or any combination thereof. In a preferred embodiment, the tonicity adjuster is selected from sucrose, trehalose, sorbitol and sodium chloride, or any combination thereof. Most preferably, the formulation of the present invention includes sucrose, preferably at a concentration of 8% ± 1% (w / v), most preferably at a concentration of 8% (w / v).

[0205] In one embodiment, the formulation of the present invention includes a surfactant, preferably a nonionic surfactant. In one embodiment, the surfactant is poloxamer 188 or a polysorbate, preferably a polysorbate, preferably polysorbate 80 or polysorbate 20. In a preferred embodiment, the surfactant is polysorbate 80. Therefore, in a preferred embodiment, the formulation of the present invention includes polysorbate 80 at a concentration of 0.02% ± 0.01% (w / v), and most preferably polysorbate 80 at a concentration of 0.02% (w / v).

[0206] Therefore, the formulation of the present invention comprises the antibody as defined above in L-histidine / L-histidine monohydrochloride buffer, and may further comprise any of the excipients mentioned. Therefore, the present invention relates to a formulation comprising an anti-SOD1 antibody as defined above at a concentration of about 10 to 50 mg / mL, preferably about 20±5 mg / mL, most preferably 20 mg / mL, and L-histidine / L-histidine monohydrochloride buffer at a pH of about 6.0±1, preferably wherein the concentration of L-histidine / L-histidine monohydrochloride buffer is 20±10 mM, most preferably 20 mM, and preferably further comprising:

[0207] an antioxidant, preferably L-methionine, preferably at a concentration of 0.1% ± 0.05% (w / v) L-methionine, most preferably at a concentration of 0.1% (w / v) L-methionine; or

[0208] A tonicity adjusting agent, preferably sucrose, preferably at a concentration of 8% ± 1% (w / v), most preferably at a concentration of 8% (w / v); or

[0209] A surfactant, preferably a polysorbate, preferably polysorbate 80, preferably polysorbate 80 at a concentration of 0.02% ± 0.01 (w / v), most preferably polysorbate 80 at a concentration of 0.02% (w / v); or

[0210] an antioxidant, preferably L-methionine, preferably at a concentration of 0.1% ± 0.05% (w / v), most preferably at a concentration of 0.1% (w / v), and a tonicity modifier, preferably sucrose, preferably at a concentration of 8% ± 1% (w / v), most preferably at a concentration of 8% (w / v); or

[0211] an antioxidant, preferably L-methionine, preferably L-methionine at a concentration of 0.1% ± 0.05% (w / v), most preferably L-methionine at a concentration of 0.1% (w / v), and a surfactant, preferably a polysorbate, preferably polysorbate 80, preferably polysorbate 80 at a concentration of 0.02% ± 0.01 (w / v), most preferably polysorbate 80 at a concentration of 0.02% (w / v); or

[0212] a tonicity adjusting agent, preferably sucrose, preferably sucrose at a concentration of 8% ± 1% (w / v), most preferably sucrose at a concentration of 8% (w / v), and a surfactant, preferably a polysorbate, preferably polysorbate 80, preferably polysorbate 80 at a concentration of 0.02% ± 0.01 (w / v), most preferably polysorbate 80 at a concentration of 0.02% (w / v); or

[0213] an antioxidant, preferably L-methionine, preferably L-methionine at a concentration of 0.1%±0.05% (w / v), most preferably L-methionine at a concentration of 0.1% (w / v), and a tonicity modifier, preferably sucrose, preferably sucrose at a concentration of 8%±1% (w / v), most preferably sucrose at a concentration of 8% (w / v); and a surfactant, preferably a polysorbate, preferably polysorbate 80, preferably polysorbate 80 at a concentration of 0.02%±0.01 (w / v), most preferably polysorbate 80 at a concentration of 0.02% (w / v).

[0214] In one embodiment, the formulation of the present invention may include one or more other excipients, and in a preferred embodiment, the formulation of the present invention is substantially free of any other additional excipient or excipients. In a particularly preferred embodiment, the formulation of the present invention is substantially free of one or more excipients other than those specifically listed above.

[0215] As used in this disclosure, the phrase "substantially free" means the exclusion of any recited element or group of elements, and the optional inclusion of other elements having similar or different properties to the recited elements, which do not materially alter the basic or novel characteristics of the particular dosage regimen, method, or composition.

[0216] In one embodiment, the formulation of the present invention can have any of the above compositions, provided that the antibody is stable at 5°C±2°C for at least 1 month, preferably at least 3 months, more preferably at least 6 months, more preferably at least 12 months, more preferably at least 18 months, more preferably at least 24 months, more preferably at least 30 months, more preferably at least 36 months, more preferably at least 44 months, and most preferably at least 53 months; at 25°C±2°C for at least 1 month, preferably at least 3 months, most preferably at least 6 months; and / or at 40°C±2°C for at least 1 week.

[0217] The stability of the formulations of the present invention can be determined by various parameters such as the presence of aggregates (particularly high molecular weight species (HMWS and other low molecular weight species (LMWS))) and monomer content, the presence of acidic and basic species and the reduction of antibodies in HC and LC as performed in Example 6.

[0218] Complete IgG antibodies are expressed as tetramers consisting of two heavy chains (HC) and two light chains (LC) connected by disulfide bonds. During production and storage, due to different cleavage mechanisms, cleavage of the primary structure of HC or LC can occur, resulting in the reduction of antibodies to LC and HC, which may have a negative impact on the safety and efficacy of the product. Therefore, this reduction should be avoided.

[0219] Protein degradation such as aggregation in therapeutic antibody formulations must also be minimized, as aggregation can lead to lower in vivo efficacy, increased variability between batches of therapeutic products, and, perhaps most importantly, patient immunogenicity.

[0220] In addition, there are charge variants of antibodies, which can be analyzed by separation techniques based on charge. Compared with the main substance, these variants are generally referred to as acidic or basic substances. Charge variants can significantly affect the in vitro and in vivo properties of antibodies, and therefore these variants should also be avoided in therapeutic antibody preparations.

[0221] Thus, in one embodiment, the formulation of the present invention is considered to be stable when its content of aggregated substances (HMWS and LMWS) of antibodies is equal to or less than 8%, preferably equal to or less than 5%, more preferably equal to or less than 3%, more preferably equal to or less than 2%, respectively, and its content of monomers is equal to or greater than 92%, preferably equal to or greater than 95%, more preferably equal to or greater than 97%, more preferably equal to or greater than 98%, respectively, after storage at 5°C±2°C for 1 to 3 months, preferably 1 to 6 months, more preferably 1 to 9 months, more preferably 1 to 12 months, more preferably 1 to 18 months, more preferably 1 to 24 months, more preferably 1 to 30 months, more preferably 1 to 36 months, more preferably 1 to 44 months, and most preferably 1 to 53 months. In other words, the formulation of the present invention is considered stable when its content of aggregated substances (HMWS and LMWS) of antibodies is equal to or less than 8%, preferably equal to or less than 5%, more preferably equal to or less than 3%, more preferably equal to or less than 2%, and its content of monomers is equal to or greater than 92%, preferably equal to or greater than 95%, more preferably equal to or greater than 97%, more preferably equal to or greater than 98%, respectively, after storage at 5°C±2°C for at least 1 month, preferably at least 3 months, more preferably at least 6 months, more preferably at least 9 months, more preferably at least 12 months, more preferably at least 18 months, more preferably at least 24 months, more preferably at least 30 months, more preferably at least 36 months, more preferably at least 44 months, and most preferably at least 53 months. The content of aggregated substances is preferably measured by SEC.

[0222] In addition, or alternatively, when the formulation of the present invention is stored at 25°C ± 2°C and 60% ± 5% RH for 1 month to 3 months, preferably 1 month to 6 months, the content of aggregated substances (HMWS and LMWS) of the antibody is equal to or less than 8%, preferably equal to or less than 5%, more preferably equal to or less than 4%, and the content of monomers is equal to or greater than 92%, preferably equal to or greater than 95%, more preferably equal to or greater than 96%, respectively, the formulation of the present invention is considered to be stable. In other words, when the formulation of the present invention is stored at 25°C ± 2°C and 60% ± 5% RH for at least 1 month, preferably at least 3 months, more preferably at least 6 months, the content of aggregated substances (HMWS and LMWS) of the antibody is equal to or less than 8%, preferably equal to or less than 5%, more preferably equal to or less than 4%, and the content of monomers is equal to or greater than 92%, preferably equal to or greater than 95%, more preferably equal to or greater than 96%, respectively, the formulation of the present invention is considered to be stable. The content of aggregated substances is preferably measured by SEC.

[0223] In addition, or alternatively, the formulation of the present invention is considered stable when the content of aggregated substances (HMWS and LMWS) of the antibody is equal to or less than 8%, preferably equal to or less than 5%, more preferably equal to or less than 2%, and the content of monomers is equal to or greater than 92%, preferably equal to or greater than 95%, more preferably equal to or greater than 98%, respectively, after storage at 40°C ± 2°C and 75% ± 5% RH for at least 1 week. The content of aggregated substances is preferably measured by SEC.

[0224] In addition, or alternatively, when the content of the unreduced antibody (not reduced to its LC and HC) of the formulation of the present invention is equal to or greater than 90%, more preferably equal to or greater than 95% after storage at 5°C±2°C for 1 month to 3 months, preferably 1 month to 6 months, more preferably 1 month to 9 months, more preferably 1 month to 12 months, more preferably 1 month to 18 months, more preferably 1 month to 24 months, more preferably 1 month to 30 months, more preferably 1 month to 36 months, more preferably 1 month to 44 months, and most preferably 1 month to 53 months, the formulation of the present invention is considered to be stable. In other words, when the content of the unreduced antibody (not reduced to its LC and HC) of the formulation of the present invention is equal to or greater than 90%, more preferably equal to or greater than 95% after storage at 5°C±2°C for at least 1 month, preferably at least 3 months, more preferably at least 6 months, more preferably at least 9 months, more preferably at least 12 months, more preferably at least 18 months, more preferably at least 24 months, more preferably at least 30 months, more preferably at least 36 months, more preferably at least 44 months, and most preferably at least 53 months, the formulation of the present invention is considered to be stable. The content of unreduced antibody is preferably measured by reducing CS-SDS.

[0225] In addition, or alternatively, the formulation of the present invention is considered to be stable when the content of unreduced antibodies (not reduced to their LC and HC) of the formulation of the present invention is equal to or greater than 90%, preferably equal to or greater than 95% after storage for 1 month to 3 months, preferably 1 month to 6 months. In other words, the formulation of the present invention is considered to be stable when the content of unreduced antibodies (not reduced to their LC and HC) is equal to or greater than 90%, preferably equal to or greater than 95% after storage at 25°C ± 2°C and 60% ± 5% RH for at least 1 month, preferably at least 3 months, more preferably at least 6 months. The content of unreduced antibodies is preferably measured by reduced CS-SDS.

[0226] In addition, or alternatively, the formulation of the present invention is considered stable when its unreduced antibody (not reduced to its LC and HC) content is equal to or greater than 90%, preferably equal to or greater than 95% after storage at 40°C ± 2°C and 75% ± 5% RH for at least 1 week. The content of unreduced antibody is preferably measured by reduced CS-SDS.

[0227] In addition, or alternatively, the formulation of the present invention is considered to be stable when the content of acidic substances of the antibodies of the formulation is equal to or less than 45%, preferably equal to or less than 40%, more preferably equal to or less than 35%, more preferably equal to or less than 30%, more preferably equal to or less than 27% after storage at 5°C±2°C for 1 month to 3 months, preferably 1 month to 6 months, more preferably 1 month to 9 months, more preferably 1 month to 12 months, more preferably 1 month to 18 months, more preferably 1 month to 24 months, more preferably 1 month to 30 months, more preferably 1 month to 36 months, more preferably 1 month to 44 months, and most preferably 1 month to 53 months. In other words, when the content of acidic substances of the antibody of the formulation of the present invention is equal to or less than 45%, preferably equal to or less than 40%, more preferably equal to or less than 35%, more preferably equal to or less than 30%, more preferably equal to or less than 27% after storage at 5°C ± 2°C for at least 1 month, preferably at least 3 months, more preferably at least 6 months, more preferably at least 9 months, more preferably at least 12 months, more preferably at least 18 months, more preferably at least 24 months, more preferably at least 30 months, more preferably at least 36 months, more preferably at least 44 months, and most preferably at least 53 months, the formulation of the present invention is considered to be stable. The content of acidic substances is preferably measured by cIEF.

[0228] In addition, or alternatively, the formulation of the present invention is considered to be stable when the content of basic substances of the antibody of the formulation is equal to or less than 15%, preferably equal to or less than 10%, more preferably equal to or less than 7% after storage at 5°C±2°C for 1 month to 3 months, preferably 1 month to 6 months, more preferably 1 month to 9 months, more preferably 1 month to 12 months, more preferably 1 month to 18 months, more preferably 1 month to 24 months, more preferably 1 month to 30 months, more preferably 1 month to 36 months, more preferably 1 month to 44 months, and most preferably 1 month to 53 months. In other words, the formulation of the present invention is considered stable when the content of basic substances in the antibody is equal to or less than 15%, preferably equal to or less than 10%, more preferably equal to or less than 7% after the formulation of the present invention is stored at 5°C ± 2°C for at least 1 month, preferably at least 3 months, more preferably at least 6 months, more preferably at least 9 months, more preferably at least 12 months, more preferably at least 18 months, more preferably at least 24 months, more preferably at least 30 months, more preferably at least 36 months, more preferably at least 44 months, and most preferably at least 53 months. The content of basic substances is preferably measured by cIEF.

[0229] In addition, or alternatively, the formulation of the present invention is considered stable when the content of acidic substances in the antibody of the formulation is equal to or less than 45%, preferably equal to or less than 40%, more preferably equal to or less than 35%, more preferably equal to or less than 30%, more preferably equal to or less than 27% after storage for 1 month to 3 months, preferably 1 month to 6 months. In other words, the formulation of the present invention is considered stable when the content of acidic substances in the antibody of the formulation is equal to or less than 45%, preferably equal to or less than 40%, more preferably equal to or less than 35%, more preferably equal to or less than 30%, more preferably equal to or less than 27% after storage at 25°C ± 2°C and 60% ± 5% RH for at least 1 month, preferably at least 3 months, more preferably at least 6 months. The content of acidic substances is preferably measured by cIEF.

