Methods for treating patients with heterozygous familial hypercholesterolemia (heFH)

Abstract

This invention relates to a method for treating patients with heterozygous familial hypercholesterolemia (heFH), comprising administering a pharmaceutical composition containing a PCSK9 inhibitor to a patient with heterozygous familial hypercholesterolemia. In some embodiments, the PCSK9 inhibitor is an anti-PCSK9 antibody, such as the exemplary antibody referred to herein as mAb316P. The method of the present invention can be used to treat patients with heterozygous familial hypercholesterolemia whose cholesterol is poorly controlled with the maximum tolerated dose of statins, with or without other lipid-lowering therapy.

Description

[0001] This invention application is a divisional application of the invention patent application filed on July 16, 2015, with application number 201580049619.4 (international application number PCT / US2015 / 040754) entitled "Method for treating patients with heterozygous familial hypercholesterolemia (heFH)". Technical Field

[0002] This invention relates to the field of therapeutic treatment of diseases and conditions associated with elevated lipid and lipoprotein levels. More specifically, this invention relates to the use of PCSK9 inhibitors in the treatment of patients with heterozygous familial hypercholesterolemia who have poorly controlled cholesterol levels with the maximum tolerated dose of statins, with or without other lipid-lowering therapy. Background Technology

[0003] Heterozygous familial hypercholesterolemia (heFH) is a hereditary lipid metabolism disorder that predisposes affected individuals to cardiovascular (CV) disease. Patients with heFH have very low low-density lipoprotein cholesterol (LDL-C) levels, typically >190 mg / dL at diagnosis, which is associated with a high risk of premature CV disease. Observational studies have shown a reduced risk of coronary heart disease (CHD) in heFH patients treated with statins; however, even with treatment, the risk of CHD in heFH patients remains higher than in the general population. Despite the availability of lipid-lowering therapy (LLT), approximately 80% of heFH patients do not achieve recommended LDL-C levels. Given the increased CV risk in the heFH population, more intensive cholesterol-lowering treatment is needed for these patients.

[0004] Current LDL-C lowering medications include statins, cholesterol absorption inhibitors (such as ezetimibe [EZE]), fibrates, niacin, and bile acid sequestrants. Statins are the most commonly prescribed medications because they have shown greater ability to lower LDL-C and reduce CHD events. However, many patients at risk of cardiovascular disease (CVD) still have poorly controlled low-density lipoprotein cholesterol (LDL-C) despite statin therapy. Summary of the Invention

[0005] This invention provides a method for treating hypercholesterolemia. Specifically, the method of this invention can be used to treat patients with heterozygous familial hypercholesterolemia who have poorly controlled cholesterol levels with the maximum tolerated dose of statins, with or without other lipid-lowering therapy.

[0006] According to one aspect, the method of the present invention includes administering one or more doses of a PCSK9 inhibitor to a patient with heterozygous familial hypercholesterolemia who has hypercholesterolemia that is poorly controlled with the maximum tolerated dose of statins with or without other lipid-lowering therapy (i.e., hypercholesterolemia poorly controlled with the maximum tolerated dose of statins with or without other lipid-improving therapy in the absence of a PCSK9 inhibitor). According to some embodiments of the invention, the PCSK9 inhibitor is administered as add-on therapy to the patient's existing statin therapy with or without other lipid-lowering therapy in patients with heterozygous familial hypercholesterolemia.

[0007] According to another aspect, the method of the present invention includes selecting a patient with heterozygous familial hypercholesterolemia whose cholesterol is poorly controlled by the maximum tolerated dose of statins (e.g., maximum tolerated dose statin therapy) with or without other lipid-lowering treatment, and administering to the patient one or more doses of a PCSK9 inhibitor in combination with (and "in addition to") statin therapy.

[0008] Another aspect of the invention includes a method for treating a patient with heterozygous familial hypercholesterolemia (heFH) who has inadequate control of hypercholesterolemia with or without the maximum tolerated dose of statins, with or without other lipid-lowering therapy, the method being carried out by administering one or more doses of a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor to the patient, wherein the patient still exhibits inadequate control of hypercholesterolemia despite treatment with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, in the absence of a PCSK9 inhibitor.

[0009] Another aspect of the invention includes a method for lowering low-density lipoprotein cholesterol (LDL-C) in patients with heterozygous familial hypercholesterolemia (heFH) who have undercontrolled cholesterol levels with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, the method being carried out by administering one or more doses of a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor to the patients who, despite treatment with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, in the absence of a PCSK9 inhibitor, still exhibit undercontrolled hypercholesterolemia.

[0010] Another aspect of the invention includes a method for treating hypercholesterolemia in patients with heterozygous familial hypercholesterolemia (heFH) who have undercontrolled hypercholesterolemia with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, the method being carried out by administering one or more doses of a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor to the patient who, despite treatment with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, in the absence of a PCSK9 inhibitor, still exhibits undercontrolled hypercholesterolemia.

[0011] Another aspect of the invention includes a method for improving serum levels of one or more lipid components in patients with heterozygous familial hypercholesterolemia (heFH), said patients having inadequate control of lipid components with or without treatment with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, said method being performed by administering one or more doses of a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor to said patients, said patients exhibiting inadequate control of lipid components despite treatment with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, in the absence of a PCSK9 inhibitor. In some aspects, the invention provides a reduction in serum levels of lipid components selected from the group consisting of: LDL-C, Apo B, non-HDL-C, total cholesterol, Lp(a), and triglycerides. In some aspects, the invention provides an increase in serum levels of lipid components selected from the group consisting of: HDL-C and Apo A1.

[0012] In some aspects of this invention, the diagnosis of heFH is made by genotyping or clinical criteria. In some aspects, the clinical criteria are the Simon Broome Register Diagnostic Criteria for heterozygous familial hypercholesterolemia, or the WHO / Dutch Lipid Network criteria, with a score >8.

[0013] In some aspects of the invention, the PCSK9 inhibitor is an antibody or antigen-binding fragment thereof that specifically binds to PCSK9.

[0014] In some aspects of the invention, the antibody or antigen-binding fragment thereof comprises a heavy chain and a light chain complementarity-determining region (CDR) of a heavy chain variable region / light chain variable region (HCVR / LCVR) amino acid sequence pair selected from SEQ ID NO: 1 / 6 and 11 / 15. In some aspects, the antibody or antigen-binding fragment thereof comprises a heavy chain and a light chain CDR amino acid sequence having SEQ ID NO: 12, 13, 14, 16, 17, and 18. In some aspects, the antibody or the antigen-binding fragment thereof comprises an HCVR having the amino acid sequence of SEQ ID NO: 11 and an LCVR having the amino acid sequence of SEQ ID NO: 15. In some aspects, the antibody or the antigen-binding fragment thereof comprises a heavy chain and a light chain CDR amino acid sequence having SEQ ID NO: 2, 3, 4, 7, 8, and 10. In some aspects, the antibody or the antigen-binding fragment thereof comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 6.

[0015] In some aspects of the invention, the antibody or its antigen-binding fragment binds to the same epitope on PCSK9 with another antibody, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0016] In some aspects of the invention, the antibody or its antigen-binding fragment competes with another antibody for binding to PCSK9, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0017] In some aspects of the invention, the antibody specifically binding to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 75 mg every two weeks. In some aspects, if the patient's LDL-C is measured to be <70 mg / dL after 5 or more doses, the dose of about 75 mg is maintained. In some aspects, if the patient's LDL-C is measured to be ≥70 mg / dL after 5 or more doses, the dose of about 75 mg is discontinued, and the antibody specifically binding to PCSK9 or its antigen-binding fragment is subsequently administered to the patient at a dose of about 150 mg every two weeks. In some aspects, the antibody specifically binding to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 150 mg every two weeks.

[0018] In some aspects of the invention, the PCSK9 inhibitor is administered to a patient in combination with the maximum tolerated dose of a statin. In some aspects, the maximum tolerated dose of the statin treatment comprises a daily dose of atorvastatin of about 40 mg to about 80 mg. In some aspects, the maximum tolerated dose of the statin treatment comprises a daily dose of rosuvastatin of about 20 mg to about 40 mg. In some aspects, the maximum tolerated dose of the statin treatment comprises a daily dose of simvastatin of about 80 mg.

[0019] In some aspects of the invention, the PCSK9 inhibitor is administered to patients in combination with other lipid-lowering therapies.

[0020] In some aspects of the invention, the method improves at least one of the following hypercholesterolemia-related parameters selected from the group consisting of: (a) a patient’s low-density lipoprotein cholesterol (LDL-C) reduced by at least 40%; (b) a patient’s apolipoprotein B (ApoB) reduced by at least 30%; (c) a patient’s non-high-density lipoprotein cholesterol (non-HDL-C) reduced by at least 40%; (d) a patient’s total cholesterol reduced by at least 20%; (e) a patient’s high-density lipoprotein cholesterol (HDL-C) increased by at least 3%; (f) a patient’s triglycerides reduced by at least 5%; (g) a patient’s lipoprotein a (Lp(a)) reduced by at least 20%; and (h) a patient’s apolipoprotein A1 increased by at least 1%.

[0021] Specifically, the present invention includes, but is not limited to, the following:

[0022] 1. A method for treating a patient with heterozygous familial hypercholesterolemia (heFH) who has inadequate control of hypercholesterolemia with or without the maximum tolerated dose of statins, with or without other lipid-lowering therapy, the method comprising administering one or more doses of a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor to the patient, wherein the patient exhibits inadequate control of hypercholesterolemia despite treatment with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, in the absence of a PCSK9 inhibitor.

[0023] 2. The method of implementation plan 1, wherein the diagnosis of heFH is made by genotyping or clinical criteria.

[0024] 3. The method of implementation scheme 2, wherein the clinical criteria are the Simon Broome Register Diagnostic Criteria for heterozygous familial hypercholesterolemia or the WHO / Dutch Lipid Network criteria, with a score >8.

[0025] 4. The method of any one of embodiments 1-3, wherein the PCSK9 inhibitor is an antibody that specifically binds to PCSK9 or an antigen-binding fragment thereof.

[0026] 5. The method of embodiment 4, wherein the antibody or its antigen-binding fragment comprises a heavy chain and a light chain complementarity-determining region (CDR) of a heavy chain variable region / light chain variable region (HCVR / LCVR) amino acid sequence pair selected from SEQ ID NO: 1 / 6 and 11 / 15.

[0027] 6. The method of embodiment 5, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18.

[0028] 7. The method of embodiment 6, wherein the antibody or its antigen-binding fragment comprises an HCVR having the amino acid sequence of SEQ ID NO: 11 and an LCVR having the amino acid sequence of SEQ ID NO: 15.

[0029] 8. The method of embodiment 5, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0030] 9. The method of embodiment 8, wherein the antibody or its antigen-binding fragment comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 6.

[0031] 10. The method of embodiment 4, wherein the antibody or its antigen-binding fragment binds to the same epitope on PCSK9 with another antibody, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0032] 11. The method of embodiment 4, wherein the antibody or its antigen-binding fragment competes with another antibody for binding to PCSK9, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0033] 12. The method of implementation scheme 4, wherein the antibody that specifically binds to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 75 mg and at a frequency of once every two weeks.

[0034] 13. The method of implementation scheme 12, wherein if the patient's LDL-C is measured to be <70 mg / dL after 5 or more doses, the dose of approximately 75 mg is maintained.

[0035] 14. The method of implementation scheme 12, wherein if the patient's LDL-C is maintained at ≥70 mg / dL after 5 or more doses, the approximately 75 mg dose is discontinued, and the patient is subsequently administered the antibody that specifically binds to PCSK9 or its antigen-binding fragment at a frequency of approximately every two weeks at a dose of approximately 150 mg.

[0036] 15. The method of embodiment 4, wherein the antibody that specifically binds to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 150 mg and at a frequency of once every two weeks.

[0037] 16. The method of any one of embodiments 1-15, wherein the PCSK9 inhibitor is administered to the patient in combination with the maximum tolerated dose of a statin.

[0038] 17. The method of any one of embodiments 1-16, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 40 mg to about 80 mg of atorvastatin.

[0039] 18. The method of any one of embodiments 1-16, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 20 mg to about 40 mg of rosuvastatin.

[0040] 19. The method of any one of embodiments 1-16, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 80 mg of simvastatin.

[0041] 20. The method of any one of embodiments 16-19, wherein the PCSK9 inhibitor is administered to a patient in combination with other lipid-lowering therapies.

[0042] 21. The method of any one of embodiments 1-20, wherein said method improves at least one hypercholesterolemia-related parameter selected from the group consisting of:

[0043] (a) The patient's low-density lipoprotein cholesterol (LDL-C) is reduced by at least 40%;

[0044] (b) The patient's apolipoprotein B (ApoB) is reduced by at least 30%;

[0045] (c) The patient's non-high-density lipoprotein cholesterol (non-HDL-C) is reduced by at least 40%;

[0046] (d) The patient's total cholesterol decreased by at least 20%;

[0047] (e) The patient's high-density lipoprotein cholesterol (HDL-C) is increased by at least 3%;

[0048] (f) The patient's triglyceride levels are reduced by at least 5%;

[0049] (g) The patient's lipoprotein a (Lp(a)) is reduced by at least 20%; and

[0050] (h) Patients with an increase of at least 1% in apolipoprotein A-1.

[0051] 22. A method for reducing low-density lipoprotein cholesterol (LDL-C) in patients with heterozygous familial hypercholesterolemia (heFH) who have inadequate control of their cholesterol levels with or without treatment with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, the method comprising administering one or more doses of a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor to the patients who, despite treatment with the maximum tolerated dose of statins with or without other lipid-lowering therapy in the absence of a PCSK9 inhibitor, still exhibit inadequate control of their hypercholesterolemia.

[0052] 23. The method of implementation scheme 22, wherein the diagnosis of heFH is made by genotyping or clinical criteria.

[0053] 24. The method of implementation scheme 23, wherein the clinical criteria are the Simon Broome registry diagnostic criteria for heterozygous familial hypercholesterolemia, or the WHO / Dutch Lipid Network criteria, with a score >8.

[0054] 25. The method of any one of embodiments 22-24, wherein the PCSK9 inhibitor is an antibody that specifically binds to PCSK9 or an antigen-binding fragment thereof.

[0055] 26. The method of embodiment 25, wherein the antibody or its antigen-binding fragment comprises a heavy chain and a light chain complementarity-determining region (CDR) of a heavy chain variable region / light chain variable region (HCVR / LCVR) amino acid sequence pair selected from SEQ ID NO:1 / 6 and 11 / 15.

[0056] 27. The method of embodiment 26, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18.

[0057] 28. The method of embodiment 27, wherein the antibody or its antigen-binding fragment comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 6.

[0058] 29. The method of embodiment 26, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0059] 30. The method of embodiment 29, wherein the antibody or antigen-binding fragment thereof comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 6.

[0060] 31. The method of embodiment 25, wherein the antibody or its antigen-binding fragment binds to the same epitope on PCSK9 with another antibody, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0061] 32. The method of embodiment 25, wherein the antibody or its antigen-binding fragment competes with another antibody for binding to PCSK9, the other antibody comprising a heavy chain and light chain CDR amino acid sequence having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0062] 33. The method of embodiment 25, wherein the antibody that specifically binds to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 75 mg and at a frequency of once every two weeks.

[0063] 34. The method of implementation scheme 33, wherein if the patient's LDL-C is measured to be <70 mg / dL after 5 or more doses, the dose of approximately 75 mg is maintained.

[0064] 35. The method of embodiment 33, wherein if the patient's LDL-C is maintained at ≥70 mg / dL after 5 or more doses, the approximately 75 mg dose is discontinued, and the patient is subsequently administered the antibody that specifically binds to PCSK9 or its antigen-binding fragment at a dose of approximately 150 mg at a frequency of approximately every two weeks.

[0065] 36. The method of embodiment 25, wherein the antibody that specifically binds to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 150 mg and at a frequency of once every two weeks.

[0066] 37. The method of any one of embodiments 22-36, wherein the PCSK9 inhibitor is administered to the patient in combination with the maximum tolerated dose of a statin.

[0067] 38. The method of any one of embodiments 22-37, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 40 mg to about 80 mg of atorvastatin.

[0068] 39. The method of any one of embodiments 22-37, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 20 mg to about 40 mg of rosuvastatin.

[0069] 40. The method of any one of embodiments 22-37, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 80 mg of simvastatin.

[0070] 41. The method of any one of embodiments 37-40, wherein the PCSK9 inhibitor is administered to a patient in combination with other lipid-lowering therapies.

[0071] 42. The method of any one of embodiments 22-41, wherein said method improves at least one hypercholesterolemia-related parameter selected from the group consisting of:

[0072] (a) The patient's low-density lipoprotein cholesterol (LDL-C) is reduced by at least 40%;

[0073] (b) The patient's apolipoprotein B (ApoB) is reduced by at least 30%;

[0074] (c) The patient's non-high-density lipoprotein cholesterol (non-HDL-C) is reduced by at least 40%;

[0075] (d) The patient's total cholesterol decreased by at least 20%;

[0076] (e) The patient's high-density lipoprotein cholesterol (HDL-C) is increased by at least 3%;

[0077] (f) The patient's triglyceride levels are reduced by at least 5%;

[0078] (g) The patient's lipoprotein a (Lp(a)) is reduced by at least 20%; and

[0079] (h) Patients with an increase of at least 1% in apolipoprotein A-1.

[0080] 43. A method for treating hypercholesterolemia in patients with heterozygous familial hypercholesterolemia (heFH) who have inadequate control of their cholesterol levels with or without the maximum tolerated dose of statins, the method comprising administering one or more doses of a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor to the patient, wherein the patient has inadequate control of their hypercholesterolemia despite treatment with the maximum tolerated dose of statins, with or without the presence of a PCSK9 inhibitor.

[0081] 44. The method of implementation scheme 43, wherein the diagnosis of heFH is made by genotyping or clinical criteria.

[0082] 45. The method of implementation scheme 44, wherein the clinical criteria are the Simon Broome registry diagnostic criteria for heterozygous familial hypercholesterolemia, or the WHO / Dutch Lipid Network criteria, with a score >8.

[0083] 46. ​​The method of any one of embodiments 43-45, wherein the PCSK9 inhibitor is an antibody that specifically binds to PCSK9 or an antigen-binding fragment thereof.

[0084] 47. The method of embodiment 46, wherein the antibody or its antigen-binding fragment comprises a heavy chain and a light chain complementarity-determining region (CDR) of a heavy chain variable region / light chain variable region (HCVR / LCVR) amino acid sequence pair selected from SEQ ID NO:1 / 6 and 11 / 15.

