Methods of treating systemic sclerosis

Abstract

The present invention relates to methods of treating systemic sclerosis, and specifically provides methods for treating systemic sclerosis by administering a dual V-region bispecific antibody that specifically binds to IL-4 and IL-13.

Description

[0001] This divisional application of the present invention is based on the patent application for invention with the application date of May 22, 2020, application number 202080037823.5 (international application number PCT / US2020 / 034342), and title "Methods for Treating Systemic Sclerosis".

[0002] Cross - reference to related applications

[0003] This application claims the priority benefits of U.S. Provisional Application No. 62 / 852,941 filed on May 24, 2019, European Patent Application No. EP19306309.6 filed on October 8, 2019, and U.S. Provisional Application No. 62 / 979,875 filed on February 21, 2020, each of which is incorporated herein by reference in its entirety.

[0004] Submission of ASCII text file sequence listing

[0005] The content of the following submitted ASCII text file is incorporated herein by reference in its entirety: the computer - readable form (CRF) of the sequence listing (file name: 183952031841SEQLIST.TXT, recording date: May 21, 2020, size: 16KB). Technical field

[0006] The present invention relates to bispecific anti - IL - 4 - anti - IL - 13 antibodies for treating systemic sclerosis (also known as scleroderma). Background art

[0007] Systemic sclerosis (also known as scleroderma) is a chronic disabling condition characterized by three key features: immune dysregulation, small-vessel vasculopathy, and fibrosis. There are two main subgroups in the accepted classification of systemic sclerosis (SSc): limited cutaneous SSc (lcSSc) and diffuse cutaneous SSc (dcSSc) (LeRoy E.C. et al., J. Rheumatol. 1988, 15(2):202-5). In lcSSc, fibrosis is limited to the distal upper and lower extremities and may be associated with facial involvement. Although fibrosis tends to stabilize during the first few years of development, the condition may continue to progress in visceral organs, particularly the lungs, leading to the development of pulmonary arterial hypertension (PAH), which is the major cause of lcSSc-related death in the later stages of lcSSc. In contrast, dcSSc is a rapidly progressive disorder that extends beyond the limited form and affects a larger area of the skin, most likely with truncal manifestations. These patients often have early visceral organ involvement and more prominent systemic symptoms such as arthralgia, tendon friction rubs, and weight loss. Although skin fibrosis is the distinguishing hallmark, pathological changes in the lungs, gastrointestinal tract, kidneys, and heart ultimately determine the clinical outcome. However, the extent of skin involvement and its rate of progression may reflect the severity, outcome, and survival of visceral organ complications (Domsic R.T. et al., Ann. Rheum. Dis. 2011, 70(1):104-9; Cottrell T.R. et al. Ann. Rheum. Dis. 2014, 73(6):1060-6). Over the past few decades, the survival rate of patients with dcSSc has improved; currently, the estimated mean 10-year survival rate is approximately 70% to 80%. During the most recent decades, the mortality rate associated with renal crisis has decreased significantly through the use of angiotensin-converting enzyme (ACE) inhibitors, while lung involvement is the major cause of death in these patients (Elhai M. et al., Rheumatology (Oxford) 2012, 51(6):1017-26; Nikpour M. and Baron M., Curr. Opin. Rheumatol 2014, 26(2):131-7; Nihtyanova S.I. et al., QJM 2010, 103(2):109-15; Winstone T.A. et al., Chest 2014, 146(2):422-36).

[0008] In 2014, the prevalence of SSc was estimated to be approximately 120,000 in the United States and the five countries of the European Union (i.e., France, Germany, Italy, Spain, and the United Kingdom), with more than 60% of cases being diffuse overall. Using the new American College of Rheumatology / European League Against Rheumatism (ACR / EULAR) 2013 classification criteria, which are more sensitive than the previous ACR 1980 criteria, future prevalence may increase by up to 20% (van den Hoogen F. et al., Ann. Rheum. Dis. 2013, 72(11):1747-55). Overall, the disease is more frequent in women (3-6:1) and certain ethnic groups (e.g., black race).

[0009] Currently, there are no approved therapies for SSc. The general treatment strategy is to address specific SSc manifestations (e.g., Raynaud's phenomenon, digital ulcers, gastrointestinal involvement, PAH, etc.) while controlling any underlying inflammatory processes in the skin or visceral organs using effective immunosuppressive therapies (e.g., cyclophosphamide, mycophenolate mofetil, azathioprine, methotrexate, rituximab). Since these immunosuppressive therapies do not target specific pathways associated with the fibrotic process, they are not particularly effective and are often accompanied by severe side effects. Therefore, there is an unmet need to find effective targeted therapies with a limited side effect profile for this disease population.

[0010] All references (including patent applications and publications) cited herein are incorporated by reference in their entirety. SUMMARY OF THE INVENTION

[0011] In some aspects, the present invention provides a method for treating systemic sclerosis (SSc) in a human subject having SSc, the method comprising subcutaneously administering to the subject about 200 mg of a dual V-region bispecific antibody or antigen-binding fragment that specifically binds IL-4 and IL-13. In some embodiments, 200 mg of the bispecific antibody is administered to the subject about once a week or about once every 5 to 9 days. In some embodiments, the treatment is administered for at least about 24 weeks. In some embodiments, the bispecific antibody is in a pharmaceutical formulation. In some embodiments, the pharmaceutical formulation comprises about 100 mg / ml bispecific antibody, about 6.3 mM sodium dihydrogen phosphate, about 37 mM Tris, about 5% (w / v) sucrose, about 3% (w / v) proline, and about 0.2% (w / v) polysorbate 80, wherein the pH of the formulation is about 7.0. In some embodiments, the formulation is reconstituted from a lyophilized formulation. In some embodiments, the bispecific antibody is administered in combination with another agent. In some embodiments, the other agent is administered before, simultaneously with, or after the bispecific antibody. In some embodiments, the systemic sclerosis is diffuse cutaneous systemic sclerosis.

[0012] In some embodiments of the present invention, the bispecific antibody or bispecific antibody fragment thereof comprises a light chain polypeptide comprising a light chain variable domain VL hB-B13 and a light chain variable domain VL hBD4-8 and a heavy chain polypeptide comprising a heavy chain variable domain VH hB-B13 and a heavy chain variable domain VH hBD4-8 wherein: VL hB-B13 comprises three CDRs comprising the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10); VL hBD4-8 comprises three CDRs comprising the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16); VH hB-B13 comprises three CDRs comprising the amino acid sequences GFSLTDSSIN (SEQID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13); VH hBD4-8Comprises three CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18), and LKEYGNYDSFYFDV (SEQ ID NO:19). In some embodiments, VL hB-B13 Comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:1; VL hBD4-8 Comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:3; VH hB-B13 Comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:2; VH hBD4-8 Comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:4. In some embodiments, VL hB-B13 Comprises the amino acid sequence of SEQ ID NO:1; VL hBD4-8 Comprises the amino acid sequence of SEQ ID NO:3; VH hB-B13 Comprises the amino acid sequence of SEQ ID NO:2; VH hBD4-8 Comprises the amino acid sequence of SEQ ID NO:4. In some embodiments, the light chain polypeptide comprises the structure N-VL hB-B13 -Linker-VL hBD4-8 -CL-C and the heavy chain polypeptide comprises the structure N-VH hB-B13 -Linker-VH hBD4-8 -CH1-C. In some embodiments, the light chain comprises the structure N-VL hB-B13 -Linker-VL hBD4-8 -CL-C and the heavy chain comprises the structure N-VH hB-B13 -Linker-VH hBD4-8 -CH1-CH2-CH3-C. In some embodiments, the linker comprises the amino acid sequence of SEQ ID NO:6. In some embodiments, the bispecific antibody or its bispecific antibody fragment comprises two identical light chain polypeptides and two identical heavy chain polypeptides. In some embodiments, the light chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:23. In some embodiments, the light chain polypeptide comprises the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises the amino acid sequence of SEQ ID NO:23.

[0013] In some aspects, the present invention provides a method of reducing sclerotic plaques in a human subject with SSc, the method comprising administering to the subject an effective amount of an anti-IL4 / anti-IL13 bispecific antibody; wherein at about 24 weeks after initial administration of the bispecific antibody, the sclerotic plaques are reduced by at least about 20%, 40%, 60%, 80%, or 100% compared to baseline. In some embodiments, the baseline is determined prior to treatment. In some embodiments, the baseline is a normal control from an individual without scleroderma. In some embodiments, the baseline is a historical control. In some embodiments, a portion of the treated human subjects with SSC have an improved modified Rodnan skin score (mRSS) of at least about 20%, 40%, and 60% compared to baseline at about 24 weeks after initial administration of the bispecific antibody. In some embodiments, the improved mRSS is measured as the least squares mean change from baseline. In some embodiments, the least squares mean change from baseline exceeds any one of about -3.00, -3.5, -4.0, -4.5, -5.0, -5.5, or -6.0.

[0014] In some embodiments of the method of reducing sclerotic plaques in a human subject with SSc, the anti-IL4 / anti-IL13 antibody is RKB. In some embodiments, about 200 mg of the anti-IL4 / anti-IL13 antibody is administered subcutaneously to the subject. In some embodiments, 200 mg of the bispecific antibody is administered to the subject, about once a week or about once every 5 to 9 days. In some embodiments, the treatment is administered for at least about 24 weeks. In some embodiments, the bispecific antibody is in a pharmaceutical formulation. In some embodiments, the pharmaceutical formulation comprises about 100 mg / ml bispecific antibody, about 6.3 mM sodium dihydrogen phosphate, about 37 mM Tris, about 5% (w / v) sucrose, about 3% (w / v) proline, and about 0.2% (w / v) polysorbate 80, wherein the pH of the formulation is about 7.0. In some embodiments, the formulation is reconstituted from a lyophilized formulation. In some embodiments, the bispecific antibody is administered in combination with another agent. In some embodiments, the other agent is administered before, simultaneously with, or after the bispecific antibody. In some embodiments, the systemic sclerosis is diffuse cutaneous systemic sclerosis.

[0015] In some embodiments of the method of reducing sclerotic plaques in a human subject with SSc, the bispecific antibody or a bispecific antibody fragment thereof comprises a light chain polypeptide comprising a light chain variable domain VL hB-B13 and a light chain variable domain VL hBD4-8 and a heavy chain polypeptide comprising a heavy chain variable domain VH hB-B13and the heavy chain variable domain VH hBD4-8 heavy chain polypeptide; wherein: VL hB-B13 comprises three CDRs containing the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10); VL hBD4-8 comprises three CDRs containing the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16); VH hB-B13 comprises three CDRs containing the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13); VH hBD4-8 comprises three CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18) and LKEYGNYDSFYFDV (SEQ ID NO:19). In some embodiments, VL hB-B13 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:1; VL hBD4-8 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:3; VH hB-B13 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:2; VH hBD4-8 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:4. In some embodiments, VL hB-B13 comprises the amino acid sequence of SEQ ID NO:1; VL hBD4-8 comprises the amino acid sequence of SEQ ID NO:3; VH hB-B13 comprises the amino acid sequence of SEQ ID NO:2; VH hBD4-8 comprises the amino acid sequence of SEQ ID NO:4. In some embodiments, the light chain polypeptide comprises the structure N-VL hB-B13 -linker-VL hBD4-8 -CL-C and the heavy chain polypeptide comprises the structure N-VH hB-B13 -linker-VH hBD4-8 -CH1-C. In some embodiments, the light chain comprises the structure N-VL hB-B13 -linker-VL hBD4-8 -CL-C and the heavy chain comprises the structure N-VH hB-B13-Linker-VH hBD4-8 -CH1-CH2-CH3-C. In some embodiments, the linker comprises the amino acid sequence of SEQ ID NO:6. In some embodiments, the bispecific antibody or bispecific antibody fragment thereof comprises two identical light chain polypeptides and two identical heavy chain polypeptides. In some embodiments, the light chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:23. In some embodiments, the light chain polypeptide comprises the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises the amino acid sequence of SEQ ID NO:23.

[0016] Specifically, the present invention includes but is not limited to the following:

[0017] 1. A method for treating systemic sclerosis (SSc) in a human subject having SSc, the method comprising subcutaneously administering to the subject about 200 mg of a dual V region bispecific antibody or antigen-binding fragment that specifically binds IL-4 and IL-13.

[0018] 2. The method according to item 1, wherein 200 mg of the bispecific antibody is administered to the subject about once a week or about once every 5 to 9 days.

[0019] 3. The method according to item 1 or 2, wherein the treatment is administered for at least about 24 weeks.

[0020] 4. The method according to any one of items 1-3, wherein the bispecific antibody is in a pharmaceutical formulation.

[0021] 5. The method according to item 4, wherein the pharmaceutical formulation comprises about 100 mg / ml bispecific antibody, about 6.3 mM sodium dihydrogen phosphate, about 37 mM Tris, about 5% (w / v) sucrose, about 3% (w / v) proline, and about 0.2% (w / v) polysorbate 80, wherein the pH of the formulation is about 7.0.

[0022] 6. The method according to item 5, wherein the formulation is reconstituted from a lyophilized formulation.

[0023] 7. The method according to any one of items 1-6, wherein the bispecific antibody is administered in combination with another agent.

[0024] 8. The method according to item 7, wherein the other agent is administered before, simultaneously with, or after the bispecific antibody.

[0025] 9. The method according to any one of items 1 - 8, wherein the systemic sclerosis is diffuse cutaneous systemic sclerosis.

[0026] 10. The method according to any one of items 1 - 9, wherein the bispecific antibody or its bispecific antibody fragment comprises a light chain polypeptide containing light chain variable domains VL hB-B13 and light chain variable domain VL hBD4-8 and a heavy chain polypeptide containing heavy chain variable domains VH hB-B13 and heavy chain variable domain VH hBD4-8 ; wherein:

[0027] VL hB-B13 comprises three CDRs containing the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10);

[0028] VL hBD4-8 comprises three CDRs containing the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16),

[0029] VH hB-B13 comprises three CDRs containing the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13),

[0030] VH hBD4-8 comprises three CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18), and LKEYGNYDSFYFDV (SEQ ID NO:19).

[0031] 11. The method according to item 10, wherein:

[0032] VL hB-B13 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:1,

[0033] VL hBD4-8 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:3, VH hB-B13 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:2, VHhBD4-8 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:4.

[0034] 12. The method according to item 10 or 11, wherein:

[0035] VL hB-B13 comprises the amino acid sequence of SEQ ID NO:1,

[0036] VL hBD4-8 comprises the amino acid sequence of SEQ ID NO:3,

[0037] VH hB-B13 comprises the amino acid sequence of SEQ ID NO:2,

[0038] VH hBD4-8 comprises the amino acid sequence of SEQ ID NO:4.

[0039] 13. The method according to any one of items 9 - 11, wherein the light chain polypeptide comprises the structure N-VL hB-B13 - linker - VL hBD4-8 - CL - C and the heavy chain polypeptide comprises the structure N-VH hB-B13 - linker - VH hBD4-8 - CH1 - C.

[0040] 14. The method according to any one of items 9 - 13, wherein the light chain comprises the structure N-VL hB-B13 - linker - VL hBD4-8 - CL - C and the heavy chain comprises the structure N-VH hB-B13 - linker - VH hBD4-8 - CH1 - CH2 - CH3 - C.

[0041] 15. The method according to item 13 or 14, wherein the linker comprises the amino acid sequence of SEQ ID NO:6.

[0042] 16. The method according to any one of items 10 - 15, wherein the bispecific antibody or its bispecific antibody fragment comprises two identical light chain polypeptides and two identical heavy chain polypeptides.

[0043] 17. The method according to any one of items 10 - 16, wherein the light chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:23.

[0044] 18. The method according to any one of items 10 - 17, wherein the light chain polypeptide comprises the amino acid sequence of SEQ ID NO: 22 and the heavy chain polypeptide comprises the amino acid sequence of SEQ ID NO: 23.

[0045] 19. A method of reducing sclerotic plaques in a human subject with SSc, the method comprising administering to the subject an effective amount of an anti - IL4 / anti - IL13 bispecific antibody; wherein at about 24 weeks after the initial administration of the bispecific antibody, compared to baseline, the sclerotic plaques are reduced by at least about 20%, 40%, 60%, 80%, or 100%.

[0046] 20. The method according to item 19, wherein a portion of the treated human subjects with SSC have at least about 20%, 40%, and 60% improvement in the modified Rodnan skin score (mRSS) compared to baseline at about 24 weeks after the initial administration of the bispecific antibody.

[0047] 21. The method according to item 20, wherein the improved mRSS is measured as the least - squares mean change from baseline.

[0048] 22. The method according to item 20 or 21, wherein the least - squares mean change from baseline exceeds any one of about - 3.00, - 3.5, - 4.0, - 4.5, - 5.0, - 5.5, or - 6.0.

[0049] 23. The method according to any one of items 19 - 22, wherein the anti - IL4 / anti - IL13 antibody is RKB.

[0050] 24. The method according to any one of items 19 - 23, wherein about 200 mg of the anti - IL4 / anti - IL13 antibody is administered subcutaneously to the subject.

[0051] 25. The method according to item 24, wherein 200 mg of the bispecific antibody is administered to the subject about once a week or about once every 5 to 9 days.

[0052] 26. The method according to item 24 or 25, wherein the treatment is administered for at least about 24 weeks.

[0053] 27. The method according to any one of items 19 - 26, wherein the bispecific antibody is in a pharmaceutical formulation.

[0054] 28. The method according to item 27, wherein the pharmaceutical formulation comprises about 100 mg / ml of a bispecific antibody, about 6.3 mM sodium dihydrogen phosphate, about 37 mM Tris, about 5% (w / v) sucrose, about 3% (w / v) proline, and about 0.2% (w / v) polysorbate 80, wherein the pH of the formulation is about 7.0.

[0055] 29. The method according to item 27 or 28, wherein the formulation is reconstituted from a lyophilized formulation.

[0056] 30. The method according to any one of items 19 - 29, wherein the bispecific antibody is administered in combination with another agent.

[0057] 31. The method according to item 30, wherein the other agent is administered before, simultaneously with, or after the bispecific antibody.

[0058] 32. The method according to any one of items 19 - 31, wherein the systemic sclerosis is diffuse cutaneous systemic sclerosis.

[0059] 33. The method according to any one of items 19 - 32, wherein the bispecific antibody or a bispecific antibody fragment thereof comprises a light chain polypeptide containing the light chain variable domain VL hB-B13 and the light chain variable domain VL hBD4-8 and a heavy chain polypeptide containing the heavy chain variable domain VH hB-B13 and the heavy chain variable domain VH hBD4-8 ; wherein:

[0060] VL hB-B13 comprises three CDRs containing the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10);

[0061] VL hBD4-8 comprises three CDRs containing the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16),

[0062] VH hB-B13 comprises three CDRs containing the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13),

[0063] VH hBD4-8Comprising three CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18), and LKEYGNYDSFYFDV (SEQ ID NO:19).

[0064] 34. The method according to item 33, wherein:

[0065] VL hB-B13 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:1,

[0066] VL hBD4-8 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:3, VH hB-B13 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:2, VH hBD4-8 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:4.

[0067] 35. The method according to item 33 or 34, wherein:

[0068] VL hB-B13 Comprising the amino acid sequence of SEQ ID NO:1,

[0069] VL hBD4-8 Comprising the amino acid sequence of SEQ ID NO:3,

[0070] VH hB-B13 Comprising the amino acid sequence of SEQ ID NO:2,

[0071] VH hBD4-8 Comprising the amino acid sequence of SEQ ID NO:4.

[0072] 36. The method according to any one of items 33 - 35, wherein the light chain polypeptide comprises the structure N - VL hB-B13 - linker - VL hBD4-8 - CL - C and the heavy chain polypeptide comprises the structure N - VH hB-B13 - linker - VH hBD4-8 - CH1 - C.

[0073] 37. The method according to any one of items 33 - 36, wherein the light chain comprises the structure N - VL hB-B13 - linker - VL hBD4-8 - CL - C and the heavy chain comprises the structure N - VH hB-B13 - linker - VH hBD4-8 - CH1 - CH2 - CH3 - C.

[0074] 38. The method according to item 36 or 37, wherein the linker comprises the amino acid sequence of SEQ ID NO:6.

[0075] 39. The method according to any one of items 33 - 38, wherein the bispecific antibody or its bispecific antibody fragment comprises two identical light chain polypeptides and two identical heavy chain polypeptides.

[0076] 40. The method according to any one of items 33 - 39, wherein the light chain polypeptide comprises an amino acid sequence having at least about 90% identity with the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises an amino acid sequence having at least about 90% identity with the amino acid sequence of SEQ ID NO:23.

[0077] 41. The method according to any one of items 33 - 40, wherein the light chain polypeptide comprises the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises the amino acid sequence of SEQ ID NO:23. BRIEF DESCRIPTION OF THE DRAWINGS

[0078] Figure 1 is a diagram of an exemplary bispecific anti - IL - 4 / anti - IL - 13 antibody comprising two light chain polypeptides and two heavy chain polypeptides. The two light chains comprise part N - VL hB-B13 - linker - VL hBD4-8 - CL - C and the two heavy chain polypeptides comprise part N - VH hB-B13 - linker - VH hBD4-8 - CH1 - CH2 - CH3 - C. The linker sequence comprises (G4S)2; i.e., GGGGSGGGGS (SEQ ID NO:6).