[0230] In addition, or alternatively, the formulation of the present invention is considered to be stable when the content of alkaline substances in the antibody of the formulation is equal to or less than 15%, preferably equal to or less than 10%, more preferably equal to or less than 7% after storage for 1 month to 3 months, preferably 1 month to 6 months. In other words, the formulation of the present invention is considered to be stable when the content of alkaline substances in the antibody of the formulation is equal to or less than 15%, preferably equal to or less than 10%, more preferably equal to or less than 7% after storage at 25°C ± 2°C and 60% ± 5% RH for at least 1 month, preferably at least 3 months, more preferably at least 6 months. The content of alkaline substances is preferably measured by cIEF.

[0231] In addition, or alternatively, when the content of acidic substances of the antibody of the formulation of the present invention is equal to or less than 45%, preferably equal to or less than 40%, more preferably equal to or less than 35%, more preferably equal to or less than 30%, more preferably equal to or less than 27% after storage at 40°C ± 2°C and 75% ± 5% RH for at least 1 week, the formulation of the present invention is considered to be stable. The content of acidic substances is preferably measured by cIEF.

[0232] In addition, or alternatively, the formulation of the present invention is considered stable when the content of basic substances in the antibody is equal to or less than 15%, preferably equal to or less than 10%, more preferably equal to or less than 7% after storage at 40°C ± 2°C and 75% ± 5% RH for at least 1 week. The content of basic substances is preferably measured by cIEF.

[0233] Furthermore, the potency of the antibody as well as the appearance of the formulation, particularly clarity, color and / or visible particles, pH, osmotic pressure, and particulate matter, should remain stable during storage.

[0234] Thus, in one embodiment, under all the above storage conditions, the relative potency of the antibodies in the formulations of the invention is 60% to 140%, more preferably 70% to 130%, more preferably 80% to 120%, more preferably 90% to 110%, and most preferably 93% to 110%. See Tables 14 to 17 for details. Potency is preferably determined by FRET binding.

[0235] Most preferably, the formulation of the invention comprises or consists essentially of 20 mg / mL anti-SOD1 antibody, preferably AP-101, in 20 mM L-histidine / L-histidine monohydrochloride buffer at pH 6.0, 8% (w / v) sucrose, 0.1% (w / v) L-methionine and 0.02% (w / v) polysorbate 80, and preferably exhibits any one or a combination of any one of the above stability criteria.

[0236] The present invention also relates to treating ALS and other neurodegenerative diseases associated with SOD1 accumulation, such as AD or PD, by administering the above-mentioned antibodies according to the dosing regimen of the present invention. Preferably, the antibodies are administered in the form of preparations and medicaments of the present invention, respectively. The method may also include diagnosing the subject to be treated as described above and / or monitoring the therapeutic effect of the antibody and the progression of ALS as described above, for example using the high-sensitivity immunoassay disclosed in WO 2021 / 185961 A1; see above.

[0237] The invention further relates to a medicament comprising the formulation of the invention. In one embodiment, the invention relates to a medicament of the invention for use in the treatment of a disease associated with SOD1 accumulation, preferably ALS. In one embodiment, the invention relates to a medicament of the invention for use according to the invention.

[0238] The present invention also relates to a pharmaceutical container comprising a preparation of the present invention and a drug, respectively. In one embodiment, the container is a prefilled syringe, an injection pen, an ampoule, a bottle, an automatic syringe, a glass vial or an infusion bag. In a preferred embodiment, the container of the present invention is an infusion bag or a class of vials, more preferably a glass vial, and most preferably a disposable glass vial. In one embodiment, the container of the present invention is a disposable glass vial sealed with a rubber stopper and an easy-open cover (flip-off cap). In one embodiment, the glass and the container are 8 ml glass vials, respectively.

[0239] In one embodiment, the container of the invention is a glass vial as defined above, which provides about 100 mg of an antibody at a concentration of 20 mg / mL. Thus, the dosage strength of one vial is 100 mg. In one embodiment, the container of the invention, in particular the vial, comprises an overfill of about 10% volume.

[0240] Several documents are cited throughout this specification. The contents of all cited references (including references cited in this application, issued patents, published patent applications, including background sections and manufacturer specifications, specifications, etc.) are hereby expressly incorporated by reference; however, no admission is made that any of the cited documents are prior art with respect to the present invention.

[0241] A more complete understanding can be obtained by reference to the following specific examples, which are provided herein for purposes of illustration only and are not intended to limit the scope of the invention.

[0242] Example

[0243] Example 1: Phase 1 Study of AP-101 in ALS Patients

[0244] A multicenter, open-label, single ascending dose study (SAD) in familial and sporadic ALS patients has been conducted to evaluate the safety, tolerability, and pharmacokinetics of AP-101 administered intravenously (IV) in humans.

[0245] In short, AP-101 is a fully human IgG1 antibody that has high affinity for and selectively binds to misfolded SOD1. A 3+3 study design was used, which allowed each cohort to be expanded to n=6 if any safety signals were observed in the first 3 participants. After a 28-day screening period, AP-101 was administered by IV infusion in 3 cohorts at SAD levels: 100 mg (cohort 1), 500 mg (cohort 2), and 2500 mg (cohort 3). Participants were observed on-site within 24 hours after dosing and attended scheduled visits for up to 12 weeks after dosing for safety assessments and collection of pharmacokinetic (PK) samples. As an exploratory objective, CSF samples were collected at screening to measure misfolded SOD1. Nine patients, three in each cohort, completed the study. One SAE was lower back pain that occurred at the lowest dose, but was unrelated to treatment. Overall, AP-101 was found to be safe and tolerable when administered as a single IV infusion. No toxicity or reactions were observed related to the doses of drug administered up to 2500 mg.

[0246] Participants were all over 18 years old and diagnosed with ALS according to the El Escorial criteria (Brooks et al., Amyotroph Lateral Scler Other Motor Neuron Disord. 1 (2000), 293-299), and genetic testing was performed to determine whether the participants carried pathogenic SOD1 mutations. The onset of ALS symptoms, especially muscle weakness, occurred within the last 48 months before trial recruitment. The participants were required to have an upright slow vital capacity (SVC) ≥ 60% predicted based on age, height, gender and race. Concomitant use of riluzole and edaravone was allowed, provided that the participants took stable doses for ≥ 30 days or completed ≥ 2 cycles before screening. Participants who used non-invasive ventilation (NIV) for more than 4 hours per day were excluded from the trial, as were participants who took other investigational products for ALS within 30 days before recruitment or were previously exposed to stem cell therapy.

[0247] Definition and Methodology

[0248] Adverse events (AEs)

[0249] For the studies described below, clinical trial AEs were defined as any adverse medical event associated with the use of study drugs, regardless of whether they were considered drug-related. Any injection / infusion site reactions that occurred were recorded as AEs, and the time of day, time associated with injection / infusion, erythema size, amount, induration, and pruritus were recorded. The severity of all AEs was graded according to the National Cancer Institute-Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 5.0. For AEs that were not specifically graded by these standards, the following criteria apply. For each episode, the highest severity achieved was reported.

[0250] Grade 1: Mild; asymptomatic or mild symptoms; clinical or diagnostic observation only; no intervention required.

[0251] Grade 2: Moderate; minimal, local, or noninvasive intervention required; limitations on age-appropriate instrumental activities of daily living (ADL).

[0252] Grade 3: severe or medically significant but not immediately life-threatening; requiring hospitalization or prolonged hospitalization; loss of function; limiting self-care ADL.

[0253] Grade 4: Life-threatening consequences; urgent intervention required.

[0254] Grade 5: Death related to AE.

[0255] Instrumental ADLs are things like preparing food, buying groceries or clothes, using the phone, managing money, etc. Self-care ADLs are bathing, dressing and undressing, feeding oneself, using the toilet, taking medications, and being out of bed.

[0256] Clinical laboratory evaluation

[0257] If a study patient develops elevated alanine aminotransferase (ALT) that is at least and / or greater than 3 times (≥3X) the upper limit of the normal range (ULN), alkaline phosphatase (ALP) ≥2X ULN, or elevated total bilirubin (TBL) ≥2X ULN, liver tests (within 3 to 5 days, including ALT, aspartate aminotransferase (AST), ALP, TBL, direct bilirubin, gamma-glutamyltransferase (GGT)), and creatinine kinase are repeated to confirm the abnormality, determine if it is related to hepatotoxicity, and determine if it is increasing or decreasing. If the abnormality persists or worsens, the investigator will initiate clinical and laboratory monitoring in consultation with the sponsor. Monitoring will continue until levels normalize and / or return to near baseline levels. In addition to these selected safety tests, patients will be followed up in consultation with the sponsor for clinically indicated cases of treatment-emergent liver abnormalities.

[0258] Vital signs measurement

[0259] Vital signs (blood pressure [BP], heart rate, respiratory rate, and temperature) were measured at scheduled time points. Single measurements were performed at screening and at entry to the study site. Three BP and pulse rate in the supine position were collected at all other time points. Temperature was obtained as a single measurement. Pre-dose vital signs were collected approximately 1 hour before scheduled dosing. At the time point for obtaining orthostatic measurements, patients lay supine for at least 5 minutes and stood for approximately 2 minutes. When three BP or pulse rate measurements preceded orthostatic measurements, the last supine BP or pulse rate measurement was used for orthostatic calculations. If the patient felt unable to stand, only supine vital signs were recorded. If CS worsened, these changes were recorded as AEs in the eCRF.

[0260] Physical examination

[0261] A physical examination was performed based on the investigator's discretion. If findings of CS were observed at the baseline examination, they were recorded as medical history during the physical examination. Otherwise, they were recorded as AEs. The subject's height was measured during the initial physical examination performed during the screening visit. Weight was measured at predetermined time points. If worsening of CS was found, the change was recorded as an AE in the eCRF. The investigator continued to monitor the subject until the parameters returned to their baseline status or until agreed between the investigator and the sponsor.

[0262] Neurologic examination

[0263] Directed neurological examinations were performed by the investigator or designee at pre-determined time points. If abnormalities were found at these time points, additional examinations were performed until the patient returned to baseline. Mandatory elements of the examination included examination of cranial nerves, tremor, extraocular muscle movements, brachial and patellar deep tendon reflexes, finger-nose pointing, and Romberg sign.

[0264] Electrocardiogram

[0265] A standard 12-lead ECG will be recorded. The ECG will be interpreted on-site by a qualified physician (the investigator or a qualified designee) as soon as possible after the time of ECG acquisition. The investigator or a qualified designee will record whether the ECG is normal or abnormal; if abnormal, whether the ECG tracing is NCS or CS. Worsening of CS will be reported as an AE.

[0266] C-SSRS

[0267] The C-SSRS (Mental Health Scaled by Suicidality) was collected at predetermined time points. The C-SSRS questionnaire assesses suicidal thoughts, their potential intensity, and behaviors aimed at fulfilling these thoughts. Each patient answered the C-SSRS twice at screening, once covering their entire lifetime and once covering the past month / year. Each patient answered the questionnaire again at the EOS, and any changes in the responses to each question were recorded.

[0268] AP-101 Concentration Measurement

[0269] The concentrations of AP-101 in human serum and CSF were determined by using an immunoassay with electrochemiluminescence (ECL) detection and validated at Nexelis (Seattle, WA) in the range of 100.0-3200.0 ng / mL (serum) and 10.0-1280.0 ng / mL (CSF).

[0270] ALSFRS-R

[0271] Throughout the study time course, each patient's responses to the ALSFRS-R (ALS Life Skills Function) questionnaire were collected. ALSFRS-R is a clinician-administered, validated rating tool used to monitor the progression of functional loss in life skills in ALS patients. Its score is significantly correlated with the test results using the Sickness Impact Profile (Cedarbaum et al., Neurol. Sci. 169 (1999), 13-21; Damiano et al., Med. Care 37 (1999), 15-26), which is commonly used to measure health and quality of life. ALSFRS-R consists of twelve life skill categories, each with one question and a score from 0 to 4. A rating of zero (0) indicates complete loss of function, while 4 indicates intact function (Cedarbaum et al. 1999, supra). The total ALSFRS-R score is calculated as the sum of the answers to the 12 questions. Each patient answered the ALSFRS-R at screening, pre-dose (Day 1), follow-up (Day 28), and EOS (Day 84). Changes from baseline in ALSFRS-R domains were calculated and presented for each patient.

[0272] SVC

[0273] Throughout the study time course, each patient's respiratory function changes were evaluated and measured with %SVC. SVC, the amount of air released by slow, non-forced exhalation, is a standard method for assessing airflow limits. In addition to the activity of the expiratory muscles, exhalation is partly due to the elastic recoil of the respiratory system. Due to the poor understanding of the degeneration of respiratory motor nerves and the associated loss of respiratory muscle control and plasticity, elastic recoil is usually lost in ALS. In ALS, SVC is associated with clinically significant events such as the use of assisted ventilation and tracheostomy, and ALS patients with slower SVC decline have been shown to have longer survival times. Based on these findings, SVC is used as a clinical prognostic marker indicating disease progression in ALS (Andrews et al., JAMA Neurol 75 (2018), 58-64). Percent (%) SVC is a measure of respiratory function and is expected to decline over time as the disease progresses in ALS patients. Standing % SVC was determined by 3-5 measurements at Screening, Pre-dose (Day 1), Follow-up (Day 28), and EOS (Day 84). Changes from Baseline to Day 28 and to EOS were calculated and listed for each patient.

[0274] Safety Endpoints Methodology

[0275] Safety analyses were performed according to SAP for all enrolled patients, regardless of whether they completed all protocol requirements. For continuous variables, summary statistics included number of patients, mean, median, standard deviation (SD), minimum, and maximum values. Categorical endpoints were summarized using number of patients, frequency, and percentage.

[0276] All treatment and protocol-related AEs were recorded and listed. Safety data were summarized using descriptive methodology when event frequency permitted.

[0277] Pharmacokinetic endpoint methodology

[0278] PK analysis was performed on data from all patients who received study drug and had evaluable PK. Both noncompartmental analysis (NCA) and a 2-compartment model were used to elucidate the PK of AP 101. In NCA, serum concentrations of AP-101 and actual sample collection times were used to determine individual PK parameters using standard noncompartmental procedures using R 4.0.4 (Vienna, Austria). The main PK parameters calculated included C 最大 (maximum observed drug concentration), t 最大 (time to reach maximum observed drug concentration), AUC 0-t , AUC 0-inf (area under the drug concentration-time curve), t 1 / 2(terminal elimination half-life) and λz (first-order terminal elimination rate constant). The 2-compartment model was developed using NONMEM version 7.4 (San Francisco, CA). Considering the 2-compartment PK characteristics exhibited by AP-101, parameters such as CL and volume of distribution (V d ) were predicted by the model, but not by NCA. Individual serum AP-101 PK parameters were calculated using NCA. Actual sampling times were used for parameter derivation.