[0085] 48. The method of embodiment 47, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18.

[0086] 49. The method of embodiment 48, wherein the antibody or antigen-binding fragment thereof comprises an HCVR having the amino acid sequence of SEQ ID NO: 11 and an LCVR having the amino acid sequence of SEQ ID NO: 15.

[0087] 50. The method of embodiment 47, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0088] 51. The method of embodiment 50, wherein the antibody or its antigen-binding fragment comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 6.

[0089] 52. The method of embodiment 46, wherein the antibody or its antigen-binding fragment binds to the same epitope on PCSK9 with another antibody, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0090] 53. The method of embodiment 46, wherein the antibody or its antigen-binding fragment competes with another antibody for binding to PCSK9, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0091] 54. The method of embodiment 46, wherein the antibody that specifically binds to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 75 mg and at a frequency of once every two weeks.

[0092] 55. The method of implementation scheme 54, wherein if the patient's LDL-C is measured to be <70 mg / dL after 5 or more doses, the dose of approximately 75 mg is maintained.

[0093] 56. The method of implementation scheme 54, wherein if the patient's LDL-C is maintained at ≥70 mg / dL after 5 or more doses, the approximately 75 mg dose is discontinued, and the patient is subsequently administered the antibody that specifically binds to PCSK9 or its antigen-binding fragment at a frequency of approximately every two weeks at a dose of approximately 150 mg.

[0094] 57. The method of embodiment 46, wherein the antibody that specifically binds to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 150 mg and at a frequency of once every two weeks.

[0095] 58. The method of any one of embodiments 43-57, wherein the PCSK9 inhibitor is administered to the patient in combination with the maximum tolerated dose of a statin.

[0096] 59. The method of any one of embodiments 43-58, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 40 mg to about 80 mg of atorvastatin.

[0097] 60. The method of any one of embodiments 43-58, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 20 mg to about 40 mg of rosuvastatin.

[0098] 61. The method of any one of embodiments 43-58, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 80 mg of simvastatin.

[0099] 62. The method of any one of embodiments 58-61, wherein the PCSK9 inhibitor is administered to a patient in combination with other lipid-lowering therapies.

[0100] 63. The method of any one of embodiments 43-62, wherein the method improves at least one hypercholesterolemia-related parameter selected from the group consisting of:

[0101] (a) The patient's low-density lipoprotein cholesterol (LDL-C) is reduced by at least 40%;

[0102] (b) The patient's apolipoprotein B (ApoB) is reduced by at least 30%;

[0103] (c) The patient's non-high-density lipoprotein cholesterol (non-HDL-C) is reduced by at least 40%;

[0104] (d) The patient's total cholesterol decreased by at least 20%;

[0105] (e) The patient's high-density lipoprotein cholesterol (HDL-C) is increased by at least 3%;

[0106] (f) The patient's triglyceride levels are reduced by at least 5%;

[0107] (g) The patient's lipoprotein a (Lp(a)) is reduced by at least 20%; and

[0108] (h) Patients with an increase of at least 1% in apolipoprotein A-1.

[0109] 64. A method for improving serum levels of one or more lipid components in patients with heterozygous familial hypercholesterolemia (heFH) who are poorly controlled with the maximum tolerated dose of statins with or without other lipid-lowering therapy, the method comprising administering one or more doses of a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor to the patient, wherein the patient exhibits poor lipid component control despite treatment with the maximum tolerated dose of statins with or without other lipid-lowering therapy in the absence of a PCSK9 inhibitor, wherein the lipid component is selected from the group consisting of: LDL-C, Apo B, non-HDL-C, total cholesterol, HDL-C, Lp(a), triglycerides, and ApoA1.

[0110] 65. The method of implementation plan 64, wherein the diagnosis of heFH is made by genotyping or clinical criteria.

[0111] 66. The method of implementation plan 65, wherein the clinical criteria are the Simon Broome registry diagnostic criteria for heterozygous familial hypercholesterolemia, or the WHO / Dutch Lipid Network criteria, with a score >8.

[0112] 67. The method of any one of embodiments 64-66, wherein the PCSK9 inhibitor is an antibody that specifically binds to PCSK9 or an antigen-binding fragment thereof.

[0113] 68. The method of embodiment 67, wherein the antibody or its antigen-binding fragment comprises a heavy chain and a light chain complementarity-determining region (CDR) of a heavy chain variable region / light chain variable region (HCVR / LCVR) amino acid sequence pair selected from SEQ ID NO:1 / 6 and 11 / 15.

[0114] 69. The method of embodiment 68, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18.

[0115] 70. The method of embodiment 69, wherein the antibody or its antigen-binding fragment comprises an HCVR having the amino acid sequence of SEQ ID NO: 11 and an LCVR having the amino acid sequence of SEQ ID NO: 15.

[0116] 71. The method of embodiment 68, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0117] 72. The method of embodiment 71, wherein the antibody or its antigen-binding fragment comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO: 6.

[0118] 73. The method of embodiment 67, wherein the antibody or its antigen-binding fragment binds to the same epitope on PCSK9 with another antibody, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0119] 74. The method of embodiment 67, wherein the antibody or its antigen-binding fragment competes with another antibody for binding to PCSK9, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

[0120] 75. The method of embodiment 67, wherein the antibody that specifically binds to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 75 mg and at a frequency of once every two weeks.

[0121] 76. The method of embodiment 75, wherein if the patient's LDL-C is measured to be <70 mg / dL after 5 or more doses, the dose of approximately 75 mg is maintained.

[0122] 77. The method of embodiment 75, wherein if the patient’s LDL-C is maintained at ≥70 mg / dL after 5 or more doses, the approximately 75 mg dose is discontinued, and the patient is subsequently administered the antibody that specifically binds to PCSK9 or its antigen-binding fragment at a dose of approximately 150 mg at a frequency of approximately every two weeks.

[0123] 78. The method of embodiment 67, wherein the antibody that specifically binds to PCSK9 or its antigen-binding fragment is administered to the patient at a dose of about 150 mg and at a frequency of once every two weeks.

[0124] 79. The method of any one of embodiments 64-78, wherein the PCSK9 inhibitor is administered to the patient in combination with the maximum tolerated dose of a statin.

[0125] 80. The method of any one of embodiments 64-79, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 40 mg to about 80 mg of atorvastatin.

[0126] 81. The method of any one of embodiments 64-79, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 20 mg to about 40 mg of rosuvastatin.

[0127] 82. The method of any one of embodiments 64-79, wherein the maximum tolerated dose of statin treatment comprises a daily dose of about 80 mg of simvastatin.

[0128] 83. The method of any one of embodiments 79-82, wherein the PCSK9 inhibitor is administered to a patient in combination with other lipid-lowering therapies.

[0129] 84. The method of embodiment 64, wherein the lipid component is LDL-C, and the improvement is a decrease in serum LDL-C levels compared to baseline.

[0130] 85. The method of embodiment 64, wherein the lipid component is Apo B, and the improvement is a decrease in serum Apo B levels compared to baseline.

[0131] 86. The method of embodiment 64, wherein the lipid component is non-HDL-C, and the improvement is a reduction in serum non-HDL-C levels compared to baseline.

[0132] 87. The method of embodiment 64, wherein the lipid component is total cholesterol, and the improvement is a decrease in serum total cholesterol levels compared to baseline.

[0133] 88. The method of embodiment 64, wherein the lipid component is Lp(a), and the improvement is a decrease in the serum level of Lp(a) compared to baseline.

[0134] 89. The method of embodiment 64, wherein the lipid component is triglycerides, and the improvement is a decrease in serum triglyceride levels compared to baseline.

[0135] 90. The method of embodiment 64, wherein the lipid component is Apo A1, and the improvement is an increase in serum Apo A1 levels relative to baseline.

[0136] 91. The method of embodiment 64, wherein the lipid component is HDL-C, and the improvement is an increase in serum HDL-C levels relative to baseline.

[0137] 92. The method of any one of embodiments 64-83, wherein said improvement is one or more parameters selected from the group consisting of:

[0138] (a) The patient's low-density lipoprotein cholesterol (LDL-C) is reduced by at least 40%;

[0139] (b) The patient's apolipoprotein B (ApoB) is reduced by at least 30%;

[0140] (c) The patient's non-high-density lipoprotein cholesterol (non-HDL-C) is reduced by at least 40%;

[0141] (d) The patient's total cholesterol decreased by at least 20%;

[0142] (e) The patient's high-density lipoprotein cholesterol (HDL-C) is increased by at least 3%;

[0143] (f) The patient's triglyceride levels are reduced by at least 5%;

[0144] (g) The patient's lipoprotein a (Lp(a)) is reduced by at least 20%; and

[0145] (h) Patients with an increase of at least 1% in apolipoprotein A-1.

[0146] Other embodiments of the invention will become apparent from the detailed description below. Attached Figure Description

[0147] Figure 1 This is a diagram of the research design of ODYSSEY FH I (Example 2).

[0148] Figure 2 This is a graph showing the percentage change from baseline over time in the ITT population of the ODYSSEY FHI study for treatment with alirocumab or placebo (Example 2). Least squares (LS) means and standard errors (SD) were obtained from MMRM (mixed-effects model with repeated measures) analysis.

[0149] Figure 3 This is a diagram of the research design for ODYSSEY FH II (Example 3).

[0150] Figure 4 This is a graph showing the percentage change from baseline over time for the LDL-C LS mean (+ / - SE) in the ITT population during the ODYSSEY FH II study (Example 3). Least squares (LS) mean and standard error (SE) were obtained from MMRM (mixed effects model with repeated measures) analysis.

[0151] Figure 5 This is a graph showing the percentage change from baseline over time in the mean (+ / - SE) of LDL-C LS in the mITT population during the efficacy treatment period in the ODYSSEY FH II study (Example 3).

[0152] Figure 6 This is a diagram of the study design for ODYSSEY HIGH FH (Example 4). The markers in the study design are defined as follows: FU: follow-up; HeFH, heterozygous familial hypercholesterolemia; LLT, lipid-lowering therapy; OLE, open-label extension.

[0153] Figure 7 This is a graph showing the percentage change from baseline over time in the ITT population for treatment with alirocumab or placebo in the ODYSSEY HIGH FH study (Example 4). Least squares (LS) means and standard errors (SE) were obtained from MMRM (mixed effects model with repeated measures) analysis.

[0154] Figure 8 This is a graph showing the LDL-C values ​​calculated from the LS mean (SE) of the ODYSSEY FH I and FH II studies against time. The values ​​shown on the graph represent the % change in the LS mean from baseline to week 24 and week 52.

[0155] Figure 9 This is a graph showing the LDL-C values ​​calculated from the mean (SE) of the LDL-C values ​​over time in the ODYSSEY FH I and FH II studies. The values ​​shown below the graph represent the number of patients analyzed at multiple time points.

[0156] Figure 10 This is a graph showing LDL-C levels in patients receiving alirocumab over time, depending on whether the dose is increased to 150 mg Q2W or maintained at 75 mg Q2W (ITT analysis).

[0157] Figures 11A-11C A plot depicting subgroup analyses (alirocumab vs. placebo) showing a decrease in LDL-C from baseline to week 24 is presented, based on population statistics and baseline characteristics. Figure 11A ), statin / LLT use ( Figure 11B ) and baseline lipids ( Figure 11C (ITT analysis, pooled data from FH I and FH II). Moderate chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate ≥30 and ≤60 mL / min / 1.73 m 2 In FH I, 20 / 323 and 9 / 163 patients in the alirocumab and placebo groups, respectively, had moderate CKD at baseline. The corresponding values ​​in FH II were 2 / 167 and 1 / 82. A “high-intensity” statin dose refers to atorvastatin 40–80 mg or rosuvastatin 20–40 mg.

[0158] Figure 12 This is a diagram illustrating patient management in the ODYSSEY HIGH FH study.

[0159] Figure 13 This is a graph showing the percentage change in LDL-C levels from baseline to week 24 in individual patients during the ODYSSEY HIGH FH study. All patients had background statins (at maximum tolerated levels). One subgroup of patients also received further lipid-lowering therapy.

[0160] Figures 14A-14B A plot of LDL-C values ​​calculated from the LS mean (SE) of the ODYSSEY HIGH FH study versus time is presented. Figure 14A In part, the values ​​shown in the graph are the mean LS percentages (in mg / dL) at weeks 24 and 52. Figure 14B The values ​​shown in the figure are the mean % values ​​of LS at weeks 24 and 78 (expressed in mg / dL). All patients had background statins (at maximum tolerated levels). One subgroup of patients also received further lipid-lowering therapy. Detailed Implementation

[0161] Before describing this invention, it should be understood that the invention is not limited to the specific methods and experimental conditions described, but that the methods and conditions can vary. It should also be understood that the terminology used herein is for the purpose of describing particular embodiments only and is not intended to be limiting, as the scope of the invention is defined only by the appended claims.

[0162] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention pertains. As used herein, the term “about” when referring to a specific stated numerical value means that the value may differ from the stated value by no more than 1%. For example, as used herein, the expression “about 100” includes 99 and 101 and all values ​​in between (e.g., 99.1, 99.2, 99.3, 99.4, etc.).

[0163] While any methods and materials similar or equivalent to those described herein may be used in the practice of this invention, preferred methods and materials are described herein. All publications mentioned herein are incorporated herein by reference in their entirety.

[0164] Heterozygous familial hypercholesterolemia poorly controlled with the maximum tolerated dose of statins, with or without other lipid-lowering therapy.

[0165] This invention generally relates to methods and compositions for treating patients with heterozygous familial hypercholesterolemia who have undercontrolled hypercholesterolemia with the maximum tolerated dose of statins, with or without other lipid-lowering therapy; that is, hypercholesterolemia that is undercontrolled with a treatment regimen comprising the maximum tolerated daily dose of statins. As used herein, the term “undercontrolled” in the context of hypercholesterolemia means that a patient’s serum low-density lipoprotein cholesterol (LDL-C), total cholesterol, and / or triglyceride levels have not decreased to a reasonably medically acceptable level (considering the patient’s relative risk of coronary heart disease) after at least 4 weeks of treatment with a stable daily dose of statins. For example, “patients with undercontrolled hypercholesterolemia” includes patients with serum LDL-C concentrations greater than or equal to about 70 mg / dL, 100 mg / dL, 130 mg / dL, 140 mg / dL, or higher (depending on the patient’s underlying cardiac risk) after at least 4 weeks of stable daily statin therapy.

[0166] According to some embodiments, patients with heterozygous familial hypercholesterolemia who are inadequately controlled with maximum tolerated dose statin therapy, with or without other lipid-lowering treatment, and who can be treated with the method of the present invention, have hypercholesterolemia (i.e., serum LDL-C concentration greater than or equal to 70 mg / dL in patients with a recorded cardiovascular history or serum LDL-C ≥100 mg / dL in patients without a recorded cardiovascular history), even though said patients have been taking a stable daily dose of statin (with or without other lipid-improving therapy) for at least 4, 5, 6, or more weeks. In some embodiments, the hypercholesterolemia in patients with heterozygous familial hypercholesterolemia is inadequately controlled with maximum tolerated dose statin therapy (also referred to as a "daily maximum tolerated dose therapeutic statin therapy regimen").

[0167] As used herein, “maximum tolerated dose statin therapy” means a treatment regimen that includes administering a daily dose of statin, which is the maximum tolerated dose for a specific patient. Maximum tolerated dose means the highest dose of statin that can be administered to a patient without causing unacceptable adverse effects. Maximum tolerated dose statin therapy includes, but is not limited to, for example, 40–80 mg of atorvastatin daily, or 20–40 mg of rosuvastatin daily, or 80 mg of simvastatin (if this dose has been received for >1 year). However, if there are acceptable reasons not to use higher doses, patients who cannot tolerate the above-mentioned statin doses may take a lower daily dose of atorvastatin, rosuvastatin, or simvastatin. Some examples of acceptable reasons for patients to take a lower statin dose include: adverse reactions to higher doses, advanced age, low body mass index (BMI), regional practice, local prescribing information, concomitant medications, and comorbid conditions such as impaired glucose tolerance / impaired fasting glucose.

[0168] The present invention also includes a method for treating a patient with heterozygous familial hypercholesterolemia who is poorly controlled by treatment with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, the method comprising daily administration of other statins such as cerivastatin, pitavastatin, fluvastatin, lovastatin, and pravastatin.

[0169] Patient selection

[0170] The present invention includes methods and compositions for treating patients with heterozygous familial hypercholesterolemia who have poorly controlled cholesterol levels with the maximum tolerated dose of statins, with or without other lipid-lowering therapy.

[0171] The diagnosis of heFH must be made through genotyping or clinical criteria. For patients who have not undergone genotyping, a clinical diagnosis can be based on a score >8 on the Simon Broome criteria or the WHO / Dutch Lipid Network criteria, which have specific criteria for FH.

[0172] According to the Simon Broome Registry diagnostic criteria for heterozygous familial hypercholesterolemia, the precise definition of familial hypercholesterolemia is: 1) Total C > 6.7 mmol / L (260 mg / dL) or LDL cholesterol > 4.0 mmol / L (155 mg / dL) in children <16 years of age, or Total C > 7.5 mmol / L (290 mg / dL) or LDL cholesterol > 4.9 mmol / L (190 mg / dL) in adults (pre-treatment levels or highest levels during treatment); plus either A) tendon xanthoma in the patient, or in first-degree relatives (parents, siblings, children), or in second-degree relatives (grandparents, uncles / aunts); or B) DNA-based evidence of LDL receptor mutations or familial apo B-100 deficiency.

[0173] According to the Simon Broome Registry diagnostic criteria for heterozygous familial hypercholesterolemia, probable familial hypercholesterolemia is defined as: 1) total cholesterol >6.7 mmol / L (260 mg / dL) or LDL cholesterol >4.0 mmol / L (155 mg / dL) in children <16 years of age or total cholesterol >7.5 mmol / L (290 mg / dL) or LDL cholesterol >4.9 mmol / L (190 mg / dL) in adults (pre-treatment levels or highest levels during treatment); and at least one of the following: A) a family history of myocardial infarction (MI) in second-degree relatives under 50 years of age or in first-degree relatives under 60 years of age; and B) a family history of elevated cholesterol >7.5 mmol / L (290 mg / dL) in first- or second-degree relatives in adults, or >6.7 mmol / L (260 mg / dL) in children or siblings under 16 years of age.

[0174] The WHO criteria (Dutch Lipid Network Clinical Criteria) for diagnosing heterozygous familial hypercholesterolemia (heFH) are shown in the examples, as in Table 2.