[0079] Figure 2 is a diagram of a clinical trial study in patients with systemic sclerosis. Patients were randomized (R) into a treatment group (top) or a placebo group (bottom), the treatment group received subcutaneous injection of Romilkimab (RKB; also known as SAR156597) at 200 mg weekly for 24 weeks, the placebo group received subcutaneous injection of placebo weekly for 24 weeks. A screening period before the treatment period and a follow - up period after the treatment period were included. During the screening period, visits were made at D1 (day 1), W2 (week 2), W4, W8, W12, W24, and W35. Phone calls were made at W6, W16, W18, and W30 (indicated by parentheses).

[0080] Figure 3It is a graph showing the least-squares mean change in mRSS at each visit. A 90% confidence interval is given for each estimate. The solid line represents patients receiving placebo, and the dashed line represents patients receiving 200 mg qw RKB.

[0081] Figure 4 It is a graph showing the least-squares mean change in the HAQ-DI composite score at each visit. A 90% confidence interval is given for each estimate. The solid line represents patients receiving placebo, and the dashed line represents patients receiving 200 mg qw RKB.

[0082] Figure 5 It is a graph showing the least-squares mean change in FVC (L) at each visit. A 90% confidence interval is given for each estimate. The solid line represents patients receiving placebo, and the dashed line represents patients receiving 200 mg qw RKB.

[0083] Figure 6 It is a graph showing the least-squares mean change in DLco (mmol / min / kPa) [corrected for hemoglobin] at each visit. A 90% confidence interval is given for each estimate. The solid line represents patients receiving placebo, and the dashed line represents patients receiving 200 mg qw RKB.

[0084] Figure 7 It is a graph showing the Kaplan-Meier curves of the time to the first event reflecting progression in the romosozumab and placebo groups. QW, once daily. *Censored = patients who left the study before the event or the study ended before the event occurred.

[0085] Figure 8A and Figure 8B It is a graph showing, in patients treated with romosozumab and placebo, the mean change from baseline to week 24 in Figure 8A () TARC and Figure 8B () periostin. QW, once a week; SE, standard error; TARC, thymus and activation-regulated chemokine. DETAILED DESCRIPTION

[0086] Each publication, patent application, patent, and other reference cited herein is hereby incorporated by reference in its entirety to the extent that it is not inconsistent with the present disclosure.

[0087] It should be noted here that, as used in this specification and the appended claims, the singular forms "a", "an", and "the" include plural referents unless the context clearly indicates otherwise.

[0088] For purposes of describing and defining the present invention, it should be noted that the term "substantially" is used herein to denote a degree of inherent uncertainty that may be attributed to any quantitative comparison, value, measurement, or other representation. The term "substantially" is also used herein to denote the degree to which a quantitative representation may vary from a reference while still causing no change in the basic function of the subject matter being discussed.

[0089] In addition, in accordance with the present invention, conventional molecular biology, microbiology, and recombinant DNA techniques within the skill of the art may be employed. Such techniques are well explained in the literature. See, for example, Sambrook, Fritsch, and Maniatis, Molecular Cloning: A Laboratory Manual, 2nd edition (1989) Cold Spring Harbor Laboratory Press, Cold Spring Harbor, New York (hereinafter "Sambrook et al., 1989"); DNA Cloning: A Practical Approach, Volumes I and II (D.N. Glover ed. 1985); Oligonucleotide Synthesis (M.J. Gait ed. 1984); Nucleic Acid Hybridization [B.D. Hames and S.J. Higgins eds. (1985)]; Transcription And Translation [B.D. Hames and S.J. Higgins eds. (1984)]; Animal Cell Culture [R.I. Freshney ed. (1986)]; Immobilized Cells And Enzymes [IRL Press, (1986)]; B. Perbal, A Practical Guide To Molecular Cloning (1984); F.M. Ausubel et al. (eds.), Current Protocols in Molecular Biology, John Wiley & Sons, Inc. (1994).

[0090] The following non-limiting definitions of some terms and phrases are provided to guide the person skilled in the art.

[0091] The terms "polypeptide" and "protein" are used interchangeably to refer to polymers of amino acid residues and are not limited to a minimum length. Such polymers of amino acid residues may contain natural or non-natural amino acid residues and include, but are not limited to, peptides, oligopeptides, dimers, trimers, and multimers of amino acid residues. The definition encompasses both full-length proteins and fragments thereof. The term also includes post-expression modifications of polypeptides such as glycosylation, sialylation, acetylation, phosphorylation, and the like. In addition, for the purposes of the present invention, "polypeptide" refers to a protein that includes modifications to the native sequence (such as deletions, additions, and substitutions, which are generally conservative in nature), provided that the protein maintains the desired activity. These modifications may be intentional (such as by site-directed mutagenesis) or may be accidental (such as by mutations in the host producing the protein or due to errors in PCR amplification).

[0092] As used herein, the term "polynucleotide" or "nucleic acid" refers to polymeric forms of nucleotides (ribonucleotides or deoxyribonucleotides) of any length. Thus, the term includes, but is not limited to, single-stranded, double-stranded, or multi-stranded DNA or RNA; genomic DNA; cDNA; DNA-RNA hybrids; or polymers comprising purine and pyrimidine bases or other natural, chemically modified, or biochemically modified nucleobases, non-natural, or derivatized nucleobases. The backbone of a polynucleotide may comprise sugar and phosphate groups (such as are typically found in RNA or DNA), or modified or substituted sugars or phosphate groups. Alternatively, the backbone of a polynucleotide may comprise a polymer of synthetic subunits (such as phosphoramidates) and may thus be an oligodeoxynucleoside phosphoramidate (P-NH2) or a mixed phosphoramidate-phosphodiester oligomer. In addition, double-stranded polynucleotides can be obtained from chemically synthesized single-stranded polynucleotide products by synthesizing the complementary strand and annealing the strands under appropriate conditions, or by de novo synthesis of the complementary strand using DNA polymerase with an appropriate primer.

[0093] "Interleukin-4" (IL-4) refers to a naturally occurring or endogenous mammalian IL-4 protein and to proteins having an amino acid sequence identical to the amino acid sequence of the naturally occurring or endogenous corresponding mammalian IL-4 protein; for example, recombinant proteins, synthetic proteins (i.e., produced using synthetic organic chemical methods). Thus, as defined herein, the term includes mature IL-4 proteins, polymorphic or allelic variants, and other isoforms of IL-4 and modified or unmodified forms of the foregoing (e.g., lipidated, glycosylated). Naturally occurring or endogenous IL-4 includes wild-type proteins such as mature IL-4, polymorphic or allelic variants, and other isoforms and mutant forms that occur naturally in mammals (e.g., humans, non-human primates). Such proteins can be recovered or isolated from, for example, sources that naturally produce IL-4. These proteins and proteins having an amino acid sequence identical to the naturally occurring or endogenous corresponding IL-4 are referred to by the name of the corresponding mammalian. For example, where the corresponding mammalian is a human, the protein is referred to as human IL-4. A number of mutant IL-4 proteins are known in the art, such as those disclosed in WO 03 / 038041.

[0094] "Interleukin 13" (IL-13) refers to a naturally occurring or endogenous mammalian IL-13 protein, and encompasses proteins having an amino acid sequence identical to that of the naturally occurring or endogenous corresponding mammalian IL-13 protein (e.g., recombinant proteins, synthetic proteins (i.e., produced using synthetic organic chemistry methods)). Thus, as defined herein, the term includes mature IL-13 proteins, polymorphic or allelic variants, and other isoforms of IL-13 (e.g., produced by alternative splicing or other cellular processes) and modified or unmodified forms of the foregoing (e.g., lipidation, glycosylation). Naturally occurring or endogenous IL-13 includes wild-type proteins such as mature IL-13, polymorphic or allelic variants, and other isoforms and mutant forms naturally present in mammals (e.g., humans, non-human primates). For example, as used herein, IL-13 encompasses a human IL-13 variant in which Arg at position 110 of mature human IL-13 is replaced by Gln (position 110 of mature IL-13 corresponds to position 130 of the precursor protein), said variant being associated with asthma (atopic and non-atopic asthma) and other variants of IL-13. (Heinzmann et al., Hum Mol Genet. (2000) 9:549-559). Such proteins can be recovered or isolated from sources that naturally produce IL-13, for example. These proteins and proteins having an amino acid sequence identical to that of the naturally occurring or endogenous corresponding IL-13 are referred to by the name of the corresponding mammal. For example, where the corresponding mammal is a human, the protein is referred to as human IL-13. A number of mutant IL-13 proteins are known in the art, such as those disclosed in WO03 / 035847.

[0095] In some aspects, the present invention relates to the treatment of systemic sclerosis (SSc). In some embodiments, the present invention relates to the treatment of diffuse cutaneous systemic sclerosis (dcSSc). In some embodiments, the present invention relates to the treatment of limited cutaneous SSc (lcSSc). IL-4 and IL-13 are therapeutically important cytokines based on their biological functions and play key roles in many diseases including asthma (Curr Opin Allergy Clin Immunol 2005, Vol. 5, 161-166). IL-4 has been shown to inhibit autoimmune diseases, and both IL-4 and IL-13 have shown potential to enhance anti-tumor immune responses. Since both cytokines are involved in the pathogenesis of allergic or fibrotic diseases, inhibitors of these cytokines may provide therapeutic benefits.

[0096] The phrase "substantially identical" with respect to an antibody chain polypeptide sequence can be interpreted as an antibody chain exhibiting at least 70%, 80%, 90%, 95%, 96%, 97%, 98%, 99% or higher sequence identity with a reference polypeptide sequence. The term with respect to a nucleic acid sequence can be interpreted as a nucleotide sequence exhibiting at least about 85%, 90%, 95%, 96%, 97%, 98%, 99% or higher sequence identity with a reference nucleic acid sequence. Identity can be determined by using any bioinformatics tool available to those of ordinary skill in the art. For example, sequence identity is typically determined using the Basic Local Alignment Search Tool (BLAST) (Altschul et al., J. Mol. Biol. (1990) 215:403-410).

[0097] The term "identity" or "homology" can mean the percentage of nucleotide bases or amino acid residues in a candidate sequence that are identical to the corresponding residues in the sequence to which it is being compared, after aligning the sequences and introducing gaps (if necessary) to achieve the maximum percentage of sequence identity throughout the sequences, and without considering any conservative substitutions as part of the sequence identity. Neither extensions nor insertions at the N-terminus or C-terminus should be construed as reducing identity or homology. Methods and computer programs for alignment are available and well-known in the art. Sequence identity can be measured using sequence analysis software.

[0098] "Substitution" variants are those variants in which at least one amino acid residue in the native sequence is removed and replaced at the same position by a different amino acid. Substitutions can be single substitutions, in which only one amino acid in the molecule is replaced, or can be multiple substitutions, in which two or more amino acids in the same molecule are replaced. Multiple substitutions can be located at contiguous sites. Similarly, one amino acid can be replaced by multiple residues, in which case such a variant includes both a substitution and an insertion. "Insertion" variants are those variants in which one or more amino acids are inserted adjacent to a particular position in the native sequence. Adjacent amino acids mean those linked to the α-carboxyl or α-amino functional groups of the amino acid. "Deletion" variants are those variants in which one or more amino acids are removed from the native amino acid sequence. Typically, deletion variants will have one or two amino acids deleted in a particular region of the molecule.

[0099] The term "antibody" is used in the broadest sense and specifically encompasses monoclonal antibodies (including full-length monoclonal antibodies), polyclonal antibodies, multispecific antibodies (e.g., bispecific antibodies), antigen-binding antibody fragments, or synthetic polypeptides carrying one or more CDRs or sequences derived from CDRs, provided that the polypeptide exhibits the desired biological activity. Antibodies (Ab) and immunoglobulins (Ig) are glycoproteins with the same structural features. Generally speaking, an antibody is considered to be an Ig with a defined or recognized specificity. Thus, while an antibody exhibits binding specificity for a particular target, immunoglobulins include antibodies as well as other antibody-like molecules lacking target specificity. The antibodies of the present invention can belong to any class (e.g., IgG, IgE, IgM, IgD, IgA, etc.) or subclass (e.g., IgG1, IgG2, IgG2a, IgG3, IgG4, IgA1; IgA2, etc.) ("class" and "isotype" and "subclass" and "subisotype" are used interchangeably herein). Native or wild-type (i.e., obtained from non-artificially manipulated members of a population) antibodies and immunoglobulins are typically heterotetrameric glycoproteins of approximately 150,000 daltons, composed of two identical light (L) chains and two identical heavy (H) chains. Each heavy chain has a variable domain (VH) at one end and multiple constant domains thereafter. Each light chain has a variable domain (VL) at one end and a constant domain at the other end. "Non-artificially manipulated" means not treated to contain or express foreign antigen-binding molecules. Compared with alleles or polymorphisms, or variants or derivatives obtained by some form of manipulation (such as mutagenesis, using recombinant methods, etc. to alter the amino acids of the antigen-binding molecule), wild-type can refer to the most common allele or species found in a population, or to an antibody obtained from a non-manipulated animal.

[0100] As used herein, an "anti-IL-4 antibody" means an antibody or polypeptide (derivative) derived therefrom that specifically binds to IL-4 as defined herein, including but not limited to molecules that inhibit or substantially reduce the binding of IL-4 to its receptor or inhibit the activity of IL-4.

[0101] As used herein, an "anti-IL-13 antibody" means an antibody or polypeptide (derivative) derived therefrom that specifically binds to IL-13 as defined herein, including but not limited to molecules that inhibit or substantially reduce the binding of IL-13 to its receptor or inhibit the activity of IL-13.

[0102] As used herein, "anti-IL-4 / anti-IL-13 bispecific antibody" means a bispecific antibody that specifically binds to IL-4 and / or IL-13 as defined herein or a polypeptide (derivative) derived therefrom, including but not limited to a molecule that inhibits or substantially reduces the binding of IL-4 to its receptor or inhibits IL-4 activity and / or substantially reduces the binding of IL-13 to its receptor or inhibits IL-13 activity.

[0103] In the context of the variable domains of an antibody, the term "variable" refers to certain portions of the relevant molecule that are widely different in sequence between two or more antibodies and are used for the specific recognition and binding of a particular antibody to its specific target. However, the variability is not evenly distributed throughout the variable domains of the antibody. The variability is concentrated in three segments called complementarity determining regions (CDRs; i.e., CDR1, CDR2, and CDR3, also known as hypervariable regions) in both the light and heavy chain variable domains. The more highly conserved portions of the variable domains are called framework (FR) regions or sequences. The variable domains of native heavy and light chains each contain four FR regions connected by three CDRs, which predominantly adopt a β-sheet conformation, and the CDRs form loops that connect the β-sheet structures and in some cases form part of the β-sheet structures. The CDRs in each chain often remain together in the vicinity of the FR regions and, together with the CDRs from the other chain, contribute to the formation of the target (epitope or determinant) binding site of the antibody (see Kabat et al. Sequences of Proteins of Immunological Interest, National Institute of Health, Bethesda, Maryland (1987)). As used herein, unless otherwise specified, immunoglobulin amino acid residues are numbered according to the Kabat et al. immunoglobulin amino acid residue numbering system. A CDR can have the ability to specifically bind to a cognate epitope.

[0104] As used in the present invention, the term "hinge" or "hinge region" refers to a flexible polypeptide of amino acids contained between the first and second constant domains of an antibody.

[0105] Phrases and terms such as "fragment", "functional fragment", "variant", "derivative", or "analogue" of an antibody, antigen, or antigen-binding protein, and forms thereof, are compounds or molecules that have a qualitative biological activity in common with the full-length antibody or the antigen of interest. For example, a functional fragment or analogue of an anti-IL-4 antibody is a functional fragment or analogue that can bind to the IL-4 molecule, or can hinder or substantially reduce the ability of a ligand or agonist or antagonist antibody to bind to IL-4. In another example, a functional fragment or analogue of an anti-IL-13 antibody is a functional fragment or analogue that can bind to the IL-13 molecule, or can hinder or substantially reduce the ability of a ligand or agonist or antagonist antibody to bind to IL-13. In yet another example, a functional fragment or analogue of an anti-IL-4 / anti-IL-13 bispecific antibody is a functional fragment or analogue that can bind to the IL-4 molecule and / or the IL-13 molecule, or can hinder or substantially reduce the ability of a ligand or agonist or antagonist antibody to bind to IL-4 and / or IL-13.

[0106] In addition, the terms "fragment" and "antibody fragment" refer to a portion of a complete or full-length chain or antibody, typically the target-binding or variable region. In some examples, the fragment of an antibody fragment of an antibody-like binding molecule contains an antigen-binding domain. With respect to a bispecific antibody-like binding molecule, the molecule contains two or more antigen-binding domains. For example, a fragment or analogue of an anti-IL-4 and / or anti-IL-13 antibody is a fragment or analogue that can hinder or substantially reduce the ability of a receptor to bind a ligand or initiate signal transduction. As used herein, "fragment", "functional fragment", and "antibody fragment" generally refer to an antibody that can hinder or substantially reduce the ability of a receptor to bind a ligand or initiate signal transduction.

[0107] The monoclonal antibodies herein specifically include "chimeric" antibodies, wherein a portion of the heavy and / or light chain is identical or homologous to the corresponding sequence in an antibody derived from a particular species or belonging to a particular antibody class or subclass (type or subtype), and the remainder of one or more chains is identical or homologous to the corresponding sequence in an antibody derived from another species or belonging to another antibody class or subclass, and fragments of such antibodies, provided that they exhibit the desired biological activity of binding to IL-4 and / or IL-13 or affecting the activity or metabolism of IL-4 and / or IL-13 (U.S. Patent No. 4,816,567; and Morrison et al. (1984), Proc Natl Acad Sci USA 81:6851). Thus, CDRs from one class of antibodies can be transplanted into the FRs of antibodies of a different class or subclass.

[0108] Monoclonal antibodies are highly specific for a particular target site, epitope, or determinant. In addition, compared to conventional (polyclonal) antibody preparations that typically include different antibodies directed against different determinants (epitopes) of an antigen, each monoclonal antibody is directed against a specific determinant on the target. In addition to their specificity, monoclonal antibodies have the advantage of being synthesized by host cells, being free of contamination by other immunoglobulins, and providing the genes and mRNA encoding the antibody chains for cloning. The modifier "monoclonal" indicates that the antibody is characterized as being obtained from a substantially homogeneous population of antibodies and should not be construed as requiring that the antibody be produced by any particular method. The parent monoclonal antibodies used in the present invention can be prepared by the hybridoma method described by Kohler et al. (1975), Nature 256:495, or can be prepared by recombinant methods well known in the art.

[0109] As used herein, the term "multivalent antibody" refers to an antibody that contains two or more antigen-binding sites and is thus capable of binding two or more antigens that may have the same or different structures simultaneously. The term "bivalent" means that the antibody contains two antigen-binding sites. The term "tetravalent" means that the antibody contains four antigen-binding sites.

[0110] As used herein, the term "antigen-binding site" refers to the portion of an antibody that contains a region that specifically binds to and is complementary to a part or all of an antigen. In the case of a large antigen, the antibody may bind only to a specific part of the antigen, which is called an epitope. The antigen-binding domain can be provided by one or more antibody variable domains. Preferably, the antigen-binding domain is constituted by the association of the variable domain of the antibody light chain (VL) and the variable domain of the antibody heavy chain (VH).

[0111] As used herein, the term "antigen" refers to a molecule or part of a molecule that can be bound by the antibodies of the present invention. An antigen may have one or more epitopes. Examples of antigens recognized by the antibodies of the present invention include, but are not limited to, serum proteins such as cytokines (e.g., IL-4, IL-5, IL-9, and IL-13), bioactive peptides, cell surface molecules (e.g., receptors), transport proteins, ion channels, viruses, and bacterial proteins.

[0112] As used herein, the term "monospecific" means that the multivalent antibodies of the present invention recognize only one antigen and all antigen-binding sites are the same.

[0113] As used herein, the term "bispecific" means that the multivalent antibodies of the present invention recognize two different epitopes on the same antigen or on two different antigens.

[0114] The term "bispecific antibody (BsAb)" refers to a molecule that incorporates the antigen-binding sites of two antibodies within a single molecule. Thus, a bispecific antibody is able to bind two different antigens simultaneously. In addition to applications for diagnostic purposes, BsAbs pave the way for new therapeutic applications by redirecting potent effector systems to diseased areas or by increasing the neutralizing or stimulatory activity of the antibody.

[0115] There has been a continuing interest in generating bispecific antibodies (BsAbs) that incorporate the antigen-binding sites of two antibodies within a single molecule. Thus, such a molecule would be able to bind two different antigens simultaneously. In addition to applications for diagnostic purposes, they also, for example, pave the way for new therapeutic applications by redirecting potent effector systems to diseased areas (where cancer cells often develop mechanisms that inhibit the normal immune responses triggered by monoclonal antibodies, such as antibody-dependent cell cytotoxicity (ADCC) or complement-dependent cytotoxicity (CDC)), or by increasing the neutralizing or stimulatory activity of the antibody. Initial attempts to couple the binding specificities of two intact antibodies directed against different target antigens for therapeutic purposes utilized chemically fused heteroconjugate molecules (Staerz et al. (1985), Nature 314:628-631).