[0279] Trial Design and Evaluation

[0280] This was a non-randomized, open-label, first-in-human, single ascending dose (SAD) trial. A "3+3" study design was used, allowing for expansion of each cohort to n=6 if any safety signals were observed in the first three participants in that cohort. After a 28-day screening period, participants received a single dose of AP-101 intravenously (IV) at a dose level determined by their cohort: 100 mg in cohort 1, 500 mg in cohort 2, or 2500 mg in cohort 3.

[0281] In particular, AP-101 was administered by IV infusion over at least 60 minutes and up to 120 minutes. The AP-101 drug product for IV administration was formulated according to Examples 3 and 4. AP-101 for injection was supplied as a solution in a disposable glass vial. The vial was manufactured to provide 100 mg of AP-101 at a concentration of 20 mg / mL. To ensure complete extraction and delivery of the labeled amount of 100 mg of AP-101, the vial contained approximately 10% overfill. The drug product was filled into Type I glass vials and sealed with a rubber stopper and an easy-open cap. The study drug was administered as an IV infusion over at least 60 minutes and up to 120 minutes. For administration of 100 mg, 500 mg, and 2500 mg doses of AP-101, the volumes infused were 5 ml, 25 ml, and 125 ml.

[0282] The sentinel dosing period was 21 days for cohort 1 and seven days for cohorts 2 and 3, with safety data reviewed by the Safety Review Committee (SRC) prior to dosing of subsequent participants in the cohort. Participants were enrolled at least 24 hours after dosing and returned to the clinical trial site for up to 12 weeks after dosing for safety assessments and collection of PK samples.

[0283] The primary endpoints were the incidence of treatment-emergent adverse events (TEAEs) and serious adverse events (SAEs), as well as the incidence of abnormalities in clinical safety measures (vital signs, clinical laboratory evaluations, physical examinations, neurological examinations, and electrocardiograms (ECGs)). As with investigational products with neurological indications, suicidal ideation was assessed using the Columbia-Suicide Severity Rating Scale (C-SSRS). Secondary endpoints were measures of pharmacokinetics in both serum and cerebrospinal fluid (CSF). Exploratory endpoints included changes in quality of life and function, assessed by the ALS Functional Rating Scale Revised (ALSFRS-R), and changes in respiratory function, assessed using SVC. CSF levels of misfolded SOD1 were also included as an exploratory measure.

[0284] Statistical analysis

[0285] The full analysis set (FAS) consisted of all enrolled participants who received one dose of AP-101, which included nine participants. All treatment and protocol adverse events (AEs) and their frequencies were recorded, classified, and summarized using descriptive methodology. Summary statistics for each cohort were summarized by dose level. Standard descriptive statistics were used to summarize the safety parameters of this study. Results from individual question answers from the C-SSRS assessment were listed by participant, visit, time point, and dose. No further analysis was performed on the results of the C-SSRS.

[0286] Serum AP-101 PK parameters (e.g., C 最大 The PK parameters were summarized by dose level using descriptive statistics and the mean and individual AP-101 serum concentration-time profiles were derived. CSF PK was performed as a secondary objective at a unique time point for each participant in Cohorts 2 and 3.

[0287] Numerical rating responses to each question of the ALSFRS-R are presented by time point, participant, and cohort. Changes in total ALSFRS-R scores for participants were reported from baseline to Day 28 and to the end of the study (EOS). Results of individual SVC tests, measured as %SVC, are presented by time point, participant, and cohort. Changes in %SVC from baseline to Day 28 and EOS were calculated and reported.

[0288] result

[0289] Nine participants were screened and recruited to AP-101-01. All participants met the El Escorial criteria for ALS diagnosis, eight had definite or probable sALS, and one had fALS due to pathogenic variants in the SOD1 gene. Three participants were recruited per dose cohort, and all completed the study.

[0290] The characteristics of the participants are detailed in Table 1. Due to the small sample size of this safety study, differences in baseline characteristics were observed.

[0291] Table 1: Baseline demographics and disease characteristics.

[0292]

[0293] Security

[0294] Overall, AP-101 was found to be safe and tolerable when administered as a single IV infusion. Forty-seven treatment-emergent adverse events (TEAEs), defined as AEs occurring after administration of study drug, were reported. Twenty patients were at the 100 mg dose level, six patients were at the 500 mg dose level, and 21 patients were at the 2500 mg dose level. Of the patients treated, eight (89%) experienced a TEAE. All patients in Cohorts 1 and 3 (100%) and in Cohort 2 (67%) experienced an AE. The most commonly reported TEAEs were falls (7 events), headache (6 events), and fatigue (3 events). Two (2) Grade 2 non-ALS TEAEs were recorded: one (1) fatigue event and one (1) back pain event, but all TEAEs were unrelated to treatment. No dose-limiting toxicities, treatment-related TEAEs, or reactions related to administration of the study product were observed.

[0295] No abnormal clinical laboratory test results were recorded in the study. No clinically significant (CS) vital sign abnormalities were found. All patients except 1 patient (89%) experienced at least one abnormal physical examination at all time points, and all patients (100%) experienced at least one abnormal neurological examination. Six (6) of 9 patients (67%) had an abnormal ECG at all time points: one (1) patient in Cohort 1 (33% of Cohort 1, N=1), 2 patients in Cohort 2 (67%, N=2), and 3 patients in Cohort 3 (100%, N=3). All patients except 1 had abnormal readings prior to dosing.

[0296] Most baseline physical and neurological examination screening results were abnormal, and the majority of these results were attributed to ALS. Most participants had no change in physical and neurological examination results from baseline values. Non-ALS-related abnormal findings at time points beyond screening included musculoskeletal injuries and neuropathy, attributed to laboratory chemistry sampling. Rash, gingival abscess, and wheeze were also recorded. All abnormal test results were not clinically significant (NCS). ECG abnormalities recorded as deviations from baseline were common, but none were associated with AEs and all were considered NCS. There was no apparent correlation between administration of study drug and patients' physical condition or cardiac function.

[0297] Changes in mental health status were measured using the C-SSRS. Although one participant indicated that they had experienced suicidal ideation in their lifetime, no participant indicated suicidal ideation or behavior prior to screening, recently, or at the end of the study.

[0298] Pharmacokinetics (PK)

[0299] Blood samples for PK analysis were collected prior to dosing and at the following time points after IV administration of AP-101: 5 minutes, and 0.25, 0.5, 1, 4, 8, 12, 24, 48, and 72 hours post-dose. Median t 最大 It is noteworthy that AP-101 concentrations exhibited an unusual behavior at the end of the IV infusion, where t 最大 None occurred at the first time point after infusion. AP-101 exposure generally increased in proportion to the dose. Exposure (C 最大 and AUC 0-inf ) had moderate to high variability (CV%), and C 最大 The range was 25.9 to 35.1, and the AUC 0-inf The range was 20.2 to 37.7. In the 500 mg dose group, the AUC 0-inf The extrapolated portion was greater than 20%. AUC of one patient in the 2500 mg dose group 0-inf The extrapolated fraction was also greater than 20%, and therefore these patients were excluded from the summary statistics. The geometric mean elimination half-life (t 1 / 2 ) values ​​appeared similar, with the 2500 mg dose having a lower value. 1 / 2 The PK model predicted value was approximately 244 hours.

[0300] effect

[0301] Evaluation of the change from baseline in ALSFRS-R score and the change from baseline in %SVC were included as exploratory efficacy endpoints. Misfolded SOD1 levels in CSF at baseline were included as an exploratory analysis.

[0302] ALSFRS-R was collected at screening, pre-dose (baseline), day 28, and EOS. The ALSFRS-R was assessed as a total score as a change in functional status loss or gain at EOS compared to baseline (pre-dose). Five participants experienced a loss in overall functional status with an ALSFRS-R total score ranging from 1 to 8. Two participants had no change in function, and two participants had a gain in functional status with an ALSFRS-R increase of 2 to 4 points.

[0303] SVC will be collected at screening, pre-dose (baseline), Day 28, and at EOS; however, due to staffing limitations and COVID-19 restrictions, four participants missed five SVC time points. In addition, SVC could not be assessed at EOS for three participants, and could not be assessed at baseline for another participant. Considering these variables in the data, the overall %SVC decreased from baseline to the last observed SVC (which was Day 28 for three participants), with decreases ranging from 2% to 32%. One participant experienced no change in %SVC, while two participants had an increase in %SVC from baseline to EOS of 3% to 5%.

[0304] Summarize

[0305] In summary, given the data surrounding misfolded SOD1 pathology in sALS and SOD1-fALS, AP-101 is a fully human IgG1 antibody that has high affinity and selective binding to misfolded SOD1 protein. This was a first-in-human, single ascending dose, non-randomized, open-label study of AP-101 conducted in multiple centers in Canada. Overall, AP-101 was found to be safe and tolerable when administered as a single IV infusion. There was no correlation between any TEAEs, SAEs, or other abnormal findings and administration of the study product. No dose-limiting toxicities or IV infusion-related reactions were observed.

[0306] PK analysis showed that AP-101 exposure was generally proportional to dose and clearance was bi-exponential (see Figure 2), but as mentioned above, the PK profile is also variable. The time versus concentration curves show that AP-101 is slowly cleared from the body. On day 84 (2016 hours), the mean concentration in the lowest dose group (100 mg) was 731 ng / mL. Analyses and further modeling support the conclusion that the PK profile of AP-101 is consistent with every 3-week dosing and that a 500 mg loading dose can help quickly reach the desired steady state. These analyses suggest that the elimination of AP-101 is slow and that dosing every 3 weeks will provide sufficiently constant drug levels.

[0307] Changes from baseline in both ALSFRS-R and SVC were included as exploratory measures, and overall, there were more functional losses than gains. No conclusions can be drawn regarding the effects of AP-101 on functional or respiratory status due to the lack of a control group and the lack of a recruitment strategy to account for heterogeneity in disease status.

[0308] Example 2: Phase 2a Study of AP-101 in ALS Patients

[0309] The Phase 2a, multicenter, randomized, double-blind, placebo-controlled study of AP-101 in patients with familial amyotrophic lateral sclerosis (fALS) and sporadic amyotrophic lateral sclerosis (sALS) was designed to evaluate safety, tolerability, pharmacodynamic (PD) markers, and pharmacokinetics (PK); see also Clinical Trials Government Identifier: NCT05039099. AP-101 has been used in humans in a single ascending dose study and was found to be safe and tolerable at doses up to and including 2500 mg (see Example 1).

[0310] Two participant cohorts will participate in this study: fALS patients and sALS patients with confirmed SOD1 mutations. Patients in each participant cohort will be randomized in a 2:1 ratio to either AP-101 treatment or placebo. Patients will be allowed to continue riluzole or edaravone during the study, based on inclusion / exclusion criteria. After completing 6 months of treatment, participants will be invited to participate in a 6-month open-label extension (OLE), which will continue to evaluate the long-term safety of AP-101. In addition to safety and tolerability, the goal of the current study is to determine the effect of AP-101 on measurable levels of several ALS-related biomarkers. The modified ALSFRS-R is a recognized clinical endpoint for functional effects on ALS disease progression (FDA 2019; EMA 2015). Based on this evidence, the current study will look at the effect of AP-101 on multiple potential biomarkers of disease, including SOD1, misfolded SOD1, pNfH, and NfL. The primary and secondary objectives of this study are described in the study details for the Phase 2a study published under the Clinical Trials Government Identifier: NCT05039099.

[0311] Potential participants who develop symptoms within 24 months of screening will be screened 28 days prior to baseline (Day 1). Each participant's study eligibility will be reviewed based on all enrollment criteria outlined below.

[0312] The screening procedure is presented in the SoE shown in Table 2.

[0313]

[0314]

[0315]

[0316] Participants will receive a 500 mg loading dose of AP-101 on Day 1 and then receive regular doses of 2500 mg starting on Day 2. After Day 2, dosing will be every 3 weeks for a period of 6 months starting on Day 22 according to the SoE (Table 2). Participants will be followed for safety and PK for 3 months after the last dose of study treatment, following the last dose or upon early termination for any reason at any time point in the study.

[0317] Safety / tolerability, PK, and exploratory assessments will be performed at defined time points during the study. Cerebrospinal fluid (CSF) and other biological samples for biomarker analysis will also be collected from each participant per the SoE. Efficacy measures (Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised [ALSFRS-R], slow vital capacity [SVC], pulse oximetry, handheld dynamometer [HHD]) and the King staging tool will be evaluated per the SoE.

[0318] After completing 6 months of treatment, participants will be invited to participate in a 6-month open-label extension (OLE), which continues to evaluate the long-term safety of AP-101. If participating in the OLE, patients will complete planned safety and PK follow-up after their last dose of AP-101.

[0319] A maximum of 63 participants (21 fALS and 42 sALS) will be randomized to the study intervention, resulting in approximately 18 evaluable participants with fALS and 36 evaluable participants with sALS completing the study. Participants who withdraw from the study prior to completion of all study activities may be replaced at the Sponsor's discretion. Participants will complete the study when all scheduled procedures for the Week 24 dosing and Day 28 follow-up visits as indicated in the SoE are completed.

[0320] The total study duration for participants is expected to be approximately 10 months, including screening, a 6-month treatment period, and a 3-month safety follow-up period. For participants continuing into the 6-month OLE, the 3-month safety follow-up period will begin at the end of the OLE or upon early termination of the study for any reason. Participants will be screened within 28 days prior to enrollment in each group and randomized to AP-101 2500 mg IV or placebo, administered according to the SoE during the 6-month treatment period. After completing the treatment period, participants may continue to participate in the study as part of the OLE if they complete all study visits during the treatment period. All study treatments will be administered at the study site. Calculated PK results (exposure) and body clearance of the drug following intravenous (IV) administration [CL] will be used as supporting data for any dose modifications, if available.