[0175] According to some implementation schemes, patients with heterozygous familial hypercholesterolemia can be selected based on having one or more additional risk factors selected from the following groups: age (e.g., greater than 40, 45, 50, 55, 60, 65, 70, 75, or 80 years), race, nationality, sex (male or female), exercise habits (e.g., regular exerciser, non-exerciser), other existing medical conditions (e.g., type II diabetes, hypertension, myocardial infarction, ischemic stroke, etc.) and current medication status (e.g., currently using beta-blockers, niacin, ezetimibe, fibrates, omega-3 fatty acids, bile acid resins, etc.).

[0176] According to the present invention, patients with heterozygous familial hypercholesterolemia can be selected based on a combination of the aforementioned selection criteria or treatment characteristics.

[0177] PCSK9 inhibitors were administered as add-on therapy to the maximum tolerated dose of statins.

[0178] This invention includes a method in which a patient with heterozygous familial hypercholesterolemia who is poorly controlled with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, is administered a PCSK9 inhibitor at a specific dosage and frequency, wherein the administration of the PCSK9 inhibitor is as add-on therapy to the patient's therapeutic statin regimen. For example, according to some embodiments, if a patient with heterozygous familial hypercholesterolemia is poorly controlled with the maximum tolerated dose of statins, with or without other lipid-lowering therapy (including, for example, 40-80 mg atorvastatin), the patient may be administered a PCSK9 inhibitor at a specific dosage and dosing interval while the patient continues their stable daily therapeutic statin regimen.

[0179] The method of the present invention includes an add-on treatment regimen in which the PCSK9 inhibitor is administered as an add-on to the same stable maximum tolerated daily dose (MTBD) therapeutic statin regimen (i.e., the same dosage of statin), which is the same stable MTBD therapeutic statin regimen taken by a patient at risk of heterozygous familial hypercholesterolemia prior to receiving the PCSK9 inhibitor. In other embodiments, the PCSK9 inhibitor is administered as an add-on to the MTBD therapeutic statin regimen (which contains an amount of statin that is more or less than the statin dose taken by the patient prior to receiving the PCSK9 inhibitor). For example, after initiating a therapeutic treatment regimen including administration of the PCSK9 inhibitor at a specific frequency and dosage, the daily dose of statin administered to or prescribed to the patient may (a) remain unchanged, (b) increase, or (c) decrease (e.g., titrate up or down) depending on the patient's treatment needs, compared to the daily statin dose taken by a high-risk cardiovascular patient prior to initiating the PCSK9 inhibitor therapeutic treatment regimen.

[0180] Therapeutic effects

[0181] The present invention results in improved serum levels of one or more lipid components selected from the group consisting of: LDL-C, ApoB, non-HDL-C, total cholesterol, HDL-C, triglycerides, Apo A-1, and Lp(a). For example, according to some embodiments of the invention, administration of a pharmaceutical composition containing a PCSK9 inhibitor to patients with heterozygous familial hypercholesterolemia who are poorly controlled by a stable daily maximum tolerated dose of therapeutic statins (i.e., administration of a PCSK9 inhibitor in addition to the patient's maximum tolerated dose of statins) results in a decrease in serum low-density lipoprotein cholesterol (LDL-C) of at least about 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, or greater, from the mean percentage of baseline; a decrease in ApoB of at least about 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, or greater, from the mean percentage of baseline; and a decrease in non-HDL-C of at least about 40%. %, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, or greater percentage decrease from baseline in total cholesterol; at least about 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, or greater percentage decrease from baseline in HDL-C; at least about 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, or greater percentage increase from baseline in triglycerides; at least about 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, or greater percentage decrease from baseline in Apo A-1 is increased by at least about 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, or greater percentage of the mean from the baseline; and / or Lp(a) is decreased by at least about 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, or greater percentage of the mean from the baseline.

[0182] PCSK9 inhibitors

[0183] The method of the present invention comprises administering a therapeutic composition containing a PCSK9 inhibitor to a patient with heterozygous familial hypercholesterolemia poorly controlled with the maximum tolerated dose of statins, with or without other lipid-lowering therapy. As used herein, a “PCSK9 inhibitor” is any substance that binds to or interacts with PCSK9 and inhibits the normal biological function of PCSK9 in vitro or in vivo. Non-limiting examples of the PCSK9 inhibitor class include small molecule PCSK9 antagonists, peptide-based PCSK9 antagonists (e.g., “peptibody” molecules), and antibodies or antigen-binding fragments of antibodies that specifically bind to human PCSK9.

[0184] As used herein, the terms “human proprotein convertase subtilisin / kexin 9” or “human PCSK9” or “hPCSK9” mean PCSK9 having the nucleic acid sequence shown in SEQ ID NO: 197 and the amino acid sequence of SEQ ID NO: 198, or a biologically active fragment thereof.

[0185] As used herein, the term "antibody" refers to an immunoglobulin molecule comprising four polypeptide chains, as well as immunoglobulin molecules containing their multimers (e.g., IgM), wherein the four polypeptide chains are two heavy (H) chains and two light (L) chains linked together by disulfide bonds. Each heavy chain comprises a heavy chain variable region (hereinafter referred to as HCVR or VH) and a heavy chain constant region. The heavy chain constant region comprises three domains, CH1, CH2, and CH3. Each light chain comprises a light chain variable region (hereinafter referred to as LCVR or VL) and a light chain constant region. The light chain constant region comprises one domain (CL1). The VH and VL regions can be further subdivided into hypervariable regions (called complementarity-determining regions (CDRs)) interspersed with more conserved regions called framework regions (FRs). Each VH and VL consists of three CDRs and four FRs, arranged in the following order from the amino terminus to the carboxyl terminus: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In different embodiments of the invention, the FR of the anti-PCSK9 antibody (or its antigen-binding portion) may be identical to the human germline sequence, or may be natural or artificially modified. The common amino acid sequence may be defined based on parallel (side-by-side) analysis of two or more CDRs.

[0186] As used herein, the term "antibody" also includes the antigen-binding fragment of a complete antibody molecule. As used herein, the terms "antigen-binding portion," "antigen-binding fragment," etc., of an antibody include any naturally occurring, enzymatically obtained, synthetic, or genetically engineered polypeptide or glycoprotein that specifically binds to an antigen to form a complex. The antigen-binding fragment of an antibody can be derived from a complete antibody molecule, for example, using any suitable standard technique (such as proteolytic digestion or recombinant genetic engineering techniques involving the manipulation and expression of DNA encoding antibody variable domains and optional constant domains). This DNA is known and / or readily available from, for example, commercial sources, DNA libraries (including, for example, phage-antibody libraries), or can be synthetic. The DNA can be sequenced and chemically manipulated or used with molecular biology techniques to, for example, arrange one or more variable domains and / or constant domains into suitable conformations, or introduce codons, generate cysteine ​​residues, modify, add or delete amino acids, etc.

[0187] Non-limiting examples of antigen-binding fragments include: (i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single-chain Fv (scFv) molecules; (vi) dAb fragments; and (vii) minimal recognition units composed of amino acid residues of a hypervariable region of a mimicking antibody (e.g., a separated complementarity-determining region (CDR) such as a CDR3 peptide), or of a constrained FR3-CDR3-FR4 peptide. Other engineered molecules, such as domain-specific antibodies, single-domain antibodies, domain-deficient antibodies, chimeric antibodies, CDR-grafted antibodies, biantibodies, triantibodies, tetraantibodies, microantibodies, nanobodies (e.g., monovalent nanobodies, bivalent nanobodies, etc.), small modular immunopharmaceuticals (SMIPs), and shark variable IgNAR domains, are also included in the term "antigen-binding fragments" as used herein.

[0188] Antigen-binding fragments of antibodies typically contain at least one variable domain. The variable domain can be of any size or have any amino acid composition, and typically contains at least one CDR adjacent to or co-framed with one or more frame sequences. In antigen-binding fragments having a VH domain linked to a VL domain, the VH and VL domains can be positioned relative to each other in a suitable arrangement. For example, the variable region can be dimerized and contain VH-VH, VH-VL, or VL-VL dimers. Alternatively, the antigen-binding fragment of an antibody can contain a monomeric VH or VL domain.

[0189] In some embodiments, the antigen-binding fragment of the antibody may contain at least one variable domain covalently linked to at least one constant domain. Non-limiting exemplary configurations of the variable and constant domains visible within the antigen-binding fragment of the antibody of the present invention include: (i) VH-CH1; (ii) VH-CH2; (iii) VH-CH3; (iv) VH-CH1-CH2; (v) VH-CH1-CH2-CH3; (vi) VH-CH2-CH3; (vii) VH-CL; (viii) VL-CH1; (ix) VL-CH2; (x) VL-CH3; (xi) VL-CH1-CH2; (xii) VL-CH1-CH2-CH3; (xiii) VL-CH2-CH3; and (xiv) VL-CL. In any configuration of the variable and constant domains (including the exemplary configurations described above), the variable and constant domains may be directly interconnected or connected via fully or partially hinged or connector regions. The hinge region may consist of at least two (e.g., 5, 10, 15, 20, 40, 60 or more) amino acids, which create flexible or semi-flexible connections between adjacent variable and / or constant domains in a single polypeptide molecule. Furthermore, the antigen-binding fragment of the antibody of the present invention may comprise any of the aforementioned variable and constant domain configurations non-covalently interconnected and / or linked to one or more monomeric VH or VL domains (e.g., via disulfide bonds) to form a homodimer or heterodimer (or other multimer).

[0190] Just like complete antibody molecules, antigen-binding fragments can be monospecific or multispecific (e.g., bispecific). Multispecific antigen-binding fragments of antibodies typically contain at least two distinct variable domains, each capable of specifically binding to a different antigen or to a different epitope on the same antigen. Any form of multispecific antibody (including the exemplary bispecific antibody forms disclosed herein) can be modified using conventional techniques available in the art to suit the antigen-binding fragments of the antibodies of this invention.

[0191] The constant region of an antibody is important for its ability to fix complement and mediate cell-dependent cytotoxicity. Therefore, antibody isotypes can be selected based on their suitability for antibody-mediated cytotoxicity.

[0192] As used herein, the term "human antibody" is intended to include antibodies having variable and constant regions derived from human germline immunoglobulin sequences. The human antibodies of the present invention may (e.g., in CDRs, and particularly in CDR3) include amino acid residues not encoded by human germline immunoglobulin sequences (e.g., mutations introduced by random or site-specific mutagenesis in vitro or by somatic mutations in vivo). However, the term "human antibody" as used herein is not intended to include antibodies in which germline CDR sequences derived from other mammalian species (e.g., mice) are transposed onto human frame sequences.

[0193] As used herein, the term "recombinant human antibody" is intended to include all human antibodies prepared, expressed, generated, or isolated by recombinant methods, such as antibodies expressed using a recombinant expression vector transfected into host cells (described further below), antibodies isolated from recombinant, combined human antibody libraries (described further below), antibodies isolated from animal (e.g., mouse) transgenic human immunoglobulin genes (see, for example, Taylor et al. (1992) Nucl. Acids Res. 20:6287-6295), or antibodies prepared, expressed, generated, or isolated by any other means involving splicing human immunoglobulin gene sequences into other DNA sequences. Such recombinant human antibodies have variable and constant regions derived from human germline immunoglobulin sequences. However, in some implementations, such recombinant human antibodies undergo in vitro mutagenesis (or in vivo somatic mutagenesis when using animals transgenic for human Ig sequences) and thus the amino acid sequences of the VH and VL regions of the recombinant antibody are sequences that, although derived from and associated with human germline VH and VL sequences, are not naturally present within the human antibody germline repertoire.

[0194] Human antibodies can exist in two forms, which are related to hinge heterogeneity. In one form, the immunoglobulin molecule contains a stable four-chain structure of approximately 150-160 kDa, where dimers are linked together by interchain heavy chain disulfide bonds. In the second form, the dimers are not linked by interchain disulfide bonds, and the molecule, approximately 75-80 kDa, is formed by covalently coupled light and heavy chains (half-antibodies). These forms are extremely difficult to separate even after affinity purification.

[0195] The frequency of the second form in various intact IgG isotypes is due to (but not limited to) structural differences associated with the hinge region isotype of the antibody. Single amino acid substitutions in the hinge region of the human IgG4 hinge can significantly reduce the occurrence of the second form (Angal et al. (1993) Molecular Immunology 30:105) to levels typically observed with the human IgG1 hinge. This invention covers antibodies with one or more mutations in the hinge, CH2, or CH3 region, which may be desirable, for example, in production, to improve the yield of the desired antibody form.

[0196] As used herein, "isolated antibody" means an antibody that has been identified, isolated, and / or recovered from at least one component of the antibody in its natural environment. For example, antibodies that have been isolated or recovered from at least one component of an organism, or from tissues or cells where the antibody is naturally present or produced, are "isolated antibodies" for the purposes of this invention. Isolated antibodies also include recombinant intracellular in situ antibodies. Isolated antibodies are antibodies that have undergone at least one purification or isolation step. According to some embodiments, isolated antibodies may be substantially free of other cellular material and / or chemicals.

[0197] The term "specific binding" or similar expression means that an antibody or its antigen-binding fragment forms a relatively stable complex with an antigen under physiological conditions. Methods for determining whether an antibody specifically binds to an antigen are well known in the art and include, for example, equilibrium dialysis, surface plasmon resonance, etc. For example, antibodies that "specifically bind" PCSK9 as used in this context include antibodies or portions thereof that bind to PCSK9 at KD values ​​below about 1000 nM, below about 500 nM, below about 300 nM, below about 200 nM, below about 100 nM, below about 90 nM, below about 80 nM, below about 70 nM, below about 60 nM, below about 50 nM, below about 40 nM, below about 30 nM, below about 20 nM, below about 10 nM, below about 5 nM, below about 4 nM, below about 3 nM, below about 2 nM, below about 1 nM, or below about 0.5 nM, as determined by surface plasmon resonance assay. However, isolated antibodies that specifically bind to human PCSK9 are cross-reactive to other antigens, such as PCSK9 molecules from other (non-human) species.

[0198] Anti-PCSK9 antibodies usable in the methods of this invention may contain one or more amino acid substitutions, insertions, and / or deletions in the frame regions and / or CDR regions of the heavy and light chain variable domains, compared to their corresponding germline sequences. Such mutations can be readily identified by comparing the amino acid sequences disclosed herein with germline sequences available from, for example, public antibody sequence databases. This invention includes methods involving the use of antibodies and their antigen-binding fragments (derived from any amino acid sequence disclosed herein), wherein one or more amino acids in one or more frame and / or CDR regions are mutated to corresponding residues in the germline sequence from which the antibody is derived, or mutated to corresponding residues in another human germline sequence, or mutated to conserved amino acid substitutions of corresponding germline residues (such sequence changes are collectively referred to herein as “germline mutations”). Those skilled in the art, starting with the heavy and light chain variable region sequences disclosed herein, can readily produce numerous antibodies and antigen-binding fragments containing one or more individual germline mutations or combinations thereof. In some embodiments, all frame and / or CDR residues in the VH and / or VL domains are mutated back to residues found in the initial germline sequence from which the antibody is derived. In other embodiments, only certain residues are mutated back to the initial germline sequence, such as mutated residues found only in the first 8 amino acids of FR1 or the last 8 amino acids of FR4, or mutated residues found only in CDR1, CDR2, or CDR3. In other embodiments, one or more frame and / or CDR residues are mutated to corresponding residues of a different germline sequence (i.e., a germline sequence different from the initial germline sequence from which the antibody originated). Furthermore, the antibodies of the present invention may contain any combination of two or more germline mutations within the frame and / or CDR regions, for example, certain individual residues mutated to corresponding residues of a specific germline sequence, while other residues different from the initial germline sequence are retained or mutated to corresponding residues of a different germline sequence. Once obtained, antibodies containing one or more germline mutations and antigen-binding fragments can be readily tested for one or more desired properties, such as improved binding specificity, increased binding affinity, improved or enhanced antagonistic or agonistic biological properties (as applicable), reduced immunogenicity, etc. The use of antibodies and antigen-binding fragments obtained in this general manner is covered within the scope of the present invention.

[0199] The present invention also includes methods relating to the use of anti-PCSK9 antibodies comprising variants of any HCVR, LCVR, and / or CDR amino acid sequences disclosed herein, having one or more conserved substitutions. For example, the present invention includes the use of anti-PCSK9 antibodies having HCVR, LCVR, and / or CDR amino acid sequences having conserved amino acid substitutions of 10 or fewer, 8 or fewer, 6 or fewer, 4 or fewer, etc., compared to any HCVR, LCVR, and / or CDR amino acid sequences disclosed herein.

[0200] As used herein, the term “surface plasmon resonance” refers to an optical phenomenon that allows for the analysis of real-time interactions by detecting changes in protein concentration within a biosensor matrix, for example, using a BIAcore™ system (Biacore Life Sciences division of GE Healthcare, Piscataway, NJ).

[0201] As used in this article, the term "KD" refers to the equilibrium dissociation constant of a specific antibody-antigen interaction.

[0202] The term "epitope" refers to an antigenic determinant that interacts with a specific antigen-binding site (called a complementary site) in the variable region of an antibody molecule. A single antigen may have more than one epitope. Therefore, different antibodies can bind to different regions of the antigen and may have different biological effects. Epitopes can be conformational or linear. Conformational epitopes are generated from spatially juxtaposed amino acids from different segments of a linear polypeptide chain. Linear epitopes are generated from adjacent amino acid residues in the polypeptide chain. In some cases, epitopes may include sugar, phosphoryl, or sulfonyl groups on the antigen.

[0203] According to some embodiments, the anti-PCSK9 antibody used in the method of the present invention is an antibody with pH-dependent binding characteristics. As used herein, the expression "pH-dependent binding" means that the antibody or its antigen-binding fragment exhibits "reduced binding to PCSK9 at acidic pH compared to neutral pH" (the two expressions are used interchangeably for the purposes of this invention). For example, antibodies "with pH-dependent binding characteristics" include antibodies and their antigen-binding fragments that bind PCSK9 at neutral pH with a higher affinity at acidic pH than at neutral pH. In some embodiments, the antibody and antigen-binding fragment of the present invention bind PCSK9 at neutral pH with an affinity at least 3, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100 or more times higher than at acidic pH.