[0116] Bispecific antibodies were initially prepared by fusing two hybridomas, each capable of producing a different immunoglobulin (Milstein and Cuello, 1983, 1984), but the complexity of the species generated in cell culture (up to ten different species) made them difficult to purify and expensive (George and Huston, 1997). Although promising results have been obtained using heteroconjugates or bispecific antibodies generated from cell fusions as cited above, several factors render them impractical for large-scale therapeutic applications. Such factors include: rapid clearance of the heteroconjugate in vivo, the need for labor-intensive techniques to generate either type of molecule, the need for extensive purification of the heteroconjugate from homoconjugates or monospecific antibodies, and generally low yields.

[0117] Genetic engineering is increasingly being used to design, modify, and generate antibodies or antibody derivatives with a desired set of binding properties and effector functions. A variety of recombinant methods have been developed to efficiently generate BsAbs as both antibody fragments (Carter et al. (1995), J. Hematotherapy 4:463-470; Pluckthun et al. (1997) Immunotechology 3:83-105; Todorovska et al. (2001) J. Immunol. Methods 248:47-66) and full-length IgG forms (Carter (2001) J. Immunol. Methods 248:7-15).

[0118] Abbott describes murine dual variable domain IgG (DVD-IgG) bispecific antibodies in patent US7612181, which are based on the dual Fv format described in a Unilever patent (US5989830). A humanized bispecific format is described in WO 2009 / 052081 (TBTI), which is incorporated herein by reference in its entirety. Adding constant domains to the corresponding chains of the dual Fv (adding CHI-Fc to the heavy chain and a κ or λ constant domain to the light chain) results in a functional bispecific dual V-region antibody-like binding protein.

[0119] As used herein, the term "multispecific" means that the multivalent antibodies of the invention recognize multiple different epitopes on the same antigen or on multiple different antigens.

[0120] As used herein, the term "linker" refers to a peptide suitable for linking the variable domains of the antibody constructs of the invention. The peptide linker can contain any amino acids, and the amino acids glycine (G) and serine (S) are preferred. The linkers can be the same or different from each other between the heavy chain polypeptide and the light chain polypeptide and within the heavy chain polypeptide and the light chain polypeptide. In addition, the length of the linker can be 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20 amino acids. In some embodiments, the peptide linker unit for the heavy chain domain and for the light chain domain is GGGGS. The number of linker units for the heavy chain and the light chain can be equal to each other (symmetric order) or different (asymmetric order). In some embodiments, the peptide linker contains two units for the heavy chain domain and for the light chain domain (e.g., GGGGSGGGGS; SEQ ID NO:6).

[0121] The peptide linker is preferably long enough to provide sufficient flexibility to prevent the antibody moieties from interfering with each other's activities, such as due to steric hindrance, to allow proper protein folding, and (if desired) to allow the antibody molecule to interact with two or more (possibly widely spaced) receptors on the same cell; however, the peptide linker is preferably short enough to allow the antibody moieties to remain stable in the cell. Thus, the length, composition, and / or conformation of the peptide linker can be readily selected by those skilled in the art to optimize the desired properties of the multivalent antibody.

[0122] The "humanized" form of a non-human (e.g., murine) antibody, as compared to a human antibody, is a chimeric immunoglobulin, immunoglobulin chain, or fragment thereof that contains sequences derived from a non-human immunoglobulin. Generally, a humanized antibody will comprise substantially all of one (and usually two) variable domains, wherein all or substantially all of the CDR regions correspond to those of the non-human immunoglobulin, and all or substantially all of the FR regions are those of a human immunoglobulin template sequence. A humanized antibody may also comprise an immunoglobulin constant region (Fc), typically at least a portion of the immunoglobulin constant region of a selected human immunoglobulin template. Generally, the goal is to render the antibody molecule minimally immunogenic in the human body. Thus, it may also be possible to change one or more amino acids in one or more CDRs to amino acids that are less immunogenic to the human host, without substantially minimizing the specific binding function of the one or more CDRs to IL-4 and / or IL-13. Alternatively, the FRs may be non-human, but the amino acids with the highest immunogenicity are replaced with amino acids that are less immunogenic. However, CDR grafting, as discussed above, is not the only way to obtain a humanized antibody. For example, modifying only the CDR regions may not be sufficient, since framework residues often play a role in determining the three-dimensional structure of the CDR loops and the overall affinity of the antibody for its ligand. Thus, any means may be employed to modify a non-human parental antibody molecule to an antibody molecule that is less immunogenic to humans, and full sequence identity to a human antibody is not always required. Thus, humanization can also be achieved, for example, by replacing only a few residues, particularly those that are exposed on the antibody molecule and not buried within the molecule and thus less accessible to the host immune system. This approach is taught herein with respect to replacing "mobile" or "flexible" residues on the antibody molecule, with the goal of reducing or attenuating the immunogenicity of the resulting molecule without compromising the specificity of the antibody for its epitope or determinant. See, e.g., Studnicka et al., Prot Eng 7(6)805-814, 1994; Mol Imm 44:1986-1988, 2007; Sims et al., J Immunol 151:2296 (1993); Chothia et al., J Mol Biol 196:901 (1987); Carter et al., Proc Natl Acad Sci USA 89:4285 (1992); Presta et al., J Immunol 151:2623 (1993); WO 2006 / 042333 and U.S. Patent No. 5,869,619.

[0123] When used in reference to IL-4 and / or IL-13, an "antibody homolog" or "homolog" refers to any molecule that specifically binds IL-4 and / or IL-13 as taught herein. Thus, antibody homologs include natural or recombinant antibodies (modified or unmodified), antibody portions (such as Fab or Fv molecules) that retain the biological property of interest (such as binding IL-4 or IL-13), single-chain antibodies, polypeptides carrying one or more CDR regions, and the like. The amino acid sequence of a homolog need not be identical to the amino acid sequence of a naturally occurring antibody, but may be altered or modified to carry substituted amino acids, inserted amino acids, deleted amino acids, amino acids other than the twenty amino acids normally found in proteins, etc., to obtain a polypeptide with enhanced or other beneficial properties.

[0124] Antibodies having a homologous sequence are those antibodies whose amino acid sequence has sequence homology to the amino acid sequence of an IL-4 antibody, an IL-13 antibody, or a bispecific IL-4 / IL-13 antibody of the present invention. Preferably, the homology is to the amino acid sequence of the variable region of an antibody of the present invention. "Sequence homology" of amino acid sequences as applied herein is defined as one sequence having at least about 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% sequence homology to another amino acid sequence, for example, determined by the FASTA search method according to Pearson and Lipman, Proc Natl Acad Sci USA 85,2444-2448 (1988).

[0125] Chimeric antibodies are antibodies having different portions of antibodies from different sources (such as different antibodies, different antibody classes, different animal species), for example, an antibody having a variable region from a murine monoclonal antibody paired with a human immunoglobulin constant region, and the like. Thus, humanized antibodies are a type of chimeric antibody. Methods for producing chimeric antibodies are known in the art, see, for example, Morrison, 1985, Science 229:1202; Oi et al., 1986, BioTechniques 4:214; Gillies et al., 1989, J Immunol Methods 125:191-202; and U.S. Patent Nos. 5,807,715, 4,816,567, and 4,816,397.

[0126] Also included within the scope of the present invention are functional equivalents of the subject antibodies. The term "functional equivalent" includes antibodies having homologous sequences, antibody homologs, chimeric antibodies, artificial antibodies, and modified antibodies, e.g., each functional equivalent being defined by its ability to bind IL-4 and / or IL-13, inhibit the signaling capacity or function of IL-4 and / or IL-13, or inhibit the binding of IL-4 and / or IL-13 to its receptor. Those skilled in the art will appreciate that the group of molecules referred to as "antibody fragments" overlaps with the group referred to as "functional equivalents". Methods for generating functional equivalents that retain the ability to bind IL-4 and / or IL-13 are known to those skilled in the art and are disclosed, for example, in WO 93 / 21319, EPO Serial No. 239,400, WO 89 / 09622, EPO Serial No. 338,745, and EPO Serial No. 332,424.

[0127] Functional equivalents of the present application also include modified antibodies, e.g., antibodies modified by covalently attaching any type of molecule to the antibody. For example, modified antibodies include antibodies that have been modified, e.g., by glycosylation, acetylation, polyethylene glycolylation, deamidation, phosphorylation, amidation, derivatization by known protecting / blocking groups, proteolytic cleavage, attachment to a cell ligand, attachment to a toxin or cytotoxic moiety, or attachment to another protein, etc. The covalent attachment need not result in an antibody that is free from generating an anti-idiotypic response. The modifications can be achieved by known techniques, including but not limited to specific chemical cleavage, acetylation, formylation, metabolic synthesis, etc. Additionally, modified antibodies can contain one or more non-classical amino acids.

[0128] As used herein, "treatment" is a method for obtaining a beneficial or desired clinical outcome. For the purposes of the present invention, beneficial or desired clinical outcomes include, but are not limited to, the following: alleviation of symptoms, diminution of the extent of the disease, stabilization of the disease state (e.g., not worsening), prevention of the spread of the disease (e.g., metastasis), delay or slowing of disease progression, amelioration or palliation of the disease state, and remission (whether partial or total), whether detectable or not. "Treatment" can also mean prolongation of survival as compared to the expected survival in the absence of treatment.

[0129] As used herein, the term "preventive treatment" refers to a treatment in which an individual is known or suspected of having a disorder or being at risk of developing a disorder, but has not exhibited symptoms of the disorder or has exhibited minimal symptoms of the disorder. An individual undergoing preventive treatment can be treated prior to the onset of symptoms.

[0130] "Isolated" or "purified" antibodies are substantially free of cellular material or other contaminating proteins from the cell or tissue source or culture medium from which the protein is derived, or when chemically synthesized, are substantially free of chemical precursors or other chemicals. For example, the language "substantially free of cellular material" includes antibody preparations in which the polypeptide / protein is separated from the cellular components of the cells from which the polypeptide / protein is isolated or recombinantly produced. Thus, antibodies that are substantially free of cellular material include antibody preparations having less than about 30%, 20%, 10%, 5%, 2.5%, or 1% (by dry weight) of contaminating protein. When an antibody is recombinantly produced, the antibody is also preferably substantially free of culture medium, i.e., the culture medium accounts for less than about 20%, 10%, 5%, 2.5%, or 1% of the volume of the protein preparation. When an antibody is produced by chemical synthesis, the antibody is preferably substantially free of chemical precursors or other chemicals and reagents, i.e., the antibody of interest is separated from the chemical precursors or other chemicals involved in the synthesis of the protein. Accordingly, such antibody preparations have less than about 30%, 20%, 10%, 5%, or 1% (by dry weight) of chemical precursors or compounds other than the antibody of interest. In some embodiments of the invention, the antibody is isolated or purified. In some embodiments, the invention provides a composition comprising an anti-IL-4 / anti-IL-13 bispecific antibody, wherein greater than about 95%, 96%, 97%, 98%, 99% of the polypeptide in the composition is the anti-IL-4 / anti-IL-13 bispecific antibody.

[0131] As used herein, the terms "therapeutic agent" and "therapeutic agents" refer to any one or more agents that can be used for the treatment, management, or amelioration of diseases, disorders, conditions, etc. associated with abnormal IL-4 and / or IL-13 metabolism and activity.

[0132] As used herein, "dose" refers to the amount of any one or more agents that can be used for the treatment, management, or amelioration of diseases, disorders, conditions, etc. associated with abnormal IL-4 and / or IL-13 metabolism and activity.

[0133] As used herein, "safe dose" refers to any one or more pharmaceutical agents or the dose of any one or more pharmaceutical agents that can be used for the treatment, management, or improvement of diseases, disorders, conditions, etc. related to abnormal IL-4 and / or IL-13 metabolism and activity, while maintaining a clinically acceptable benefit / risk profile. The safe doses of the dual V-region antibody-like binding proteins or fragments thereof disclosed herein are selected from 10 mg, 20 mg, 40 mg, 50 mg, 80 mg, 100 mg, 150 mg, 200 mg, and 300 mg. An embodiment of the safe dose is from about 10 mg to about 300 mg. Another embodiment of the safe dose is any dose of 200 mg, about 200 mg, up to 200 mg, or not greater than about 200 mg. In other embodiments, the safe dose is about 50 mg, or about 100 mg, or about 200 mg. In some embodiments, the safe dose is administered once a week. In some embodiments, the safe dose is administered once every 7 ± 2 days (i.e., every 5 - 9 days). In some embodiments, the safe dose is administered every other week (i.e., every two weeks). In some embodiments, the safe dose is administered subcutaneously (SC). In some embodiments, the safe dose is administered subcutaneously (SC) over a period of at least about 24 weeks. In some embodiments, a bispecific antibody of 200 mg is administered once a week. In some embodiments, a bispecific antibody of 200 mg is administered once every 7 ± 2 days (i.e., every 5 - 9 days). In some embodiments, a bispecific antibody of 200 mg is administered every other week (i.e., every two weeks). In some embodiments, a bispecific antibody of 200 mg is administered subcutaneously (SC). In some embodiments, a bispecific antibody of 200 mg is administered subcutaneously (SC) once a week over a period of at least about 24 weeks.

[0134] When the term "about" is used in reference to a value or parameter herein, it includes (and describes) embodiments that refer to the value or parameter itself. For example, a description of "about X" includes a description of "X". When used in conjunction with a numerical value, the term "about" is intended to cover a numerical range that has a lower limit that is 5%, 10%, or 15% less than the indicated value and an upper limit that is 5%, 10%, or 15% greater than the indicated value, and the term includes the indicated value.

[0135] Anti-IL4 - Anti-IL13 bispecific antibody

[0136] In some aspects, the present invention provides methods for treating SSc by administering a bispecific antibody that binds IL-4 and IL-13. Bispecific dual variable domain (dual V domain) antibody-like binding proteins having four binding sites that specifically bind IL-4 and IL-13 are reported in WO 2009 / 052081, WO 2012 / 125775, WO 2015 / 121318, WO 2014 / 177568, and WO2015 / 198146 (each of which is incorporated herein by reference in its entirety).

[0137] An embodiment of the invention is a method for treating SSc using a bispecific antibody that has been engineered to comprise a dual V domain antibody-like protein or a fragment thereof that specifically binds two different epitopes on the same antigen or on two different antigens.

[0138] In some embodiments, the light chain variable region (VL) and the heavy chain variable region (VH) of the dual V domain antibody-like binding molecule have the following sequences (CDR sequences are shown in bold).

[0139]

[0140]

[0141] In some aspects, the present invention provides methods for treating SSc by administering to a subject a bispecific antibody that specifically binds IL-13 and IL-4 or a bispecific antigen-binding antibody fragment thereof, wherein the bispecific antibody or bispecific antigen-binding antibody fragment comprises a light chain polypeptide comprising a light chain variable domain VL hB-B13 and a light chain variable domain VL hBD4-8 ; a heavy chain polypeptide comprising a heavy chain variable domain VH hB-B13 and a heavy chain variable domain VH hBD4-8 ; wherein:

[0142] VL hB-B13 comprises three CDRs comprising the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ IDNO:9), and QQNAEDSRT (SEQ ID NO:10);

[0143] VL hBD4-8 comprises three CDRs comprising the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16);

[0144] VH hB-B13comprises three CDRs containing the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13); and

[0145] VH hBD4-8 comprises three CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18) and LKEYGNYDSFYFDV (SEQ ID NO:19) or the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDASDGETR (SEQ ID NO:21), and LKEYGNYDSFYFDV (SEQ ID NO:19).

[0146] In some embodiments, the present invention provides a method for treating SSc by administering to a subject a bispecific antibody that specifically binds to IL-13 and IL-4 or a bispecific antigen-binding antibody fragment thereof, wherein the bispecific antibody or bispecific antigen-binding antibody fragment comprises a light chain polypeptide containing a light chain variable domain VL hB-B13 and a light chain variable domain VL hBD4-8 and a heavy chain polypeptide containing a heavy chain variable domain VH hB-B13 and a heavy chain variable domain VH hBD4-8 ; wherein:

[0147] VL hB-B13 comprises CDRs containing the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10) and VLhB-B13 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:1;

[0148] VL hBD4-8 comprises CDRs containing the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16) and VLhBD4-8 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:3;

[0149] VH hB-B13comprising CDRs containing the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13) and VHhB-B13 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:2; and

[0150] VH hBD4-8 comprising CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18), and LKEYGNYDSFYFDV (SEQ ID NO:19) and VHhBD4-8 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:4; or

[0151] VH hBD4-8 comprising CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDASDGETR (SEQ ID NO:21), and LKEYGNYDSFYFDV (SEQ ID NO:19) and VHhBD4-8 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:5.

[0152] In some embodiments, the present invention provides a method for treating SSc by administering to a subject a bispecific antibody that specifically binds IL-13 and IL-4 or a bispecific antigen-binding antibody fragment thereof, wherein the bispecific antibody or bispecific antigen-binding antibody fragment comprises a light chain polypeptide comprising a light chain variable domain VL hB-B13 and a light chain variable domain VL hBD4-8 and a heavy chain polypeptide comprising a heavy chain variable domain VH hB-B13 and a heavy chain variable domain VH hBD4-8 ; wherein:

[0153] VL hB-B13 comprises the amino acid sequence of SEQ ID NO:1,

[0154] VL hBD4-8 comprises the amino acid sequence of SEQ ID NO:3,

[0155] VH hB-B13 comprises the amino acid sequence of SEQ ID NO:2,

[0156] VH hBD4-8 comprises the amino acid sequence of SEQ ID NO:4 or SEQ ID NO:5.

[0157] In some embodiments of the bispecific antibodies or bispecific antigen-binding antibody fragments described above, the light chain polypeptide comprises the structure N-VL hB-B13 -linker-VL hBD4-8 -CL-C and the heavy chain polypeptide comprises the structure N-VH hB-B13 -linker-VH hBD4-8 -CH1-C. In some embodiments of the bispecific antibodies or bispecific antigen-binding antibody fragments described above, the light chain polypeptide comprises the structure N-VL hB-B13 -linker-VL hBD4-8 -CL-C and the heavy chain polypeptide comprises the structure N-VH hB-B13 -linker-VH hBD4-8 -CH1-CH2-CH3-C. In some embodiments, the linker comprises the amino acid sequence of SEQ ID NO:6.

[0158] In some embodiments of the bispecific antibodies or bispecific antigen-binding antibody fragments described above, the light chain polypeptide comprises the following sequence:

[0159] DIVLTQSPAS LAVSLGQRAT ISCRASESVD SYGQSYMHWY QQKAGQPPKL

[0160] LIYLASNLES GVPARFSGSG SRTDFTLTID PVQAEDAATY YCQQNAEDSR

[0161] TFGGGTKLEI KGGGGSGGGG SDIQMTQSPA SLSVSVGDTI TLTCHASQNI

[0162] DVWLSWFQQK PGNIPKLLIY KASNLHTGVP SRFSGSGSGT GFTLTISSLQ

[0163] PEDIATYYCQ QAHSYPFTFG GGTKLEIKRT VAAPSVFIFP PSDEQLKSGT

[0164] ASVVCLLNNF YPREAKVQWK VDNALQSGNS QESVTEQDSK DSTYSLSSTLTLSKADYEKHKVYACEVTHQ GLSSPVTKSF NRGEC(SEQ ID NO:22)

[0165] In some embodiments of the bispecific antibodies or bispecific antigen-binding antibody fragments described above, the heavy chain polypeptide comprises the following sequence:

[0166] EVQLKESGPG LVAPGGSLSI TCTVSGFSLT DSSINWVRQP PGKGLEWLGM

[0167] IWGDGRIDYA DALKSRLSIS KDSSKSQVFL EMTSLRTDDT ATYYCARDGY

[0168] FPYAMDFWGQ GTSVTVSSGG GGSGGGGSQV QLQQSGPELV KPGASVKISC

[0169] KASGYSFTSY WIHWIKQRPG QGLEWIGMID PSDGETRLNQ RFQGRATLTV

[0170] DESTSTAYMQ LRSPTSEDSA VYYCTRLKEY GNYDSFYFDV WGAGTLVTVS

[0171] SASTKGPSVF PLAPCSRSTS ESTAALGCLV KDYFPEPVTV SWNSGALTSG

[0172] VHTFPAVLQS SGLYSLSSVV TVPSSSLGTK TYTCNVDHKP SNTKVDKRVE

[0173] SKYGPPCPPC PAPEFEGGPS VFLFPPKPKD TLMISRTPEV TCVVVDVSQE

[0174] DPEVQFNWYV DGVEVHNAKT KPREEQFNST YRVVSVLTVL HQDWLNGKEY

[0175] KCKVSNKGLP SSIEKTISKA KGQPREPQVY TLPPSQEEMT KNQVSLTCLV

[0176] KGFYPSDIAV EWESNGQPEN NYKTTPPVLD SDGSFFLYSR LTVDKSRWQEGNVFSCSVMHEALHNHYTQK SLSLSLG(SEQ ID NO:23)

[0177] In some embodiments of the bispecific antibodies or bispecific antigen-binding antibody fragments described above, the light chain polypeptide comprises the structure N-VL hBD4-8 -linker-VLhB-B13 -CL-C and the heavy chain polypeptide comprises the structure N-VH hBD4-8 -linker-VH hB-B13 -CH1-C. In some embodiments of the bispecific antibody or bispecific antigen-binding antibody fragment described above, the light chain polypeptide comprises the structure N-VL hBD4-8 -linker-VL hB-B13 -CL-C and the heavy chain polypeptide comprises the structure N-VH hBD4-8 -linker-VH hB-B13 -CH1-CH2-CH3-C. In some embodiments, the linker comprises the amino acid sequence of SEQ ID NO:6.