[0321] Participants were considered to have completed the study if all scheduled procedures for the Week 24 dosing and 28-day follow-up visit were completed as indicated in the SoE (Table 2). The end of the study was defined as the date after the last participant completed 6 months of study treatment and completed any applicable follow-up visits.

[0322] Rationality of dosage

[0323] The proposed dose of 2500 mg AP-101 was selected based on a first-in-human (FIH) dose-finding study in ALS patients (NCT03981536) and a toxicity study in cynomolgus monkeys (Study 8384444). This dose level has been confirmed to have an acceptable safety and tolerability profile after a single IV administration. The current study is designed with 2 loading doses on consecutive days, followed by repeated dosing every 3 weeks for 6 months. Based on computer simulation modeling of PK data obtained from the FIH study, the dosing regimen is designed to allow patients to reach steady state as quickly as possible. The dosing frequency is based on maintaining steady state throughout the treatment phase of the study.

[0324] Based on available preclinical, toxicology, and clinical data, it is recommended to administer loading doses of 500 mg and 2500 mg on consecutive days, followed by 2500 mg IV every 3 weeks. The dose level is based on preclinical efficacy studies in transgenic mouse models of ALS, which showed that weekly intraperitoneal administration of mouse chimeric α-miSOD1 at 3, 10, or 30 mg / kg (180-1800 mg dose equivalent, FDA 2005) showed efficacy at specific endpoints. In addition, no significant toxicity (weight loss) was observed in these animals.

[0325] The potential for AP-101 to produce toxic or adverse effects was evaluated in a 1-month study in cynomolgus monkeys (Study 8384444) consisting of 2 IV injections 2 weeks apart, each followed by an approximately 2-week post-dose observation period. Monkeys are a relevant toxicological species because AP-101 binds to human and monkey SOD-1; AP-101 does not bind to rodent SOD1. No AP-101-related effects on toxicological or safety pharmacology parameters occurred at doses up to and including 400 mg / kg (24,000 mg for a 60-kg human), the highest dose tested. Therefore, 400 mg / kg is considered the no observed adverse effect level (NOAEL).

[0326] In this 1-month study, monkeys received IV boluses of 10, 60, or 400 mg / kg AP-101 on days 1 and 15 of the study, followed by necropsy on day 29 of the study. The highest dose was selected to provide multiples of the proposed human dose. Toxicity assessments were based on mortality, clinical observations, body weights, ophthalmological observations, clinical pathology (hematology, coagulation, clinical chemistry, and urinalysis parameters), and anatomical pathology (organ weights, macroscopic and microscopic pathology).

[0327] No AP-101-related effects were observed in any of the study parameters evaluated. Serum AP-101 was measured at several time points and CSF AP-101 was measured at a single time point at necropsy 2 weeks after the second dose of AP-101. Serum exposure increased from 10 to 400 mg / kg in a dose-proportional manner with no evidence of accumulation over this dosing interval. AP-101 was detectable in some CSF samples of monkeys dosed at 60 and 400 mg / kg collected at necropsy (approximately 2 weeks after the second IV dose).

[0328] Table 3 lists the associated safety margins based on the NOAEL from the 1-month monkey study. The proposed clinical starting dose of 100 mg is 235-fold lower than the NOAEL determined in the 1-month monkey study and slightly lower than the lowest efficacy dose in the transgenic mouse efficacy study, while the highest proposed clinical dose of 2500 mg is approximately 10-fold lower than the toxicology study NOAEL and slightly higher than the maximum efficacy dose in the transgenic mouse efficacy study (as described above, the chimeric molecule was tested in the transgenic mouse study). The proposed clinical studies use conservative dose escalation and appropriate safety monitoring. The results of the 1-month monkey study, as well as the clinical study design, suggest that AP-101 has a safety profile that supports the initiation of clinical development. Based on the PK observed in cynomolgus monkeys and humans, human exposure multiples were calculated using the PK profile; see Table 3.

[0329] Table 3: Safety margins for intravenous administration of AP-101 based on administered dose and predicted exposure

[0330]

[0331] Abbreviation: AUC 0-336 = area under the plasma concentration-time curve from time 0 to 336 hours; NOAEL = no observed adverse effect level.

[0332] a Dose multiples are based on animal dose / human dose in mg / kg. Exposure multiples are calculated as observed AUC0-336 in animals / predicted AUC0-336 in humans.

[0333] b The NOAEL was established in a 1-month repeat-dose toxicity study (Study 8384444).

[0334] In a 6-month repeat-dose study (Study 8384445), monkeys were given 60 or 400 mg / kg AP-101 IV every 2 weeks for 26 weeks (13 doses total). Toxicity assessments were based on mortality, clinical observations, body weights, ophthalmic observations, clinical pathology (hematology, coagulation, clinical chemistry, and urinalysis parameters), and anatomical pathology (organ weights, macroscopic and microscopic pathology). No AP-101-related effects were observed in any of the study parameters evaluated, and therefore the NOAEL was considered to be 400 mg / kg. Consistent with the absence of adverse reactions in the 1- and 6-month monkey toxicology studies, no drug-related adverse events occurred during the FIH study (AP101-01).

[0335] Dose preparation instructions for AP-101 for injection, 100 mg per vial (5 mL, 20 mg / mL)

[0336] The AP-101 drug product is administered by slow intravenous (IV) infusion, with a 500 mg dose using a syringe pump and a 2500 mg dose using an IV bag. AP-101 for injection is provided as a solution in a single-use glass vial for clinical trial use. Further details are outlined in Examples 3 to 6.

[0337] Study Group

[0338] Eligibility of study participants will be based on the results of the assessments described in the SoE, including screening, medical and disease history, physical examination, vital signs, clinical laboratory tests, Columbia Suicide Severity Rating Scale (CSSR-S), ALS Specific Quality of Life Revised (ALSSQOL-SF), and ECG. Detailed criteria for inclusion and exclusion are listed in the study details of the Phase 2a study published under the Clinical Trials Government Identifier: NCT05039099.

[0339] Study Intervention

[0340] Study interventions were defined as any one or more study interventions, one or more marketed products, placebo, or one or more medical devices intended to be administered to / used by study participants according to the study protocol.

[0341] One or more study interventions administered

[0342] Following randomization on Day 1, participants will receive one dose of AP-101 500 mg or placebo and another dose of AP-101 2500 mg or placebo on Day 2. Thereafter, at each visit during the treatment period, AP-101 2500 mg or matching placebo will be administered to all participants via IV infusion over at least 60 minutes. Based on the study site's standard operating procedures, the infusion duration may be increased, or the infusion may be stopped, if deemed necessary, or if an infusion reaction is observed. However, IV administration needs to be completed within no more than 2 hours (120 minutes) from the start of the infusion. During the infusion and throughout patient visits, the study site must have resuscitation equipment, emergency medications, and appropriately trained staff available during the infusion and for up to 6 hours after the participant completes the infusion. The actual start and stop times of the infusion will be recorded in the Electronic Data Capture (EDC).

[0343] The AP-101 drug product is a monoclonal antibody for IV administration. AP-101 for injection is provided for clinical trial use as a solution in a single-use glass vial. The vial is manufactured to provide 100 mg of AP-101 at a concentration of 20 mg / mL. To ensure complete extraction and delivery of the labeled amount of 100 mg of AP-101, the vial contains an overfill of approximately 10%. The drug product is filled into single-use Type I glass vials.

[0344] Preparation / Handling / Storage / Responsibility

[0345] AP-101 vials are stable and should be stored under refrigerated conditions (2° to 8°C). Pharmacy personnel will be trained and instructed on the preparation of each dose of AP-101 IV solution. Further instructions regarding preparation, handling, storage, and responsibilities are as follows:

[0346] 1. The investigator or designee must confirm that all received study interventions have maintained appropriate storage conditions during shipment and report and resolve any discrepancies prior to use of the study intervention.

[0347] 2. Only participants recruited into the study may receive the study intervention. Only researchers may provide, prepare, or administer the study intervention. All study interventions must be stored in a secure, environmentally controlled, and monitored (manual or automated) area in accordance with labeled storage conditions, accessible only to researchers and authorized researchers.

[0348] 3. The investigator or authorized research staff is responsible for the accountability, verification, and record maintenance of the study intervention (i.e., receipt, verification, and final disposition records).

[0349] 4. The investigator or designee is responsible for returning all unused medication to the sponsor or designee at the end of the study. In some cases, if during the study site selection the evaluator has verified and documented that the site has appropriate facilities and written procedures to handle clinical materials, the site may destroy the materials.

[0350] Measures to reduce bias: randomization and blinding

[0351] This is a double-blind study. All participants will be centrally assigned to the randomized study intervention on Day 1 using an interactive web response system (IWRS). The study intervention will be delivered at the study visit as summarized in the SoE. If the blind is breached by the investigator, site personnel performing the assessment, or the participant, the participant must be discontinued from the study with the opportunity to be recruited to the OLE. If a participant's continued participation in the study is required for ethical reasons, the investigator must obtain specific approval from the sponsoring clinical study physician for the participant to continue in the study.

[0352] The IWRS will be incorporated into the unblinding instructions. In an emergency situation, the investigator has the sole responsibility to decide whether there is a legitimate reason to unblind a participant's intervention assignment. The safety of the participant must always be the primary consideration when making such a decision. If a participant's intervention assignment is unblinded, the sponsor must be notified immediately after the unblinding is broken. The date and reason for the unblinding must be recorded in the original documentation and case report form, if applicable.

[0353] Participants will be randomized in a 2:1 ratio to receive the study intervention. Throughout the course of the study, the investigator will remain blinded to each participant's assigned study intervention. To maintain this blinding, an additional uninvolved and unblinded third party will be responsible for preparing all blinded study interventions for each participant's treatment assignment. Unblinded third party personnel will receive training and instruction to prepare each dose of the study intervention, i.e., AP-101 or matching placebo solution for IV administration. After randomization, the blinded study intervention will be administered to the participant by blinded staff.

[0354] If a Quality Assurance audit is conducted, one or more auditors will be allowed access to unblinded study intervention records at one or more sites to verify that randomization / allocation was completed accurately.

[0355] Study intervention compliance

[0356] Study interventions will be administered under the medical supervision of the Investigator or designee. Records of treatment administration will be made at the site. The date and time of each dose administered will be recorded in the source document and in the electronic case report form (eCRF).

[0357] Combination therapy

[0358] Treatment with riluzole and / or edaravone is permitted as standard of care agents, where approved. Participants are required to be on a stable dose for at least 30 days prior to screening and remain on a stable dose throughout the study. Riluzole or edaravone cannot be initiated during the placebo-controlled portion of the study; however, once participants are enrolled in the planned open-label extension, utilization of either may be initiated. In general, concomitant medications should be avoided; however, over-the-counter medications may be used at the investigator’s discretion. (e.g., acetaminophen for headaches). If concomitant medications are necessary (other than over-the-counter medications), inclusion or continuation of the subject is at the investigator’s discretion in consultation with the sponsor. Any medications used during the course of the study must be recorded. Marijuana use is permitted during the study period at the investigator’s discretion, as directed.

[0359] Dose Modifications

[0360] Dose levels, sampling schedules, and timing of procedures (e.g., PK sample collection, ECG timing) may be adjusted given safety or PK data that emerge during the study. This is the first multiple-dose study of AP-101, and therefore safety data will be the primary criterion for any dose modifications. Safety data, particularly AEs, SAEs, and adverse laboratory abnormalities, will be independently evaluated by the Investigator, Sponsor, and SRC and will be considered related to study drug unless there is clear evidence that the event is not related to study drug. Calculated PK results (exposure) and body clearance of drug after IV administration [CL] will be used as supporting data for any dose modifications. After reviewing these data, the Investigator, Sponsor, and SRC will agree on the appropriate dose modification. Any dose modification must be agreed upon by the Investigator, Sponsor, and SRC.

[0361] Infused prodrug

[0362] No promedication is planned for the infusion. However, if an infusion reaction occurs, appropriate medication may be administered at the discretion of one or more study investigators. If an infusion reaction is observed, acetaminophen (500 to 1000 mg) and / or an antihistamine may be administered orally or IV 30 to 60 minutes prior to the start of the infusion for subsequent dosing. The decision to administer promedication to a specific participant who experiences an infusion reaction will be made by the Investigator, Sponsor, and SRC and will be documented in the study files. Any promedication administered will be documented as co-therapy.

[0363] Management of infusion reactions

[0364] The risk of infusion reactions exists with any biologic; therefore, all participants should be closely monitored. Signs and symptoms that may occur as part of an infusion reaction include, but are not limited to: fever, chills, nausea, headache, bronchospasm, hypotension, angioedema, throat irritation, rash, pruritus, myalgia, and dizziness. If a significant infusion reaction occurs, the following guidelines should be followed:

[0365] -Slow down (e.g., reduce infusion rate by 50% [e.g., 12 mL / hr to 6 mL / hr or slower]) or stop the study product infusion based on the development of signs / symptoms:

[0366] -If slowed, the infusion should be completed at a slower rate as tolerated,

[0367] - If the investigator determines that the infusion should not continue, no further attempts to dose the participant should be made

[0368] -Supportive care should be provided based on symptoms / signs.

[0369] Discontinuation of study intervention and participant discontinuation / withdrawal

[0370] Participants who discontinue treatment prematurely for any reason should complete AE and other follow-up procedures, see SoE.

[0371] Discontinuation of study intervention

[0372] If the Sponsor or Investigator identifies a participant who does not meet the enrollment criteria and was accidentally enrolled, a discussion must occur between the Sponsor and Investigator to determine whether the participant can continue to participate in the study. If both parties agree that continuation is medically appropriate, the Investigator must obtain written approval from the Sponsor to allow the accidentally enrolled participant to continue in the study with or without treatment with the investigational product.

[0373] F

[0374] Participants will be discontinued from the study if:

[0375] - Enrollment in any other clinical study involving an investigational product, or enrollment in any other type of medical research that is judged to be scientifically or medically incompatible with this study

[0376] - Need to stop participating in the study for medical, safety, regulatory or other reasons consistent with applicable laws, regulations and good clinical practice (GCP)

[0377] -If the investigator, in consultation with the Sponsor-designated Medical Monitor, determines that a systemic hypersensitivity reaction related to study drug administration has occurred, the participant should be permanently discontinued from study drug use.

[0378] - Investigator's decision

[0379] - The investigator decides that the participant should be discontinued from the study

[0380] - If a participant requires treatment for any reason with another therapeutic agent that has been shown to be effective for the study indication, the study should be discontinued prior to the introduction of the new agent

[0381] - Participants decide

[0382] - Participant or legal representative requests to withdraw from the study.