[0204] According to this aspect of the invention, an anti-PCSK9 antibody with pH-dependent binding characteristics may have one or more amino acid variations relative to the parental anti-PCSK9 antibody. For example, an anti-PCSK9 antibody with pH-dependent binding characteristics may contain one or more histidine substitutions or insertions in one or more CDRs of the parental anti-PCSK9 antibody. Therefore, according to some embodiments of the invention, a method is provided comprising administering an anti-PCSK9 antibody comprising a CDR amino acid sequence (e.g., heavy chain and light chain CDRs) identical to the CDR amino acid sequence of the parental anti-PCSK9 antibody, except that one or more amino acids in one or more CDRs of the parental antibody are substituted with histidine residues. An anti-PCSK9 antibody with pH-dependent binding may have, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9 or more histidine substitutions, either in a single CDR of the parental antibody or distributed throughout multiple (e.g., 2, 3, 4, 5 or 6) CDRs of the parental anti-PCSK9 antibody. For example, the present invention includes the use of an anti-PCSK9 antibody with pH-dependent binding, comprising one or more histidine substitutions in HCDR1, one or more histidine substitutions in HCDR2, one or more histidine substitutions in HCDR3, one or more histidine substitutions in LCDR1, one or more histidine substitutions in LCDR2, and / or one or more histidine substitutions in LCDR3 of the parental anti-PCSK9 antibody.

[0205] As used herein, the term "acidic pH" means a pH of 6.0 or lower (e.g., below about 6.0, below about 5.5, below about 5.0, etc.). The term "acidic pH" includes pH values ​​of about 6.0, 5.95, 5.90, 5.85, 5.8, 5.75, 5.7, 5.65, 5.6, 5.55, 5.5, 5.45, 5.4, 5.35, 5.3, 5.25, 5.2, 5.15, 5.1, 5.05, 5.0 or lower. As used herein, the term "neutral pH" means a pH of about 7.0 to about 7.4. The term "neutral pH" includes pH values ​​of about 7.0, 7.05, 7.1, 7.15, 7.2, 7.25, 7.3, 7.35, and 7.4.

[0206] Preparation of human antibodies

[0207] Methods for generating human antibodies in transgenic mice are known in the art. Any such known method can be used in the context of this invention to produce human antibodies that specifically bind to human PCSK9.

[0208] Using VELOCIMMUNE™ technology (see, for example, US 6,596,541, Regeneron Pharmaceuticals) or any other known method for producing monoclonal antibodies, a high-affinity chimeric antibody against PCSK9, having a human variable region and a mouse constant region, was initially isolated. The VELOCIMMUNE® technology involves the generation of transgenic mice having a genome containing human heavy and light chain variable regions (operably linked to endogenous mouse constant region loci), such that the mice respond to antigen stimulation to produce antibodies containing both human variable and mouse constant regions. DNA encoding the heavy and light chain variable regions of the antibody is isolated and operably linked to DNA encoding the human heavy and light chain constant regions. This DNA is then expressed in cells capable of expressing a fully human antibody.

[0209] Typically, VELOCIMMUNE® mice are challenged with a target antigen, and lymphocytes (such as B cells) are recovered from the antibody-expressing mice. These lymphocytes can be fused with myeloma cell lines to prepare immortalized hybridoma cell lines, and these hybridoma cell lines can be screened and selected to identify hybridoma cell lines that produce antibodies specifically against the target antigen. DNA encoding the variable regions of the heavy and light chains can be isolated and ligated to desired homotype heavy and light chain constant regions. Such antibody proteins can be produced in cells (e.g., CHO cells). Alternatively, DNA encoding antigen-specific chimeric antibodies or light and heavy chain variable domains can be directly isolated from antigen-specific lymphocytes.

[0210] Initially, a high-affinity chimeric antibody containing a human variable region and a mouse constant region is isolated. The antibody is characterized using standard procedures known to those skilled in the art, and desirable characteristics are selected, including affinity, selectivity, epitopes, etc. The mouse constant region is replaced with a desirable human constant region to generate the fully human antibody of the present invention, such as wild-type or modified IgG1 or IgG4. While the selected constant region can vary depending on the specific application, high-affinity antigen binding and target-specific characteristics are present within the variable region.

[0211] Generally, antibodies suitable for use in the methods of this invention possess high affinity, as described above, which is measured by binding to antigens immobilized on a solid phase or in a solution phase. A suitable human constant region is used to replace the mouse constant region to generate the fully human antibody of this invention. While the selected constant region can vary depending on the specific application, high-affinity antigen binding and target-specific characteristics are present in the variable region.

[0212] Specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind to PCSK9 and can be used in the methods of the present invention include any antibody or antigen-binding fragment containing three heavy chain CDRs (HCDR1, HCDR2, and HCDR3), wherein the heavy chain CDRs are contained within a heavy chain variable region (HCVR) having an amino acid sequence selected from SEQ ID NO: 1 and 11, or a substantially similar sequence having at least 90%, at least 95%, at least 98%, or at least 99% sequence identity. Alternatively, specific examples of human antibodies or antigen-binding fragments of antibodies that specifically bind to PCSK9 and can be used in the methods of the present invention include any antibody or antigen-binding fragment comprising three heavy chain CDRs (HCDR1, HCDR2, and HCDR3), said heavy chain CDRs being contained within a heavy chain variable region (HCVR) having an amino acid sequence selected from SEQ ID NO 37, 45, 53, 61, 69, 77, 85, 93, 101, 109, 117, 125, 133, 141, 149, 157, 165, 173, 181, and 189, or substantially similar sequences having at least 90%, at least 95%, at least 98%, or at least 99% sequence identity. The antibody or antigen-binding fragment may comprise three light chain CDRs (LCDR1, LCDR2, and LCDR3) contained within a light chain variable region (LCVR) having an amino acid sequence selected from SEQ ID NO: 6 and 15, or a substantially similar sequence having at least 90%, at least 95%, at least 98%, or at least 99% sequence identity. Alternatively, the antibody or antigen-binding fragment may comprise three light chain CDRs (LCDR1, LCDR2, and LCDR3) contained within a light chain variable region (LCVR) having an amino acid sequence selected from SEQ ID NO: 41, 49, 57, 65, 73, 81, 89, 97, 105, 113, 121, 129, 137, 145, 153, 161, 169, 177, 185, and 193, or a substantially similar sequence having at least 90%, at least 95%, at least 98%, or at least 99% sequence identity.

[0213] In some embodiments of the present invention, the antibody or its antigen-binding fragment comprises six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) from the heavy chain and light chain variable region amino acid sequence pair (HCVR / LCVR), wherein the HCVR / LCVR is selected from the group consisting of SEQ ID NO: 1 / 6 and 11 / 15. Alternatively, in some embodiments of the invention, the antibody or antigen-binding protein comprises six CDRs (HCDR1, HCDR2, HCDR3, LCDR1, LCDR2, and LCDR3) from the heavy chain and light chain variable region amino acid sequence pair (HCVR / LCVR), wherein the HCVR / LCVR is selected from the group consisting of: SEQ ID NO: 37 / 41, 45 / 49, 53 / 57, 61 / 65, 69 / 73, 77 / 81, 85 / 89, 93 / 97, 101 / 105, 109 / 113, 117 / 121, 125 / 129, 133 / 137, 141 / 145, 149 / 153, 157 / 161, 165 / 169, 173 / 177, 181 / 185, and 189 / 193.

[0214] In some embodiments of the present invention, the anti-PCSK9 antibody or its antigen-binding fragment that can be used in the methods of the present invention has the HCDR1 / HCDR2 / HCDR3 / LCDR1 / LCDR2 / LCDR3 amino acid sequence selected from SEQ ID NO: 2 / 3 / 4 / 7 / 8 / 10 (mAb316P) and 12 / 13 / 14 / 16 / 17 / 18 (mAb300N) (see U.S. Patent Application Publication No. 2010 / 0166768).

[0215] In some embodiments of the present invention, the antibody or its antigen-binding fragment comprises an HCVR / LCVR amino acid sequence pair selected from SEQ ID NO: 1 / 6 and 11 / 15. Alternatively, in some embodiments of the present invention, the antibody or antigen-binding protein comprises an HCVR / LCVR amino acid sequence pair selected from the group consisting of: SEQ ID NO: 37 / 41, 45 / 49, 53 / 57, 61 / 65, 69 / 73, 77 / 81, 85 / 89, 93 / 97, 101 / 105, 109 / 113, 117 / 121, 125 / 129, 133 / 137, 141 / 145, 149 / 153, 157 / 161, 165 / 169, 173 / 177, 181 / 185, and 189 / 193.

[0216] Pharmaceutical Composition and Administration

[0217] This invention includes a method comprising administering a PCSK9 inhibitor to a patient with heterozygous familial hypercholesterolemia who is poorly controlled with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, wherein the PCSK9 inhibitor is contained in a pharmaceutical composition. The pharmaceutical compositions of this invention are formulated with suitable carriers, excipients, and other formulations that provide suitable transport, delivery, tolerability, etc. A large number of suitable formulations are available in all formularies known to medicinal chemists: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. These formulations include, for example, powders, pastes, ointments, gels, waxes, oils, lipids, vesicle-containing lipids (cationic or anionic) (such as LIPOFECTIN™), DNA conjugates, anhydrous absorbent pastes, oil-in-water and water-in-oil emulsions, carbowax emulsions (polyethylene glycol of various molecular weights), semi-solid gels, and semi-solid mixtures containing carbowax. See also Powell et al., "Compendium of excipients for parenteral formulations" PDA (1998) J Pharm Sci Technol 52:238-311.

[0218] Various delivery systems are known and can be used to administer the pharmaceutical compositions of the present invention, such as those encapsulated in liposomes, microparticles, microcapsules, recombinant cells expressing mutant viruses, and receptor-mediated endocytosis (see, for example, Wu et al., 1987, J. Biol. Chem. 262:4429-4432). Administration methods include, but are not limited to, intradermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural, and oral routes. The composition can be administered via any convenient route, such as by infusion or bolus, by absorption through the epithelial or mucosal layers of the skin (e.g., oral mucosa, rectal and intestinal mucosa), and can be administered together with other bioactive agents.

[0219] The pharmaceutical compositions of the present invention can be administered subcutaneously or intravenously using standard needles and syringes. Furthermore, for subcutaneous delivery, a pen delivery device can be readily applied to deliver the pharmaceutical compositions of the present invention. Such a pen delivery device can be reusable or disposable. Reusable pen delivery devices typically employ a replaceable cartridge containing the pharmaceutical composition. Once all the pharmaceutical composition in the cartridge has been administered and the cartridge is empty, the empty cartridge can be easily discarded and replaced with a new cartridge containing the pharmaceutical composition. The pen delivery device can then be reused. In disposable pen delivery devices, there is no replaceable cartridge. Instead, the disposable pen delivery device is pre-filled with the pharmaceutical composition, which is stored in a reservoir within the device. Once the pharmaceutical composition in the reservoir is depleted, the entire device is discarded.

[0220] Many reusable pens and autoinjector delivery devices can be used for subcutaneous delivery of the pharmaceutical compositions of the present invention. Examples include, but are not limited to, AUTOPEN™ (Owen Mumford, Inc., Woodstock, UK), DISETRONIC™ pen (Disetronic Medical Systems, Bergdorf, Switzerland), HUMALOG MIX 75 / 25™ pen, HUMALOG™ pen, HUMALIN 70 / 30™ pen (Eli Lilly and Co., Indianapolis, IN), NOVOPEN™ I, II and III (Novo Nordisk, Copenhagen, Denmark), NOVOPEN JUNIOR™ (Novo Nordisk, Copenhagen, Denmark), BD™ pen (Becton Dickinson, Franklin Lakes, NJ), OPTIPEN™, OPTIPEN PRO™, OPTIPEN STARLET™, and OPTICLIK™ (sanofi-aventis, Frankfurt, Germany), to name just a few. Examples of disposable pen delivery devices applicable to the subcutaneous delivery of the pharmaceutical compositions of the present invention include, but are not limited to, the SOLOSTAR™ pen (sanofi-aventis), FLEXPEN™ (Novo Nordisk), and KWIKPEN™ (Eli Lilly), and SURECLICK. TM Automatic injector (Amgen, Thousand Oaks, CA), PENLET TM(Haselmeier, Stuttgart, Germany), EPIPEN (Dey, LP), and HUMIRA TM Pens (Abbott Labs, Abbott Park IL), to name just a few.

[0221] In some cases, the drug composition can be delivered using a controlled-release system. In one embodiment, a pump can be used (see Langer; Sefton, 1987, CRC Crit. Ref. Biomed. Eng. 14:201). In another embodiment, polymeric materials can be used, see Medical Applications of Controlled Release, Langer and Wise (eds.), 1974, CRC Pres., Boca Raton, Florida. In yet another embodiment, the controlled-release system can be placed adjacent to the target of the composition, thus requiring only a portion of the systemic dose (see, for example, Goodson, 1984, in Medical Applications of Controlled Release, cf., vol.2, pp. 115-138). Other controlled-release systems are discussed in the review in Langer, 1990, Science 249:1527-1533.

[0222] Injectable preparations may include dosage forms for intravenous, subcutaneous, intradermal, and intramuscular injection, infusion, etc. These injectable preparations can be prepared by known methods. For example, injectable formulations can be prepared by dissolving, suspending, or emulsifying the aforementioned antibody or its salts in a sterile aqueous or oily medium conventionally used for injection. Aqueous media for injection include, for example, physiological saline, isotonic solutions containing glucose and other adjuvants, which can be used in combination with suitable solubilizers such as alcohols (e.g., ethanol), polyols / polymeric alcohols (e.g., propylene glycol, polyethylene glycol), nonionic surfactants [e.g., polysorbate 80, HCO-50 (a polyoxyethylene (50 mol) adduct of hydrogenated castor oil)], etc. Oily media include, for example, sesame oil, soybean oil, etc., which can be used in combination with solubilizers such as benzyl benzoate, benzyl alcohol, etc. Injectable preparations thus prepared are preferably filled into suitable ampoules.

[0223] Advantageously, the above-described pharmaceutical compositions for oral or parenteral use are prepared into unit dose dosage forms, said unit dose being suitable for combining with the active ingredient. Such unit dose dosage forms include, for example, tablets, pills, capsules, injections (ampoules), suppositories, etc.

[0224] dose

[0225] The amount of PCSK9 inhibitor (e.g., anti-PCSK9 antibody) administered according to the method of the invention to patients with heterozygous familial hypercholesterolemia poorly controlled by the maximum tolerated dose of statins, with or without other lipid-lowering therapy, is typically a therapeutically effective amount. As used herein, the phrase "therapeutically effective amount" means a dose of PCSK9 inhibitor that results in a detectable improvement (at least about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75% or more from baseline) of one or more parameters selected from the group consisting of: LDL-C, ApoB, non-HDL-C, total cholesterol, HLDL-C, triglycerides, Apo A-1, and Lp(a).

[0226] For anti-PCSK9 antibodies, the therapeutically effective dose can be from approximately 0.05 mg to approximately 600 mg, for example, approximately 0.05 mg, approximately 0.1 mg, approximately 1.0 mg, approximately 1.5 mg, approximately 2.0 mg, approximately 10 mg, approximately 20 mg, approximately 30 mg, approximately 40 mg, approximately 50 mg, approximately 60 mg, approximately 70 mg, approximately 75 mg, approximately 80 mg, approximately 90 mg, approximately 100 mg, approximately 110 mg, approximately 120 mg, approximately 130 mg, approximately 140 mg, approximately 150 mg, approximately 160 mg, approximately 170 mg, approximately 180 mg, approximately 190 mg, approximately 200 mg, approximately 210 mg, approximately 220 mg, approximately 230 mg, approximately 240 mg, approximately 250 mg, approximately 260 mg, approximately 270 mg, approximately 280 mg, approximately 290 mg, approximately 300 mg, approximately 310 mg, approximately 320 mg, etc. Anti-PCSK9 antibody in the following amounts: approximately 330 mg, approximately 340 mg, approximately 350 mg, approximately 360 mg, approximately 370 mg, approximately 380 mg, approximately 390 mg, approximately 400 mg, approximately 410 mg, approximately 420 mg, approximately 430 mg, approximately 440 mg, approximately 450 mg, approximately 460 mg, approximately 470 mg, approximately 480 mg, approximately 490 mg, approximately 500 mg, approximately 510 mg, approximately 520 mg, approximately 530 mg, approximately 540 mg, approximately 550 mg, approximately 560 mg, approximately 570 mg, approximately 580 mg, approximately 590 mg, or approximately 600 mg.

[0227] The amount of anti-PCSK9 antibody contained in each dose can be expressed as milligrams of antibody per kilogram of patient body weight (i.e., mg / kg). For example, anti-PCSK9 antibody can be administered to patients at a dose of about 0.0001 to about 10 mg / kg of patient body weight.

[0228] Combination therapy

[0229] As described elsewhere herein, the method of the present invention may include administering a PCSK9 inhibitor in combination with a previously prescribed stable maximum daily tolerated dose of a therapeutic statin to a patient with heterozygous familial hypercholesterolemia. According to some embodiments of the invention, in addition to statins, additional therapeutic agents may be administered in combination with the PCSK9 inhibitor to the patient. Examples of such additional therapeutic agents include, for example, (1) agents that inhibit cholesterol uptake or bile acid reabsorption (e.g., ezetimibe); (2) agents that increase lipoprotein metabolism (e.g., niacin); and / or (3) LXR transcription factor activators that act in the clearance of cholesterol (e.g., 22-hydroxycholesterol).

[0230] Application plan

[0231] According to some embodiments of the invention, multiple doses of a PCSK9 inhibitor (i.e., a pharmaceutical composition comprising a PCSK9 inhibitor) may be administered to a subject over a defined time course (e.g., as an adjunct to a daily therapeutic statin regimen). A method according to this aspect of the invention comprises sequentially administering multiple doses of a PCSK9 inhibitor to a patient with heterozygous familial hypercholesterolemia poorly controlled with the maximum tolerated dose of statins, with or without other lipid-lowering therapy. As used herein, “sequential administration” means administering each dose of the PCSK9 inhibitor to the subject at different time points, for example, at different times separated by predetermined intervals (e.g., hours, days, weeks, or months). The invention includes a method comprising sequentially administering a single initial dose of a PCSK9 inhibitor to a patient with heterozygous familial hypercholesterolemia, followed by one or more secondary doses of a PCSK9 inhibitor, and optionally subsequently one or more tertiary doses of a PCSK9 inhibitor.

[0232] The terms “initial dose,” “secondary dose,” and “tertiary dose” refer to the order in which the various doses of a pharmaceutical composition containing a PCSK9 inhibitor are administered. Therefore, an “initial dose” is the dose administered at the start of a treatment regimen (also known as a “baseline dose”); a “secondary dose” is the dose administered after the initial dose; and a “tertiary dose” is the dose administered after the secondary dose. The initial, secondary, and subsequent doses may all contain the same amount of PCSK9 inhibitor, but they are typically administered at different frequencies. However, in some embodiments, the amounts of PCSK9 inhibitor contained in the initial, secondary, and / or tertiary doses during treatment may differ (e.g., adjusted up or down as appropriate). In some embodiments, two or more doses (e.g., 2, 3, 4, or 5 doses) are administered at the start of treatment as “loading agents,” followed by subsequent doses (e.g., “maintenance agents”) administered at a lower frequency.