[0178] In some embodiments of the bispecific antibody or bispecific antigen-binding antibody fragment described above, the bispecific antibody or bispecific antigen-binding antibody fragment comprises two light chains and two heavy chains. In some embodiments, the bispecific antibody or bispecific antigen-binding antibody fragment is derived from an IgG4 antibody.

[0179] In some embodiments, the present invention provides a method for treating SSc by administering to a subject an antibody or antigen-binding antibody fragment that specifically binds IL-13, wherein the antibody or antibody fragment comprises a light chain variable domain containing CDRs having the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10) and a heavy chain variable domain containing CDRs having the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13). In some embodiments, the light chain variable domain comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:1 and the heavy chain variable domain comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:2. In some embodiments, the light chain variable domain comprises the amino acid sequence of SEQ ID NO:1 and the heavy chain variable domain comprises the amino acid sequence of SEQ ID NO:2. In some embodiments, the antibody competes with the antibody or antibody fragment described above for binding to IL-13. In some embodiments, the antibody binds to the same epitope as the antibody or antibody fragment described above. In some embodiments, the antibody is a bispecific antibody or bispecific antibody fragment. In some embodiments, the antibody specifically binds IL-13 and IL-4.

[0180] In some embodiments, the present invention provides a method for treating SSc by administering to a subject an antibody or an antigen-binding fragment thereof that specifically binds to IL-4, wherein the antibody or antibody fragment thereof comprises a light chain variable domain containing CDRs having the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16) and a heavy chain variable domain containing CDRs having the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18), and LKEYGNYDSFYFDV (SEQ ID NO:19) or the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDASDGETR (SEQ ID NO:21), and LKEYGNYDSFYFDV (SEQ ID NO:19). In some embodiments, the light chain variable domain comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:3 and the heavy chain variable domain comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:4 or SEQ ID NO:5. In some embodiments, the light chain variable domain comprises the amino acid sequence of SEQ ID NO:3 and the heavy chain variable domain comprises the amino acid sequence of SEQ ID NO:4 or SEQ ID NO:5. In some embodiments, the antibody competes with the antibody or antibody fragment described above for binding to IL-4. In some embodiments, the antibody binds to the same epitope as the antibody or antibody fragment described above. In some embodiments, the antibody is a bispecific antibody or a bispecific antibody fragment thereof. In some embodiments, the antibody specifically binds to IL-4 and IL-13.

[0181] In some embodiments of the bispecific antibody or bispecific antigen-binding antibody fragment described above, the bispecific antibody or bispecific antigen-binding antibody fragment competes with the bispecific antibody or bispecific antigen-binding antibody fragment described above for binding to IL-13 and / or IL-4. In some embodiments of the bispecific antibody or bispecific antigen-binding antibody fragment described above, the bispecific antibody or bispecific antigen-binding antibody fragment binds to the same epitope as the bispecific antibody or bispecific antigen-binding antibody fragment described above.

[0182] In some aspects, the present invention provides methods for treating SSc by administering to a subject a pharmaceutical composition comprising a bispecific antibody that specifically binds IL-13 and IL-4 as described above or a bispecific antigen-binding antibody fragment thereof. In some embodiments, the pharmaceutical composition comprises a bispecific antibody that specifically binds IL-13 and IL-4 as described above or a bispecific antigen-binding antibody fragment thereof and a pharmaceutically acceptable carrier.

[0183] In some aspects, the present invention provides a composition for treating SSc, wherein the composition comprises a bispecific antibody that specifically binds IL-13 and IL-4 as described above or a bispecific antigen-binding antibody fragment thereof. In some embodiments, the composition is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or a bispecific antigen-binding antibody fragment thereof. In some embodiments, the composition is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or a bispecific antigen-binding antibody fragment thereof once a week. In some embodiments, the composition is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or a bispecific antigen-binding antibody fragment thereof once every other week. In some embodiments, the composition is formulated to provide a subject with a dose of 200 mg of the bispecific antibody or a bispecific antigen-binding antibody fragment thereof once every 7 days ± 2 days. In some embodiments, the composition is formulated to provide a subject with a dose of 200 mg of the bispecific antibody or a bispecific antigen-binding antibody fragment thereof once every 5 - 9 days. In some embodiments, the composition is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or a bispecific antigen-binding antibody fragment thereof once a week. In some embodiments, the composition is formulated to provide a subject subcutaneously with a dose of about 200 mg of the bispecific antibody or a bispecific antigen-binding antibody fragment thereof once a week for at least about 24 weeks.

[0184] In some embodiments, the present invention provides the use of a bispecific antibody that specifically binds to IL-13 and IL-4, or a bispecific antigen-binding antibody fragment thereof, as described above, in the manufacture of a medicament for treating SSc in a subject. In some embodiments, the composition is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or its bispecific antigen-binding antibody fragment. In some embodiments, the medicament is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or its bispecific antigen-binding antibody fragment once a week. In some embodiments, the medicament is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or its bispecific antigen-binding antibody fragment once every other week. In some embodiments, the medicament is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or its bispecific antigen-binding antibody fragment once every other week. In some embodiments, the medicament is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or its bispecific antigen-binding antibody fragment once a week for at least about 24 weeks. In some embodiments, the medicament is formulated to provide a subject with a dose of about 200 mg of the bispecific antibody or its bispecific antigen-binding antibody fragment once a week. In some embodiments, the medicament is formulated to provide a subject subcutaneously with a dose of about 200 mg of the bispecific antibody or its bispecific antigen-binding antibody fragment once a week for at least about 24 weeks.

[0185] In some embodiments, the present invention provides a method for treating SSc by administering to a subject with SSc huTBTI3_2_1 or SAR156597 or rimekimab (RKB) comprising a bispecific antibody that specifically binds to IL-13 and IL-4, or a bispecific antigen-binding antibody fragment thereof, wherein the bispecific antibody or its bispecific antigen-binding antibody fragment comprises (a) a light chain polypeptide containing two variable light chain domains, wherein one variable light chain domain comprises the amino acid sequence of SEQ ID NO:1 and one variable light chain domain comprises the amino acid sequence of SEQ ID NO:3; (b) a heavy chain polypeptide containing two variable heavy chain domains, wherein one variable heavy chain domain comprises the amino acid sequence of SEQ ID NO:2 and one variable heavy chain domain comprises the amino acid sequence of SEQ ID NO:4; (c) a peptide linker that links SEQ ID NO:1 to SEQ ID NO:3, and a peptide linker that links SEQ ID NO:2 to SEQ ID NO:4, wherein the peptide linker has an amino acid sequence consisting of SEQ ID NO:6; and (d) a constant region domain.

[0186] To prolong the serum circulation of antibodies in vivo, various techniques can be used. For example, with or without a multifunctional linker, an inert polymeric molecule such as high molecular weight polyethylene glycol (PEG) can be attached to the antibody by site-specific conjugation to the N-terminus or C-terminus of the antibody, or via the ε-amino group present on lysine residues. Linear or branched polymer derivatives that result in minimal loss of biological activity can be used. The degree of conjugation can be closely monitored by SDS-PAGE and mass spectrometry to ensure correct conjugation of the PEG molecule to the antibody. Unreacted PEG can be separated from the antibody-PEG conjugate by size exclusion or by ion exchange chromatography. Methods known to those skilled in the art can be used, such as testing the binding activity and in vivo efficacy of the PEGylated antibody by immunoassays described herein.

[0187] Antibodies with increased in vivo half-life can also be generated by introducing one or more amino acid modifications (i.e., substitutions, insertions, or deletions) into the IgG constant domain or its FcR-binding fragment (such as the Fc or hinge-Fc domain fragment), see, for example, WO 98 / 23289; WO 97 / 34631; and U.S. Patent No. 6,277,375.

[0188] In addition, antibodies can be conjugated to albumin to make the antibody more stable in vivo or have a longer in vivo half-life. Such techniques are known in the art, see, for example, WO 93 / 15199, WO 93 / 15200, and WO 01 / 77137; and EPO413,622. Antibodies can also be modified, for example, by glycosylation, acetylation, phosphorylation, amidation, derivatization with known protecting / blocking groups, proteolytic cleavage, attachment to cell ligands or other proteins, etc.

[0189] The antibodies of the present invention can also be described or specified according to their binding affinity for IL-4 and / or IL-13. Anti-IL-4 and / or anti-IL-13 antibodies can have a K -7 dissociation constant of less than about 10 -6 M, less than about 10 -5 M, or less than about 10 D M. Higher binding affinity in the target antibody can be beneficial, such as having a K -8 dissociation constant of from about 10 -15 to about 10 -8 M, from about 10 -12 to about 10 -9 M, from about 10 - 11 to about 10 -8 M, or from about 10 -10 to about 10 DThose. The present invention also provides antibodies that competitively inhibit the binding of an antibody to an epitope of the present invention, as determined by any method known in the art for determining competitive binding (e.g., the immunoassays described herein). In a preferred embodiment, the antibody will competitively inhibit the binding to the epitope by at least about 95%, at least about 90%, at least about 85%, at least about 80%, at least about 75%, at least about 70%, at least about 60% or at least about 50%.

[0190] The antibodies of the invention can be administered and / or formulated with one or more additional therapeutic or active agents. When the ligand is administered with an additional therapeutic agent, the ligand can be administered before, concurrently with, or after the administration of the additional agent. Generally, the ligand and the additional agent are administered in a manner that provides overlapping therapeutic effects. Additional agents that can be administered or formulated with the ligand of the invention include, for example, various immunotherapeutic drugs such as cyclosporine, methotrexate, doxorubicin or cisplatin, antibiotics, antifungal agents, antiviral agents, and immunotoxins. For example, when an antagonist is administered to prevent, inhibit, or treat pulmonary inflammation or respiratory diseases (such as asthma), it can be co-administered with: phosphodiesterase inhibitors (such as inhibitors of phosphodiesterase 4), bronchodilators (such as β2-agonists, anticholinergics, theophylline), short-acting β-agonists (such as albuterol, salbutamol, bambuterol, fenoterol, isoetherine, isoproterenol, levalbuterol, metaproterenol, pirbuterol, terbutaline, and tomlate), long-acting β-agonists (such as formoterol and salmeterol), short-acting anticholinergics (such as ipratropium bromide and oxitropium bromide), long-acting anticholinergics (such as tiotropium bromide), theophylline (such as short-acting formulations, long-acting formulations), inhaled steroids (such as beclomethasone, beclometasone, budesonide, flunisolide, fluticasone propionate, and triamcinolone), oral steroids (such as methylprednisolone, prednisolone, prednisolon, and prednisone), combinations of short-acting β-agonists and anticholinergics (such as albuterol / salbutamol / ipratropium and fenoterol / ipratropium), combinations of long-acting β-agonists and inhaled steroids (such as salmeterol / fluticasone and formoterol / budesonide), and mucolytics (such as erdosteine, acetylcysteine, bromhexine, carbocysteine, guaifenesin, and glycerol iodide).

[0191] Other suitable co-therapeutic agents that can be administered together with the antibodies of the present invention to prevent, inhibit or treat asthma (e.g., allergic asthma) include corticosteroids (e.g., beclomethasone, budesonide, fluticasone), cromolynates, nedocromil, β-agonists (e.g., salbutamol, terbutaline, bambuterol, fenoterol, carbuterol, tolubuterol, salmeterol, formoterol), zafirlukast, salmeterol, prednisone, prednisolone, theophylline, zileutron, montelukast, and leukotriene modifiers. The ligands of the present invention can be co-administered with a variety of co-therapeutic agents (including cytokines, analgesics / antipyretics, antiemetics, and chemotherapeutic agents) suitable for treating diseases (e.g., SSc, Th-2 mediated diseases, YL-A mediated diseases, IL-13 mediated diseases, and IL-4 mediated diseases).

[0192] As known in the art or as described herein, the antibodies of the present invention can be provided in a pharmaceutically acceptable composition. The terms "physiologically acceptable", "pharmacologically acceptable", etc. mean approved by a regulatory agency of the federal or state government or listed in the U.S. Pharmacopeia or other generally recognized pharmacopeias for use in animals, and more particularly in humans.

[0193] The bispecific anti-IL-4 / IL-13 antibody can be administered to a mammal, and particularly to a human, in any acceptable manner to treat SSc. The introduction methods include but are not limited to parenteral, subcutaneous, intraperitoneal, intralung, intranasal, epidural, inhalation, and oral routes; and if immunosuppressive treatment is required, intralesional administration. Parenteral infusion includes intramuscular, intradermal, intravenous, intraarterial, or intraperitoneal administration. The antibody or composition can be administered by any convenient route, such as by infusion or bolus injection, by absorption through the epithelial or mucosal lining (e.g., oral mucosa, rectal, and intestinal mucosa, etc.), and can be co-administered with other bioactive agents. The administration can be systemic or local. In addition, it may be desirable to introduce the therapeutic antibody or composition of the present invention into the central nervous system by any suitable route (including intraventricular and intrathecal injection); intraventricular injection can be facilitated, for example, by an intraventricular catheter attached to a reservoir (such as an Ommaya reservoir). In addition, the antibody is administered by pulse infusion, particularly in a suitable manner with a decreasing antibody dose. In some embodiments, the bispecific anti-IL-4 / IL-13 antibody is administered subcutaneously to a human subject.

[0194] Therapeutic formulations of polypeptides or antibodies can be prepared as lyophilized formulations or aqueous solutions for storage, and are prepared by mixing a polypeptide of desired purity with optional "pharmaceutically acceptable" carriers, diluents, excipients or stabilizers commonly used in the art (i.e., buffers, stabilizers, preservatives, isotonic agents, non-ionic detergents, antioxidants and various other additives), see Remington's Pharmaceutical Sciences, 16th Edition, ed. Osol (1980). Such additives are generally non-toxic to the recipient at the doses and concentrations employed, and thus, excipients, diluents, carriers, etc. are pharmaceutically acceptable.

[0195] Examples of formulations of bispecific antibody-like molecules that bind IL-4 and IL-13 are provided in WO 2014 / 177568 (which is incorporated herein by reference in its entirety). It has surprisingly been found that highly stable anti-IL-4 / anti-IL-13 bispecific antibody formulations are in the form of a liquid and a lyophilized powder comprising an anti-IL-4 / anti-IL-13 bispecific antibody and a buffer system, wherein the pH of the formulation is about pH 7, and wherein the formulation has a low salt concentration in order to reduce the ionic strength of the formulation. The formulation may optionally further comprise a non-ionic surfactant, a sugar and / or a non-ionic stabilizer. These formulations improve upon conventional formulations which often lead to molecular aggregation (HMW) of the antibody when increasing the antibody concentration in the formulation, and lead to the formation of visible and invisible particles. Specifically, the formulations of the present invention exhibit good stability with respect to visible particles, invisible particles, low molecular weight proteins and high molecular weight proteins.

[0196] In some embodiments, the present invention provides a stable antibody formulation comprising: a bispecific anti-IL-4 / anti-IL-13 antibody or an antigen-binding fragment thereof comprising a light chain of the formula VL1-linker-VL2 and a heavy chain of the formula VH1-linker-VH2, wherein VL1 and VH1 form an IL-13 antigen-binding domain and VL2 and VH2 form an IL-4 antigen-binding domain; and a buffer system adapted to maintain the pH of the formulation at about pH 7; and wherein the formulation has a low salt concentration to reduce the ionic strength of the formulation. In some embodiments, VL1 comprises the three CDR sequences of SEQ ID NO:1; VH1 comprises the three CDR sequences of SEQ ID NO:2; VL2 comprises the three CDR sequences of SEQ ID NO:3; and VH2 comprises the CDR sequences of SEQ ID NO:4 or 5. In alternative specific embodiments, VL1 comprises the amino acid sequence of SEQ ID NO:1; VH1 comprises the amino acid sequence of SEQ ID NO:2; VL2 comprises the amino acid sequence of SEQ ID NO:3; and VH2 comprises the amino acid sequence of SEQ ID NO:4 or 5. In some embodiments, the light chain comprises the formula N-VL1-linker-VL2-CL, wherein CL is the light chain constant domain of the antibody, and wherein the heavy chain comprises the formula N-VH1-linker-VH2-CH1-CH2-CH3, wherein CH2-CH3 corresponds to the Fc domain of the antibody. In a specific embodiment, the linker comprises the amino acid sequence of SEQ ID NO:6. In some embodiments, the antibody or its antigen-binding fragment further comprises a constant region domain. In some embodiments, the constant region domain is selected from CHI, CH2, CH3, and CL. In some embodiments, the bispecific antibody or its antigen-binding fragment is a humanized IgG4 bispecific antibody or its antigen-binding fragment.

[0197] In some embodiments, the concentration of the antibody or its antigen-binding fragment in any of the formulations described above is about 100 mg / mL.

[0198] In some embodiments of the present invention, the buffer system in any of the formulations described above comprises at least two buffers. In a specific embodiment, the buffer system concentration is about 10 mM. In a specific embodiment, the buffer system comprises a Tris buffer and a phosphate buffer. In a specific embodiment, the Tris buffer concentration is about 3.7 mM. In a specific embodiment, the phosphate buffer concentration is about 6.3 mM. In a specific embodiment, the Tris buffer concentration is about 3.7 mM and the phosphate buffer concentration is about 6.3 mM.

[0199] In some embodiments of the present invention, any one of the above-described formulations further comprises a non-ionic surfactant. In a specific embodiment, the concentration of the non-ionic surfactant is from about 0.05% to about 0.2% (w / v). In a specific embodiment, the non-ionic surfactant is polysorbate. In a specific embodiment, the polysorbate is polysorbate 80. In a specific embodiment, the concentration of polysorbate 80 is from about 0.05% to about 0.2% (w / v). In a specific embodiment, the concentration of polysorbate 80 is about 0.2% (w / v).

[0200] In some embodiments of the present invention, any one of the above-described formulations further comprises a sugar. In a specific embodiment, the concentration of the sugar is about 5% (w / v). In a specific embodiment, the sugar is a disaccharide. In a specific embodiment, the disaccharide is sucrose. In a specific embodiment, the concentration of sucrose is about 5% (w / v).

[0201] In some embodiments of the present invention, the formulation further comprises a non-ionic stabilizer. In a specific embodiment, the concentration of the non-ionic stabilizer is from about 1% to about 3% (w / v). In a specific embodiment, the non-ionic stabilizer is an amino acid or a sugar. In a specific embodiment, the amino acid is proline. In a specific embodiment, the sugar is mannitol. In a specific embodiment, the concentration of proline is from about 1% to about 3% (w / v). In a specific embodiment, the concentration of proline is about 3% (w / v). In a specific embodiment, the concentration of mannitol is about 3% (w / v).

[0202] In some embodiments of the present invention, the formulation is a lyophilized formulation. In some embodiments of the present invention, the formulation is a reconstituted lyophilized formulation.

[0203] In some embodiments of the present invention, the formulation exhibits good stability with respect to visible particles, invisible particles, low molecular weight proteins, and high molecular weight proteins.

[0204] One embodiment of the present invention provides a method of treating SSc in a subject, the method comprising administering a bispecific anti-IL-4 / anti-IL-13 antibody or an antigen-binding fragment thereof, wherein the antibody is in a stable antibody formulation, the antibody formulation comprising: about 100 mg / mL of the bispecific antibody or an antigen-binding fragment thereof, wherein the antibody or antigen-binding fragment thereof comprises a heavy chain polypeptide and a light chain polypeptide, the heavy chain polypeptide comprising a variable region having the amino acid sequence of SEQ ID NO:2 and a variable region having the amino acid sequence of SEQ ID NO:4, and the light chain polypeptide comprising a variable region having the amino acid sequence of SEQ ID NO:1 and a variable region having the amino acid sequence of SEQ ID NO:3; about 10 mM of a buffer system, wherein the buffer system comprises about 3.7 mM of Tris buffer and about 6.3 mM of phosphate buffer; about 0.2% (w / v) polysorbate 80; about 5% (w / v) sucrose; and about 3% (w / v) proline; wherein the pH of the formulation is about pH 7.

[0205] One embodiment of the present invention provides a method of treating SSc in a subject, the method comprising administering a bispecific anti-IL-4 / anti-IL-13 antibody or an antigen-binding fragment thereof, wherein the antibody is in a stable lyophilized antibody formulation, the lyophilized antibody formulation comprising: about 100 mg / mL of the bispecific antibody or an antigen-binding fragment thereof as described herein; about 10 mM of a buffer system, wherein the buffer system comprises about 3.7 mM of Tris buffer and about 6.3 mM of phosphate buffer; about 0.2% (w / v) polysorbate 80; about 5% (w / v) sucrose; and about 3% (w / v) mannitol; wherein the pH of the formulation is about pH 7.