[0383] - Termination of the study by the sponsor or regulatory agency

[0384] Participants who withdraw from the study prior to completion of all study activities may be replaced at the Sponsor's discretion. If clinically significant findings are identified after enrollment (including but not limited to changes from baseline in the QT interval corrected using the [Bazett formula [QTcB] or Fridericia formula [QTcF]]), the Investigator or a qualified designee will decide whether the participant may continue to participate in the study and whether any changes in participant management are required. A review of the printed ECG at the time of collection must be documented. Any new clinically relevant findings should be reported as an AE. See SoE for data collected at intervention discontinuation and follow-up, and any further evaluations that need to be completed. Temporary discontinuations are not permitted for the current study.

[0385] Participant discontinuation / withdrawal from the study

[0386] Participants can withdraw from the study:

[0387] - At any time upon his / her own request

[0388] -At the request of his / her designee (e.g., parent or legal guardian)

[0389] - For safety, conduct, compliance or administrative reasons, at the sole discretion of the investigator

[0390] - If the participant becomes pregnant during the study

[0391] - If enrolled in any other clinical study involving an investigational product, or enrolled in any other type of medical research that is judged to be scientifically or medically incompatible with this study

[0392] - If a participant requires treatment for any reason with another therapeutic agent that has been shown to be effective for the study indication, the study should be discontinued prior to the introduction of the new agent.

[0393] Discontinuation is expected to be uncommon. In the event of a study discontinuation, an early discontinuation visit should be conducted, if possible, as indicated in the SoE. Refer to the SoE for data collected at study discontinuation and follow-up, and any further evaluations that need to be completed. Participants will be permanently discontinued from the study intervention and the study at that time. If a participant withdraws consent for future disclosures, the Sponsor may retain and continue to use any data collected prior to the withdrawal of consent. If a participant withdraws from the study, he / she may request that any collected and untested samples be destroyed, and the Investigator must document this in the site study records.

[0394] If the Sponsor or Investigator identifies a participant who does not meet the enrollment criteria and was accidentally enrolled, the participant should be discontinued from study treatment unless extenuating circumstances make it necessary for the participant to continue study treatment. If the Investigator and the Sponsor Clinical Study Physician agree that continuation of the study is medically appropriate, the Investigator must obtain written approval from the Sponsor Clinical Study Physician to allow the accidentally enrolled participant to continue in the study with or without treatment with the investigational product. Safety follow-up should be conducted as outlined in the SoE and in the Safety Assessments and AEs section below.

[0395] Lost to follow-up

[0396] If a participant fails to return for scheduled visits multiple times and the study site cannot contact him or her, the participant will be considered lost to follow-up. Site personnel or designees should make every effort to contact participants who fail to return for scheduled visits or who are otherwise unavailable for follow-up by the site. Site personnel or an independent third party will attempt to collect vital status for all randomized participants, including those who are not taking the study product, within legal and ethical boundaries. Vital status information can be searched in public resources. If vital status is determined to be death, this will be recorded and the participant will not be considered lost to follow-up. Sponsor personnel will not be involved in any attempts to collect vital status information.

[0397] Research Assessment and Procedures

[0398] -The SoE summarizes the research process and its timing.

[0399] - When an urgent safety issue occurs or becomes aware, it should be discussed promptly with the Sponsor to determine whether the participant should continue or discontinue the study intervention.

[0400] - Compliance with study design requirements, including those specified in the SoE, is fundamental and necessary for the conduct of the study.

[0401] -All screening evaluations must be completed and reviewed to confirm that potential participants meet all eligibility criteria. The investigator will maintain a screening log to record details of all participants screened and confirm eligibility or record reasons for screening failure, if applicable.

[0402] Please see the section on Laboratory Testing below, which lists the laboratory tests that will be performed in this study.

[0403] Table 4 provides a summary of the maximum number and volume of all invasion specimens sampled during the study period.

[0404] Table 4: Summary of blood sampling for protocol AP101-02

[0405]

[0406] a Includes surface antigen sampling of hepatitis B virus (HBsAg) & hepatitis C virus (HCV) as well as clinical safety laboratory measures.

[0407] b For safety reasons, additional samples may be drawn as necessary, including for analysis of hypersensitivity reactions.

[0408] In addition to the blood sampling volumes listed in Table 4, three post-screening CSF samples of 5 mL each, for a total of 15 mL, will be collected. A 5 mL screening CSF sample will also be drawn. Unless otherwise specified in this protocol, all samples collected for specific laboratory testing will be destroyed within 60 days of receipt of confirmed test results. Certain samples may be retained for longer periods of time if necessary to comply with applicable laws, regulations, or laboratory accreditation standards.

[0409] Efficacy evaluation

[0410] Efficacy in this study will be measured by reduction in the rate of disease progression as measured by the ALSFRS-R; lung function as measured by slow vital capacity (SVC) and / or pulse oximetry; muscle strength as measured by a handheld dynamometer (HHD); quality of life as measured by the ALSSQOL-SF; and disease stage by the King staging tool.

[0411] Survival data may be confounded by the use of ventilation strategy. Therefore, a composite measure of time to death, tracheostomy, or permanent ventilator use was used.

[0412] The ALSFRS-R will be assessed at the visits and times specified in the SoE. The ALSFRS-R is a validated rating tool used to monitor the progression of functional loss in patients with ALS. ALSFRS-R scores are significantly correlated with quality of life as measured by the Sickness Impact Profile, indicating that functional quality is an important determinant of quality of life in ALS. The ALSFRS-R has been shown to predict survival. It measures 4 areas of function, including breathing, bulbar function, gross motor skills, and fine motor skills. There are 12 questions, each with a score of 0 to 4, with a possible total score of 48, with higher scores indicating better function (Cedarbaum et al., J. Neurol. Sci. 169 (1999), 13-21).

[0413] Upright SVC was determined according to the criteria established by the American Thoracic Society and the European Respiratory Society by performing 3-5 measurements at visits and times specified in the SoE (Goncalves de Barros et al., J. Bras. Pneumol 39 (2013), 317-322).

[0414] SpO2 stands for peripheral capillary oxygen saturation and is an estimate of the amount of oxygen in the blood. Low SPO2 is associated with worsening respiratory function. SpO2 measurements will be made based on SoE.

[0415] Muscle strength will be assessed using the HHD instrument at the visits and times specified in the SoE. Muscle strength is an important determinant of ALS function and ultimate survival. Quantitative muscle strength will be evaluated using the HHD, which tests the isometric strength of multiple muscles using standard body positions. Approximately 8 muscle groups will be examined bilaterally in both the upper and lower extremities. Statistical analysis of the 4 muscle groups (HHD0) can be used to accurately predict outcomes.

[0416] Participants' ALS will be staged according to King's staging tool, measured at the visits and times specified in the SoE (Roche et al., Brain 135 (Part 3) (2012), 847-852). This tool uses the following ALS progression classification:

[0417] -Stage 1: Onset of symptoms (first area affected)

[0418] - Stage 2A: Diagnosis

[0419] - Stage 2B: Second area affected

[0420] - Stage 3: Third area affected

[0421] - Stage 4A: Gastrostomy required

[0422] -Stage 4B: Non-invasive ventilation required

[0423] This functional staging system stratifies patients based on their independence (stages 1 and 2) and need for major interventions (feeding tube, respiratory support).

[0424] Security Assessment

[0425] Safety assessments will include clinical laboratories (hematology, clinical chemistry, endocrinology, and urinalysis), coagulation assessments, physical and neurologic examinations, ECG, vital signs, pregnancy test, CSSR-S, quality of life, AE documentation, and AE grading using the National Cancer Institute Common Terminology Criteria for Adverse Events v.5.0 (NCI CTCAE). Additional selected clinical tests may be obtained if treatment-emergent liver abnormalities occur, as detailed in the Liver Monitoring Tests section below. Planned time points for all safety assessments are provided in the SoE.

[0426] A complete physical examination will include, at a minimum, an assessment of the cardiovascular, respiratory, gastrointestinal, and neurologic systems. Height (screening only) and weight will also be measured and recorded. A brief physical examination will include, at a minimum, an assessment of the skin, lungs, cardiovascular system, and abdomen (liver and spleen). Investigators should pay particular attention to clinical signs associated with preexisting serious illness.

[0427] The investigator or designee will perform a directed neurological examination. If abnormalities are noted at these time points, additional examinations should be performed until the participant returns to baseline. The examiner should be familiar with the participant's baseline examination. Mandatory elements of the examination include examination of cranial nerves, tremor, extraocular muscle movements, brachial and patellar deep tendon reflexes, finger-to-nose testing, and Romberg's sign. Participants who develop clinically significant changes on the neurological examination should be considered for further examination (Workup).

[0428] For each participant, vital sign measurements, including blood pressure, pulse rate, and temperature, will be recorded. A single measurement will be taken at the screening and baseline visits. Supine blood pressure and pulse rate will be collected three times at all other time points. Temperature will be obtained by a single measurement. Pre-dose vital signs should be collected approximately 1 hour before scheduled dosing. Participants should lie supine for at least 5 minutes and stand for approximately 2 minutes at the time point at which orthostatic measurements are obtained. When three blood pressure or pulse rate measurements are taken before orthostatic measurements, the last supine blood pressure or pulse rate measurement will be used for orthostatic calculations. If a participant feels unable to stand, only supine vital signs will be recorded. If possible, unplanned orthostatic vital signs should be assessed during any AE with dizziness or posture-induced symptoms. Additional vital signs may be measured during each study period if necessary.

[0429] For each participant, a 12-lead digital ECG will be collected. It is recommended that sites perform the ECG prior to any blood sample collection. Participants must lie supine for approximately 5 to 10 minutes prior to ECG collection and remain supine but awake during ECG collection. ECGs may be obtained at additional times when deemed clinically necessary. All recorded ECGs should be kept at the study site. The ECG will be interpreted by a qualified physician (the Investigator or qualified designee) on-site as soon as possible after the ECG is collected, and ideally while the participant is still present, to determine whether the participant meets the inclusion criteria at the relevant visit or visits and to manage the participant promptly if any clinically relevant findings are noted. If clinically significant quantitative or qualitative changes from baseline are noted after enrollment, the Investigator will assess the participant's symptoms (e.g., palpitations, near syncope, syncope) to determine whether the participant can continue in the study. The Investigator or qualified designee is responsible for determining whether any changes to participant management are warranted and must document his / her review of the printed ECG at the time of evaluation, making at least 1 copy of the ECG for each point in time. Machine-read ECG intervals and heart rate may be used for data analysis and report writing purposes unless the ECG is read de novo by a cardiologist prior to completion of the final study report (in which case the de novo read data will be used).

[0430] Below, a list of clinical laboratory tests to be performed and the timing and frequency of SoEs is provided in the corresponding sections.

[0431] - The Investigator must review laboratory results, document that review, and report any clinically relevant changes that occur during the study as AEs. Laboratory results must be retained with the original documentation unless the original documentation protocol or similar references an electronic location that accommodates the expected retention period. Clinically significant abnormal laboratory findings are those that are not related to the underlying disease unless, in the Investigator's judgment, are more severe than expected for the participant's condition.

[0432] - All laboratory tests considered to have clinically significant abnormal values ​​during study participation or within 12 weeks after the last dose of the study intervention should be repeated until the values ​​return to normal or baseline or are no longer considered clinically significant by the investigator or medical monitor.

[0433] - If these values ​​do not return to normal / baseline within a time deemed reasonable by the Investigator, the cause should be determined and notified to the Sponsor.

[0434] -All protocol-required laboratory evaluations must be performed in accordance with the SoE, standard collection requirements, and laboratory manual.

[0435] -If a laboratory value resulting from a non-protocol-mandated laboratory evaluation performed at a local laboratory designated by the investigator requires a change in the management of the participant or is considered clinically significant by the investigator (e.g., a SAE or AE or dose modification), this information is reported as an AE.

[0436] With regard to blood clotting, the prothrombin time (PT) w / INR test measures the length of time it takes for a blood clot to form in a blood sample.

[0437] Regarding quality of life, measurement of health-related quality of life is a valuable measure of treatment efficacy, and the ALSSQOL-SF questionnaire will be used. This assessment will be performed at the time points indicated in the SoE. The ALSSQOL-SF is a 20-item instrument that measures the overall quality of life (QOL) of individuals with ALS and 6 specific domains for individuals with ALS (Felgoise et al., Muscle Nerve 58 (2018), 646-654).

[0438] Suicidal ideation and behavior risk monitoring will be assessed using the C-SSRS, a semi-structured clinical interview that assesses the severity of suicidal ideation, intensity of suicidal ideation, and suicidal behavior. The C-SSRS will be assessed at the visits and times specified in the SoE.

[0439] Adverse Events, Serious Adverse Events, and Investigational Product Complaints

[0440] Definitions of the following events can be found in the Adverse Events section below:

[0441] -AE

[0442] -SAE

[0443] -Investigation Product Complaints (IPC)

[0444] These events will be reported by the participant (or, where appropriate, by a caregiver, surrogate, or legally authorized representative of the participant). The Investigator and any qualified designees are responsible for detecting, documenting, and recording events that meet these definitions and for maintaining accountability for follow-up of events that are serious, considered related to the study intervention or study procedures, or that lead to a participant’s discontinuation from the study. Care should be taken not to introduce bias in detecting events. Open-ended, non-leading verbal questioning of participants is the preferred method for inquiring about the occurrence of events. After the initial report, the Investigator is required to proactively follow up with each participant at subsequent visits / contacts. All SAEs and AEs of special interest will be followed up until the issue is resolved, stabilized, the event is explained, or the participant is lost to follow-up (defined above). For investigational product complaints, the Investigator is responsible for ensuring that follow-up includes any additional investigations indicated to clarify the nature and / or causality. Table 5 below describes the timing, cutoff dates, and mechanisms for collecting events.

[0445] Table 5: Timing, cutoff dates, and mechanisms for collecting events. Abbreviations: AE = adverse event; eCRF = electronic case report form; ICF = informed consent document; PC = product complaint; SAE = serious adverse event. *Serious adverse events due to disease progression, including deaths, should not be reported unless the investigator considers them to be possibly related to study treatment.