[0233] According to an exemplary embodiment of the invention, each secondary and / or tertiary dose is administered 1-26 weeks after the immediately preceding predose (e.g., 1, 1½, 2, 2½, 3, 3½, 4, 4½, 5, 5½, 6, 6½, 7, 7½, 8, 8½, 9, 9½, 10, 10½, 11, 11½, 12, 12½, 13, 13½, 14, 14½, 15, 15½, 16, 16½, 17, 17½, 18, 18½, 19, 19½, 20, 20½, 21, 21½, 22, 22½, 23, 23½, 24, 24½, 25, 25½, 26, 26½, or more weeks). The term "immediately preceding predose" means, in a multiple administration sequence, an antigen-binding molecule administered to the patient in a sequence without a spacer before the next subsequent dose.

[0234] Methods according to this aspect of the invention may include administering any number of secondary and / or tertiary doses of a PCSK9 inhibitor to a patient with heterozygous familial hypercholesterolemia. For example, in some embodiments, a single secondary dose is administered to the patient. In other embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8 or more) secondary doses are administered to the patient. Similarly, in some embodiments, a single tertiary dose is administered to the patient. In other embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8 or more) tertiary doses are administered to the patient.

[0235] In implementations involving multiple secondary agents, each secondary agent can be administered at the same frequency as the other secondary agents. For example, each secondary agent may be administered 1 to 2, 4, 6, 8, or more weeks after an adjacent pre-dose to a patient with heterozygous familial hypercholesterolemia. Similarly, in implementations involving multiple tertiary agents, each tertiary agent can be administered at the same frequency as the other tertiary agents. For example, each tertiary agent may be administered 1 to 2, 4, 6, 8, or more weeks after an adjacent pre-dose to a patient. Alternatively, the frequency of administration of secondary and / or tertiary agents to a patient may vary as the treatment regimen progresses. The physician may also adjust the administration frequency during the treatment process based on the individual patient's needs following a clinical examination.

[0236] This invention includes administration regimens that include an up-titer option (also referred to herein as “dose modification”). As used herein, an “up-titer option” means that if a patient does not achieve a specified reduction in one or more defined treatment parameters after receiving a specific number of doses of a PCSK9 inhibitor, the dose of the PCSK9 inhibitor is subsequently increased. For example, in a treatment regimen comprising administering 75 mg doses of an anti-PCSK9 antibody every two weeks to a patient with heterozygous familial hypercholesterolemia poorly controlled with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, if the patient does not achieve a serum LDL-C concentration below 70 mg / dL after 8 weeks (i.e., 5 doses administered at weeks 0, 2, 4, 6, and 8), the dose of the anti-PCSK9 antibody is subsequently increased to, for example, 150 mg, every two weeks (starting from week 12).

[0237] In some implementations, the anti-PCSK9 antibody is administered to the subject at a dose of approximately 75 mg every two weeks, for example, at least 6 doses.

[0238] In some implementations, the antibody is administered to the subject at a dose of approximately 75 mg every two weeks for 12 weeks, and if the subject's LDL-C value is below 70 mg / dL at week 8, the dose is maintained at 75 mg every two weeks.

[0239] In other embodiments, the antibody is administered to the subject at a dose of approximately 75 mg every two weeks for 12 weeks, and if the subject's LDL-C value is greater than or equal to 70 mg / dL at week 8, the dose is titrated up to approximately 150 mg every two weeks.

[0240] In some implementations, the anti-PCSK9 antibody is administered to the subject at a dose of approximately 150 mg every two weeks, for example, at least 6 doses.

[0241] Example

[0242] The following examples are provided to provide a complete disclosure and description to those skilled in the art regarding how to prepare and use the methods and compositions of the present invention, and are not intended to limit the scope of what the inventors consider their invention. Efforts have been made to ensure the accuracy of the figures used (e.g., amounts, temperatures, etc.), but some experimental errors and deviations should be taken into account. Unless otherwise stated, parts refer to parts by weight, molecular weight is the average molecular weight, temperature is in degrees Celsius, and pressure is atmospheric pressure or close to atmospheric pressure.

[0243] Example 1: Generation of human antibodies against human PCSK9

[0244] Human anti-PCSK9 antibody was generated as described in U.S. Patent No. 8,062,640. An exemplary PCSK9 inhibitor used in the following examples is a human anti-PCSK9 antibody, designated “mAb316P”, also known as “Alirocumab”. mAb316P has the following amino acid sequence characteristics: containing the heavy chain variable region (HCVR) of SEQ ID NO: 1; containing the light chain variable region (LCVR) of SEQ ID NO: 6; containing the heavy chain complementarity-determining region 1 (HCDR1) of SEQ ID NO: 2; containing HCDR2 of SEQ ID NO: 3; containing HCDR3 of SEQ ID NO: 4; containing the light chain complementarity-determining region 1 (LCDR1) of SEQ ID NO: 7; containing LCDR2 of SEQ ID NO: 8; and containing LCDR3 of SEQ ID NO: 10.

[0245] Example 2: A randomized, double-blind, placebo-controlled, parallel-group study evaluating the efficacy and safety of Alirocumab in patients with heterozygous familial hypercholesterolemia poorly controlled with lipid-modifying therapy.

[0246] introduction

[0247] This study included patients with heterozygous familial hypercholesterolemia (heFH) who had or did not have a recorded history of myocardial infarction (MI) or ischemic shock.

[0248] The study aims to evaluate the efficacy and safety of Alirocumab in patients with heFH who require additional medication management because their current lipid improvement therapy (LMT) has failed to achieve their LDL-C treatment goals.

[0249] To conduct this study ( Figure 1The purpose was to demonstrate that in heFH patients not at their LDL-C target, Alirocumab 75 mg Q2W or 75 mg Q2W / 150 mg Q2W as add-on therapy to statins ± other LMTs produced a statistically significant and clinically meaningful reduction in LDL-C. This population not at their LDL-C target in optimized LMTs represents the highest-risk group with well-identified, unmet medical needs that can be addressed by adding Alirocumab to their LDL-C-lowering therapy.

[0250] Research Objectives

[0251] The primary objective of this study was to demonstrate the reduction in LDL-C resulting from addition therapy with Alirocumab as a stable maximum tolerated daily statin (with or without other LMTs) (compared to placebo after 24 weeks of treatment in patients with heFH).

[0252] The secondary objectives of this study were: 1) to evaluate the effect of Alirocumab 75 mg on LDL-C after 12 weeks of treatment compared with placebo; 2) to evaluate the effect of Alirocumab on other lipid parameters (i.e., Apo B, non-HDL-C, total-C, Lp(a), HDL-C, TG levels, and Apo A-1 levels); 3) to evaluate the long-term effect of Alirocumab on LDL-C; 4) to evaluate the safety and tolerability of Alirocumab; 5) to evaluate the development of anti-Alirocumab antibodies; and 6) to evaluate the pharmacokinetic (PK) of Alirocumab.

[0253] Research Design

[0254] This is a randomized, double-blind, placebo-controlled, parallel-group, unbalanced (2:1, Alirocumab:placebo), multicenter, multinational study to evaluate the efficacy and safety of Alirocumab in patients with heFH who are undercontrolled with LMT (i.e., stable maximum tolerated daily statin therapy ± other LMTs). Undercontrolled was defined as LDL-C ≥70 mg / dL (1.81 mmol / L) at the screening visit (week-3) in patients with a documented history of cardiovascular disease, or LDL-C ≥100 mg / dL (2.59 mmol / L) at the screening visit (week-3) in patients without a documented history of cardiovascular disease. Randomization was stratified based on a history of myocardial infarction or ischemic stroke [present / absent], statin therapy (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily versus any daily dose of simvastatin, atorvastatin less than 40 mg daily or rosuvastatin less than 20 mg daily), and geographic region. Following randomization, patients received double-blind study treatment (alirocumab or placebo) at Q2W for an 18-month (78-week) period on a stable maximum tolerated daily statin regimen ± other LMTs. At week 12, patients randomized to alirocumab could undergo dose-up titration based on their week 8 LDL-C levels. After completing the 18-week double-blind treatment period, all patients who successfully completed the study were eligible to participate in an open-label extension study. Therefore, all patients received alirocumab upon entry into the open-label extension study, regardless of their study treatment received during the 18-week double-blind treatment period.

[0255] The study consisted of three phases: screening, double-blind treatment, and follow-up.

[0256] The screening period can last up to 3 weeks, including interim visits, during which patients (or another designated person such as a spouse or relative) are trained to self-inject / inject placebo of Alirocumab. Eligibility assessments are conducted to allow for randomization of patients into the study.

[0257] The double-blind treatment period (DBTP) is a randomized, double-blind 18-week study treatment period. The first injection of the double-blind period is administered at the location of randomization (week 0 [D1] - V3). Subsequent injections are administered by the patient (self-injection) or other designated persons (such as spouses, relatives, etc.) at a location chosen by the patient (home, etc.). Patients randomized to Alirocumab receive a 75 mg dose of the investigational drug product (IMP) from randomization (V3) until week 12 (V6) (i.e., weeks 0, 2, 4, 6, 8, and 10). At the week 12 visit (V6), these patients were administered the following in a double-blind manner: either 1) if LDL-C <70 mg / dL (1.81 mmol / L) at week 8, they continued Alirocumab 75 mg Q2W from week 12 until the last injection at week 76; or 2) if LDL-C ≥70 mg / dL (1.81 mmol / L) at week 8, they were titrated up from week 12 to Alirocumab 150 mg Q2W until the last injection at week 76.

[0258] The follow-up period (if applicable) is 8 weeks after the end of DBTP for patients who do not agree to participate in the open-label extension study or if the study treatment is discontinued early.

[0259] Lipid parameters were measured in the laboratory by the central laboratory during the study.

[0260] Patients who achieved two consecutive calculated LDL-C levels <25 mg / dL (0.65 mmol / L) during the study period were monitored and managed.

[0261] Statins and other LMTs (if applicable) should be stable (including dosage) during the first 24 weeks of DBTP, unless there are exceptions, by which primary considerations are given to ensure that such changes are justified. From week 24 onwards, background LMTs may be modified only under the specific conditions described below.

[0262] Throughout the study, starting from screening, patients should follow a stable diet (NCEP-ATPIII Therapeutic Lifestyle Modification [TLC] diet or equivalent). Table 1 provides a summary of TLC diets for high cholesterol.

[0263] Table 1

[0264]

[0265] * ATP III allows individuals with metabolic syndrome to increase total fat intake to 35% of total calories and decrease carbohydrate intake to 50%. Any increase in fat intake should be in the form of polyunsaturated or monounsaturated fats. Trans fats are another type of LDL-raising fat that should be kept in low amounts.

[0266] Carbohydrates should primarily come from foods rich in complex carbohydrates, including grains (especially whole grains), fruits, and vegetables.

[0267] For patients who do not agree to participate in open-label extended treatment or who terminate study treatment early, the study duration includes a screening period of up to 3 weeks, a 78-week double-blind treatment protocol (DBTP) for efficacy and safety assessment, and an 8-week post-treatment follow-up period following the last DBTP visit. Therefore, the maximum study duration for each patient is approximately 89 weeks (i.e., 20 months) (up to 3 weeks of screening + 78 weeks of double-blind treatment + 8 weeks of follow-up). The study endpoint for each patient is the last protocol-planned visit or resolution / stabilization of all SAEs and AESI, whichever occurs last.

[0268] Patient choice

[0269] Inclusion criteria: 1) Having heFH Patients who are taking statins at the maximum tolerated daily dose Those who were undercontrolled at a stable dose (with or without other LMTs) before the screening visit (week -3).

[0270] The diagnosis of heFH must be made through genotyping or clinical criteria. For patients who have not undergone genotyping, a clinical diagnosis can be made based on the WHO / Dutch Lipid Network criteria with a score >8 or the Simon Broome criteria which contain criteria for specific FH.

[0271] According to the Simon Broome Registry diagnostic criteria for heterozygous familial hypercholesterolemia, the exact definition of familial hypercholesterolemia is: 1) Total cholesterol >6.7 mmol / L (260 mg / dL) or LDL cholesterol >4.0 mmol / L (155 mg / dL) in children <16 years of age or Total cholesterol >7.5 mmol / L (290 mg / dL) or LDL cholesterol >4.9 mmol / L (190 mg / dL) in adults (pre-treatment levels or highest levels during treatment); plus either A) tendon xanthoma in the patient, or in first-degree relatives (parents, siblings, children) or second-degree relatives (grandparents, uncles / aunts); or B) DNA-based evidence of LDL receptor mutation or familial Apo B deficiency.

[0272] Based on the Simon Broome Registry diagnostic criteria for heterozygous familial hypercholesterolemia, probable familial hypercholesterolemia is defined as: 1) total cholesterol >6.7 mmol / L (260 mg / dL) or LDL cholesterol >4.0 mmol / L (155 mg / dL) in children <16 years of age or total cholesterol >7.5 mmol / L (290 mg / dL) or LDL cholesterol >4.9 mmol / L (190 mg / dL) in adults (pre-treatment levels or highest levels during treatment); and at least one of the following: A) a family history of myocardial infarction (MI) in a second-degree relative under 50 years of age or in a first-degree relative under 60 years of age; and B) a family history of elevated cholesterol >7.5 mmol / L (290 mg / dL) in an adult first- or second-degree relative, or >6.7 mmol / L (260 mg / dL) in a child or sibling under 16 years of age.

[0273] The WHO criteria (Dutch Lipid Network Clinical Criteria) for heterozygous familial hypercholesterolemia (heFH) are shown in Table 2.

[0274] Table 2

[0275]

[0276] The maximum tolerated dose is defined as follows (any of the following is acceptable): 1) Rosuvastatin 20 mg or 40 mg daily; 2) Atorvastatin 40 mg or 80 mg daily; 3) Simvastatin 80 mg daily (if this dose has been used for >1 year); or 4) If the patient cannot use any of the above statin doses, they should be treated with the daily dose of atorvastatin, rosuvastatin, or simvastatin that the investigator deems appropriate for the patient. Some examples of acceptable reasons for patients to use lower statin doses include, but are not limited to: adverse reactions to higher doses, advanced age, low body mass index, regional practice, local prescribing information, concomitant medications, and comorbidities such as impaired glucose tolerance / impaired fasting glucose.

[0277] Patients meeting all of the above inclusion criteria were screened for exclusion criteria as follows (which are categorized and numbered in the following three segments): exclusion criteria related to the study method, exclusion criteria related to the active comparator and / or mandatory background treatment, and exclusion criteria related to Alirocumab.

[0278] Exclusion criteria related to the study methods were: 1) patients were not diagnosed with heFH by genotyping or clinical criteria; 2) patients had LDL-C <70 mg / dL (<1.81 mmol / L) at the screening visit (week -3) and patients had a documented history of cardiovascular disease.Cardiovascular disease is defined as coronary artery disease, ischemic stroke, or peripheral artery disease; 3) LDL-C <100 mg / dL (<2.59 mmol / L) at the screening visit (week -3) and the patient has no documented history of cardiovascular disease; 4) No stable dose of LMT (including statins) for at least 4 weeks prior to the screening visit (week -3) and from screening to randomization, and / or no fenofibrate for at least 6 weeks, if applicable; 5) Currently receiving statins other than simvastatin, atorvastatin, or rosuvastatin; 6) Not receiving simvastatin, atorvastatin, or rosuvastatin daily or at the registered dose; 7) Daily dose higher than atorvastatin 80 mg, rosuvastatin 40 mg, or simvastatin 40 mg (if receiving simvastatin 80 mg or rosuvastatin 40 mg daily). (Except for patients who have taken more than 1 mg for more than one year and are eligible); 8) Use of fibrates other than fenofibrate within 6 weeks of the screening visit (week-3) or between the screening and randomization visits; 9) Use of nutritional supplements or over-the-counter treatments that may affect lipids, which have not been used at a stable dose / amount for at least 4 weeks before the screening visit (week-3) or between the screening and randomization visits; 10) Use of red yeast rice products within 4 weeks of the screening visit (week-3) or between the screening and randomization visits; 11) Received plasma extraction therapy within 2 months prior to the screening visit (week-3) or plan to receive it during the study period. Patients receiving plasma collection therapy; 12) recent (within 3 months prior to the screening visit [week -3] or between screening and randomization visits) MI, unstable angina leading to hospitalization, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), uncontrolled arrhythmia, stroke, transient ischemic attack (TIA), carotid revascularization, endovascular or surgical intervention for peripheral vascular disease; 13) planned PCI, CABG, carotid or peripheral vascular revascularization during the study period; 14) systolic blood pressure at the screening or randomization visit. >160 mmHg or diastolic blood pressure >100 mmHg; 15) History of New York Heart Association (NYHA) Class III or IV heart failure within the past 12 months; 16) Known history of hemorrhagic stroke; 17) Age <18 years or legal age of adulthood at the screening visit (week-3), whichever is greater; 18) Patients who have not previously received cholesterol-lowering dietary guidance prior to the screening visit (week-3); 19) Newly diagnosed (within 3 calendar months prior to randomization visit [week 0]) or poorly controlled (at the screening visit [week-3] glycosylated hemoglobin A1c [HbA1c]). 1c20) Diabetes mellitus >9%); 21) Presence of any clinically significant, uncontrolled, known endocrine disorder affecting serum lipids or lipoproteins. Note: Patients receiving thyroid replacement therapy may be included if the dose has been stable for at least 12 weeks between screening and randomization visit, and TSH is within the normal range in a central laboratory at screening visit; 22) History of surgery for obesity treatment within 12 months prior to screening visit (week-3); 23) Unstable weight, defined as a change of >5 kg within 2 months prior to screening visit (week-3); 24) Known history of heterozygous FH; 25) Known history of PCSK9 loss of function (i.e., genetic mutation or sequence variation); 26) Use of systemic corticosteroids, unless used as replacement therapy for pituitary / adrenal disorders and administered at a stable regimen for at least 6 weeks prior to randomization visit (week 0).Note: Topical, intra-articular, nasal, inhaled, and ocular steroid therapy is not considered “systemic” and is permitted; 26) Use of continuous estrogen or testosterone replacement therapy unless the therapy has been stable for the past 6 weeks prior to the screening visit (week-3) and there are no plans to change the treatment regimen during the study; 27) History of cancer within the past 5 years, excluding adequately treated basal cell carcinoma, squamous cell carcinoma, or cervical cancer in situ; 28) Known history of a positive HIV test; 29) The patient has received any investigational drug other than the Alirocumab training placebo kit within 1 month or 5 half-lives (whichever is longer); 30) The patient has previously been treated with at least one dose of Alirocumab or any other anti-PCSK9 monoclonal antibody in other clinical trials; 31) The patient withdrew informed consent during the screening period (the patient did not wish to continue or was unable to return); 32) Conditions / circumstances such as: a) Any clinically significant abnormalities identified at the time of screening. The following conditions, in the judgment of the investigator or any sub-investigator, would impede the safe completion of the study or constrain the assessment of the endpoint, such as major systemic disease, patients with short life expectancy; or b) patients whom the investigator or any sub-investigator deems unsuitable for the study for any reason, such as: patients deemed unable to meet the requirements of a specific experimental protocol (e.g., scheduled visits); patients deemed unable to administer or tolerate long-term injections as prescribed by the investigator or patient; the investigator or any sub-investigator, pharmacist, research collaborator, other research staff directly involved in implementing the experimental protocol, or their relatives, etc.; any other actual or anticipated circumstances (e.g., geographical or social) that the investigator believes would limit or restrict the patient's participation in the study process; or 33) laboratory findings during screening (excluding randomization week 0 laboratory): positive test for hepatitis B surface antigen or hepatitis C antibody; positive serum β-hCG or urine pregnancy test (including week 0) in women with potential delivery risk (WOCBP); triglycerides >400 mg / dL (>4.52 mmol / L) (one laboratory test allowed); estimated glomerular filtration rate (eGFR) <30 mL / min / 1.73 m based on the four-variable modified diet for kidney disease (MDRD) study equation. 2 (Calculated by the central laboratory); Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) >3 x upper limit of normal (ULN) (1 replicate test allowed); CPK >3 x ULN (1 replicate test allowed); TSH < lower limit of normal (LLN) or > ULN (1 replicate test allowed).