[0206] In some embodiments, the antibodies of the invention can be conjugated to a variety of effector molecules, such as heterologous polypeptides, drugs, radiolabeled nucleotides, or toxins, see, e.g., WO 92 / 08495; WO 91 / 14438; WO 89 / 12624; U.S. Patent No. 5,314,995; and EPO 396,387. The antibody or fragment thereof can be conjugated to a therapeutic moiety such as a cytotoxin (e.g., a cell inhibitor or cytocidal agent), a therapeutic agent, or a radioactive metal ion (e.g., an α emitter such as 213Bi). Cytotoxins or cytotoxic agents include any agent that is detrimental to cells. Examples include paclitaxel, cytochalasin B, gramicidin D, ethidium bromide, emetine, mitomycin, etoposide, teniposide, vincristine, vinblastine, colchicine, doxorubicin, daunorubicin, dihydroxy anthracindione, mitoxantrone, mithramycin, actinomycin D, 1-dehydrotestosterone, glucocorticoids, procaine, tetracaine, lidocaine, propranolol, and puromycin and their analogs or homologs. Therapeutic agents include, but are not limited to, antimetabolites (e.g., methotrexate, 6-mercaptopurine, 6-thioguanine, cytarabine, 5-fluorouracil, and dacarbazine), alkylating agents (e.g., mechlorethamine, chlorambucil, melphalan, carmustine (BSNU) and lomustine (CCNU), cyclophosphamide, busulfan, dibromomannitol, streptozocin, mitomycin C, and cis-dichlorodiamine platinum (II) (DDP) cisplatin), anthracyclines (e.g., daunorubicin, doxorubicin, and idarubicin), antibiotics (e.g., actinomycin D, actinomycin, bleomycin, mithramycin, and anthramycin (AMC)), and antimitotic agents (e.g., vincristine and vinblastine).

[0207] Techniques for conjugating such therapeutic moieties to antibodies are well known, see, e.g., Arnon et al., Monoclonal Antibodies and Cancer Therapy; Reisfeld et al. (eds.), pp. 243-56, Alan R. Liss (1985); Hellstrom et al., Controlled Drug Delivery, 2nd ed.; Robinson et al. (eds.), pp. 623-53, Marcel Dekker (1987); Thorpe, Monoclonal Antibodies '84: Biological And Clinical Applications; Pinchera et al. (eds.), pp. 475-506 (1985); Monoclonal Antibodies For Cancer Detection and Therapy, Baldwin et al. (eds.), pp. 303-16, Academic Press (1985); and Thorpe et al., Immunol Rev 62:119 (1982). Alternatively, an antibody can be conjugated to a second antibody to form an antibody hetero-conjugate, such as a bispecific antibody, see, e.g., U.S. Patent No. 4,676,980.

[0208] The conjugates of the invention can be used to modify a given biological response and the therapeutic agent or drug moiety is not limited to classical chemotherapeutic agents. For example, the drug moiety can be a protein or polypeptide having the desired biological activity. Such proteins can include, for example, toxins such as abrin, ricin A, Pseudomonas exotoxin, or diphtheria toxin; proteins such as tumor necrosis factor, α-interferon, β-interferon, nerve growth factor, platelet-derived growth factor, tissue plasminogen activator; apoptotic agents such as TNF-α, TNF-β, AIM I (WO 97 / 33899), AIM II (WO 97 / 34911), Fas ligand (Takahashi et al., Int Immunol, 6:1567 (1994)), VEGF (WO 99 / 23105); thrombogenic agents; anti-angiogenic agents such as angiostatin or endostatin; or biological response modifiers such as lymphokines, interleukin-1 (IL-I), interleukin-2 (IL-2), interleukin-6 (IL-6), granulocyte macrophage colony stimulating factor (GM-CSF), granulocyte colony stimulating factor (GCSF) or other growth factors.

[0209] Formulations for in vivo administration must be sterile. This can be accomplished, for example, by filtration through sterile filtration membranes. For example, the liquid formulations of the invention can be sterilized by filtration using a 0.2 μm or 0.22 μm filter.

[0210] Treatment method

[0211] In some aspects, the present invention provides a method for treating SSc in a human subject suffering from SSc, the method comprising subcutaneously administering to the subject about 200 mg of a dual V-region bispecific antibody or antigen-binding fragment that specifically binds to IL-4 and IL-13 as described herein. In some embodiments, the SSc is diffuse cutaneous systemic sclerosis (dcSSc). In some embodiments, the SSc is limited cutaneous systemic sclerosis (lcSSc). In some embodiments, about 200 mg of the bispecific antibody is administered to the subject about once a week or about once every 5 to 9 days. In some embodiments, the bispecific antibody is administered once every 7±2 days (i.e., every 5-9 days). In some embodiments, the bispecific antibody is administered every other week (i.e., every two weeks). In some embodiments, the bispecific antibody is administered subcutaneously (SC). In some embodiments, the bispecific antibody is administered subcutaneously (SC) over a period of at least about 24 weeks.

[0212] In some embodiments, the bispecific antibody is in a pharmaceutical formulation. In some embodiments, the pharmaceutical formulation comprises about 100 mg / ml bispecific antibody, about 6.3 mM sodium dihydrogen phosphate, about 37 mM Tris, about 5% (w / v) sucrose, about 3% (w / v) proline, and about 0.2% (w / v) polysorbate 80, wherein the pH of the formulation is about 7.0. In some embodiments, the formulation is reconstituted from a lyophilized formulation.

[0213] In some embodiments of any of the treatment methods described herein, the bispecific antibody or bispecific antibody fragment thereof comprises a light chain polypeptide containing a light chain variable domain VL hB-B13 and a light chain variable domain VL hBD4-8 and a heavy chain polypeptide containing a heavy chain variable domain VH hB-B13 and a heavy chain variable domain VH hBD4-8 wherein: VL hB-B13 comprises three CDRs containing the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10); VL hBD4-8 comprises three CDRs containing the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16), VH hB-B13Comprising three CDRs containing the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13), VH hBD4-8 Comprising three CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18), and LKEYGNYDSFYFDV (SEQ ID NO:19). In some embodiments, VL hB-B13 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:1, VL hBD4-8 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:3, VH hB-B13 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:2, VH hBD4-8 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:4. In some embodiments, VL hB-B13 Comprising the amino acid sequence of SEQ ID NO:1, VL hBD4-8 Comprising the amino acid sequence of SEQ ID NO:3, VH hB-B13 Comprising the amino acid sequence of SEQ ID NO:2; VH hBD4-8 Comprising the amino acid sequence of SEQ ID NO:4. In some embodiments, the light chain polypeptide comprises the structure N-VL hB-B13 -linker-VL hBD4-8 -CL-C and the heavy chain polypeptide comprises the structure N-VH hB-B13 -linker-VH hBD4-8 -CH1-C. In some embodiments, the light chain comprises the structure N-VL hB-B13 -linker-VL hBD4-8 -CL-C and the heavy chain comprises the structure N-VH hB-B13 -linker-VH hBD4-8-CH1-CH2-CH3-C. In some embodiments, the linker comprises the amino acid sequence of SEQ ID NO:6. In some embodiments, the bispecific antibody or bispecific antibody fragment thereof comprises two identical light chain polypeptides and two identical heavy chain polypeptides. In some embodiments, the light chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:23. In some embodiments, the light chain polypeptide comprises the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises the amino acid sequence of SEQ ID NO:23. In some embodiments, the anti-IL4 / anti-IL13 bispecific antibody is RKB.

[0214] In some embodiments, the method of treating scleroderma with a specific antibody or bispecific antibody fragment thereof as described herein is additive with background therapy.

[0215] In some aspects, the present invention provides a method for reducing sclerotic plaques in a human subject with SSc, the method comprising administering to the subject an effective amount of an anti-IL4 / anti-IL13 bispecific antibody; wherein at any one of about 4, 8, 12, 24, 36, 48 weeks or greater than 48 weeks after the initial administration of the bispecific antibody, the sclerotic plaques are reduced by at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% compared to baseline. In some embodiments, at about 24 weeks after the initial administration of the bispecific antibody, the sclerotic plaques are reduced by at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% compared to baseline. In some embodiments, at about 12 weeks after the initial administration of the bispecific antibody, the sclerotic plaques are reduced by at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% compared to baseline. In some embodiments, at about 8 weeks after the initial administration of the bispecific antibody, the sclerotic plaques are reduced by at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% compared to baseline. In some embodiments, at about 4 weeks after the initial administration of the bispecific antibody, the sclerotic plaques are reduced by at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% compared to baseline. In some embodiments, the baseline is determined for a human subject with SSc prior to the therapeutic administration of the bispecific antibody. In some embodiments, the baseline is the level in a human subject without SSc. In some embodiments, a portion of the treated human subjects with SSC have at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% improvement in the modified Rodnan skin score (mRSS) compared to baseline at any one of about 4, 8, 12, 24, 36, 48 weeks or greater than 48 weeks after the initial administration of the bispecific antibody. In some embodiments, a portion of the treated human subjects with SSC have at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% improvement in the mRSS compared to baseline at about 24 weeks after the initial administration of the bispecific antibody. In some embodiments, a portion of the treated human subjects with SSC have at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% improvement in the mRSS compared to baseline at about 12 weeks after the initial administration of the bispecific antibody.In some embodiments, a portion of the treated human subjects with SSC have at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% improvement in mRSS compared to baseline at about 8 weeks after initial administration of the bispecific antibody. In some embodiments, a portion of the treated human subjects with SSC have at least about 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90% improvement in mRSS compared to baseline at about 4 weeks after initial administration of the bispecific antibody. mRSS is performed by palpating the skin in 17 regions of the body (fingers, hands, forearms, arms, feet, legs and thighs, face, chest and abdomen), using a 0 - 3 scale, where 0 = normal, 1 = mild thickness, 2 = moderate thickness and 3 = severe thickness. The total skin score can range from 0 (no thickening) to 51 (severe thickening in all 17 regions).

[0216] In some embodiments, the present invention provides a method for improving the Health Assessment Questionnaire Disability Index (HAQ - DI) in human subjects with scleroderma, the method comprising administering to the subject an effective amount of an anti - IL4 / anti - IL13 bispecific antibody; wherein the improvement in HAQ - DI is improved at any one of about 4, 8, 12, 24, 36, 45 weeks or greater than 45 weeks after initial administration of the bispecific antibody, compared to baseline. In some embodiments, HAQ - DI is measured by the Scleroderma Health Assessment Questionnaire (SHAQ). Patients complete the SHAQ at baseline and during treatment, which includes the standard HAQ - DI for measuring functional disability and 5 SSc - specific VAS assessments. The SHAQ is a standard, validated and accepted health assessment questionnaire for SSc patients to evaluate physical / functional disability related to skin and systemic fibrosis.

[0217] The HAQ-DI contains 8 activity domains (dressing, rising from a chair, eating, walking, hygiene, reaching, grasping, and ordinary daily activities), with at least 2 questions in each domain, for a total of 20 items. For each item, the patient reports the degree of difficulty experienced in performing the activity. Each item has 4 possible responses, ranging from 0 (no difficulty) to 3 (unable to perform). For each of the 8 domains included in the HAQ-DI, the score is the single highest response within the domain. If an aid or device was used and if the highest score is 0 or 1, the score is increased to 2; if the highest score is 2 or 3, the score remains as is. The HAQ-DI composite score is then calculated as the average of the scores for the 8 domains. If 1 or 2 domains are missing, the HAQ-DI composite score is obtained by dividing the sum of the domains by the number of domains answered. If three or more domains are missing, the HAQ-DI composite score is missing. The composite score is reported and falls between 0 and 3 on an ordinal scale. The score is interpreted as 0 (no functional impairment) to 3 (maximum functional impairment).

[0218] The HAQ-DI also contains a VAS that the patient uses to report the degree of pain experienced in the past week. The VAS is a 10-cm line that is converted to a continuous scale from 0 to 3, where 1 cm is equivalent to 0.3 points. The anchors of the VAS are 0 (no pain) to 100 (very severe pain). To obtain the patient score, a ruler is used to measure the distance (in centimeters) from the left anchor to the patient's mark, and then multiplied by 0.3. The VAS pain score is not included in the HAQ-DI composite score.

[0219] In some embodiments, the present invention provides a method for improving respiratory function in a human subject with SSc, the method comprising administering to the subject an effective amount of an anti-IL4 / anti-IL13 bispecific antibody; wherein improvement in respiratory function is measured by the predicted forced vital capacity (FVC) and / or the predicted diffusing capacity of the lung for carbon monoxide (DLco) compared to baseline at about 4, 8, 12, 24, 36, 48 weeks or more than 48 weeks after the initial administration of the bispecific antibody. In some embodiments, the baseline is determined for a human subject with SSc prior to the therapeutic administration of the bispecific antibody. In some embodiments, the baseline is the level in a human subject without SSc.

[0220] Pulmonary function tests are secondary endpoints that evaluate the change in respiratory function from baseline to the sampling time, as measured by the actual FVC and the actual DLco (corrected for hemoglobin). The absolute change in the actual values and the percent change in the predicted values of FVC and DLco from baseline to the sampling time are evaluated. Unless automatically corrected during the measurement process, the manual correction of DLco for hemoglobin is based on the following formula: 1) For male patients: DLco实测值 / (因子) , where the factor = (1.7 x Hb) / (10.22 + Hb); 2) For female patients: DLco 实测值 / (因子) , where the factor = (1.7 x Hb) / (9.38 + Hb). Hb refers to hemoglobin, and the value is taken from the same visit at which DLco is performed.

[0221] In some embodiments, the present invention provides methods for reducing pain, improving vascular function, improving gastrointestinal function, reducing Raynaud's phenomenon, and / or reducing digital ulcers in human subjects with SSc, the methods comprising administering to the subject an effective amount of an anti-IL4 / anti-IL13 bispecific antibody.

[0222] In some embodiments, improvement of gastrointestinal function is measured by the UCLA Scleroderma Clinical Trials Consortium Gastrointestinal 2.0 score compared to baseline at any one of about 4, 8, 12, 24, 36, 48 weeks or greater than 48 weeks after initial administration of the bispecific antibody. In some embodiments, the UCLA Scleroderma Clinical Trials Consortium Gastrointestinal 2.0 score at about 24 weeks after initial administration of the bispecific antibody is improved compared to baseline. The UCLA SCTC GIT 2.0 tool is a validated self-report questionnaire for assessing quality of life (QOL) related to gastrointestinal function in SSc patients (Khanna D. et al., Arthritis Rheum. 2009, 61:1257-63). It uses a 7-item Likert scale that has domains of reflux, bloating / flatulence, diarrhea, fecal soilage, constipation, emotional well-being, and social function.

[0223] In some embodiments, reduction of pain is measured by the change in the number of tender joints 28 (TJC28) at about 24 weeks after initial administration of the bispecific antibody. TJC28 is an assessment of overall joint pain based on examination of 28 key joints. It is a reliable and validated method for assessing general joint pain. The 28 joints that are part of the assessment include: shoulders (2 joints), elbows (2 joints), wrists (2 joints), metacarpophalangeal (10 joints), proximal interphalangeal (10 joints), and knees (2 joints).

[0224] In some embodiments, reduction of digital ulcers is measured by the number of digital ulcers at any one of about 4, 8, 12, 24, 36, 48, or greater than 48 weeks after initial administration of the bispecific antibody. In some embodiments, reduction of digital ulcers is measured by the number of digital ulcers at about 24 - 48 weeks after initial administration of the bispecific antibody. Digital ulcer counts capture the number of active sores (or digital ulcers) on the fingertips secondary to SSc (as opposed to secondary to local trauma or injury). In some embodiments, fissures, crevices, or even skin breaks related to calcinosis are excluded.

[0225] In some embodiments, the present invention provides a method for improving the Composite Response Index for Cutaneous Diffuse Systemic Sclerosis (CRISS) in a human subject with SSc, the method comprising administering to the subject an effective amount of an anti - IL4 / anti - IL13 bispecific antibody; wherein at any one of about 4, 8, 12, 24, 36, 48 weeks or greater than 48 weeks after initial administration of the bispecific antibody, the improvement in CRISS is improved compared to baseline. In some embodiments, at about 24 weeks after initial administration of the bispecific antibody, the improvement in CRISS is improved compared to baseline. The CRISS tool summarizes changes in clinical and patient - reported outcomes using a single composite score that reflects the probability of improvement in patients with dcSSc (Khanna D. et al., Arthritis Care Res. (Hoboken) 2016, 68(2):167 - 78). For an effective therapeutic agent for dcSSc, CRISS can summarize that the probability of improvement is higher in subjects treated with an anti - IL4 / anti - IL13 bispecific antibody (e.g., RKB) compared to an ineffective agent or background. CRISS is a two - step process as described below.

[0226] Step 1: Patients with new or worsening cardiopulmonary and / or renal involvement due to SSc are considered not to have improved (irrespective of improvement in other core items) and are assigned an improvement probability equal to 0.0. Specifically, if a subject develops any one of the following: new scleroderma renal crisis; a decline in FVC predicted % ≥ 15% (relative), confirmed by another FVC % within one month, high - resolution computed tomography (HRCT) - confirmed ILD (if previous HRCT of the chest did not show ILD) and FVC predicted % below 80% predicted; new onset of left ventricular failure requiring treatment (defined as left ventricular ejection fraction ≤ 45%); or new onset of PAH requiring treatment on right heart catheterization (attributable to SSc) (PAH is defined as mean pulmonary artery pressure ≥ 25 mm Hg at rest and pulmonary artery wedge pressure ≤ 15 mm Hg at end - expiration and pulmonary vascular resistance > 3 Wood units).

[0227] Step 2: For the remaining patients, Step 2 involves calculating the predicted probability of improvement (predicted probability from the formula derivation of the logistic regression model) for each subject using the following formula:

[0228]

[0229] where ΔmRSS indicates the change in mRSS from baseline, ΔFVC represents the change in FVC predicted value % from baseline, ΔPt-glob indicates the change in patient global assessment, ΔMD-glob represents the change in physician global assessment, and ΔHAQ-DI is the change in HAQ-DI. All changes are absolute changes (time 2 - time 基线 ).

[0230] The patient and physician global assessments of overall health status are used in the Step 2 calculation of CRISS. These two assessments are based on a Likert scale ranging from 0 (excellent) to 10 (very poor) (Khanna D. et al., Arthritis Care Res. 2016, 68(2):167 - 78).

[0231] In some embodiments, the present invention provides a method for improving the composite response index of the EuroQol five - dimension five - level (EQ - 5D - 5L) index in human subjects with scleroderma, the method comprising administering to the subject an effective amount of an anti - IL4 / anti - IL13 bispecific antibody; wherein at any one of about 4, 8, 12, 24, 36, 48 weeks or greater than 48 weeks after initial administration of the bispecific antibody, the improvement in EQ - 5D - 5L is improved compared to baseline. In some embodiments, at about 24 weeks after initial administration of the bispecific antibody, the improvement in EQ - 5D - 5L is improved compared to baseline. The EQ - 5D - 5L questionnaire is a standardized health status measure developed by the EuroQol Group to provide a simple, generic health measure for clinical and economic evaluation. The EQ - 5D - 5L is designed to be self - completed by patients.

[0232] The EQ-5D consists of two discrete measures: the EQ-5D descriptive system and the EQ VAS. The EQ-5D descriptive system has five items, each measuring one health dimension: mobility, self-care, usual activities, pain / discomfort, and anxiety / depression. Each dimension / item has a five-level Likert-type response scale: no problems, slight problems, moderate problems, severe problems, and extreme problems. The responses for the five dimensions can be combined into a single five-digit number that describes the health profile of the responder and can be converted into a single index value for calculating quality-adjusted life years (QALYs), thus informing the economic evaluation of healthcare interventions. The EQ VAS provides a quantitative measure of health as judged by an individual responder on a vertical visual analogue scale. The EQ VAS 'thermometer' has endpoints of 100 ("the best health you can imagine") at the top and 0 ("the worst health you can imagine") at the bottom.

[0233] Intracellular signal transduction following the ligation of IL-4 and IL-13 to their cell surface receptors is mediated by phosphorylation of the signal transducer and activator of transcription 6 (Stat6), a signaling molecule.

[0234] Chemokine (C-C motif) ligand 17 (CCL17) is a small cytokine belonging to the CC chemokine family. CCL17 is also known as thymus and activation-regulated chemokine (TARC). TARC is induced by phosphorylation by IL-4 and / or IL-13 (Wirnsberger et al., (2006) Eur J Immunol. 36:1882-91; Liddiard et al., (2006) BMC Mol Biol. 29:7:45; Monick et al., (2007) J Immunol. 179:1648-58). Thus, inhibition of IL-4 and / or IL-13-mediated signaling, for example by an IL-4 / IL-13-binding antibody-like protein, is associated with inhibition of TARC induction. In some embodiments, the methods disclosed herein include methods of detecting the binding of an antibody or antibody-like binding protein or fragment thereof that has been administered to a subject to IL-4 and / or IL-13, the method comprising (a) administering the antibody or antibody-like binding protein or fragment thereof to the subject; and (b) determining the amount of CCL17 / TARC in a blood, serum, or plasma sample drawn from the subject, wherein a decrease in the amount of CCL17 / TARC in the sample relative to a sample drawn from the subject prior to administration of the antibody or antibody-like binding protein or fragment thereof indicates binding of the antibody or antibody-like binding protein or fragment thereof to IL-4 and / or IL-13. In some embodiments, the subject is a human subject. In some embodiments, the antibody or antibody-like binding protein or fragment thereof is a dual V-region antibody-like binding protein or fragment thereof. In some embodiments, the dual V-region antibody-like binding protein or fragment thereof is specific for IL-4 or IL-13, or is bispecific for IL-4 and IL-13. In some embodiments, step (c) further comprises: increasing the dose if the decrease in TARC / CCL17 measured in step (b) is below a threshold (i.e., if the decrease in TARC / CCL17 levels is insufficient); or decreasing the dose if the decrease in TARC / CCL17 measured in step (b) is above a threshold (i.e., if the decrease in TARC / CCL17 is excessive). In some embodiments, the threshold of step (c) is a decrease of about 10%, or about 15%, or about 20%, or about 25%, or about 30%, or about 35%, or about 40%, or about 45%, or about 50%, or about 55%, or about 60%, or about 65% in the amount of TARC / CCL17 relative to the amount of TARC / CCL17 in the subject measured prior to administration of the dose.In some embodiments, the threshold is a reduction of about 20% to about 60%, or about 40% to about 50%, in the amount of TARC / CCL17 relative to the amount of TARC / CCL17 measured in the subject before administration of the dose. In some embodiments, the threshold is a 43% reduction in the amount of TARC / CCL17 relative to the amount of TARC / CCL17 measured in the subject before administration of the dose. For example, a 43% reduction for a 200 mg dose represents the binding of the 200 mg dose of the bispecific anti-IL-4 / IL-13 dual V region antibody-like binding protein to IL-4 / IL-13.