[0446]

[0447]

[0448] Adverse Events of Special Interest

[0449] Lumbar punctures (LP) will be performed at several time points in this study to obtain CSF. Headaches may occur in up to 60% of patients undergoing LP, and back pain may occur in up to 40%. More serious adverse events are rare and include brain herniation, intracranial subdural hemorrhage, spinal epidural hemorrhage, and infection.

[0450] Hypersensitivity reactions may occur following administration of any monoclonal antibody. Acute hypersensitivity reactions, including infusion reactions or anaphylaxis, may occur during or within hours of an infusion. Sites should be staffed with appropriately trained medical personnel and appropriate medical equipment when study participants receive study medication. Participants who experience systemic hypersensitivity reactions are advised to be treated in accordance with national and international guidelines. For systemic urticaria or anaphylaxis, additional blood samples should be collected as described in the “Recommended Laboratory Tests for Hypersensitivity Events” section below. Laboratory results are provided to the Sponsor through a central laboratory.

[0451] Subjects should be monitored for hypotension, fever, chills, bronchospasm, angioedema, and other signs or symptoms of serious allergic reactions. The infusion should be slowed or stopped and reactions managed as directed in the study protocol. If such reactions occur, additional data describing each symptom should be provided to the Sponsor in the eCRF. Delayed-type hypersensitivity reactions may occur days or weeks after infusion. Subjects should be monitored for fever, rash, arthralgia, myalgia, hematuria, hematologic changes, liver or renal tests. Delayed-type hypersensitivity reactions may be managed symptomatically and treated with corticosteroids. For any confirmed / suspected case of delayed-type hypersensitivity reaction to AP-101, subjects should not receive additional doses of AP-101.

[0452] Overdose treatment

[0453] For this study, any dose of AP-101 exceeding 2500 mg of AP-101 within a 24-hour period (± 4 hours) will be considered an overdose. Overdose is not expected as study medication will be administered by trained staff. In the event of an overdose, the investigator should:

[0454] 1. Contact medical supervision immediately.

[0455] 2. Closely monitor participants for any AEs / SAEs and laboratory abnormalities until AP-101 is no longer detectable systemically (at least 100 days).

[0456] 3. Record the amount of the dose exceeded and the duration of the overdose in the eCRF.

[0457] The investigator will decide whether to interrupt or modify the dose based on the clinical evaluation of the participant in consultation with the Medical Monitor.

[0458] Pharmacokinetics (PK)

[0459] At the visits and times specified in the SoE, venous sample collection will be performed to determine serum concentrations of AP-101. CSF sampling will also be collected at baseline and at specified time points during the study, per the SoE. The Sponsor may modify sampling times at its discretion based on review of interim PK data, if they become available. The actual PK sample collection date and time will be recorded.

[0460] Samples will be analyzed in laboratories approved by the Sponsor and stored in facilities designated by the Sponsor. Concentrations of AP-101 will be measured in serum and CSF using validated immunoassays. Bioanalytical samples collected to measure study drug concentrations will be retained for up to 1 year after the last participant visit. Table 4 presents a summary of the sampling for this study.

[0461] Pharmacodynamics (PD)

[0462] Pharmacodynamic assessments in this study include changes in total SOD1, mSOD1, pNfH, and NfL, as well as other exploratory assessments. Levels of mSOD1 will be retrospectively measured from participants' CSF at baseline and after at least 1 time point after treatment with AP-101. This is an exploratory endpoint that will be used to investigate whether there is a correlation between levels of mSOD1 and response, and whether treatment with AP-101 can reduce detectable levels of mSOD1 in participants.

[0463] SOD1 and mSOD1 assays

[0464] Levels of total SOD1 and misfolded SOD1 will be measured retrospectively from participants' CSF at baseline and after at least 1 time point of treatment with AP-101. This is an exploratory endpoint that will be used to investigate whether there is a correlation between levels of SOD1 and response, and whether treatment with AP-101 can reduce detectable levels of SOD1 in participants. Correlations with other exploratory biomarkers and endpoints will also be performed.

[0465] Neurofilament assay

[0466] During the 6-month study, levels of pNfH and NfL will be measured in CSF and serum at various time points. This endpoint will be used to determine the effect of AP-101 on pNfH and NfL levels. The correlation of pNfH and NfL with other exploratory biomarkers and endpoints will also be examined.

[0467] Genetics

[0468] All participants will undergo mandatory genetic testing for common variants associated with ALS, which will be performed by a certified genetic laboratory. Blood samples for DNA isolation will be collected from participants.

[0469] Biomarkers

[0470] Additional biomarkers will include creatinine and transcriptional and microRNA profiles from various biofluids. These are exploratory biomarkers of disease activity and will be examined at various time points during the study, as indicated in the SoE.

[0471] - This study will analyze biomarkers related to the mechanism of action of AP-101. Samples collected for these analyses may also be used to develop related research methods or validate diagnostic tools or assays.

[0472] Additional samples may be collected during the course of the study with permission and approval from the investigator and sponsor.

[0473] Immunogenicity assessment

[0474] Antibodies to AP-101 will be evaluated in serum samples collected from all participants according to the SoE. In addition, serum samples will be collected at the final visit from participants who discontinue the study intervention or withdraw from the study. These samples will be tested by the Sponsor or Sponsor's designee. Serum samples will be screened for antibodies that bind to AP-101, and titers of confirmed positive samples will be reported. Additional analyses may be performed to verify the stability of antibodies to AP-101 and / or to further characterize the immunogenicity of AP-101. Testing and characterization of antibodies to AP-101 will be performed by the Sponsor using validated assays, or under the Sponsor's supervision. All samples collected for the detection of antibodies to the study intervention will also be evaluated for AP-101 serum concentrations to interpret the antibody data. Antibodies may be further characterized and / or evaluated for their ability to neutralize the activity of one or more study interventions. Samples may be stored for up to 2 years (or as per local regulations) after the last participant's final visit in the study at an institution selected by the Sponsor to enable further analysis of the immune response to AP-101.

[0475] Statistical considerations

[0476] Descriptive statistics, rather than hypothesis testing, will be used for the statistical evaluation of efficacy, safety, and tolerability.

[0477] A maximum of 63 participants (21 fALS and 42 sALS) will be randomized in a 2:1 ratio to study intervention or placebo, resulting in approximately 18 evaluable fALS participants and 36 evaluable sALS participants completing the study. This sample size is based on clinical considerations and is not adequate for hypothesis testing.

[0478] The populations described in Table 6 will be defined.

[0479] Table 6: Populations used for analysis

[0480]

[0481] All PK and PD (including neurofilament) analyses will be performed on the safety population.

[0482] The Sponsor or its designee will be responsible for the statistical analysis of this study. All CIs will be given at the 2-sided 90% level. Any change to the data analysis methods described in the protocol will require amendment only if it changes the major features of the protocol. Any other changes to the data analysis methods described in the protocol, and the reasons for making the changes, will be described in the statistical analysis plan and the clinical study report. Additional exploratory analyses of the data will be performed when deemed appropriate. The statistical analysis plan will be finalized before unblinding, and it will include more technical and detailed descriptions of the statistical analyses described in this section. This section summarizes the planned statistical analyses of the most important endpoints, including the primary and key secondary endpoints.

[0483] The Sponsor or its designee will be responsible for the statistical analysis of this study. The statistical analysis will be detailed in the statistical analysis plan. Safety analysis will be performed on all participants who are dosed, regardless of whether they have completed all protocol requirements according to the safety population. For continuous variables, summary statistics will include the number of participants, mean, median, standard deviation, minimum, and maximum. Categorical endpoints will be summarized using the number, frequency, and percentage of participants. A detailed description of the disposition of participants will be provided at the end of the study. All participants who are discontinued from the study will be identified and their level of participation in the study will be summarized. If known, the reason for their discontinuation will be provided. The demographic and baseline characteristics of the participants (age, sex, race, ethnicity, height, weight, and body mass index [BMI]) will be summarized by treatment. A summary of safety will also be provided.

[0484] The primary endpoints of this study were the incidence of AEs and SAEs, including immunogenicity, and abnormalities in vital signs, clinical laboratory evaluations, physical and neurological examinations, electrocardiograms, and weight changes.

[0485] All treatment and protocol procedure AEs will be tabulated. Summary statistics for AEs and SAEs will be provided by treatment group and categorized by system organ class and preferred term. A summary by relationship to study drug and maximum severity will also be provided. AEs leading to discontinuation of study drug or study will be summarized. AEs will be summarized for the safety population. Abnormal vital signs, clinical laboratory evaluations, physical and neurologic examinations, electrocardiograms, and weight changes will be provided as tabulations. The number of participants with an abnormality and the number of abnormalities will be summarized using the safety population.

[0486] All secondary endpoints will be performed on the PK population. PK analysis will be performed only on participants who have received at least 1 full dose of study treatment and have a baseline PK sample and at least 3 post-baseline evaluable PK samples. All serum PK samples will be used in the compartmental model to describe the PK of these patients. PK parameters will be reported with descriptive statistics, including: arithmetic mean, geometric mean, standard deviation, coefficient of variation (CV) %, geometric CV %, median, minimum and maximum values ​​(Table 7).

[0487] Table 7: Pharmacokinetic parameters

[0488]

[0489] During the 6-month treatment period, AP-101 levels in CSF will be summarized by treatment at each available treatment visit and by change from baseline at each visit using the safety population. Data will be summarized by treatment.

[0490] Both pNfH and NfL will be summarized by type of each available treatment visit (CSF or plasma) and change from baseline at each visit for both the ITT and per-protocol (PP) populations. An additional summary by fALS status will be provided for the PP population.

[0491] Statistical models will be used to estimate the mean changes per month in pNfH and NfL for treated and placebo participants. The estimated changes per month along with two-sided 90% confidence intervals will be included in the summary. Graphs showing baseline levels of pNfH and NFL and their mean changes per month will be provided.

[0492] Total ALSFRS-R scores and changes from baseline will be summarized at visit according to SoE. Statistical models will be used to estimate the mean ALSFRS-R changes per month for treated and placebo participants. Estimated changes per month and two-sided 90% confidence intervals will be provided. Pulmonary function (SVC) or equivalent, muscle strength (HHD), and disease stage (King staging tool) scores will be summarized by visit and changes from baseline. Changes from baseline in the King staging tool will be summarized as the number of stages reduced since baseline. Kaplan-Meier analyses will be performed to compare treatment and placebo groups. The 25th, 50th (median), and 75th quartiles will be presented with their 90% confidence intervals and survival curves. ALSSQOL-SF will be summarized by treatment visit. Total and misfolded SOD1 in CSF and changes from baseline will be summarized at each available visit. Additional summaries by fALS status will be provided. Two-sided 90% confidence intervals will be included in the summary. A chart showing baseline levels of SOD1 and mSOD1 and their changes over time will be provided. All other biomarkers of disease activity will be summarized at each available visit, as well as changes compared to baseline. A two-sided 90% confidence interval will be provided. All safety analyses will be performed on the safety population and provided in a list. Subgroup analyses will be performed on various endpoints by fALS status (participants are fALS or sALS), including measurements of neurofilaments (NfL and pNfH) and mSOD1 and SOD1. Subgroup analysis is similar to standard analysis in that it is also stratified by treatment. Any statistical model in the subgroup analysis will include covariate terms for fALS status and interaction terms between fALS and treatment. Additional exploratory subgroup analyses may be performed.

[0493] Clinical laboratory tests

[0494] Clinical laboratory tests are detailed in Table 8.

[0495] Table 8: Safety Clinical Laboratory Tests Abbreviations: FSH = follicle stimulating hormone; HIV = human immunodeficiency virus; RBC = red blood cell; WBC = white blood cell. a Only performed during screening. b Urine drug screen and ethanol level may be repeated prior to admission to the clinical research unit and at other times as specified in the activity schedule; urine drug screen is not performed at the clinical research unit in Singapore

[0496]

[0497] Recommended Laboratory Tests for Hypersensitivity Events

[0498] Laboratory testing should be performed during a systemic hypersensitivity event. Management of adverse events may necessitate laboratory testing beyond the scope of those described below and should be performed based on clinical indications. Laboratory testing during a systemic hypersensitivity event is not performed for diagnostic purposes. Its intent is severalfold:

[0499] - Helps characterize and classify systemic hypersensitivity reactions

[0500] -Meet regulatory expectations

[0501] -To improve subsequent clinical management by helping to differentiate between the various mechanistic bases for severe allergic reactions Laboratory testing should be performed when generalized urticaria occurs or if a severe allergic reaction is suspected.

[0502] Obtain samples within 1-2 hours of the event, after the subject has stabilized; however, because analytes can remain unchanged for longer periods of time, samples can be obtained as late as 12 hours after the event. Record the time when the sample was collected. Obtain follow-up samples at the next regularly scheduled visit or 4 weeks later.

[0503] Clinical testing should include the following

[0504] - Tryptase (If the tryptase sample was obtained more than 2 hours after the event (i.e., within 2-12 hours) or not obtained because it is more than 12 hours after the event, obtain urine for N-methylhistamine (NMH) testing. Note that for serum tryptase samples obtained within 2-12 hours of the event, a urine NMH test is performed in addition to the tryptase test. Collect the first urine void after the event. Obtain a follow-up urine for NMH testing at the next regularly scheduled visit or 4 weeks later, whichever is later.

[0505] -ADA and AP-101 concentrations (PK)

[0506] -Complement: C3, C3a, and C5a

[0507] - Cytokines: IL-6, IL-1β, IL-10 (or any cytokine panel including these 3 cytokines)

[0508] Abnormal liver monitoring tests during treatment

[0509] If liver abnormalities occur during treatment, selected tests shown in Table 9 may be performed as needed and follow-up of the subject may be required.

[0510] Table 9: Liver monitoring tests. Abbreviations: ALT = alanine aminotransferase; AST = aspartate aminotransferase; CPK = creatinine phosphokinase; GGT = gamma-glutamyltransferase; Ig = immunoglobulin; INR = international normalized ratio; RBC = red blood cells; WBC = white blood cells.a Reflection / confirmation depends on regulatory requirements and / or testing availability.

[0511]

[0512] Adverse events (AEs)

[0513] AE refers to any adverse medical event that occurs in a participant who has been administered a drug product and that does not necessarily have a causal relationship to the study intervention. Therefore, an AE can be any unfavorable and unexpected sign (including abnormal laboratory findings), symptom, or disease (new or worsening) temporally associated with the use of a drug (investigational) product, whether or not related to the drug (investigational) product.