[0279] Exclusion criteria related to the active comparative and / or mandatory background treatment are: 1) all contraindications or warnings / precautions for use (where applicable) for background treatment, as listed in their respective National Product Labelling.

[0280] Exclusion criteria related to Alirocumab are: 1) known hypersensitivity to the monoclonal antibody or any component of the drug product; 2) pregnant or lactating women; or 3) women with the potential to give birth who are not protected by effective birth control methods (such as those defined in the informed consent form and / or the local protocol addendum) and / or who are unwilling or unable to undergo pregnancy testing. It should be noted that women with the potential to give birth must have a confirmatory negative pregnancy test result at the time of screening and randomization visit. They must use effective contraception throughout the duration of study treatment and for 10 weeks after their last IMP intake, and consent to repeat urine pregnancy testing at the designated visit. Postmenopausal women must have been amenorrheic for at least 12 months.

[0281] Coronary artery disease, ischemic stroke, and peripheral artery disease as defined in Exclusion Criterion 2 related to the study methods are as follows: A documented history of CHD (including one or more of the following): acute myocardial infarction (MI); silent myocardial infarction; unstable angina; coronary revascularization procedures (e.g., percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]); clinically significant CHD diagnosed by invasive or non-invasive tests (e.g., coronary angiography, treadmill stress test, stress echocardiography, or nuclear imaging).

[0282] A documented history of ischemic stroke with focal ischemic neurological deficits lasting more than 24 hours is considered to be of atherosclerotic thrombus origin. CT or MRI is necessary to rule out hemorrhagic and non-ischemic neurological diseases.

[0283] Recorded peripheral artery disease (stratified according to one of the following criteria): 1) current intermittent claudication (lower limb muscle discomfort arising from exercise that is reproducible and relieved by rest within 10 minutes) with a presumed atherosclerotic origin and an ankle-brachial index of 0.90 or less in either leg at rest; or 2) a history of intermittent claudication due to atherosclerotic disease (lower limb muscle discomfort arising from exercise that is reproducible and relieved by rest within 10 minutes) with endovascular or surgical intervention in one or both legs; or 3) a history of severe limb ischemia due to atherosclerotic disease with thrombolysis, endovascular surgery, or surgical intervention in one or both legs.

[0284] Research on treatment

[0285] Sterile Alirocumab products are provided at concentrations of 75 mg / mL and 150 mg / mL, both in 1 mL volumes via an auto-injector. The drug substance is formulated with histidine, pH 6.0, polysorbate 20, and sucrose.

[0286] The sterile placebo corresponding to Alirocumab is prepared in the same formulation as Alirocumab without the addition of protein, and is prepared in 1 mL volume in an auto-injector.

[0287] During the double-blind treatment period, Alirocumab or placebo was administered subcutaneously every two weeks, starting from week 0 and continuing until two weeks prior to the end of the double-blind treatment period (DBTP) at week 76. If the injections were scheduled for the same day as the field visit, IMP was administered after blood collection.

[0288] Ideally, the investigational drug product (IMP) should be administered subcutaneously every two weeks at approximately the same time of day; however, an acceptable window is ±3 days. The specific time of day for administration is based on patient preference.

[0289] The following types of medications are identified as non-NIMP because they are either background treatments or potential rescue medications: statins (rosuvastatin, atorvastatin, simvastatin); cholesterol absorption inhibitors (ezetimibe); bile acid conjugating polyvalent chelators (such as cholestyramine, colestipol, colesvelam); niacin; fenofibrate; and omega-3 fatty acids (≥1000 mg / day).

[0290] During the double-blind study treatment, patients were randomized in a 1:2 ratio to receive either placebo or Alirocumab, with permuted-block randomization. Randomization was stratified based on prior history of MI or ischemic stroke [present / absent], statin therapy (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily versus any daily dose of simvastatin, atorvastatin less than 40 mg daily or rosuvastatin less than 20 mg daily), and geographic region.

[0291] Concomitant medications are any treatments a patient receives as part of the study (up to follow-up). Concomitant medications should be kept to a minimum during the study. However, if they are deemed necessary for the patient's well-being and unlikely to interfere with IMP, they may be administered at the investigator's discretion at a stable dose (if possible). Any other concomitant medications are permitted in addition to the specific information provided in this section regarding concomitant medications. If a patient has an LDL-C ≥160 mg / dL (4.14 mmol / L) at the screening visit (week-3) and is being treated with statins only, i.e., without additional LMT, the investigator must report the reason why the patient did not receive a second LMT. For background LMTs, including statins, the study site must follow national product labeling for patient safety monitoring and management.

[0292] Nutritional products or over-the-counter therapies that may affect lipids are permitted only if they are used at a stable dose for at least 4 weeks prior to the screening visit, during the screening period, and maintained throughout the first 24 weeks of the double-blind treatment period. Modifications to these nutritional products or over-the-counter therapies are permitted after the 24-week visit, but should generally be avoided. Examples of such nutritional products or over-the-counter therapies include omega-3 fatty acids at doses <1000 mg, such as phytosterols found in Benecol, flaxseed oil, and psyllium.

[0293] Patients must have been on a stable maximum tolerated daily dose of statin, with or without other LMTs, for at least 4 weeks prior to the screening visit (6 weeks for fenofibrate). During the study, patients should maintain these stable maximum tolerated daily doses of statin, with or without other LMTs. Background LMTs should not be changed from the screening visit (week -3) of the double-blind treatment period until week 24. No dose adjustments, discontinuation, or initiation of other statins or other LMTs should be made during this period, unless there are exceptional circumstances, with primary consideration (including but not limited to triglyceride alerts issued by the central laboratory) to ensure that such changes are justified in the investigator's judgment.

[0294] For salvage notification of LDL-C at the week 24 visit and subsequent LDL-C increases >25%, compared to LDL-C at two consecutive randomized visits, investigators should ensure there is no reasonable explanation for inadequate LDL-C control (e.g., other medical reasons such as corticosteroid use). Specifically, this means: adherence to the diet is appropriate; background LMT is appropriate; and study treatment is administered as planned. If any of the above can reasonably explain inadequate LDL-C control, investigators should take appropriate action, namely emphasizing the absolute need for treatment adherence, arranging specific consultations with qualified nutrition professionals if necessary, emphasizing the absolute need for dietary adherence, and conducting a blinded LDL-C assessment within 1 to 2 months. If no of the above causes are found, or if appropriate actions fail to reduce LDL-C below the alarm threshold, salvage medication may be introduced.

[0295] If no cause for LDL-C exceeding the threshold is found, or if appropriate action fails to lower LDL-C below the threshold, a rescue medication may be introduced. The effectiveness of any such change will be determined based on the absence of a rescue threshold from a blinded lipid test at the next routinely scheduled laboratory draw. Patients on each regimen are already receiving the maximum tolerated dose of statins, so statin uptiing or switching will not be considered. To further lower LDL-C, investigators may consider adding: a cholesterol absorption inhibitor (ezetimibe) or a bile acid conjugating chelator (resin-based cholestyramine and colestipol or colesvelam, a non-absorbable polymer). Other lipid modifiers to consider include: fibrates (Note: When combining fibrates with other cholesterol-lowering drugs (e.g., statins), caution should be exercised due to the risk of myopathy. Fenofibrate is the preferred fibrate when combined with statins because it does not affect statin glucuronidation. The only fibrate permitted under the regimen is fenofibrate); niacin (Note: Niacin raises blood sugar, but it has been shown to effectively improve lipid profiles in diabetic patients if glucose control is maintained).

[0296] In summary, background LMT should not be modified from screening to follow-up. However, modification of background LMT is permitted up to week 24 if a confirmed TG alert is reached or if there is a definitive clinical concern (at the investigator's discretion). After week 24, modification of background LMT is permitted if a confirmed TG alert is reached, or if the salvage threshold for LDL-C is reached (and there is no other reasonable explanation), or if there is a definitive clinical concern (at the investigator's discretion).

[0297] Women who have a potential risk of childbirth must use effective contraception throughout the study treatment and for 10 weeks after the last IMP injection (e.g., follow-up).

[0298] The following concomitant medications are prohibited from use from the initial screening visit to the follow-up visit: statins other than simvastatin, atorvastatin and rosuvastatin; fibrates other than novice; and red yeast rice products.

[0299] Study endpoints

[0300] The primary efficacy endpoint is the percentage change in calculated LDL-C from baseline to week 24, defined as: 100 × (calculated LDL-C value at week 24 - calculated LDL-C value at baseline) / calculated LDL-C value at baseline. The baseline calculated LDL-C value is the last LDL-C level obtained prior to the first double-blind IMP injection. The week 24 calculated LDL-C level is the LDL-C level obtained within the week 24 analysis window and during the primary efficacy period. The primary efficacy period is defined as the time from the first double-blind IMP injection up to 21 days after the last double-blind IMP injection or up to the upper limit of the week 24 analysis window (whichever comes first). Where appropriate, all calculated LDL-C values ​​(planned or unplanned, fasting or non-fasting) may be used to provide a value for the primary efficacy endpoint, according to the above definition.

[0301] The key secondary efficacy endpoints were: 1) Percentage change in calculated LDL-C from baseline to week 12: similar definitions and rules as the primary efficacy endpoint, except that the LDL-C calculated at week 12 was the LDL-C level obtained within the week 12 analytical window and over the 12-week efficacy period. The 12-week efficacy period was defined as the time from the first double-blind IMP injection to either the sixth visit for re-providing IVRS contact or 21 days after the last double-blind IMP injection, whichever came first. Blood samples collected on the day of the sixth visit for re-providing IVRS contact were considered pre-titration; 2) Percentage change in Apo B from baseline to week 24, using the same definitions and rules as the primary endpoint; 3) Percentage change in non-HDL-C from baseline to week 24, using the same definitions and rules as the primary endpoint; 4) Percentage change in total C from baseline to week 24, using the same definitions and rules as the primary endpoint; 5) Apo B) Percentage change from baseline to week 12, using the same definitions and rules as those used for calculating the percentage change of LDL-C from baseline to week 12; 6) Percentage change of non-HDL-C from baseline to week 12, using the same definitions and rules as those used for calculating the percentage change of LDL-C from baseline to week 12; 7) Percentage change of total-C from baseline to week 12, using the same definitions and rules as those used for calculating the percentage change of LDL-C from baseline to week 12; 8) Percentage change of calculated LDL-C from baseline to week 52, using definitions and rules similar to those used when replacing week 24 as the primary endpoint with week 52.Note that the 52-week efficacy period is defined as the time from the first double-blind IMP injection to 21 days after the last double-blind IMP injection or up to the upper limit of the analysis window at week 52, whichever comes first; 9) the proportion of patients who achieved their LDL-C target at week 24, where the LDL-C target is LDL-C <70 mg / dL (1.81 mmol / L) in the case of prior CVD, or <100 mg / dL (2.59 mmol / L) in the case of no prior CVD. The proportion of patients is defined as: (number of patients who achieved their LDL-C target at week 24 / number of patients in the modified intention-to-treat (mITT) population) * 100, using the definitions and rules used for the primary endpoint; 10) the proportion of patients who achieved LDL-C <70 mg / dL (1.81 mmol / L) at week 24; 11) the percentage change in Lp(a) from baseline to week 24, using the same definitions and rules as for the primary endpoint; 12) 13) Percentage change in HDL-C from baseline to week 24, using the same definitions and rules as the primary endpoint; 14) Percentage change in HDL-C from baseline to week 12, using the same definitions and rules as the calculated percentage change in LDL-C from baseline to week 12; 15) Percentage change in Lp(a) from baseline to week 12, using the same definitions and rules as the calculated percentage change in LDL-C from baseline to week 12; 16) Percentage change in fasting TG from baseline to week 24, using the same definitions and rules as the primary endpoint; 17) Percentage change in fasting TG from baseline to week 12, using the same definitions and rules as the calculated percentage change in LDL-C from baseline to week 12; 18) Percentage change in ApoA-1 from baseline to week 24, using the same definitions and rules as the primary endpoint; and 19) Percentage change in ApoA-1 from baseline to week 12, using the same definitions and rules as the calculated percentage change in LDL-C from baseline to week 12.

[0302] Other secondary efficacy endpoints are: 1) the percentage change in LDL-C from baseline to week 78, using similar definitions and rules as those used for replacing week 24 with week 78 as the primary endpoint. The 78-week validity period is defined as the time from the first double-blind IMP injection to 21 days after the last double-blind IMP injection or up to the upper limit of the 78-week analysis window, whichever comes first; 2) the proportion of patients who achieved their LDL-C target at weeks 12, 52, and 78, where the LDL-C target is <70 mg / dL (1.81 mmol / L) for patients with prior CVD or <100 mg / dL (2.59 mmol / L) for patients without prior CVD; 3) the proportion of patients who achieved LDL-C <100 mg / dL (2.59 mmol / L) at week 24; 4) the proportion of patients who achieved LDL-C <100 mg / dL (2.59 mmol / L) at week 12; 5) the proportion of patients who achieved LDL-C <70 mg / dL (1.81 mmol / L) at week 12; 6) the calculated LDL-C. (mg / dL and mmol / L) absolute changes from baseline to weeks 12, 24, 52, and 78; 7) percentage changes from baseline to weeks 52 and 78 for Apo B, non-HDL-C, total-C, Lp(a), HDL-C, fasting TG, and Apo A-1; 8) changes in the Apo B / Apo A-1 ratio from baseline to weeks 12, 24, 52, and 78; 9) the proportion of patients with Apo B <80 mg / dL (0.8 g / L) at weeks 12, 24, 52, and 78; 10) the proportion of patients with non-HDL-C <100 mg / dL at weeks 12, 24, 52, and 78; and 11) calculated LDL-C <70 mg / dL (1.81 mmol / L) and / or a calculated LDL-C reduction ≥50% at weeks 12, 24, 52, and 78 (if calculated LDL-C... The proportion of patients with ≥70 mg / dL [1.81 mmol / L]

[0303] Other endpoints include: anti-Alirocumab antibody assessment, high-sensitivity C-reactive protein (hs-CRP), glycosylated hemoglobin A1c, EQ-5D questionnaire, pharmacogenetics, and pharmacokinetics. Anti-Alirocumab antibody status includes antibody status (positive / negative) and antibody titer. Serum samples were collected periodically throughout the study for anti-Alirocumab antibody determination. The first pre-selected sample was obtained at the randomized visit prior to IMP injection (pre-dose). Patients with an anti-Alirocumab antibody titer equal to or greater than 240 at follow-up were charged with additional samples 6 to 12 months after the last dose, and subsequently approximately every 3 to 6 months until the titer returned to below 240. The percentage change in high-sensitivity C-reactive protein (hs-CRP) was measured at baseline and at weeks 24, 52, and 78. EQ-5D is a standardized measure of health status developed by the EuroQol Group to provide a simple, universal measure of health for clinical and economic evaluation. The EQ-5D standard, used to measure health-related quality of life, defines health across five dimensions: mobility, self-care, daily activities, pain / discomfort, and anxiety / depression. Each dimension can be expressed as one of three responses (three sequential levels of severity): "No problems" (1); "Some problems" (2); "Severe problems" (3); and overall health status is defined as a five-digit number. The health status defined by the five-dimensional classification can be converted into a corresponding index score that quantifies the health status, where 0 represents "death" and 1 represents "complete health".

[0304] Research Steps

[0305] For all visits after Day 1 / Week 0 (randomized visits), a certain number of days is allowed within the timeframe. The window is ±3 days for visits at weeks 12 and 24, ±5 days for weeks 52 and 78, and ±7 days for all other field visits during the double-blind treatment and follow-up periods. During the screening period (Week -1), a +3-day window is allowed for randomized visits (Day 1 / Week 0), and a ±7-day window is allowed for injection training visits. For all visits after Day 1 / randomized visits, if a visit date changes, the next visit should be made according to the original schedule.

[0306] Security

[0307] Treatment-emergent adverse events (TEAEs) reported by patients or recorded by investigators, serious adverse events (SAEs), TEAEs leading to treatment discontinuation, occurrence of AEs of particular interest (local injection site reactions, anaphylactic events, selected neurological events, and cardiovascular events confirmed by assessment results), occurrence of PCSA (potentially clinically significant abnormality) in laboratory parameters, and exploratory analyses of patients with two consecutive calculated LDL-C < 25 mg / dL (< 0.65 mmol / L) and changes in glycemic control, including those with diabetes.