[0235] In some embodiments, protein biomarkers associated with disease activity (cartilage oligomeric matrix protein [COMP], chemokine C-C motif ligand 2 [CCL2]) and the IL-4 / IL-13 pathway (TARC, periostin, and eosinophil chemotactic factor-3) are measured to monitor treatment. In some embodiments, the presence of anti-drug antibodies (ADA) is used to monitor treatment.

[0236] In certain embodiments, the formulations of the invention can be administered in combination with one or more therapies (e.g., therapies other than the formulations of the invention that are currently being administered to prevent, treat, manage, and / or improve IL-4- and / or IL-13-mediated diseases (e.g., SSc)). The use of the term "combination" does not limit the order in which the therapies are administered to the subject. The first therapy can be administered before (e.g., 1 minute, 45 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks), simultaneously with, or after (e.g., 1 minute, 45 minutes, 30 minutes, 45 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks) the second therapy to a subject who has, has had, or is predisposed to an IL-4- and / or IL-13-mediated disease (e.g., SSc). In some embodiments, an anti-IL-4 / anti-IL13 antibody is administered in combination with a therapy for treating SSc. In some embodiments, an anti-IL-4 / anti-IL13 antibody is administered in combination with pirfenidone or nintedanib. Any additional therapy can be administered with other additional therapies in any order. Non-limiting examples of therapies that can be administered in combination with the antibodies of the invention include approved anti-inflammatory agents listed in the United States Pharmacopeia and / or the Physician's Desk Reference.

[0237] Exemplary embodiments

[0238] 1. A method for treating systemic sclerosis (SSc) in a human subject with SSc, the method comprising subcutaneously administering to the subject about 200 mg of a dual V-region bispecific antibody or antigen-binding fragment that specifically binds IL-4 and IL-13.

[0239] 2. The method according to embodiment 1, wherein 200 mg of the bispecific antibody is administered to the subject about once a week or about once every 5 to 9 days.

[0240] 3. The method according to embodiment 1 or 2, wherein the treatment is administered for at least about 24 weeks.

[0241] 4. The method according to any one of embodiments 1-3, wherein the bispecific antibody is in a pharmaceutical formulation.

[0242] 5. The method according to embodiment 4, wherein the pharmaceutical formulation comprises about 100 mg / ml bispecific antibody, about 6.3 mM sodium dihydrogen phosphate, about 37 mM Tris, about 5% (w / v) sucrose, about 3% (w / v) proline, and about 0.2% (w / v) polysorbate 80, wherein the pH of the formulation is about 7.0.

[0243] 6. The method according to embodiment 5, wherein the formulation is reconstituted from a lyophilized formulation.

[0244] 7. The method according to any one of embodiments 1-6, wherein the bispecific antibody is administered in combination with another agent.

[0245] 8. The method according to embodiment 7, wherein the another agent is administered before, simultaneously with, or after the bispecific antibody.

[0246] 9. The method according to any one of embodiments 1-8, wherein the systemic sclerosis is diffuse cutaneous systemic sclerosis.

[0247] 10. The method according to any one of embodiments 1-9, wherein the bispecific antibody or bispecific antibody fragment thereof comprises a light chain polypeptide containing light chain variable domain VL hB-B13 and light chain variable domain VL hBD4-8 and a heavy chain polypeptide containing heavy chain variable domain VH hB-B13 and heavy chain variable domain VH hBD4-8 ; wherein:

[0248] VL hB-B13Comprising three CDRs containing the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10);

[0249] VL hBD4-8 Comprising three CDRs containing the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16),

[0250] VH hB-B13 Comprising three CDRs containing the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13),

[0251] VH hBD4-8 Comprising three CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18), and LKEYGNYDSFYFDV (SEQ ID NO:19).

[0252] 11. The method according to embodiment 10, wherein:

[0253] VL hB-B13 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:1,

[0254] VL hBD4-8 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:3, VH hB-B13 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:2, VH hBD4-8 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:4.

[0255] 12. The method according to embodiment 10 or 11, wherein:

[0256] VL hB-B13 Comprising the amino acid sequence of SEQ ID NO:1,

[0257] VL hBD4-8 Comprising the amino acid sequence of SEQ ID NO:3,

[0258] VH hB-B13Comprising the amino acid sequence of SEQ ID NO:2,

[0259] VH hBD4-8 Comprising the amino acid sequence of SEQ ID NO:4.

[0260] 13. The method according to any one of embodiments 9-11, wherein the light chain polypeptide comprises the structure N-VL hB-B13 - linker - VL hBD4-8 - CL - C and the heavy chain polypeptide comprises the structure N-VH hB-B13 - linker - VH hBD4-8 - CH1 - C.

[0261] 14. The method according to any one of embodiments 10-13, wherein the light chain comprises the structure N-VL hB-B13 - linker - VL hBD4-8 - CL - C and the heavy chain comprises the structure N-VH hB-B13 - linker - VH hBD4-8 - CH1 - CH2 - CH3 - C.

[0262] 15. The method according to embodiment 13 or 14, wherein the linker comprises the amino acid sequence of SEQ ID NO:6.

[0263] 16. The method according to any one of embodiments 10-15, wherein the bispecific antibody or its bispecific antibody fragment comprises two identical light chain polypeptides and two identical heavy chain polypeptides.

[0264] 17. The method according to any one of embodiments 10-16, wherein the light chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:23.

[0265] 18. The method according to any one of embodiments 10-17, wherein the light chain polypeptide comprises the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises the amino acid sequence of SEQ ID NO:23.

[0266] 19. A method for reducing sclerotic plaques in a human subject suffering from SSc, the method comprising administering to the subject an effective amount of an anti-IL4 / anti-IL13 bispecific antibody; wherein at about 24 weeks after the initial administration of the bispecific antibody, the sclerotic plaques are reduced by at least about 20%, 40%, 60%, 80% or 100% compared to the baseline.

[0267] 20. The method according to embodiment 19, wherein a portion of the treated human subject with SSC has an improved modified Rodnan skin score (mRSS) of at least about 20%, 40%, and 60% compared to baseline at about 24 weeks after initial administration of the bispecific antibody.

[0268] 21. The method according to embodiment 20, wherein the improved mRSS is measured as the least squares mean change from baseline.

[0269] 22. The method according to embodiment 20 or 21, wherein the least squares mean change from baseline exceeds any one of about -3.00, -3.5, -4.0, -4.5, -5.0, -5.5, or -6.0.

[0270] 23. The method according to any one of embodiments 19-22, wherein the anti-IL4 / anti-IL13 antibody is RKB.

[0271] 24. The method according to any one of embodiments 19-23, wherein about 200 mg of the anti-IL4 / anti-IL13 antibody is administered subcutaneously to the subject.

[0272] 25. The method according to embodiment 24, wherein 200 mg of the bispecific antibody is administered to the subject, about once a week or about once every 5 to 9 days.

[0273] 26. The method according to embodiment 24 or 25, wherein the treatment is administered for at least about 24 weeks.

[0274] 27. The method according to any one of embodiments 19-26, wherein the bispecific antibody is in a pharmaceutical formulation.

[0275] 28. The method according to embodiment 27, wherein the pharmaceutical formulation comprises about 100 mg / ml bispecific antibody, about 6.3 mM sodium dihydrogen phosphate, about 37 mM Tris, about 5% (w / v) sucrose, about 3% (w / v) proline, and about 0.2% (w / v) polysorbate 80, wherein the pH of the formulation is about 7.0.

[0276] 29. The method according to embodiment 27, wherein the formulation is reconstituted from a lyophilized formulation.

[0277] 30. The method according to any one of embodiments 19-29, wherein the bispecific antibody is administered in combination with another agent.

[0278] 31. The method according to embodiment 30, wherein the other agent is administered before, simultaneously with, or after the bispecific antibody.

[0279] 32. The method according to any one of embodiments 19 - 31, wherein the systemic sclerosis is diffuse cutaneous systemic sclerosis.

[0280] 33. The method according to any one of embodiments 19 - 32, wherein the bispecific antibody or a bispecific antibody fragment thereof comprises a light chain polypeptide comprising a light chain variable domain VL hB-B13 and a light chain variable domain VL hBD4-8 and a heavy chain polypeptide comprising a heavy chain variable domain VH hB-B13 and a heavy chain variable domain VH hBD4-8 ; wherein:

[0281] VL hB-B13 comprises three CDRs comprising the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10);

[0282] VL hBD4-8 comprises three CDRs comprising the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16),

[0283] VH hB-B13 comprises three CDRs comprising the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13),

[0284] VH hBD4-8 comprises three CDRs comprising the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18), and LKEYGNYDSFYFDV (SEQ ID NO:19).

[0285] 34. The method according to embodiment 33, wherein:

[0286] VL hB-B13 comprises an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:1,

[0287] VL hBD4-8Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:3, VH hB-B13 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:2, VH hBD4-8 Comprising an amino acid sequence that is at least 95% identical to the amino acid sequence of SEQ ID NO:4.

[0288] 35. The method according to embodiment 32 or 33, wherein:

[0289] VL hB-B13 Comprising the amino acid sequence of SEQ ID NO:1,

[0290] VL hBD4-8 Comprising the amino acid sequence of SEQ ID NO:3,

[0291] VH hB-B13 Comprising the amino acid sequence of SEQ ID NO:2,

[0292] VH hBD4-8 Comprising the amino acid sequence of SEQ ID NO:4.

[0293] 36. The method according to any one of embodiments 33 - 35, wherein the light chain polypeptide comprises the structure N-VL hB-B13 - linker - VL hBD4-8 - CL - C and the heavy chain polypeptide comprises the structure N-VH hB-B13 - linker - VH hBD4-8 - CH1 - C.

[0294] 37. The method according to any one of embodiments 33 - 36, wherein the light chain comprises the structure N-VL hB-B13 - linker - VL hBD4-8 - CL - C and the heavy chain comprises the structure N-VH hB-B13 - linker - VH hBD4-8 - CH1 - CH2 - CH3 - C.

[0295] 38. The method according to embodiment 36 or 37, wherein the linker comprises the amino acid sequence of SEQ ID NO:6.

[0296] 39. The method according to any one of embodiments 33 - 38, wherein the bispecific antibody or its bispecific antibody fragment comprises two identical light chain polypeptides and two identical heavy chain polypeptides.

[0297] 40. The method according to any one of embodiments 33-39, wherein the light chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises an amino acid sequence having at least about 90% identity to the amino acid sequence of SEQ ID NO:23.

[0298] 41. The method according to any one of embodiments 33-40, wherein the light chain polypeptide comprises the amino acid sequence of SEQ ID NO:22 and the heavy chain polypeptide comprises the amino acid sequence of SEQ ID NO:23.

[0299] Examples

[0300] The following examples illustrate specific embodiments of the present disclosure and their various uses. The examples are stated for illustrative purposes only and should not be regarded as limiting the scope of the invention in any way.

[0301] Example 1: Efficacy and safety of the humanized anti-IL-4 / IL-13 bispecific antibody RKB in treating subjects with diffuse systemic sclerosis.

[0302] In a Phase 2 study (NCT02921971), the efficacy of RKB on skin fibrosis in subjects with diffuse cutaneous systemic sclerosis (dcSSc) was evaluated compared to placebo when administered subcutaneously for 24 weeks.

[0303] Method

[0304] A multinational, randomized, double-blind, placebo-controlled, 2-parallel-group proof-of-concept Phase 2 study investigated the efficacy and safety of 200 mg of RKB administered subcutaneously once a week over a 24-week period in subjects with diffuse SSc. Approximately 94 patients were randomized 1:1 to the following two treatment groups: 1) the RKB group (N = 47), which received 200 mg of subcutaneously administered RKB weekly; and 2) the placebo group (N = 47), which received a subcutaneously administered placebo weekly. Randomization was stratified based on the patient's history of SSc interstitial lung disease (SSc-ILD; yes or no). The study design is as Figure 2 shown.

[0305] Study population

[0306] Before randomization into the groups, subjects were screened within 28 days (D-28, Figure 2 ) prior to Day 1 to assess their eligibility to enter the study.

[0307] Inclusion criteria for eligible subjects were: Systemic sclerosis according to the ACR / EULAR 2013 criteria (van den Hoogen F. et al., Ann. Rheum. Dis. 2013, 72(11): 1747-55); and the diffuse cutaneous form of SSc according to the Leroy criteria.

[0308] Exclusion criteria included: age < 18 years; disease duration > 36 months from the time of the first non-Raynaud's phenomenon manifestation; modified Rodnan skin score (mRSS) < 10 or > 35 at screening and baseline visits; history of vasculitis (active or in remission); diagnosis of connective tissue disease (other than SSc) or overlap syndrome (e.g., polymyositis / SSc); positive human immunodeficiency virus (HIV) serology or known history of HIV infection (active or in remission); abnormal hepatitis B and / or C tests indicating active or chronic infection; positive or two confirmed indeterminate QuantiFERON-TB Gold tests at screening (irrespective of prior treatment status); severe infection within 4 weeks of screening (e.g., pneumonia, pyelonephritis), infection requiring hospitalization or intravenous antibiotics within 4 weeks of screening, or chronic bacterial infection (e.g., osteomyelitis); history of allergic reaction to any biotherapy; any clinically significant, severe, or unstable, acute, or chronic progressive, uncontrolled infection or medical condition (e.g., brain, heart, lung, kidney, liver, gastrointestinal, or neurological conditions other than SSc or SSc-ILD) or prior, active, or impending surgical disorder, or signs of any condition that may, in the judgment of the investigator, affect patient safety; at screening, forced vital capacity (FVC) predicted value % ≤ 75% and hemoglobin-corrected diffusing capacity of the lung for carbon monoxide (DLCO) predicted value % ≤ 40%; history of heart failure (including acute decompensation in the context of normal ejection fraction), left ventricular ejection fraction (LVEF) ≤ 45%, coronary artery disease, angina, myocardial infarction, ischemic cardiomyopathy, and / or hypertrophic cardiomyopathy; any prior history of malignancy or active malignancy within 5 years prior to baseline, including lymphoproliferative diseases (except for successfully treated cervical carcinoma in situ, non-metastatic squamous cell carcinoma of the skin, or basal cell carcinoma); ischemic ECG changes at screening (except those not supported by findings from left heart catheterization performed within the last year of screening) and / or other clinically significant ECG findings (including but not limited to second-degree heart block, third-degree heart block, QT prolongation (symptomatic), sick sinus syndrome, left bundle branch block (complete), right bundle branch block (complete), atrial fibrillation (uncontrolled), atrial flutter (uncontrolled), Wolff-Parkinson-White syndrome, atrioventricular nodal reentrant tachycardia, and ventricular arrhythmias (including ventricular tachycardia, ventricular fibrillation, torsades de pointes, and bradyarrhythmias)); high-dose steroids (> 10 mg / day prednisone or equivalent) or change in steroid dose within 4 weeks prior to randomization (or baseline visit), or expected change during the course of the study; prior treatment with rutixumab within 12 months prior to screening;Prior treatment with bone marrow transplantation, total lymphoid irradiation, or ablative high-dose cyclophosphamide; treatment with high-dose immunosuppressive drugs (e.g., cyclophosphamide >1 mg / kg orally / day or >750 mg intravenously / month; azathioprine >100 mg / day; methotrexate >15 mg / week; mycophenolate mofetil >2 g / day) within three months of screening, or dose changes within 4 weeks before randomization (or baseline visit), or anticipated dose changes during the course of the study; treatment with etanercept, cyclosporine A, intravenous immunoglobulin (IVIG), sirolimus, D-penicillamine, tyrosine kinase inhibitors within 4 weeks of screening, or treatment with antithymocyte globulin within 6 months of screening; treatment with infliximab, certolizumab, golimumab, abatacept, or adalimumab, tocilizumab within 8 weeks of screening, or treatment with anakinra within 1 week of screening; treatment with any study drug within one month or 5 half-lives (if known) (whichever is longer) of screening; one or more abnormal laboratory tests at screening from any of the following: alanine aminotransferase (ALT) or aspartate aminotransferase (AST) >2 times the upper limit of normal (ULN), hemoglobin <11 g / 100 mL for males and hemoglobin <10 g / 100 mL for females, neutrophils <1500 cells / mm 3 (except for <1000 cells / mm for African Americans 3 ), platelets <100,000 cells / mm 3 , C-reactive protein ≥150 μmol / L; current history of substance and / or alcohol abuse; pregnant or lactating women; and women of childbearing potential who are not protected by one or more highly effective contraceptive methods of birth control and / or are unwilling or unable to undergo a pregnancy test.

[0309] Dose regimen

[0310] After the screening period, on Day 1 (D1, Figure 2 ), each eligible subject will be randomly assigned to receive one of the following two arms: (1) 200 mg RKB administered subcutaneously once weekly (qw); and (2) placebo administered subcutaneously once weekly (qw) Figure 2) Treatment with RKB or placebo was initiated at D1 and the treatment duration was 24 weeks. The study included 8 in-person visits and 5 phone calls. Visit 1 for screening was between D-28 and D-1; Visit 2 for baseline measurement was at D1, where the subjects received the first dose; Visits 3 - 6 were at week 2, week 4, week 8, and week 12 of the treatment period; Visit 7 was during the last week of dosing (week 24); and Visit 8 was the end of the study visit for follow-up at week 35. During the in-person visits, RKB or placebo was administered after the clinical procedures and blood collection. For safety considerations, the subjects were called at week 6, week 16, week 18, and week 20 during the treatment period and at week 30 during the follow-up period. A follow-up period ( Figure 2 ) was implemented after dosing to evaluate adverse events (AEs) and pharmacokinetic analysis.

[0311] For C 谷 Population PK methods were used to estimate the pharmacokinetic parameters.

[0312] Formulation and route of administration

[0313] A 100 mg / mL RKB injection solution was prepared from RKB provided as a sterile lyophilized powder in glass vials. Each vial was filled with 125 mg of lyophilized RKB dry powder, and the final injection solution was obtained by reconstituting the entire vial contents with 1.1 mL of sterile water for injection, such that the 125 mg amount of RKB API was in a total volume of 1.25 mL, equivalent to a RKB solution with a concentration of 100 mg / mL. Then 1 mL of this 100 mg / mL RKB solution was withdrawn for dose administration. Thus, two drug vials were required to achieve a 200 mg dose and prepare a 2 mL RKB solution syringe.

[0314] For the placebo formulation, the vial containing the excipient was reconstituted with 1.1 mL of sterile water to a total volume of 1.25 mL. Two placebo product vials were required, and 1 mL was withdrawn from each vial to prepare a 2 mL placebo solution syringe.

[0315] The route of administration was subcutaneous administration in the abdomen. The subcutaneous injection sites were alternated among the four quadrants of the abdomen (avoiding the umbilical and lumbar regions) such that the same site was not injected for two consecutive weeks. The site was preferably not affected by SSc.

[0316] Starting from the initial administration, RKB or placebo was administered every 7 days ± 2 days. This window was allowed according to the protocol to accommodate various situations (e.g., pending laboratory results, management of adverse events, difficult visit scheduling).

[0317] Efficacy endpoint

[0318] The primary efficacy endpoint for evaluating the efficacy of RKB on skin fibrosis in patients with dcSSc is to assess the change in the modified Rodnan skin score (mRSS) from baseline to week 24. The two secondary endpoints for evaluating the efficacy of RKB on other aspects of dcSSc are: 1) the change in HAQ-DI as assessed by SHAQ from baseline to week 24; and 2) the change in respiratory function as measured by the actual values of FVC and DLco (corrected for hemoglobin) from baseline to week 24. Exploratory endpoints will include: the change in pain, respiratory function, vascular function (Raynaud's phenomenon), gastrointestinal function, digital ulcers, and overall assessment from SHAQ in the Visual Analogue Scale (VAS) from baseline to week 24; the change in respiratory function as measured by the predicted values of FVC% and DLco% (corrected for hemoglobin) from baseline to week 24; the change in the UCLA Scleroderma Clinical Trials Consortium Gastrointestinal 2.0 (UCLASCTC GIT 2.0) score from baseline to week 24; the change in TJC28 from baseline to week 24; the change in digital ulcer count from baseline to week 24; the CRISS from baseline to week 24; the change in the EQ-5D-5L index from baseline to week 24; the change in the efficacy endpoints (mRSS, HAQ-DI, VAS from SHAQ, actual value of FVC, predicted value of FVC%, actual value of DLco [corrected for hemoglobin], predicted value of DLco% [corrected for hemoglobin], UCLA SCTC GIT 2.0, TJC28, digital ulcer count, CRISS, and EQ-5D-5L) from baseline to week 35 (until the end of the follow-up period) and the proportion of patients with at least 20%, 40%, and 60% improvement in mRSS from baseline to week 35; and the proportion of patients with improvement in SHAQ (HAS-DI and VAS) and EQ-5D-5L (index value and VAS) based on the MIC at week 24.