[0514] Events that meet the definition of AE:

[0515] - Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) or other safety assessments (e.g., ECG, radiology scans, vital sign measurements), including those that are worsening compared with baseline and that the medical and scientific judgment of the investigator considers to be clinically significant (i.e., not related to progression of the underlying disease).

[0516] - Exacerbation of a chronic or intermittent pre-existing condition, including an increase in the frequency and / or intensity of the condition.

[0517] - New conditions detected or diagnosed after the study intervention is administered, even though they may have existed before the start of the study.

[0518] - Signs, symptoms, or clinical sequelae of suspected drug-drug interactions.

[0519] - Signs, symptoms, or clinical sequelae of suspected overdose of the study intervention or concomitant medication. Overdose itself will not be reported as an AE / SAE unless it is an intentional overdose with possible suicidal / self-harm intent. Such overdoses should be reported regardless of the presence of sequelae.

[0520] - "Lack of efficacy" or "loss of intended pharmacological action" will not be reported as an AE or SAE per se. Such conditions will be captured in the efficacy evaluation. However, if signs, symptoms, and / or clinical sequelae due to lack of efficacy meet the definition of an AE or SAE, they will be reported as an AE or SAE.

[0521] Events that do not meet the definition of AE

[0522] - Any clinically significant abnormal laboratory finding or other abnormal safety assessment associated with the underlying medical condition, unless judged by the investigator to be more severe than expected for the participant's condition.

[0523] - The disease / condition being studied or the expected progression, signs, or symptoms of the disease / condition being studied, unless the participant's condition is more severe than expected.

[0524] - Medical or surgical procedure (eg, endoscopy, appendectomy): The condition leading to the procedure is an AE.

[0525] - No adverse medical events occurred (hospitalization due to social factors and / or medical convenience).

[0526] - Expected day-to-day fluctuations in one or more pre-existing diseases or conditions that were present or detected at study entry without worsening.

[0527] SAE

[0528] If an event is not an AE as defined above, it cannot be an SAE even if it qualifies as a serious condition (e.g., hospitalization due to signs / symptoms of the disease under study, death due to disease progression).

[0529] SAEs were defined as any adverse medical event at any dose that:

[0530] a. Causes death

[0531] b. is life-threatening. The term “life-threatening” in the definition of “serious” refers to an event where the participant is at risk of death at the time of the event. It does not refer to an event that, if it were more serious, would hypothetically result in death.

[0532] c. Requires hospitalization or prolongs existing hospitalization

[0533] - In general, hospitalization means that the participant has been admitted to the hospital for observation and / or treatment that would not be appropriate in a physician's office or outpatient setting. Complications that occur during hospitalization are AEs. An event is serious if the complication prolongs hospitalization or meets any other seriousness criteria. When it is uncertain whether a "hospitalization" occurred or was necessary, the AE should be considered serious.

[0534] - Hospitalization for elective treatment of a pre-existing condition that did not worsen compared to baseline was not considered an AE.

[0535] d. Cause permanent disability / incapacity

[0536] -The term disability means a substantial impairment of a person's ability to carry out normal life functions.

[0537] - This definition is not intended to include conditions of relatively minor medical significance such as simple headache, nausea, vomiting, diarrhea, influenza, and accidental trauma (e.g., ankle sprain) that may interfere with or prevent daily functioning but do not constitute a substantial disruption.

[0538] e. Congenital anomaly / birth defect

[0539] -Abnormal pregnancy outcomes (eg, spontaneous abortion, fetal death, stillbirth, congenital anomaly, ectopic pregnancy) were considered SAEs.

[0540] f. Other situations:

[0541] - Medical or scientific judgment should be exercised in deciding whether SAE reporting is appropriate in other circumstances, such as important medical events that may not be immediately life-threatening or result in death or hospitalization but that may endanger the participant or may require medical or surgical intervention to prevent one of the other outcomes listed in the above definition. These events should generally be considered serious.

[0542] -Examples of such events include invasive or malignant cancer, intensive treatment in the emergency department or at home for allergic bronchospasm, blood dyscrasias or seizures not resulting in hospitalization, or the development of drug dependence or drug abuse.

[0543] Strength Assessment

[0544] The Investigator will assess the intensity of each AE and SAE reported during the study and assign it to category 1 of the NCI-CTCAE version 5.0 outlined in Example 1.

[0545] Causality Assessment

[0546] The Investigator is obligated to evaluate the relationship between the study intervention and each occurrence of each AE / SAE. A "reasonable possibility" of a relationship means that there are facts, evidence, and / or arguments that suggest a causal relationship, rather than that a relationship cannot be ruled out. The Investigator will use clinical judgment to determine such a relationship. Other causes, such as one or more underlying conditions, concomitant therapy, and other risk factors, as well as the temporal relationship of the event to the administration of the study intervention will be considered and investigated. The Investigator will also consult with the IB in his / her evaluation. For each AE / SAE, the Investigator must document in the medical record that he / she has reviewed the AE / SAE and has provided an assessment of causality. There may be situations where an SAE has occurred and the Investigator has included minimal information in the initial report to the Sponsor or designee. However, it is very important that the Investigator always assess the causality of each event before the initial transmission of the SAE data to the Sponsor or designee. The Investigator may change his / her opinion of causality based on follow-up information and send a follow-up SAE report with an updated assessment of causality. The assessment of causality is one of the criteria used in determining regulatory reporting requirements.

[0547] The investigator has the obligation to perform or arrange for additional measurements and / or evaluations, as medically indicated or requested by the sponsor or designee, to elucidate the nature and / or causality of the AE or SAE as fully as possible. This may include additional laboratory tests or investigations, histopathological examination, or consultation with other healthcare professionals.

[0548] Examples 3 to 6 involving AP-101 formulations

[0549] method

[0550] In some of the methods, reference is made to Ph. Eur., the European Pharmacopoeia.

[0551] Appearance (clarity, color and visible particles)

[0552] Appearance tests are performed to determine clarity, color and visible particles. The clarity test complies with Ph.Eur. <2.2.1. Clarity and opacity of liquids>. Turbidimeters are used for clarity measurements. The color test complies with Ph.Eur. <2.2.2. Chroma of liquids>. The observation method is used for color measurements. The visible particle test complies with Ph.Eur. <2.9.20. Particulate contamination: visible particles>. The observation method is used for visible particle detection.

[0553] Osmotic pressure

[0554] The osmotic pressure is determined indirectly by measuring the depression of the freezing point of a solution.

[0555] Extractable volume

[0556] The extractable volume test complies with Ph.Eur.2.9.17. The extractable volume test uses the volumetric method.

[0557] Particulate matter

[0558] The particle test complies with Ph.Eur.2.9.19. The number of sub-visible particles is determined based on the light obscuration method. When particles in the liquid pass through a narrow detection channel, the incident light perpendicular to the flow direction of the liquid is weakened due to the obstruction of the particles, resulting in a decrease in the output signal of the sensor. The change in the signal is related to the cross-sectional area.

[0559] Sterility

[0560] The sterility test for drug products is based on Ph.Eur.2.6.1. The membrane filtration test method is used by filtering the contents of the container to be tested through two 0.45 μm membranes; any microorganisms present will be retained on the membranes. Each membrane is rinsed with a determined volume of rinse solution. Two culture media are used to incubate the membranes: thioglycollate fluid medium (FTM) and soy-casein digest (TSB). FTM is transferred to one tank and TSB is transferred to another tank. The FTM and TSB tanks are incubated for 14 days (FTM at 30-35°C, and TSB at 20-25°C). The absence of microbial growth indicates that the test sample is sterile.

[0561] Further analytical procedures for controlling parameters of the drug product such as measurement of pH and protein concentration, for example, by using a UV-visible spectrophotometer, according to official quality control standards specified in Ph. Eur. and as described in standard literature, such as Mikkelsen and Cortón "Bioanalytical Chemistry", Second Edition (2016), Hoboken, New Jersey: John Wiley & Sons, Inc.dent, ISBN 9781119057703 (pdf); Schiel et al., "State-of-the-Art and Emerging Technologies for Therapeutic Monoclonal Antibody Characterization Volume 2. Biopharmaceutical Characterization: The NIST mAb Case Study", ACS Symposium Series 1201 (2015), ISBN 978-0-8412-3029-3, for example by Michels et al., Chapter 5; Kulkarni et al., "Essential chemistry for formulators of semisolid and liquid dosages", Academic Press (2016), ISBN 978-0-12-801024-2, Chapter 11-Miscellaneous Physical, Chemical, and Microbiological Test Methods, pages 193-221; or on the homepage of Protagen Protein Services (https: / / www.protagenproteinservices.com / biopharmaceuticals / antibodies ) , size exclusion chromatography (SEC), capillary electrophoresis reduced form sodium dodecyl sulfate (reduced CE-SDS), capillary isoelectric focusing (cIEF) and fluorescence resonance energy transfer (FRET) were combined.

[0562] Example 3: Development of a stable antibody formulation for antibody AP-101

[0563] The formulation development of AP-101 (referred to herein as the drug substance) included studies aimed at selecting buffer systems, excipients, and surfactants to stabilize the protein. The formulation was developed to prevent product loss and minimize the loss of purity and bioactivity to cope with the stresses encountered during production, storage, transportation, and handling.

[0564] Buffer system studies were performed to determine the optimal buffer system for antibody formulations. Based on pH screening studies, 20 mM L-histidine / L-histidine monohydrochloride buffer at pH 6.0 was selected as the final buffer system.

[0565] Different types of excipients, including disaccharides (sucrose, trehalose, and sorbitol), amino acids (L-arginine hydrochloride and L-methionine), and salts (NaCl) were evaluated through excipient studies. Samples were incubated at 25°C and 40°C for up to 4 weeks. Thermal stability, formation of insoluble aggregates, and purity were monitored. Overall, sucrose and L-methionine at concentrations of 8% (w / v) and 0.1% (w / v), respectively, were selected as the best excipients for AP-101 formulation as they were shown to minimize the formation of low molecular weight and acidic species, thereby maintaining product purity.

[0566] In the surfactant type and strength screening study, four different polysorbate 80 (PS 80) concentrations (0.005%, 0.010%, 0.020% and 0.050% (w / v)) and two different poloxamer 188 concentrations (0.05% and 0.10% (w / v)) were tested. The number and purity of subvisible particles were evaluated. PS 80 at a concentration of 0.02% (w / v) was selected as the surfactant strength because the formation of subvisible particles was effectively suppressed and acceptable stability was shown.

[0567] The final formulation developed was a target concentration of 20 mg / mL AP-101 in 20 mM L-histidine / L-histidine monohydrochloride buffer at pH 6.0, 8% (w / v) sucrose, 0.1% (w / v) L-methionine, and 0.02% (w / v) PS 80. Table 10 summarizes the excipients used in the formulation of AP-101 and their stabilizing effects.

[0568] Table 10: Role of excipients in drug substances

[0569] excipient Contribution to stability L-Histidine Buffer L-Histidine monohydrochloride Buffer sucrose Tonicity regulator L-Methionine Antioxidants Polysorbate 80 Surfactants

[0570] Example 4: Production of a Final Drug Product Including Antibody AP-101

[0571] The production of drug products is carried out by thawing of raw materials (bulk products), pooling and mixing, sterile filtration, aseptic filling, stoppering and capping. Optionally, visual inspection, UV printing, bulk packaging and storage at 2-8°C are performed. In particular, frozen raw materials stored in 10L polycarbonate bottles are thawed at room temperature (18-24°C) in a dark room. After complete thawing, the raw materials are pooled into 100L mixing bags and stirred at an appropriate speed of ≤250rpm so that movement is observed without generating foam. The mixing time is controlled at>15 minutes. Before sterile filtration, the samples are tested for pH, osmotic pressure, protein concentration, endotoxin and bioburden.

[0572] Sterile filtration was selected as the method to obtain a sterile drug product and was performed by sterile filtering the API into a 50 L disposable sterile bag using two sterile filters (0.22, polyvinylidene fluoride membrane) in series via a peristaltic pump under laminar airflow (LAF) with a Class C background. Filter integrity testing was performed on both filters before and after sterile filtration.

[0573] The drug product is then aseptically filled into 8mL sterile glass vials using a filling and sealing machine connected to a peristaltic pump system. All filling components are autoclaved and aseptically assembled. The compatibility of the drug product with the parts in contact with the filling line, the impact of the shear stress generated by the peristaltic pump, and the stability under light exposure have been evaluated to mitigate potential adverse effects on product quality attributes during production. Based on shear stress studies and previous production knowledge, the drug product is filled with a peristaltic pump at a speed of ≤350rpm. The filling pump with an automatic filler and stopper is enclosed in a restricted access barrier system (RABS) to completely close the aseptic process and provide a Class A environment.

[0574] Next, the vials are automatically stoppered with 20 mm rubber stoppers in the RABS unit. The stoppers are steam sterilized at 122°C for 30 minutes. The stoppered vials are transferred to the capping machine by a conveyor belt under laminar air flow protection for capping. The stoppered vials are capped with 20 mm plastic aluminum easy open caps. The caps are steam sterilized at 122°C for 30 minutes. Thus, the container closure system for the drug product is an 8 mL Type I glass vial sealed with a 20 mm rubber stopper and a 20 mm easy open cap.

[0575] After that, the filled vials are manually 100% visually inspected by production personnel and then statistically based AQL inspection is performed by the quality assurance department. After the visual inspection, release samples and stability samples are taken. After the visual inspection process, the partial batch number is printed on the side of the bottle cap with UV ink. The printed number is manually inspected 100%.

[0576] The filled drug product vials are then bulk packaged and labeled. The bulk packaged drug product vials are stored at 2-8°C.

[0577] Example 5: Compatibility of AP-101 formulation with clinically used materials

[0578] Stability data was collected to confirm the stability of the drug product dosing solution in a clinical trial setting. Compatibility with polyvinyl chloride IV tubes and bags, polypropylene syringes, PVC infusion sets, polyolefin IV bags, and fluorinated ethylene propylene copolymer (FEP)-indwelling catheters was evaluated. Two concentrations of 20 mg / mL (undiluted drug product) and 5 mg / mL were evaluated. Under the condition of 5 mg / mL, normal saline was used as a diluent. The solution was kept in an infusion container (syringe or IV bag) at 2 to 8 ° C for 24 hours, then kept at room temperature for 6 hours, and finally infused within a time period of 2 hours (defined as T30H). Samples were tested at T0 and T30H. Some results are shown in Tables 11 to 13.