[0308] Statistical methods

[0309] Sample size determination

[0310] A total sample size of 45 patients (30 receiving alirocumab and 15 receiving placebo) had a 95% power to detect the difference in the 30% mean percentage change in LDL-C, with a two-sided significance level of 0.05, and assumed a common standard deviation of 25%, and all 45 patients had evaluable primary endpoints. However, to meet regulatory requirements for the entire procedure, the sample size was increased to assess the safety of alirocumab. To ensure that at least 225 patients were followed up with alirocumab for 12 months in this study, assuming a dropout rate of 10% during the first 3 months and a dropout rate of 20% during the remaining 9 months, the final total sample size was increased to 471, with a randomization ratio of 2:1 (alirocumab 314: placebo 157).

[0311] Timing of analysis

[0312] The first-step analysis included the efficacy endpoint at week 52 (final efficacy analysis) and an interim safety analysis, which analyzed all safety data up to the co-study cutoff date (week 52 visit of the last patient). Analysis of lipid data beyond week 52 was descriptive. These results are presented in this paper.

[0313] The second (final) analysis was conducted at the end of the study and primarily consisted of the final analysis of efficacy endpoints up to week 78 and the final safety analysis.

[0314] Analyst population:

[0315] The primary efficacy analysis population was the intention-to-treat (ITT) population, defined as all randomized patients with an evaluable primary endpoint, namely, patients with available baseline calculated LDL-C values ​​and at least one available calculated LDL-C value within one of the analysis windows up to week 24 (including calculated LDL-C values ​​for all treatments and treatment discontinuation).

[0316] The secondary efficacy analysis population was a modified intention-to-treat (mITT) population, defined as all such randomized patients who received at least one dose or partial dose of a double-blind investigational drug product (IMP) and had a usable, calculated LDL-C value at baseline, and within one of the analysis windows during the efficacy treatment period up to week 24. The efficacy treatment period was defined as the time from the first double-blind IMP injection to 21 days after the last double-blind injection.

[0317] The safety population includes all randomized patients who received at least one dose or a partial dose of double-blind IMP.

[0318] Efficacy analysis:

[0319] The initial analysis of efficacy endpoints was performed using the ITT approach (based on the ITT population as defined above), including all lipid data regardless of whether patients continued treatment. This corresponds to the ITT estimation, defined for primary and key secondary endpoints. Additionally, the on-treatment approach (based on the mITT population as defined above) was used for analysis, including lipid data collected during efficacy treatment. This corresponds to the on-treatment estimation of key secondary endpoints.

[0320] The ITT method analyzed all patients, regardless of their treatment adherence; it assessed the benefit of the treatment strategy and reflected the effects across the patient population as comprehensively as possible. The in-treatment method analyzed treatment effects, limited to the period during which patients actually received treatment. It assessed the benefits of treatment in patients who adhered to treatment up to the identified time point.

[0321] Efficacy analysis was conducted based on randomization of treatment.

[0322] All measurements (arranged or unarranged, fasting or non-fasting) are assigned to the analysis window to provide assessments for time points from week 4 to week 78.

[0323] For the primary efficacy analysis (ITT method), a mixed-effects model with repeated measures (MMRM) was used to analyze the calculated percentage change in LDL-C from baseline to week 24. All post-baseline data were used, with the analysis window from week 4 to week 52, and missing data were accounted for by the MMRM. The model included the treatment group (placebo vs. alirocumab), randomization strata (according to IVRS), time points (weeks 4 to 52), fixed categorical effects of treatment-by-time point interactions and strata-by-time point interactions, and continuous fixed covariates of baseline LDL-C values ​​and baseline value-by-time point interactions. The model provided baseline-adjusted least-squares mean (LS mean) estimates for both treatment groups at week 24, along with their corresponding standard errors and 95% confidence intervals. To compare alirocumab versus placebo, these estimates were tested for differences at the 5% alpha level using an appropriate contrast statement.

[0324] A stratification procedure was defined to test key secondary endpoints while controlling for multiplicity (using the order of the key secondary endpoints described above). The first key secondary endpoint was the percentage change in LDL-C from baseline to week 24, calculated using the in-treatment method.

[0325] Continuous secondary variables (i.e., lipids other than TG and Lp(a)) expected to have a normal distribution were analyzed using the same MMRM model as the primary endpoint. Continuous endpoints expected to have a non-normal distribution (i.e., TG and Lp(a)) were analyzed using multiple estimation methods to handle missing values, followed by a robust regression model with the target endpoint as the response variable using M-estimation (using the SAS ROBUSTREG procedure), where the treatment group, randomization layer (according to IVRS), and corresponding baseline values ​​were used to compare treatment effects. Means for the two treatment groups, differences between these estimates, and combined estimates of their corresponding SE, 95% CI, and p-values ​​are provided (via the SAS MIANALYZE procedure).

[0326] The binary secondary efficacy endpoint was analyzed using a multiple attribution approach to handle missing values, followed by stratified logistic regression with the treatment group as the main effect and the corresponding baseline value as a covariate, stratified by a randomization factor (according to IVRS). Combined estimates of odds ratio versus placebo, 95% CI, and p-value are provided (via the SAS MIANALYZE procedure).

[0327] Security Analysis:

[0328] Safety analyses are descriptive and performed on the safety population based on actual treatment received. Safety analyses focus on the TEAE period, defined as the time from the first dose of double-blind IMP to 70 days after the last double-blind injection. TEAEs or PCSA that occurred, worsened, or became severe after patient enrollment in the open-label extended study (LTS13643) are not considered part of the TEAE period. The TEAE period is truncated at the co-study cutoff date.

[0329] result

[0330] study patients

[0331] Patient responsibility

[0332] Of the 486 randomized patients (323 in the alirocumab group and 163 in the placebo group), one patient in the alirocumab group was not treated and therefore not included in the safety population. This patient was also excluded from the ITT population (due to the patient withdrawing informed consent on day 1, there was no LDL-C value within the analysis window up to week 24).

[0333] Two randomized patients in the alirocumab group were excluded from the mITT population (one patient was excluded from the ITT population, and the other patient had no LDL-C value during efficacy treatment up to one of the analysis windows up to week 24).

[0334] Table 3 – Analytical Population

[0335]

[0336] In the alirocumab group, of the 311 patients who received at least one injection after week 12, 135 (43.4%) received an automated uptick at week 12 from alirocumab 75 mg Q2W to 150 mg Q2W in a blinded manner.

[0337] Research and Disposition

[0338] The study treatment, exposure, and safety analyses were evaluated using all data up to the study's common cutoff date (defined as the date of the last patient's week 52 visit). Therefore, this first-step analysis included data beyond week 52 and up to week 78 (or, for some patients, follow-up).

[0339] At the cutoff date of the first phase of analysis, there were 7 (1.4%) randomized patients who had completed the 78-week double-blind study treatment period and 424 (87.2%) randomized patients who were currently undergoing treatment. In the placebo group, 18 (11.0%) randomized patients prematurely discontinued the double-blind IMP treatment before week 78, while 36 (11.1%) randomized patients in the alirocumab group did so prematurely. The main reasons for treatment discontinuation were adverse events and other causes.

[0340] Furthermore, among these patients, 34 (10.5%) randomized patients in the alirocumab group prematurely discontinued the double-blind IMP before the week 52 visit, compared to 15 (9.2%) patients in the placebo group.

[0341] In this first-step analysis, the final results were available for the primary efficacy endpoint at week 24, and key secondary efficacy endpoints were assessed at weeks 12, 24, and 52. The primary endpoint was missing for 46 patients at the week 24 visit for the following reasons: 18 samples were not completed due to earlier study discontinuation, 14 samples were completed outside the analysis window, 4 samples were missing when the week 24 visit was completed, and 10 samples were completed but could not be measured (lipemia, insufficient quantity, TG > 400 mg / dL [> 4.52 mmol / L], sample loss...).

[0342] Demographic characteristics, baseline and pooled population characteristics

[0343] Compared with the placebo group, the demographic characteristics, disease characteristics, and lipid parameters at baseline were similar in the alirocumab group (see Table 4). 486 patients diagnosed by genotyping (39%) or WHO or Simon Broome criteria (61%) were randomized (2:1) to alirocumab (75 mg Q2W, potentially titrated up to 150 mg Q2W) or placebo (323 vs. 163, respectively). Half of the randomized population (51%) had a history of at least one coronary artery disease (CHD) or multiple CHD risk factors that defined these patients as having very high cardiovascular risk. The demographic characteristics, disease characteristics, and lipid parameters at baseline were similar in the alirocumab group compared with the placebo group. All patients received statin therapy, with 82% receiving what was defined as a high-intensity dose of statin (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily), and 57% receiving ezetimibe in addition to statins. The mean (SD) at baseline yielded an LDL-C of 144.6 (49.7) mg / dL [3.75 (1.29) mmol / L].

[0344] Exposure to the injections was similar across the treatment groups, with a mean exposure of 59 weeks. In the alirocumab group, of the 311 patients who received at least one injection after week 12, 135 (43.4%) received an automated uptick from alirocumab 75 mg Q2W to 150 mg Q2W in a blinded manner at week 12.

[0345] Table 4 - Baseline characteristics of the FHI patient population

[0346]

[0347] Unless otherwise stated, the percentage (N) of patients. All patients were on the basis of maximum tolerated statin ± other lipid-lowering therapy. The diagnosis of heFH must be made through genotyping or clinical criteria. For patients who have not undergone genotyping, a clinical diagnosis can be based on a score >8 on the Simon Broome criteria for definitive FH or the WHO / Dutch Lipid Network criteria. In FH I, a patient is classified as “probable” FH by genotyping – the patient’s genotyping results are still pending.

[0348] Table 5 Disease characteristics and other relevant baseline data - randomized population

[0349]

[0350] a The diagnosis of heFH was not confirmed by genotyping.

[0351] Note: At the time of screening, one patient was included based on a clinical score of 8 according to the WHO criteria. Because the clinical score indicates that the patient may have heFH rather than be definitive, genotyping was performed to confirm heFH status, but these results are still pending.

[0352] Table 6. Breakdown of Cardiovascular History and Risk Factors

[0353]

[0354] Unless otherwise stated, the percentage (N) of patients. All patients were on the basis of maximum tolerated statin ± other lipid-lowering therapy.

[0355] Table 7 Background LMT at randomization - Randomized population

[0356]

[0357] Table 8. Lipid efficacy parameters at baseline – a quantitative summary in standard units – randomized population

[0358]

[0359]

[0360]

[0361] Note: The measured LDL-C was evaluated using a β-quantitative method.

[0362] The initial protocol did not include planned collection of LDL-C measurements, but this was added in the revision. Therefore, measured LDL-C values ​​were available to fewer patients compared to calculated LDL-C values.

[0363] Dosage and duration

[0364] Exposure to the injections was similar across the treatment groups, with an average exposure of 59 weeks.

[0365] In the alirocumab group, of the 311 patients who received at least one injection after week 12, 135 (43.4%) received an automated up titration from 75 mg Q2W to 150 mg Q2W at week 12 in a blinded manner.

[0366] effect

[0367] Primary efficacy endpoint

[0368] The ITT analysis included all calculated LDL-C values ​​collected up to week 52, both those under and off treatment. The primary endpoint (the percentage change in calculated LDL-C from baseline to week 24) was analyzed on the ITT population using the mean LS estimate at week 24, based on an MMRM model. LDL-C values ​​were not calculated for 32 patients (9.9%) in the alirocumab group and 14 patients (8.6%) in the placebo group at week 24. These missing values ​​were accounted for using the MMRM model.

[0369] The results of the primary endpoint analysis are shown in Table 9, expressed in mmol / L and mg / dL.

[0370] Preliminary efficacy analysis

[0371] A statistically significant decrease in the percentage change in LDL-C from baseline to week 24 was observed in the alirocumab group (mean LS vs. baseline +9.1%) compared to the placebo group (mean LS vs. baseline -48.8%) (-57.9% difference in mean LS compared to placebo, p < 0.0001). In the alirocumab group, a decrease in LDL-C from baseline was observed from week 4 and remained throughout the study until week 78 (see [link to study]). Figure 2 (and Table 10).

[0372] Table 9. Percentage change in LDL-C from baseline calculated at week 24: MMRM – ITT Analysis – ITT Population

[0373]

[0374] Table 10 LDL-C Calculation over Time – ITT Analysis – ITT Population

[0375]

[0376]

[0377]

[0378] Key secondary efficacy endpoint

[0379] Table 11 summarizes the analysis results of key secondary endpoints in stratified order. All key secondary endpoints were statistically significant according to the stratified test procedure.

[0380] Table 11

[0381]

[0382]

[0383] In-treatment analysis of the percentage change in LDL-C from baseline to week 24 showed results highly consistent with the ITT analysis (mean difference in LS compared to placebo was -58.1% in the in-treatment analysis, compared to -57.9% in the ITT analysis). Indeed, few patients had post-treatment (i.e., more than 21 days after the last injection) LDL-C values ​​collected at week 24: 6 patients (3.7%) in the placebo group and 2 patients (0.6%) in the alirocumab group. A statistically significant reduction in the percentage change in LDL-C from baseline to week 12 (i.e., before possible uptitering) observed in the alirocumab group (mean LS +5.7% from baseline) compared to the placebo group (mean LS -43.5% from baseline) was observed in the ITT analysis (mean difference in LS compared to placebo was 49.2%, p < 0.0001).

[0384] Key secondary endpoints at different time points, including Apo B, non-HDL-C, total-C, Lp(a), HDL-C, and TG, as well as the proportion of patients achieving their LDL-C targets at week 24 and the proportion of patients achieving calculated LDL-C < 70 mg / dL, were statistically significant according to the tiered testing procedure. For the alirocumab group, the baseline mean (SD) LDL-C, non-LDL-C, ApoB, and median (IQR) Lp(a) levels were 144.7 (51.3), 170.3 (54.6), 114.3 (30.8), and 34 (12.82) mg / dL, respectively. For the placebo group, the baseline mean (SD) LDL-C, non-LDL-C, ApoB, and median (IQR) Lp(a) levels were 144.4 (46.8), 169.6 (50.6), 113.4 (28.5), and 23 (8.72) mg / dL, respectively. At week 24, the percentage changes in the mean LS (SE) of non-LDL-C and ApoB Lp(a) levels from baseline to week 24 in the alirocumab group were -42.8%, -41.1%, and -25.2%, respectively. In the placebo group, the percentage changes in the mean LS (SE) of non-LDL-C and ApoB Lp(a) levels from baseline to week 24 were 9.6%, 4.7%, and -7.5%, respectively. Compared with placebo, the mean LS values ​​of ApoB and Lp(a) were -52.4%, -45.8%, and 17.7%, respectively.

[0385] Patients with very high cardiovascular (CV) risk who reached a calculated LDL-C <70 mg / dL (1.81 mmol / L) or high CV risk who reached a calculated LDL-C <100 mg / dL (2.59 mmol / L) at week 24 had a significantly higher rate of alirocumab than placebo (72.1% in the alirocumab group vs. 2.4% in the placebo group, p <0.0001).

[0386] Two consecutive calculated LDL-C values ​​<25 mg / dL (< 0.65 mmol / L) were observed in 16 patients (5.0%). No particular safety concerns were observed in these patients.

[0387] Table 12 - Number (%) of patients with two consecutive calculated LDL-C < 25 mg / dL (< 0.65 mmol / L) during treatment - safety population

[0388]

[0389] Overview of security results:

[0390] Alirocumab was well tolerated during treatment.

[0391] Table 13 – Overview of Adverse Events: Treatment-Important Adverse Events – Safety Population

[0392]

[0393] Overall, the proportion of patients reporting at least one treatment-emergent adverse event (TEAE) (77.3% in the alirocumab group vs. 74.8% in the placebo group) or at least one TEAE leading to permanent discontinuation (3.1% in the alirocumab group vs. 4.9% in the placebo group) was similar in both groups. Musculoskeletal and connective tissue disorders (SOCs) were reported in 22.4% of patients in the alirocumab group vs. 25.2% in the placebo group. The most frequently reported TEAEs in both treatment groups were injection site reactions (11.8% vs. 9.8% in the alirocumab group vs. placebo group) and nasopharyngitis (9.9% vs. 6.7% in the alirocumab group vs. placebo group). No specific signals of TEAEs related to anaphylactic events, neurological events, neurocognitive disorders, or diabetes were detected in the events of interest. SOC "neoplasmosis (begninous, malignant, and undetermined)" was observed in 2.8% of patients in the alirocumab group, compared to 0.6% in the placebo group. No specific clinical pattern was observed for individual events (all of these events were reported by the investigator as unrelated to IMP). TEAE "judgmentally confirmed cardiovascular events" were reported in 1.9% of patients in the alirocumab group and 1.2% in the placebo group.

[0394] Researchers reported six deaths (1.9%) in the alirocumab group that were not related to IMP (compared to no deaths in the placebo group): two cases of myocardial infarction (MI) (one classified as acute MI and one as sudden cardiac death), two cases of metastatic cancer (non-small cell lung cancer and pancreatic cancer, with secondary Trousseau syndrome leading to multiple embolic strokes), one patient with colonic pseudo-obstruction following abdominal surgery, and one patient with sudden cardiac death due to congestive heart failure and coronary artery disease. Both MI patients had multiple risk factors for coronary artery disease. Regarding cancer, the time to onset of the first symptom (approximately 3.5 and 7.5 months after the start of the study product) did not indicate a causal role for the study product.

[0395] No anomalies were observed in PCSA.

[0396] Example 3: A randomized, double-blind, placebo-controlled, parallel-group study to evaluate the efficacy and safety of Alirocumab in patients with heterozygous familial hypercholesterolemia who had inadequate control of their cholesterol with lipid-improving therapy.

[0397] introduction

[0398] The aim of this study was to evaluate the efficacy and safety of alirocumab in improving lipid parameters in patients with heterozygous familial hypercholesterolemia (heFH) who failed to reach their LDL-C treatment target with maximally tolerated statin therapy (with or without additional lipid-improving therapy (LMT)). Patients who failed to reach their target with maximally tolerated statin therapy (with or without other LMT) were enrolled in this study and maintained their background treatment throughout the study.

[0399] This specific study was conducted. Figure 3 This study demonstrated that in heFH patients who did not reach their LDL-C targets, Alirocumab 75 mg q2w or 75 mg q2w / 150 mg q2w as add-on therapy to statins plus / - other LMTs produced statistically significant and clinically meaningful LDL-C reductions. This population, which does not reach LDL-C targets with optimized LMTs, represents the highest-risk group with identified unmet medical needs that can be addressed by adding Alirocumab to their LDL-C-lowering therapy.

[0400] Research Objectives

[0401] The primary objective of this study was to demonstrate that Alirocumab as add-on therapy to stable maximum tolerated daily statin therapy (with or without other LMTs) resulted in a reduction of LDL-C in heFH patients (compared to placebo after 24 weeks of treatment).