[0319] Modified Rodnan skin score

[0320] Skin fibrosis is evaluated using the mRSS, which is performed by palpating the skin in 17 regions of the body (fingers, hands, forearms, arms, feet, legs, and thighs, face, chest, and abdomen) using a 0-3 scale, where 0 = normal, 1 = mild thickness, 2 = moderate thickness, and 3 = severe thickness. The total skin score can range from 0 (no thickening) to 51 (severe thickening in all 17 regions). Only those physicians or qualified medical staff who have received standardized training are permitted to evaluate skin thickening. Efforts are made by the same medical staff to evaluate a given patient participating from baseline to EOS in order to minimize any differences between raters. The baseline and week 24 / visit 7 mRSS assessments must be performed by the same medical staff.

[0321] Respiratory function

[0322] Pulmonary function testing is a secondary endpoint, which will evaluate the change in respiratory function from baseline to week 24, as measured by the actual values of FVC and DLco (corrected for hemoglobin). The absolute change in the actual values and the % change from the predicted values of FVC and DLco from baseline to week 24 and / or week 35 are evaluated as exploratory endpoints. Manual correction of DLco for hemoglobin is based on the following formula unless automatically corrected during measurement: 1) For male patients: DLco 实测值 / (factor), where factor = (1.7x Hb) / (10.22 + Hb); 2) For female patients: DLco 实测值 / (factor), where factor = (1.7xHb) / (9.38 + Hb). Hb refers to hemoglobin, and the value is taken from the same visit at which DLco is performed. Spirometry is performed according to the 2005 ATS / ERS guidelines (Miller M.R. et al., Eur. Respir. J. 2005, 26:319 - 38), and DLco is performed according to the standard guidelines (MacIntyre N. et al., Eur. Respir. J. 2005, 26:720 - 35).

[0323] Gastrointestinal manifestations

[0324] The UCLA SCTC GIT 2.0 tool is a validated self - report questionnaire used to evaluate the quality of life (QOL) related to gastrointestinal function in SSc patients (Khanna D. et al., Arthritis Rheum. 2009, 61:1257 - 63). It uses a 7 - item Likert scale with domains of reflux, bloating / flatulence, diarrhea, fecal incontinence, constipation, emotional well - being, and social function. This is captured at all visits except visit 1 and visit 3.

[0325] Renal function

[0326] Renal function is evaluated by measuring blood urea nitrogen, creatinine, and urine analysis (dipstick) at all visits except V3. Urine analysis (dipstick) captures specific gravity, pH, glucose, ketones, blood, protein, nitrates, leukocyte esterase, urobilinogen, and bilirubin. If any parameter on the dipstick is abnormal, the urine sample is sent to the central laboratory for testing. If the dipstick is positive for protein and / or red blood cells, microscopic analysis is performed by the central laboratory.

[0327] Cardiac manifestations

[0328] Systemic sclerosis associated with cardiac manifestations was evaluated by physical examination and ECG. ECG is an established method for monitoring cardiac conduction and potential coronary heart disease and cardiomyopathy. Electrocardiograms were captured at all scheduled visits except visit 3. Cardiovascular events were reported as adverse events.

[0329] Assessment of joint pain

[0330] TJC28 is an assessment of overall joint pain based on examination of 28 key joints. It is a reliable and validated method for assessing general joint pain and was captured at all visits except visit 1 and visit 3. The 28 joints included as part of the assessment are: shoulders (2 joints), elbows (2 joints), wrists (2 joints), metacarpophalangeal (10 joints), proximal interphalangeal (10 joints), and knees (2 joints).

[0331] Digital ulcer count

[0332] The digital ulcer count captures the number of active sores (or digital ulcers) on the fingertips secondary to SSc (not secondary to local trauma or injury). Fissures, cracks, or even skin breaks related to calcinosis are not included. The digital ulcer count was performed at all visits except visit 1 and visit 3.

[0333] Scleroderma Health Assessment Questionnaire

[0334] Patients completed the SHAQ at baseline and throughout the study (except visit 1 and visit 3), which includes the standard HAQ-DI for measuring functional disability and 5 SSc-specific VAS assessments (Steen V.D. and Medsger T.A., Arthritis Rheum. 1997, 40:1984 - 91). The SHAQ is a standard, validated, and recognized health assessment questionnaire for SSc patients to assess physical / functional disability related to skin and systemic fibrosis.

[0335] The HAQ-DI contains 8 activity domains (dressing, rising from a chair, eating, walking, hygiene, reaching, grasping, and ordinary daily activities), with at least 2 questions in each domain, for a total of 20 items. For each item, the patient reports the level of difficulty experienced in performing the activity. Each item has 4 possible responses, ranging from 0 (no difficulty) to 3 (unable to perform). For each of the 8 domains included in the HAQ-DI, the score is the single highest response within the domain. If an aid or device was used and if the highest score is 0 or 1, the score is increased to 2; if the highest score is 2 or 3, the score remains as it is. The HAQ-DI composite score is then calculated as the average of the scores for the 8 domains. If 1 or 2 domains are missing, the HAQ-DI composite score is obtained by dividing the sum of the domains by the number of domains answered. If 3 or more domains are missing, the HAQ-DI composite score is missing. The composite score is reported and falls between 0 and 3 on an ordinal scale. The score is interpreted as 0 (no functional impairment) to 3 (maximum functional impairment).

[0336] The HAQ-DI also contains a VAS that the patient uses to report the level of pain experienced in the past week. The VAS is a 10-cm line that is converted to a continuous scale from 0 to 3, where 1 cm is equivalent to 0.3 points. The anchors of the VAS are 0 (no pain) to 100 (very severe pain). To obtain the patient score, a ruler is used to measure the distance (in centimeters) from the left anchor to the patient's mark, and then multiplied by 0.3. The VAS pain score is not included in the HAQ-DI composite score.

[0337] For the other 5 VASs, the patient rates respiration, vascular (Raynaud's phenomenon), gastrointestinal function, digital ulcers, and overall assessment. The patient is asked to make a mark on a 10-cm line to indicate the severity from 0 to 100, where 0 indicates no severity and 100 indicates the worst severity.

[0338] EuroQol-5D-5L

[0339] The EQ-5D-5L questionnaire is a standardized health status measure developed by the EuroQol Group to provide a simple, generic health measure for clinical and economic evaluation. The EQ-5D-5L is designed to be self-completed by the patient.

[0340] The EQ-5D includes two discrete scales: the EQ-5D descriptive system and the EQ VAS. The EQ-5D descriptive system has five items, each measuring a health dimension: mobility, self-care, usual activities, pain / discomfort, and anxiety / depression. Each dimension / item has a five-level Likert-type response scale: no problems, slight problems, moderate problems, severe problems, and extreme problems. The responses for the five dimensions can be combined into a single five-digit number that describes the responder's health profile and can be converted into a single index value for calculating quality-adjusted life years (QALYs), thus informing the economic evaluation of healthcare interventions. The EQ VAS provides a quantitative measure of health as judged by an individual responder on a vertical visual analogue scale. The EQ VAS 'thermometer' has endpoints of 100 ("the best health you can imagine") at the top and 0 ("the worst health you can imagine") at the bottom.

[0341] In the analysis, the index value was considered a continuous variable.

[0342] Composite Response Index in Diffuse Cutaneous Systemic Sclerosis

[0343] The CRISS tool summarizes changes in clinical and patient-reported outcomes using a single composite score that reflects the probability of improvement in patients with dcSSc (Khanna D. et al., Arthritis Care Res. (Hoboken) 2016, 68(2):167-78). For an effective treatment agent for dcSSc, CRISS will be able to summarize that the probability of improvement is higher in subjects treated with RKB compared to an ineffective agent such as a placebo. CRISS is a two-step process described below.

[0344] Step 1: Patients with new or worsening cardiopulmonary and / or renal involvement due to SSc are considered not to have improved (irrespective of improvement in other core items) and are assigned an improvement probability equal to 0.0. Specifically, if a subject develops any of the following: new scleroderma renal crisis; a decline in predicted FVC% ≥ 15% (relative), confirmed by another FVC% within one month, high-resolution computed tomography (HRCT) confirms ILD (if previous HRCT of the chest did not show ILD) and predicted FVC% is below 80% predicted; new onset of left ventricular failure requiring treatment (defined as left ventricular ejection fraction ≤ 45%); or new onset of PAH requiring treatment on right heart catheterization (attributable to SSc) (PAH is defined as mean pulmonary artery pressure ≥ 25 mm Hg at rest and pulmonary artery wedge pressure ≤ 15 mm Hg at end-expiration and pulmonary vascular resistance > 3 Wood units).

[0345] Step 2: For the remaining patients, Step 2 involves calculating the predicted probability of improvement (predicted probability from the formula derivation of the logistic regression model) for each subject using the following formula:

[0346]

[0347] where ΔmRSS indicates the change in mRSS from baseline, ΔFVC represents the change in predicted FVC% from baseline, ΔPt-glob indicates the change in the patient global assessment, ΔMD-glob represents the change in the physician global assessment, and ΔHAQ-DI is the change in HAQ-DI. All changes are absolute changes (time 2 - time 基线 ).

[0348] The patient and physician global assessments of overall health status were used in the Step 2 calculations of CRISS. These two assessments were based on a Likert scale ranging from 0 (excellent) to 10 (very poor) (Khanna D. et al., Arthritis Care Res. 2016, 68(2):167 - 78).

[0349] Statistics

[0350] Primary efficacy analysis

[0351] The change in mRSS from baseline to week 24 in the ITT population was analyzed using the MMRM method. All post - baseline data available from the analysis window from week 4 to week 24 were included in the analysis regardless of treatment adherence. The model included fixed categorical effects for treatment group (placebo, RKB), randomization stratum (according to IRT, SSc - ILD: yes / no), time points (week 4, week 8, week 12, week 24), randomization stratum - time point interaction and treatment - time point interaction, and continuous fixed covariates for baseline mRSS value and baseline value - time point interaction.

[0352] Results

[0353] Study patients

[0354] A total of 143 patients were screened, resulting in the randomization of 97 patients: 49 patients in the placebo group and 48 patients in the SAR15697 group. All randomized patients were exposed to the investigational medicinal product (IMP), which resulted in all 97 patients being included in the safety population. All 97 patients were included in the ITT population (Table 1).

[0355] Table 1. Summary of key analysis populations

[0356] Placebo qw RKB 200mg qw All Randomized population 49(100) 48(100) 97(100) Safety population 49 48 97 Intention-to-treat population (ITT) 49 48 97

[0357] Note: In the safety population, list the patients according to the actual treatment received (if treated). For other populations, list the patients according to their randomized treatment. Define intention-to-treat as all randomized patients. Analyze the patients in the ITT population according to the treatment group assigned by randomization.

[0358] Patient Disposition

[0359] Table 2 - Patient Disposition at End of Treatment - Randomized Population

[0360]

[0361] Note: Percentages are calculated using the number of randomized patients as the denominator for demographic and baseline characteristics

[0362] Between the two treatment groups, the overall demographics and patient characteristics at baseline were similar, but patients in the RKB group were slightly older (Table 3).

[0363] Table 3. Demographics and Patient Characteristics at Baseline - Randomized Population.

[0364]

[0365]

[0366] a If a subject chooses not to report their race / ethnicity or if the collection of such information is restricted by country, it should be entered as not reported.

[0367] b The subject is unaware of their ethnicity / race

[0368] Between the two treatment groups, the overall disease characteristics and medical history at baseline were similar, but compared to the placebo group, the mean disease duration from the time of first non-Raynaud's phenomenon was slightly shorter in the RKB group, and FVC and DLco at baseline were slightly higher (Table 4).

[0369] Table 4. SSc History and Related Baseline Characteristics - Randomized Population

[0370]

[0371] MedDRA - 21.1

[0372] Note: Patients can be counted in several categories of SSc history

[0373] If the date of the day of non-Raynaud's phenomenon manifestation is missing, enter the date as the first day of the month;

[0374] If the month is missing, the first January input date will be used

[0375] Describes the baseline data, i.e., the date and time before or equal to the date and time of the first double-blind IMP administration

[0376] (or the date and time before or equal to the date and time of randomization when the patient was randomized and untreated) of the last available value

[0377] Twenty-nine patients (59.2%) in the placebo group and twenty-five patients (52.1%) in the RKB group received background therapy within the 3 months before baseline and during the course of the study (Table 5).

[0378] Table 5. Previous and concurrent background therapies within 3 months before baseline - randomized population

[0379]

[0380] ATC: Anatomical Therapeutic Chemicals, IMP: Investigational Medicinal Product

[0381] WHO-DDE 2018 MARCH 1

[0382] Note: Drugs can be counted in several ATC categories

[0383] Previous and concurrent drugs are those that the subject took within 3 months before the first IMP intake and continued to take during the TEAE period

[0384] In the entire treatment group, anatomical classes were sorted by decreasing frequency

[0385] Within each anatomical class, standardized drug names were sorted by decreasing frequency in the overall treatment group

[0386] Patients receiving background therapy were defined as all patients who took drugs from the following list before and at baseline: methotrexate, single-component and multi-component, mycophenolate mofetil, single-component and multi-component, azathioprine, single-component and multi-component, cyclosporine, single-component and multi-component, or cyclophosphamide, single-component and multi-component

[0387] Based on examination of the patient history, 10 patients (10.3%) were misclassified in the IVRS (Table 6). More specifically, 6 patients who were stratified in the IVRS as having SSc-ILD did not have a history of SSc-ILD recorded in the clinical database, while 4 patients who were not stratified in the IVRS as having SSc-ILD did have a history of SSc-ILD recorded in the clinical database

[0388] Table 6. Summary - Randomized Populations of Patients with Stratification Factor Differences between Clinical and IVRS Databases

[0389]

[0390]

[0391] SSC - ILD: SSc - interstitial lung disease

[0392] a : According to IVRS

[0393] b : According to the clinical database

[0394] The historical antibody profiles (Table 7) were relatively evenly distributed between the two treatment groups and this could be indirectly confirmed by looking at the ANA staining patterns obtained at baseline (Table 8), particularly for the centromere - positive group.

[0395] Table 7. Descriptive Summary Table of Specific Systemic Sclerosis Autoantibodies at Baseline - Randomized Population.

[0396]

[0397] Note: Percentages are calculated using the number of randomized patients as the denominator

[0398] Table 8. Descriptive Summary Table of ANA and ANAPATT at Baseline - Randomized Population

[0399]

[0400]

[0401] Table 9. Summary of Exposure - Safety Population

[0402]

[0403]

[0404] IMP: Investigational Medicinal Product Note: Patients are considered in the treatment group they actually received (as treated)

[0405] The duration of IMP injection exposure (in weeks) is defined as:

[0406] For patients with a filled - in treatment page at the end, (last dose date + 7 - date of first dose) / 7, regardless of intermittent discontinuation;

[0407] Otherwise, ((min(Database extraction date, end date of the 24th week planned treatment visit (day 169)) - date of first IMP injection) / 7

[0408] Efficacy

[0409] Primary efficacy endpoint

[0410] Primary analysis

[0411] As shown in Table 10 and Figure 3 as indicated below, there was a significant difference between the RKB group and placebo. For the placebo group and the RKB group, the mean change in mRSS from baseline at week 24 was -2.45 (0.85) and -4.76 (0.86), respectively, resulting in a reduction of 2.31 (1.21), where the associated one-sided p-value = 0.0291.

[0412] Table 10. Absolute change in mRSS from baseline to week 24 - MMRM - ITT population

[0413]

[0414] Note: CI: Confidence interval; MMRM: Mixed model for repeated measures; mRSS: Modified Rodnan skin score; LS mean: Least squares mean calculated using the mixed model; SE: Standard error; EOT: End of treatment;

[0415] a The LS mean, SE, and p-value were estimated by MMRM analysis. The model included fixed categorical effects for treatment group, randomization strata according to IVRS, time points, treatment - time point and stratum - time point interactions, and continuous fixed effects for baseline and baseline - time point interactions.

[0416] For patients with baseline and post - baseline values, the model and data description (based on observed data) were run in at least one analysis window

[0417] Subgroup analysis

[0418] Subgroup analyses were performed based on randomization strata and background therapy.

[0419] When stratifying the data based on SSc - ILD history examination according to IVRS (Table 11), for the placebo group and the RKB group, for those without a history of SSc - ILD, the mean change in mRSS from baseline at week 24 was -1.48 (1.09) and -4.09 (1.08), respectively. For those with a history of SSc - ILD, the mean change in mRSS from baseline at week 24 was -4.08 (1.41) and -5.82 (1.42), respectively. The mean differences between the strata were not significant.

[0420] Table 11

[0421]

[0422] Note: CI: Confidence Interval; MMRM: Mixed Model for Repeated Measures; mRSS: Modified Rodnan Skin Score; SSc: Systemic Sclerosis; ILD: Interstitial Lung Disease; LS Mean: Least Squares Mean calculated using the mixed model; EOT: End of Treatment; SE:

[0423] Standard Error;

[0424] a The LS Mean, SE, and p-value were estimated by MMRM analysis. The model included fixed categorical effects for treatment groups, randomization strata according to the IVRS, time points, treatment-time point and stratum-time point interactions, and continuous fixed effects for baseline and baseline-time point interactions.

[0425] In at least one analysis window, the model and data description (based on observed data) were run for patients with baseline and post-baseline values. The randomization strata were selected according to the IVRS.

[0426] In the subgroup analysis by background therapy (Table 12), for the placebo group and the RKB group, for those without background therapy, the mean change in mRSS from baseline at Week 24 was -0.95 (1.34) and -3.64 (1.24), respectively. For those with background therapy, the mean change in mRSS from baseline at Week 24 was -3.43 (1.08) and -5.81 (1.17), respectively. Similarly, the mean differences between subgroups were not significant.

[0427] Table 12. Absolute Change in mRSS from Baseline to Week 24 by Background Therapy - MMRM - ITT Population

[0428]

[0429]

[0430] Note: CI: Confidence Interval; MMRM: Mixed Model for Repeated Measures; mRSS: Modified Rodnan Skin Score; LS Mean: Least Squares Mean calculated using the mixed model; EOT: End of Treatment; SE: Standard Error;

[0431] Patients receiving background therapy were defined as all patients who received medications from the following list before and at baseline: methotrexate, single-component and multi-component; mycophenolate mofetil, single-component and multi-component; azathioprine, single-component and multi-component; cyclosporine, single-component and multi-component; or cyclophosphamide, single-component and multi-component.

[0432] a LS means, SE, and p-values were estimated by MMRM analysis. The model included fixed categorical effects for treatment groups, randomization strata according to IVRS, time points, treatment-time point and stratum-time point interactions, and continuous fixed effects for baseline and baseline-time point interactions.

[0433] For patients with baseline and post-baseline values, the model and data description (based on observed data) were run in at least one analysis window.

[0434] Primary secondary key efficacy endpoints

[0435] HAQ-DI

[0436] For HAQ-DI, no significant differences were observed between treatment groups. As shown in Table 13 and Figure 4 For the placebo group and the RKB group, the mean change from baseline in HAQ-DI at Week 24 was -0.12 (0.08) and -0.09 (0.08), respectively, resulting in a difference of -0.03 (0.11), with the associated one-sided p-value = 0.3975.

[0437] Table 13. Absolute change in HAQ-DI composite score from baseline to Week 24 - MMRM - ITT population

[0438]

[0439]

[0440] Note: CI: Confidence interval; MMRM: Mixed model for repeated measures; LS mean: Least squares mean calculated using the mixed model; HAQ-DI: Health Assessment Questionnaire Disability Index; SE: Standard error; EOT: End of treatment;

[0441] a LS means, SE, and p-values were estimated by MMRM analysis. The model included fixed categorical effects for treatment groups, randomization strata according to IVRS, time points, treatment-time point and stratum-time point interactions, and continuous fixed effects for baseline and baseline-time point interactions.

[0442] Least squares (LS) means, standard errors (SE), and p-values were estimated by MMRM (mixed-effects model using repeated measures) analysis. The model included fixed categorical effects for treatment group, randomization strata according to IVRS, time points, treatment-time point and stratum-time point interactions, and continuous fixed effects for baseline and baseline-time point interactions. The model and data description (based on observed data) were run for patients with baseline and post-baseline values in at least one analysis window

[0443] FVC

[0444] For FVC, no significant differences were observed between treatment groups (Table 14 and Figure 5 ). For the placebo and RKB groups, the mean change from baseline in absolute FVC (L) at Week 24 was -0.08 (0.04) and -0.01 (0.04), respectively, resulting in a difference of -0.07 (0.06), with a related one-sided p-value = 0.0964.