[0579] Table 11: Results of in-use compatibility studies (1)

[0580]

[0581] Table 12: Results of in-use compatibility studies (2)

[0582]

[0583] Table 13: Results of in-use compatibility studies (3)

[0584]

[0585] 1 CSF: Colorless, slightly opalescent liquid with no visible particles

[0586] The data demonstrate that AP-101 is compatible with the clinical materials evaluated. The product diluted in saline at concentrations of 5 mg / mL and 20 mg / mL was stable for 24 hours at 2-8°C and then for up to 6 hours at room temperature and infused within 2 hours. No substantial changes in appearance, protein concentration, pH, osmolality, SEC, unreduced CE-SDS purity, or cIEF purity were observed. The results demonstrate that the drug product solution, prepared for administration, is stable for at least 24 hours at refrigerated temperatures and for 6 hours at room temperature.

[0587] Example 6: Stability of AP-101 Formulation

[0588] Stability evaluations were performed on representative batches of drug products to ensure drug performance and strength during clinical trials. Long-term stability studies (real-time studies) were performed at 5°C ± 3°C, and sample analysis was performed at T0, 1 month, 3 months, 6 months, 9 months, 12 months, 18 months, and 24 months. In addition, accelerated stability studies were performed at T0, 1 month, 3 months, and 6 months at 25°C ± 2°C and 60RH ± 5% RH (relative humidity). In addition, stability was analyzed under stress conditions at 40°C ± 2°C and 75% RH ± 5% RH.

[0589] In this context, note that

[0590] 3 months of real-time data supports a 12-month shelf life

[0591] 6 months of real-time data supports 18 months shelf life

[0592] 9 months of real-time data supports a 21-month shelf life

[0593] 12 months of real-time data supports a 24-month shelf life

[0594] 24 months of real-time data supports a 36-month shelf life

[0595] 36 months of real-time data supports a 48-month shelf life

[0596] 44 months of real-time data supports a 56-month shelf life

[0597] 53 months of real-time data supports a 65-month shelf life

[0598] The results are summarized in Tables 14 to 17. The data show that the AP-101 formulation is stable over a long period of time. There was no evidence of any significant physical or chemical changes in the drug product under any of the storage conditions employed. Since the formulation was stable over 24 months, the shelf life is expected to be at least 36 months. Stability was even confirmed for 53 months and therefore, the shelf life is expected to be up to 65 months.

[0599]

[0600]

[0601]

[0602] Table 16: Accelerated stability data of clinical batch 201809060 at 25±2°C / 60±5% RH (inverted)

[0603]

[0604] Table 17: Pressure stability data of clinical batch 201809060 at 40±2°C / 75±5% RH (inverted)

[0605]

[0606] Example 7: N-linked glycosylation of the heavy chain, N-terminal pyroglutamate modification from N-terminal glutamine, and C-terminal lysine cleavage of the heavy chain are the major post-translational modifications of AP-101

[0607] Antibody AP-101 was produced in the CHO-K1 cell line (ATCC No. CCL 61) and obtained from the cell culture after cultivation in a large-scale production bioreactor.

[0608] The AP-101 fragments obtained from sequential digestion with Lys-C and trypsin were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS / MS) and combined with free thiol analysis to identify post-translational modifications of AP-101. Characterization of antibody-based therapeutics by LC-MS analysis is a standard procedure and can be performed by a skilled technician; see, for example, Robotham and Kelly, Approaches to the Purification, Analysis and Characterization of Antibody-Based Therapeutics (2020), 1-33.

[0609] Modification of glutamine to pyroglutamic acid at the N-terminal and lysine shearing of the C-terminal of the heavy chain have been identified as major post-translational modifications, and N303 has been identified as an N-glycosylation site. In addition, small proportions of modifications such as methionine oxidation, asparagine deamidation and asparagine succinimide formation have also been observed. Table 18 summarizes the results of LC-MS / MS analysis.

[0610] Table 18: Summary of post-translational modifications of AP-101

[0611]

Claims

1. A recombinant antibody that selectively binds to misfolded and / or aggregated forms of superoxide dismutase (SOD1) for use in the treatment of amyotrophic lateral sclerosis (ALS), wherein: The treatment comprises administering to a patient in need thereof a dose of about 2500 mg of the antibody.

2. The antibody for use according to claim 1, wherein The antibody was administered once every 3 weeks.

3. The antibody for use according to claim 1 or 2, wherein The antibody is administered via intravenous (IV) infusion.

4. The antibody for use according to any one of claims 1 to 3, wherein The patient receives a loading dose of about 500 mg of the antibody, a dose of about 2500 mg of the antibody the next day, and then once every 3 weeks.

5. The antibody for use according to any one of claims 1 to 4, wherein Administration of the antibody is performed every 3 weeks for a period of at least 6 months.

6. The antibody for use according to any one of claims 1 to 5, wherein The antibody was administered at a concentration of about 20 mg / mL.

7. The antibody for use according to claim 6, wherein The antibodies were administered over a period of a minimum of 60 and a maximum of 120 minutes.

8. The antibody for use according to any one of claims 1 to 7, wherein The patient suffers from familial amyotrophic lateral sclerosis (fALS).

9. The antibody for use according to any one of claims 1 to 7, wherein The patient suffers from sporadic amyotrophic lateral sclerosis (sALS).

10. The antibody for use according to any one of claims 1 to 9, wherein The patients received a combination of riluzole, edaravone, sodium phenylbutyrate and tauroursodeoxycholic acid (PB and TUDCA) or tolfsane.

11. The antibody for use according to any one of claims 1 to 10, wherein If an infusion reaction is observed, 500 to 1000 mg of acetaminophen and / or an antihistamine may be administered orally or IV 30 to 60 minutes prior to the start of the infusion for the subsequent dose.

12. The antibody for use according to any one of claims 1 to 11, wherein The therapeutic efficacy of the antibody and the progression of ALS are monitored by assessing one or more biomarkers.

13. The antibody for use according to claim 12, wherein The biomarker is selected from the group consisting of phospho-neurofilament heavy chain (pNfH), neurofilament light chain (NfL), and misfolded SOD1 (mSOD1).

14. The antibody for use according to any one of claims 1 to 13, wherein The antibody binds to the epitope of SOD1 in the amino acid sequence 73-GGPKDEERHVGD-84 listed in SEQ ID NO:

11.

15. The antibody for use according to any one of claims 1 to 14, wherein The antibody is characterized in that it includes six CDRs of the variable heavy (VH) and variable light (VL) chains in its variable region, i.e., the binding domain, wherein: (a) VH-CDR1 comprises the amino acid sequence of SEQ ID NO: 3 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, (b) VH-CDR2 comprises the amino acid sequence of SEQ ID NO: 4 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, (c) VH-CDR3 comprises the amino acid sequence of SEQ ID NO: 5 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, (d) VL-CDR1 comprises the amino acid sequence of SEQ ID NO: 8 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, (e) VL-CDR2 comprises the amino acid sequence of SEQ ID NO: 9 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, and (f) VL-CDR3 comprises the amino acid sequence of SEQ ID NO: 10 or a variant thereof, wherein the variant comprises one or two amino acid substitutions.

16. The antibody for use according to any one of claims 1 to 15, wherein The antibody is characterized in that it comprises a VH chain and a VL chain in its variable region, i.e., the binding domain, wherein (a) the VH chain comprises an amino acid sequence that is at least 90% identical to the amino acid sequence described in SEQ ID NO: 1 or 2; and (b) the VL chain comprises an amino acid sequence that is at least 90% identical to the amino acid sequence depicted in SEQ ID NO: 6 or 7.

17. The antibody for use according to any one of claims 1 to 16, wherein The antibody comprises a human Ig constant region.

18. The antibody for use according to any one of claims 1 to 17, wherein The antibody is human IgG.

19. The antibody for use according to any one of claims 1 to 18, wherein The antibody is human IgG1.

20. The antibody for use according to any one of claims 1 to 19, wherein The antibody is of human IgG1m3 allotype.

21. The antibody for use according to any one of claims 18 to 20, wherein The antibodies include kappa (κ) or lambda (λ) light chains.

22. An antibody of use according to any one of claims 1 to 21, wherein The antibodies were AP-101 and human IgG1m3 allotype.

23. The antibody for use according to claim 22, wherein Each heavy chain consists of 453 amino acid residues having SEQ ID NO:12, and each light chain consists of 213 amino acid residues having SEQ ID:

13.

24. The antibody for use according to any one of claims 1 to 23, which is produced in CHO-K1 host cells and purified from the cell culture.

25. The antibody for use according to any one of claims 16 to 24, wherein The heavy chain of the antibody undergoes N-terminal glutamine cyclization.

26. The antibody for use according to claim 9 or 10, wherein The heavy chain undergoes C-terminal lysine cleavage.

27. The antibody for use according to any one of claims 16 to 26, which is N-glycosylated.

28. The antibody for use according to any one of claims 1 to 27, wherein The antibody is administered in the formulation of any one of claims 29 to 47.

29. A liquid aqueous formulation of a recombinant antibody as defined in any one of the preceding claims, said antibody selectively binding to misfolded and / or aggregated forms of superoxide dismutase (SOD1), wherein: The formulation is suitable for intravenous administration and comprises the antibody at a concentration of about 10 to 50 mg / mL in L-histidine / L-histidine monohydrochloride buffer at a pH of about 6.0±1, wherein the antibody is stable for at least 1 month at 5°C±2°C, at least 1 month at 25°C±2°C, and / or at 40°C±2°C for 1 week.

30. The preparation according to claim 29, wherein The antibody is characterized in that it includes six CDRs of the variable heavy (VH) and variable light (VL) chains in its variable region, i.e., the binding domain, wherein: (a) VH-CDR1 comprises the amino acid sequence of SEQ ID NO: 3 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, (b) VH-CDR2 comprises the amino acid sequence of SEQ ID NO: 4 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, (c) VH-CDR3 comprises the amino acid sequence of SEQ ID NO: 5 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, (d) VL-CDR1 comprises the amino acid sequence of SEQ ID NO: 8 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, (e) VL-CDR2 comprises the amino acid sequence of SEQ ID NO: 9 or a variant thereof, wherein the variant comprises one or two amino acid substitutions, and (f) VL-CDR3 comprises the amino acid sequence of SEQ ID NO: 10 or a variant thereof, wherein the variant comprises one or two amino acid substitutions; and Wherein, the antibody comprises a human Ig constant region.

31. The preparation according to claim 29 or 30, wherein The antibody is characterized in that it comprises a VH chain and a VL chain in its variable region, i.e., the binding domain, wherein (a) the VH chain comprises an amino acid sequence that is at least 90% identical to the amino acid sequence described in SEQ ID NO: 1 or 2; and (b) the VL chain comprises an amino acid sequence that is at least 90% identical to the amino acid sequence depicted in SEQ ID NO: 6 or 7.

32. A formulation according to any one of claims 29 to 31, wherein The antibody binds to the epitope of SOD1 in the amino acid sequence 73-GGPKDEERHVGD-84 listed in SEQ ID NO:

11.

33. The formulation according to any one of claims 29 to 32, wherein The antibody is human IgG.

34. A formulation according to any one of claims 29 to 33, wherein The antibody is human IgG1.

35. The formulation according to any one of claims 29 to 34, wherein The antibody is of human IgG1m3 allotype.

36. The formulation according to any one of claims 31 to 35, wherein The antibodies include kappa (κ) or lambda (λ) light chains.

37. The preparation according to claim 35 or 36, wherein Each heavy chain consists of 453 amino acid residues having SEQ ID NO:12, and each light chain consists of 213 amino acid residues having SEQ ID:

13.

38. A preparation according to any one of claims 29 to 37 which is produced in CHO-K1 host cells and purified from the cell culture.

39. The formulation according to any one of claims 29 to 38, wherein The antibody is AP-101.

40. The formulation according to any one of claims 31 to 39, wherein The antibody consists of two heavy chains having SEQ ID NO: 12 and two light chains having SEQ ID: 13, optionally wherein, in the heavy chain, the glutamine at the N-terminus is modified to pyroglutamic acid, and the C-terminal lysine is deleted, and wherein the heavy chain is N-glycosylated.

41. The formulation according to any one of claims 29 to 40, wherein The antibody was present at a concentration of 20 ± 5 mg / mL.

42. The formulation according to any one of claims 29 to 41, wherein The concentration of L-histidine / L-histidine monohydrochloride is 20±10 mM.

43. A formulation according to any one of claims 29 to 42, wherein The formulation also includes a tonicity adjusting agent, preferably sucrose at a concentration of 8% ± 1% (w / v).

44. A formulation according to any one of claims 29 to 43, wherein The formulation also includes a surfactant, preferably polysorbate 80 at a concentration of 0.02% ± 0.01 (w / v).

45. A formulation according to any one of claims 29 to 44, wherein The formulation also includes an antioxidant, preferably L-methionine at a concentration of 0.1% ± 0.05% (w / v).

46. ​​A formulation according to any one of claims 29 to 45, substantially free of any other additional excipients.

47. A formulation according to any one of claims 43 to 46 comprising or consisting essentially of: 20 mg / mL antibody in 20 mM L-histidine / L-histidine monohydrochloride buffer, pH 6.0, 8% (w / v) sucrose, 0.1% (w / v) L-methionine, and 0.02% (w / v) PS 80; Preferably, The antibody is AP-101.

48. A medicament comprising a formulation as claimed in any one of claims 29 to 47, preferably wherein the medicament is for use in the treatment of amyotrophic lateral sclerosis (ALS), most preferably for use in the treatment as defined in any one of the preceding claims.

49. A sterile pharmaceutical container comprising a formulation as claimed in any one of claims 29 to 47 or a medicament as claimed in claim 48, preferably wherein the container is a disposable glass vial to provide 100 mg of the antibody at a concentration of 20 mg / mL, optionally comprising an overfill of about 10% volume.

50. A method for treating ALS, wherein: The treatment is performed according to any one of claims 1 to 28, or wherein the treatment comprises administering a formulation according to any one of claims 29 to 49 or a medicament according to claim 48.

51. Use of an antibody as defined in any one of the preceding claims or a formulation according to claims 29 to 49 for the manufacture of a medicament for the treatment of ALS, wherein The treatment is carried out according to any one of claims 1 to 28.

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