[0445] Table 14. Absolute change in FVC (L) from baseline to Week 24 - MMRM - ITT population

[0446]

[0447]

[0448] Note: CI: Confidence interval; MMRM: Mixed model for repeated measures; LS mean: Least squares mean calculated using the mixed model; FVC: Forced vital capacity; SE: Standard error; EOT: End of treatment;

[0449] LS means, SE, and p-values were estimated by MMRM analysis. The model included fixed categorical effects for treatment group, randomization strata according to IVRS, time points, treatment-time point and stratum-time point interactions, and continuous fixed effects for baseline and baseline-time point interactions.

[0450] The model and data description (based on observed data) were run for patients with baseline and post-baseline values in at least one analysis window

[0451] Measured DLco (corrected for hemoglobin)

[0452] For DLco, no significant differences were observed between treatment groups (Table 15 and Figure 6 ). For the placebo and RKB groups, the mean change from baseline in absolute DLco (mmol / min / kPa) at Week 24 was -0.27 (0.10) and -0.12 (0.10), respectively, resulting in a difference of -0.15 (0.14), with a related one-sided p-value = 0.1352.

[0453] Table 15. Absolute change in DLco [corrected for hemoglobin] (mmol / min / kPa) from baseline to Week 24 - MMRM - ITT population.

[0454]

[0455]

[0456] Note: CI: Confidence Interval; MMRM: Mixed Model for Repeated Measures; LS Mean: Least Squares Mean calculated using the mixed model; DLCO: Diffusing Capacity of the Lung for Carbon Monoxide; SE: Standard Error; EOT: End of Treatment;

[0457] a LS means, SEs, and p - values were estimated by MMRM analysis. The model included fixed categorical effects for treatment group, randomization strata according to IVRS, time points, treatment - time point and stratum - time point interactions, and continuous fixed effects for baseline and baseline - time point interactions.

[0458] In at least one analysis window, the model and data description were run on patients with baseline and post - baseline values (based on the observed data)

[0459] Results for exploratory efficacy endpoints are shown in Table 16. Exploratory endpoints suggest a possible effect of ritlecitinib on overall pain, Raynaud's phenomenon, and digital ulcers.

[0460] Ritlecitinib led to a statistically significant improvement in the EQ - 5D - 5L index compared to placebo; the change in LS mean (SE) from baseline to Week 24 for ritlecitinib was 0.07 (0.03) compared to 0.00 (0.03) for placebo, resulting in a difference of 0.07 [95% CI: - 0.01, 0.15; p = 0.04] (Table 2). For ritlecitinib versus placebo, from baseline to Week 24, there were numerical improvements (i.e., decreases) between SHAQ VAS scales for overall disease severity, pain severity, vascular function, and the impact of digital ulcers on activity, and there was a small deterioration for GI function and respiratory function, but these did not reach statistical significance (Table 2).

[0461] Additional exploratory efficacy endpoints are summarized in Addendum 4. At Week 24, there was a numerical improvement (i.e., greater reduction) in the UCLA SCTC GIT 2.0 total score for romosozumab relative to placebo, resulting in a LS mean difference of -0.02 [95% CI: -0.14, 0.10; p = 0.39], and a numerical improvement in the number of tender joints 28, resulting in a difference of -1.08 [95% CI: -2.74, 0.58; p = 0.10], but there was no numerical improvement in the fingertip ulcer count (LS mean difference: 0.10 [95% CI: -0.37, 0.57; p = 0.33]). The mean (SD) predicted probability of CRISS improvement was slightly higher for romosozumab than for placebo: 0.4245 (0.4266) and 0.3811 (0.4372), respectively.

[0462] Table 16. Exploratory endpoints

[0463]

[0464] CRISS probability

[0465] For the step 1 analysis of CRISS events (Table 17) and the predicted probability of CRISS improvement (Table 18), no significant differences were observed between treatment groups. A total of two events meeting the CRISS criteria occurred, both of which (FVC decline) occurred in the placebo group. Another CRISS event (scleroderma renal crisis) was reported from the RKB group at Week 35 and was reflected in the CRISS analysis of the CSR.

[0466] Table 17. Description of CRISS events over time by analysis time point - ITT population.

[0467]

[0468] Note: CRISS = Composite Response Index for diffuse cutaneous systemic sclerosis (dcSSc); FVC:

[0469] Forced vital capacity; PAH: Pulmonary arterial hypertension; EOT: End of treatment; EOS: End of study.

[0470] Table 18. Description of the distribution of predicted CRISS probabilities at Week 12 and Week 24 - ITT population

[0471]

[0472]

[0473] CRISS = Comprehensive Response Index for diffuse cutaneous systemic sclerosis (dcSSc). CRISS reflects the probability that a patient will improve their dcSSc.

[0474] CRISS is a two-step process. Step 1: If the patient develops new or worsening cardiopulmonary and / or renal involvement due to SSc, the probability equals 0.

[0475] Step 2: exp(-5.54 - 0.81xΔMRSS + 0.21xΔFVCPP - 0.40xΔPT_glob - 0.44xΔMD_glob - 3.41xΔHAQDI) / (1 + exp(-5.54 - 0.81xΔMRSS + 0.21xΔFVCPP - 0.40xΔPT_glob - 0.44xΔMD_glob - 3.41*xΔHAQDI))

[0476] a Using unentered data provided by the Van Elteren test stratified on the randomization strata

[0477] Pre-specified subgroup analysis

[0478] In patients with more severely affected skin, the LS mean difference in mRSS was statistically significantly in favor of romosozumab compared to placebo (i.e., baseline mRSS ≥ 15 (-3.42 [95% CI: -6.21, -0.64; p = 0.01]). Response rate analysis showed that the 20%, 40%, and 60% improvements in mRSS from baseline to week 24 were higher for romosozumab than for placebo; the between-group difference in 40% improvement in mRSS was statistically significant (p = 0.02). Regardless of baseline disease duration (<20 months and ≥20 months), use of background therapy, or history of SSc-ILD, the LS mean difference in mRSS was numerically in favor of romosozumab at week 24 compared to placebo (Table 19).

[0479] Table 19: Mean change in absolute mRSS from baseline to week 24 for the pre-specified ITT population treated with romosozumab and placebo.

[0480]

[0481]

[0482] a Including methotrexate, mycophenolate mofetil, azathioprine, and cyclophosphamide.

[0483] CI, confidence interval; ITT, intention-to-treat; LS, least squares; mRSS, modified Rodnan skin score; QW, once weekly; SE, standard error; SSc-ILD, systemic sclerosis interstitial lung disease.

[0484] Post hoc analysis

[0485] The time to the first event was longer in the case of romosozumab relative to placebo ( Figure 7 ). For the time to events reflecting disease worsening, there was a trend in favor of romosozumab compared to placebo: 9 (18.8%) vs 15 (30.6%) respectively [hazard ratio: 0.47 [95% CI: 0.20, 1.11; p = 0.09, two-sided] (Table 20). This was driven by lung and skin events for romosozumab and by lung, skin, and other CRISS events for placebo.

[0486] Pharmacokinetics, immunogenicity, and biomarker endpoints

[0487] Pharmacokinetic analysis showed that romosozumab reached steady state at Week 4. The arithmetic mean (SD) C 谷 was 38.23 (17.96) μg / mL and 47.45 (30.23) μg / mL at Week 4 and Week 24, respectively. Immunogenicity testing showed that patients in neither treatment group had pre-existing positive ADA at baseline. Three patients in the romosozumab group and 0 patients in the placebo group developed positive ADA by Week 24; all were considered to be of low titer. All ADA positives were not related to TEAE. Romosozumab was associated with a statistically significant reduction in TARC relative to placebo; the LS mean difference at Week 24 was -115.56 ng / L [95% CI; -216.87, -14.26; p = 0.03] ( Figure 8A ). There was a strong trend towards a greater decline in periostin in the case of romosozumab relative to placebo; the LS mean difference at Week 24 was -16.92 μg / L [-35.19, 1.35; p = 0.07] ( Figure 8B ). There were no significant differences in other biomarkers between romosozumab and placebo (Table 21).

[0488] Table 20: Distribution of events reflecting disease progression

[0489]

[0490] CRISS, composite response index for diffuse cutaneous systemic sclerosis; DL CO , diffusing capacity of the lung for carbon monoxide; FVC, forced vital capacity; mRSS, modified Rodnan skin score; QW, once weekly.

[0491] Table 21: Mean change in protein biomarkers from baseline to Week 24 in the ITT population treated with romosozumab and placebo.

[0492]

[0493]

[0494] CCL2, chemokine (C-C motif) ligand 2; CI, confidence interval; COMP, cartilage oligomeric matrix protein; ITT, intention-to-treat; LS, least squares; QW, once weekly; SD, standard deviation; SE, standard error; TARC, thymus and activation-regulated chemokine.

[0495] Safety

[0496] Treatment-emergent adverse events

[0497] Infections were the most frequently reported TEAEs and occurred more often in the RKB group (54.2%) compared with the placebo group (46.9%). The most common infections were within the upper respiratory tract. Herpes labialis events occurred more often in the RKB group (10.4%) compared with the placebo group (2.0%).

[0498] The frequency of reporting skin and subcutaneous tissue disorders was slightly higher in the placebo group (36.7%) compared with the RKB group (31.3%). The most frequently reported event was skin ulcer (or digital ulcer), which was reported by 30.6% and 16.7% of patients in the placebo and RKB groups, respectively.

[0499] The frequency of reporting gastrointestinal disorders was higher in the RKB group (25.0%) compared with the placebo group (14.3%). The most frequently reported event was diarrhea, which occurred in 8.2% and 14.6% of patients in the placebo and SAR156507 groups, respectively.

[0500] The frequency of reporting musculoskeletal and connective tissue disorders was higher in the RKB group (22.9%) compared with the placebo group (14.3%). The frequency of reporting respiratory, thoracic and mediastinal disorders was slightly higher in the placebo group (16.3%) compared with the RKB group (12.5%). The frequency of reporting nervous system disorders was higher in the RKB group (18.8%) compared with the placebo group (6.1%). From these latter three SOCs, some significant imbalances in PT levels in the placebo and RKB groups included the following events: headache (2.0% vs 8.3%), cough (0% vs 6.3%) and arthralgia (2.0% vs 8.3%).

[0501] Table 22. Overview of adverse event profiles: treatment-emergent adverse events during the primary TEAE period, by treatment group - safety population.

[0502]

[0503] TEAE: Treatment-Emergent Adverse Event, SAE: Serious Adverse Event

[0504] n(%) = number and percentage of patients with at least one TEAE

[0505] Table 23. Number (%) of patients with one or more TEAEs occurring at PT ≥ 5% in any treatment group, by primary SOC and PT during the TEAE period - safety population

[0506]

[0507]

[0508] TEAE: Treatment-Emergent Adverse Event, SOC: System Organ Class, PT: Preferred Term - MedDRA 21.1

[0509] n(%) = number and percentage of patients with at least one TEAE

[0510] Note: Table sorted in the internationally recognized order of SOC and decreasing frequency of PT

[0511] Only SOCs with at least one PT ≥ 5% in at least one group are presented.

[0512] * Reported item not coded

[0513] Serious treatment-emergent adverse events

[0514] Nine patients (9.2%) experienced at least one TESAE, five (10.2%) and four (8.3%) patients in the placebo and RKB groups, respectively (Table 24). The most frequently reported TESAE were under the SOCs of infections and infestations disorders and cardiac disorders. The TESAE related to infections were slightly higher in the RKB group (4.2%) compared to the placebo group (2.0%). The TESAE related to cardiac disorder events were higher in the placebo group (4.1%) compared to the RKB group (0.0%). There were no differences in the remaining TESAE for each SOC between the two treatment groups.

[0515] Table 24. Number (%) of patients with treatment-emergent SAEs, by primary SOC and PT - safety population

[0516]

[0517]

[0518] SAE: Serious Adverse Event, SOC: System Organ Class, PT: Preferred Term of MedDRA 21.1

[0519] n(%) = number and percentage of patients with at least one treatment-emergent SAE

[0520] Note: The table is classified in the internationally recognized order of SOC and the decreasing frequency of PTs aggregated according to all TEAEs

[0521] * Report item not coded

[0522] Treatment-emergent adverse events leading to death

[0523] Two patients developed TEAEs leading to death in the study, with one event occurring in each of the two treatment groups (Table 25). For the TEAE leading to death in the RKB group, a 78-year-old female patient diagnosed with SSc (baseline mRSS of 35) since approximately three months after starting treatment, SSc-ILD since December 2016 shortly before screening (January 26, 2017), and with many other general medical conditions, developed worsening renal insufficiency, which was ultimately diagnosed as scleroderma renal crisis, leading to treatment discontinuation (Table 26). Notably, the patient had a baseline history of chronic renal insufficiency and renal function had been declining prior to randomization (creatinine = 94.1 μmol / L in December 2016, screening creatinine = 103 μmol / L, and baseline creatinine = 122 μmol / L), which was attributed to age-related processes according to nephrology consultation guidelines. She was diagnosed with acute renal failure (creatinine of 172.6 μmol / L) at week 6 and treated with furosemide and prednisolone. Several weeks after IMP discontinuation, the patient was then hospitalized due to the diagnosis of bilateral pneumonia. This hospitalization was complicated by rapid progression of respiratory failure, hypertension, and renal failure, leading to hemodialysis and death.

[0524] For the TEAE leading to death in the placebo group, a 31-year-old male patient receiving background therapy with methotrexate and low-dose prednisone prior to randomization into the study developed cardiomyopathy (primary SSc cardiomyopathy), was treated with high-dose corticosteroids, and this led to discontinuation of study treatment (Table 27). Ultimately, approximately nine months after discontinuation of study treatment, the patient died as a result of this event.

[0525] Table 25. Number (%) of patients with one or more TEAEs leading to death by primary SOC and PT - Safety population

[0526]

[0527] TEAE: Treatment Emergent Adverse Event, SOC: System Organ Class, PT: Preferred Term in MedDRA 21.1

[0528] n(%) = Number and percentage of patients with at least one TEAE leading to death Note: Table is classified by SOC in internationally recognized order and by decreasing frequency of PT aggregated across all TEAEs

[0529] * Reported item not coded

[0530] Adverse events leading to permanent discontinuation

[0531] Table 26. Number (%) of patients with one or more TEAEs leading to permanent treatment discontinuation by primary SOC and PT - Safety population

[0532]

[0533]

[0534] TEAE: Treatment Emergent Adverse Event, SOC: System Organ Class, PT: Preferred Term in MedDRA - 21.1

[0535] n(%) = Number and percentage of patients with at least one TEAE leading to permanent treatment discontinuation Note: Table is classified by SOC in internationally recognized order and by decreasing frequency of PT aggregated across all TEAEs

[0536] * Reported item not coded

[0537] Other significant adverse events (including AESI, labs)

[0538] As seen in Table 27, according to the protocol, a total of 2 patients experienced TEAEs considered to be AESIs. No differences in vital signs (Table 28) or ECG characteristics (Table 29) were observed between the two treatment groups. No cases of vasculitis, tuberculosis, or allergic reactions were reported.

[0539] Adverse events of special interest

[0540] Table 27. Number (%) of patients with at least one AESI - Safety population

[0541]

[0542] MedDRA - 21.1; AESI: Adverse Event of Special Interest, PT: Preferred Term a AESI categories using e - CRF checkboxes on AE

[0543] bAn increase in ALT selected using laboratory data > 3 ULN. c The AESI definition is identified using the CMQ coding list. d : The AESI definition is identified by AEHLT = "injection site reaction" and AESEV =

[0544] "severe".

[0545] e The AESI definition is identified using the CMQ coding list or for the start of medication for suspected tuberculosis, and the start of medication is selected using WHODD CDG00737 "Start of Medication for Suspected Tuberculosis".

[0546] f Acute renal failure is selected using the CMQ coding list or the "Acute Renal Failure" checkbox in the e-CRF on the AE page.

[0547] n(%) = the number and percentage of patients with at least one TEAE

[0548] Vital signs and ECG observations

[0549] Table 28. Vital signs - Number of patients with abnormalities (PCSA) during the TEAE period - Safety population

[0550]

[0551] PCSA: Potentially Clinically Significant Abnormalities (version 1.0, 24 May 2014)

[0552] Note: The number (n) represents a subset of the total number of patients who met the criteria at least once during the TEAE period.

[0553] The denominator ( / N1) for each parameter within the treatment group is the number of patients who had the parameter evaluated (not missing) after baseline during the TEAE period.

[0554] For PCSA of conditions that include only changes from baseline, the denominator is limited to patients who had (not missing) baseline and post-baseline values during the TEAE period.

[0555] Table 29. ECG - Number of patients with abnormalities (PCSA) during the TEAE period - Safety population

[0556]

[0557]

[0558] PCSA: Potentially Clinically Significant Abnormalities (Version 1.0, May 24, 2014) Note: The number (n) represents a subset of the total number of patients who met the criteria at least once during the TEAE period.

[0559] The denominator ( / N1) for each parameter within the treatment group is the number of patients who had the parameter evaluated (not missing) after baseline during the TEAE period.

[0560] For PCSA for conditions that include only changes from baseline, the denominator is limited to patients who had (not missing) baseline and post-baseline values during the TEAE period. a Summary of patients who experienced one PCSA among several categories, counted only in the worst category

[0561] The primary efficacy endpoint, measured as the absolute change in mRSS from baseline at Week 24, showed a statistically significant difference between RKB and placebo: for the placebo group and the RKB group, the absolute change in mRSS from baseline at Week 24 was -2.45 (0.85) and -4.76 (0.86), respectively, resulting in a reduction of 2.31 (1.21), with the associated one-sided p-value = 0.0291.

[0562] The secondary efficacy endpoint measured by HAQ-DI did not show a difference between RKB and placebo. The secondary efficacy endpoints of FVC and DLco also did not show a difference between the two groups, but the RKB group had a smaller decline in both parameters over 24 weeks compared to the placebo group.

[0563] For the placebo group and the RKB group, the mean change in absolute FVC (L) from baseline at Week 24 was -0.08 (0.04) and -0.01 (0.04), respectively, resulting in a difference of -0.07 (0.06), with the associated one-sided p-value = 0.0964.

[0564] For the placebo group and the RKB group, the mean change in absolute DLco (mmol / min / kPa) from baseline at Week 24 was -0.27 (0.10) and -0.12 (0.10), respectively, resulting in a difference of -0.15 (0.14), with the associated one-sided p-value = 0.1352.

[0565] The incidences of treatment-emergent adverse events (TEAE), treatment-emergent serious adverse events (TESAE), TEAEs leading to death, and TEAEs leading to treatment discontinuation were similar between the two treatment groups; for the RKB group, more TEAEs occurred within the System Organ Class (SOC) of infections and infestations and gastrointestinal disorders, while for the placebo group, more TEAEs occurred within the SOC of skin and subcutaneous tissue disorders.

Claims

1. A method for treating systemic sclerosis (SSc) in a human subject with SSc, the method comprising subcutaneously administering to the subject about 200 mg of a dual V-region bispecific antibody or antigen-binding fragment that specifically binds IL-4 and IL-13.

2. The method according to claim 1, wherein about 200 mg of the bispecific antibody is administered to the subject about once a week or about once every 5 to 9 days.

3. The method according to claim 1 or 2, wherein the treatment is administered for at least about 24 weeks.

4. The method according to any one of claims 1-3, wherein the bispecific antibody is in a pharmaceutical formulation.

5. The method according to claim 4, wherein the pharmaceutical formulation comprises about 100 mg / ml bispecific antibody, about 6.3 mM sodium dihydrogen phosphate, about 37 mM Tris, about 5% (w / v) sucrose, about 3% (w / v) proline, and about 0.2% (w / v) polysorbate 80, wherein the pH of the formulation is about 7.

0.

6. The method according to claim 5, wherein the formulation is reconstituted from a lyophilized formulation.

7. The method according to any one of claims 1-6, wherein the bispecific antibody is administered in combination with another agent.

8. The method according to claim 7, wherein the another agent is administered before, simultaneously with, or after the bispecific antibody.

9. The method according to any one of claims 1-8, wherein the systemic sclerosis is diffuse cutaneous systemic sclerosis.

10. The method according to any one of claims 1-9, wherein the bispecific antibody or bispecific antibody fragment thereof comprises a light chain polypeptide comprising a light chain variable domain VL hB-B13 and a light chain variable domain VL hBD4-8 and a heavy chain polypeptide comprising a heavy chain variable domain VH hB-B13 and a heavy chain variable domain VH hBD4-8 ; wherein: VL hB-B13 Comprising three CDRs containing the amino acid sequences RASESVDSYGQSYMH (SEQ ID NO:8), LASNLES (SEQ ID NO:9), and QQNAEDSRT (SEQ ID NO:10); VL hBD4-8 comprising three CDRs containing the amino acid sequences HASQNIDVWLS (SEQ ID NO:14), KASNLHTG (SEQ ID NO:15), and QQAHSYPFT (SEQ ID NO:16) VH hB-B13 Comprising three CDRs containing the amino acid sequences GFSLTDSSIN (SEQ ID NO:11), DGRID (SEQ ID NO:12), and DGYFPYAMDF (SEQ ID NO:13), VH hBD4-8 Comprising three CDRs containing the amino acid sequences GYSFTSYWIH (SEQ ID NO:17), IDPSDGETR (SEQ ID NO:18), and LKEYGNYDSFYFDV (SEQ ID NO:19).

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