[0402] The secondary objectives of this study were: 1) to evaluate the effect of Alirocumab 75 mg on LDL-C compared to placebo after 12 weeks of treatment; 2) to evaluate the effects of Alirocumab on other lipid parameters (e.g., ApoB, non-HDL-C, total-C, Lp[a], HDL-C, TG levels, and ApoA-1 levels); 3) to evaluate the long-term effects of Alirocumab on LDL-C; 4) to evaluate the safety and tolerability of Alirocumab; and 5) to evaluate the development of anti-Alirocumab antibodies.

[0403] Research Design

[0404] This was a randomized, double-blind, placebo-controlled, parallel-group, multinational study conducted in heFH patients with inadequate control of LMT (i.e., stable maximum tolerated day statin therapy + / - other LMTs). Inadequate control was defined as LDL-C ≥70 mg / dL (1.81 mmol / L) at the screening visit (week 2) in patients with a documented CVD history, or LDL-C ≥100 mg / dL (2.59 mmol / L) at the screening visit (week -2) in patients without a documented CVD history. Patients were randomized in a 2:1 ratio to receive 75 mg of Alirocumab or placebo every 2 weeks via SC injection, in addition to stable maximum tolerated day statin therapy (atorvastatin, rosuvastatin, or simvastatin), with or without other LMTs. Randomization was stratified based on a history of myocardial infarction (MI) or ischemic stroke and statin therapy (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily, compared to any daily dose of simvastatin, atorvastatin less than 40 mg daily, or rosuvastatin less than 20 mg daily).

[0405] The study consists of three phases: screening, treatment, and follow-up.

[0406] The screening period can last up to two weeks, including a mid-term visit, during which patients or caregivers are trained to administer a placebo via injection / self-injection.

[0407] The double-blind treatment period was 78 weeks. The first injection of the study drug was administered at the clinical site on day 1 after study evaluation was completed and as soon as possible after patient randomization to the study. Subsequent injections were administered outside the clinic by the patient / caregiver according to the dosing protocol. On the day of the clinical study visit consistent with the dosing, the next dose of the study drug was administered after all study evaluations had been completed and all laboratory samples had been collected. The final dose of the study drug was administered at week 76. At week 12, patients randomized to Alirocumab were blinded and either: 1) if LDL-C < 70 mg / dL (1.81 mmol / L) at week 8, continued with Alirocumab 75 mg every 2 weeks, or 2) if LDL-C ≥ 70 mg / dL (1.81 mmol / L) at week 8, the dose was titrated up to Alirocumab 150 mg every 2 weeks.

[0408] For patients who do not agree to participate in the open-label extended study or who discontinue study treatment prematurely, the follow-up period (if applicable) is 8 weeks after the end of DBTP.

[0409] Patients were required to follow a stable diet (equivalent to the National Cholesterol Education Program Adult Treatment Group III Therapeutic Lifestyle Modification [NCEP ATP III TLC] diet / Appendix 5) from screening to the end of the study visit. The daily dose of statins or other LMTs (if applicable) should remain stable from screening to the end of the study visit. Starting from week 24, background LMTs may be modified under certain conditions described later. Table 1 of Example 2 is relevant to this example and provides a summary of the diet for high-cholesterol TLC.

[0410] The central laboratory informs independent external physicians of any patient who achieves an LDL-C level of <25 mg / dL (0.65 mmol / L) in two consecutive calculated tests. Patients meeting this criterion are monitored.

[0411] Patient selection

[0412] The study population consisted of heFH patients who, prior to the screening visit (week -2), had been poorly controlled by at least 4 weeks of statin therapy with or without other LMTs.

[0413] Patients must meet the following criteria to be eligible for inclusion in the study: 1) Patients with heFH who have poorly controlled statin therapy at a stable dose with or without other LMTs at the maximum tolerated daily dose *** prior to the screening visit (week -2).

[0414] * Diagnosis of heFH must be made through genotyping or clinical criteria. For patients who have not undergone genotyping, a clinical diagnosis can be made based on a score of ≥8 points on the Simon Broome criteria or the WHO / Dutch Lipid Network criteria for definitive FH.

[0415] The exact familial hypercholesterolemia defined herein is the same as that in Example 2. The possible familial hypercholesterolemias defined herein are the same as those in Example 2. The WHO criteria (Dutch Lipid Network Clinical Criteria) for diagnosing syncytial familial hypercholesterolemia shown in Table 2 of Example 2 are the same as those in this example.

[0416] The definition of “insufficient control” in this document is the same as that in Example 2.

[0417] The recorded history of CHD is defined in the same way as in Example 2.

[0418] CHD risk equivalence (including one or more of the following criteria): 1) Documented peripheral artery disease (must meet one of the following criteria): A) Current intermittent claudication (lower extremity muscle discomfort due to exercise, which is reproducible and relieved by rest within 10 minutes) of suspected atherosclerotic origin, and an ankle-brachial index equal to or less than 0.90 in either leg at rest; or B) Intermittent claudication due to atherosclerotic disease (lower extremity muscle discomfort due to exercise, which is reproducible and relieved by rest within 10 minutes), with a history of endovascular surgery or surgical intervention in one or both legs; or C) History of severe limb ischemia due to atherosclerotic disease with thrombolysis, endovascular surgery, or surgical intervention in one or both legs; 2) Documented previous ischemic stroke with focal ischemic neurological deficit lasting more than 24 hours, considered to be of atherosclerotic thromboembolic origin. CT or MRI must be performed to rule out hemorrhagic and non-ischemic neurological diseases.

[0419] ***The definition of “maximum tolerated dose” in this document is the same as that in Example 2.

[0420] Patients meeting all the above inclusion criteria were screened according to the following exclusion criteria, which were classified into three subcategories: exclusion criteria related to the study method, exclusion criteria related to the active comparative and / or mandatory background treatment, and exclusion criteria related to current knowledge of Alirocumab.

[0421] Exclusion criteria related to the study methods were: 1) patients were not diagnosed with heFH by genotyping or clinical criteria; 2) patients with a documented history of CVD at the screening visit (week -2) had LDL-C <70 mg / dL (<1.81 mmol / L).Note: CVD is defined as coronary artery disease, ischemic stroke, or peripheral artery disease, as described above; 3) At the screening visit (week -2), patients with no recorded history of CVD had LDL-C <100 mg / dL (<2.59 mmol / L); 4) Patients who have not received a stable dose of LMT (including statins) for at least 4 weeks prior to the screening visit (week -2) and from screening to randomization have not received fenofibrate for at least 6 weeks, if applicable; 5) Currently receiving other statins (that are not simvastatin, atorvastatin, or rosuvastatin); 6) Not receiving simvastatin, atorvastatin, or rosuvastatin daily or at the registered dose; 7) Daily doses higher than atorvastatin 80 mg, rosuvastatin 40 mg, or simvastatin 40 mg (patients receiving simvastatin 80 mg or rosuvastatin 40 mg daily). (Except for patients who have taken more than 1 mg for more than one year and are eligible); 8) Use of fibrates other than fenofibrate within 6 weeks of the screening visit (week-2) or between the screening and randomization visits; 9) Use of nutritional supplements or over-the-counter treatments that may affect lipids, which have not been used at a stable dose / amount for at least 4 weeks before the screening visit (week-2) or between the screening and randomization visits; 10) Use of red yeast rice products within 4 weeks of the screening visit (week-2) or between the screening and randomization visits; 11) Received plasma extraction therapy within 2 months prior to the screening visit (week-2) or plan to receive it during the study period. Patients receiving plasma collection therapy; 12) Recent (within 3 months prior to the screening visit [week -2] or between screening and randomization visits) MI, unstable angina leading to hospitalization, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), uncontrolled arrhythmia, stroke, transient ischemic attack, carotid revascularization, endovascular or surgical intervention for peripheral vascular disease; 13) Patients scheduled to undergo PCI, CABG, carotid or peripheral vascular revascularization during the study period; 14) Patients with systolic blood pressure >160 mmHg at the screening or randomization visit. 15) A history of New York Heart Association (NYHA) Class III or IV heart failure within the past 12 months; 16) A known history of hemorrhagic stroke; 17) Age < 18 years or legal age of adulthood at the screening visit (week-2), whichever is greater; 18) Patients who have not previously received cholesterol-lowering dietary guidance prior to the screening visit (week-2); 19) Newly diagnosed (within 3 calendar months prior to randomization visit [week 0]) or poorly controlled (HbA1c > 9% at the screening visit [week-2]); 20) The presence of any clinically significant uncontrolled known endocrine disorder affecting serum lipids or lipoproteins.Note: Patients receiving thyroid replacement therapy may be included if their dose has been stable for at least 12 weeks between screening and randomization visit, and their thyroid-stimulating hormone (TSH) levels are within the normal range in a central laboratory at the time of screening visit; 21) History of surgery for obesity treatment within 12 months prior to screening visit (week-2); 22) Unstable weight, defined as a change of >5 kg within 2 months prior to screening visit (week-2); 23) Known history of heterozygous FH; 24) Known history of PCSK9 loss of function (i.e., genetic mutation or sequence variation); 25) Use of systemic corticosteroids, unless they are used as replacement therapy for pituitary / adrenal disorders and have been used in a stable regimen for at least 6 weeks prior to randomization visit (week 0).Note: Topical, intra-articular, nasal, inhaled, and ocular steroid therapy is not considered “systemic” and is permitted; 26) Use of continuous estrogen or testosterone replacement therapy unless the therapy has been stable for the past 6 weeks prior to the screening visit (week-2) and there are no plans to change the treatment regimen during the study; 27) History of cancer within the past 5 years, excluding adequately treated basal cell carcinoma, squamous cell carcinoma, or cervical cancer in situ; 28) Known history of a positive HIV test; 29) The patient has received any investigational drug other than the Alirocumab training placebo kit within 1 month or 5 half-lives (whichever is longer); 30) Previous treatment with at least one dose of Alirocumab or any other anti-PCSK9 monoclonal antibody in other clinical trials; 31) Conditions / circumstances such as: a) Any clinically significant abnormality identified at screening that, in the judgment of the investigator or any sub-investigator, would impede the safe completion of the study or constrain its termination. The following criteria are considered as unsuitable for the study: 1) patients with major systemic diseases or short life expectancy; 2) patients deemed unsuitable for the study by the investigator or any sub-investigator for any reason, such as: i) patients deemed unable to meet specific protocol requirements (e.g., scheduled visits); ii) patients deemed unable to administer or tolerate long-term injections as prescribed by the investigator or patient; iii) patients deemed unsuitable for the study by the investigator or any sub-investigator, pharmacist, research collaborator, other research staff directly involved in administering the protocol, or their relatives; iv) any other actual or anticipated circumstances (e.g., geographical or social) that the investigator believes would limit or restrict the patient's participation in the study process; or 32) laboratory findings during screening (excluding randomization week 0 laboratory findings unless otherwise stated): i) positive test for hepatitis B surface antigen or hepatitis C antibody; ii) positive serum β-hCG or urine pregnancy test (including week 0) in women with potential delivery risk (WOCBP); iii) TG >400 mg / dL (>4.52 mmol / L) (one laboratory repeat allowed); iv) eGFR <30 mL / min / 1.73 m according to the four-variable MDRD study equation. 2 (Calculated by the central laboratory); v) Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) >3 x upper limit of normal (ULN) (1 replicate laboratory allowed); vi) CPK >3 x ULN (1 replicate laboratory allowed); vii) TSH < lower limit of normal (LLN) or > ULN (1 replicate laboratory allowed).

[0422] Exclusion criteria related to the active comparative and / or mandatory background treatment are: 1) all contraindications or warnings / precautions for use (where applicable) for background treatment, as listed in the respective national product label.

[0423] Exclusion criteria relevant to current knowledge of Alirocumab are: 1) known hypersensitivity to the monoclonal antibody or any component of the said drug product; 2) pregnant or lactating women; or 3) women with a potential for delivery who are not protected by an effective method of birth control (as defined in the informed consent form and / or the appendix to the local operating protocol) and / or who are unwilling or unable to undergo pregnancy testing. Note: Women with a potential for delivery must have a confirmed negative pregnancy test result at the time of screening and randomization visit. They must use an effective method of contraception throughout the duration of study treatment and for 10 weeks after the last dose of the study drug, and consent to repeat urine pregnancy testing at the designated visit. The method of contraception used must meet the criteria for highly effective methods of contraception, which are based on “Considerations regarding the guidelines for conducting non-clinical safety studies of human clinical trials of drugs (CPMP / ICH / 286 / 95)”. Postmenopausal women must have been amenorrhea for at least 12 months.

[0424] Research on treatment

[0425] The study treatment is a single SC injection of 75 mg or 150 mg of Alirocumab or placebo in a self-injector, administered to an external area of ​​the abdomen, thigh, or upper arm. The first injection of the study drug is given as soon as possible at the clinical site after randomization to the study. Patients are monitored at the clinical site for 30 minutes after the first injection. Subsequent injections are administered outside the clinic by the patient / caregiver according to the dosing protocol. The dose of the study drug is administered on the same day as the clinical study visit, after all study evaluations have been performed and all laboratory samples have been collected. Subcutaneous administration of the study drug should be given every 2 weeks at approximately the same time each day (based on patient preference); administration falling within a + / - 3-day window is acceptable.

[0426] The sterile Alirocumab pharmaceutical product is delivered in an auto-injector at a concentration of 75 mg / mL or 150 mg / mL in histidine, pH 6.0, polysorbate 20, and sucrose.

[0427] A placebo matching Alirocumab is administered in an autoinjector in the same formulation as Alirocumab, without the addition of protein.

[0428] Throughout the study, all patients received a maximally tolerable stable daily statin (atorvastatin, rosuvastatin, or simvastatin) plus / - other LMTs. The statin dose and the dose of other LMTs (if applicable) should remain stable throughout the study, from screening to the end of the study visit.

[0429] During double-blind treatment, modifications to the background LMT are permitted only under certain conditions before week 24: 1) Exceptions – primary considerations (including, but not limited to, TG alerts below, issued by the central laboratory) to ensure that these changes are justified, based on the investigator’s judgment; or 2) Confirmed TG alerts – patients meet the pre-specified TG alert (TG ≥500 mg / dL [5.65 mmol / L]).

[0430] During double-blind treatment, modification of background LMT after week 24 is permitted only in certain circumstances: 1) special circumstances based on investigator's judgment; 2) confirmed TG alerts - patients meet pre-specified TG alerts (TG ≥500 mg / dL [5.65 mmol / L], or 3) LDL-C increases by at least 25% compared to the randomized visit LDL-C (with no other reasonable explanation).

[0431] For laboratory salvage alerts indicating an LDL-C increase of >25% compared to two consecutive randomized visits, investigators should ensure there is no plausible explanation for the inadequate LDL-C control (e.g., alternative medical reasons such as corticosteroid use), particularly that dietary adherence is appropriate; background LMT is appropriate; and study treatment is administered as planned. If any of the above can reasonably explain the inadequate LDL-C control, investigators should take appropriate action, namely, emphasizing the absolute need for treatment adherence, and if necessary, organizing specific consultations with qualified nutrition professionals, emphasizing the absolute need for dietary adherence, and conducting a blinded LDL-C assessment within 1 to 2 months. If no cause for the aforementioned LDL-C threshold is found, salvage medication may be initiated.

[0432] If no cause for LDL-C exceeding the threshold is found, or if appropriate action fails to lower LDL-C below the threshold, a rescue medication may be introduced. The effectiveness of any such change will be determined based on the absence of a rescue threshold from a blinded lipid test at the next routinely scheduled laboratory draw. Patients on each regimen are already receiving the maximum tolerated dose of statins, so statin uptiing or switching will not be considered. To further lower LDL-C, investigators may consider adding: a cholesterol absorption inhibitor (ezetimibe) or a bile acid conjugating chelator (resin-based cholestyramine and colestipol or colesvelam, a non-absorbable polymer). Other lipid modifiers to consider include: fibrates (Note: When combining fibrates with other cholesterol-lowering drugs (e.g., statins), caution should be exercised due to the risk of myopathy. Fenofibrate is the preferred fibrate when combined with statins because it does not affect statin glucuronidation. The only fibrate permitted under the regimen is fenofibrate); niacin (Note: Niacin raises blood sugar, but it has been shown to effectively improve lipid profiles in diabetic patients if glucose control is maintained).

[0433] For individual patients, if LDL-C ≥ 70 mg / dL at the week 8 visit, the dose of the study drug is increased (up-tied) from 75 mg every 2 weeks starting from week 12 to 150 mg SC.

[0434] Patients were randomly assigned to receive either Alirocumab or placebo in a 2:1 ratio, with randomization performed in replacement blocks. History of MI or ischemic stroke (with or without) and statin dosage ("with" represents atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily, "without" represents simvastatin, any daily dose, atorvastatin less than 40 mg daily or rosuvastatin less than 20 mg daily) were used as fixed effects; and baseline calculated LDL-C was used as a covariate.

[0435] During the study, concomitant medications should be kept to a minimum. If this is deemed necessary for the patient's well-being and unlikely to interfere with the study medication, concomitant medications (other than those prohibited during the study) may be administered at the investigator's discretion at a stable dose (if possible).

[0436] Nutritional products or over-the-counter therapies that may affect lipids are permitted only if used at a stable dose for at least 4 weeks prior to the screening visit and maintained throughout the first 24 weeks of double-blind treatment. Modifications to these nutritional products or over-the-counter therapies are permitted after the 24-week visit, but should generally be avoided. Examples of such nutritional products or over-the-counter therapies include omega-3 fatty acids at doses <1000 mg, and phytosterols, such as those found in Benecol, flaxseed oil, and psyllium.

[0437] Women with the potential to give birth must use effective contraception throughout the study treatment and for 10 weeks after the last dose of the study drug.

[0438] The following concomitant medications are prohibited from use from the initial screening visit until the end of the study visit: statins other than atorvastatin, rosuvastatin, or simvastatin; fibrates other than fenofibrate; and red yeast rice products.

[0439] Study endpoints

[0440] Baseline characteristics include standard demographic characteristics for each patient (e.g., age, race, weight, height, etc.) and disease characteristics, including medical history and medication history.

[0441] The primary efficacy endpoint is the percentage change in calculated LDL-C from baseline to week 24, defined as: 100 × (calculated LDL-C value at week 24 - calculated LDL-C value at baseline) / calculated LDL-C value at baseline. The baseline calculated LDL-C value is the last LDL-C level obtained prior to the first dose of the study drug. The week 24 calculated LDL-C is the LDL-C level obtained within the week 24 analytical window and during the primary efficacy period. The primary efficacy period is defined as the time from the first double-blind injection of the study drug to 21 days after the last double-blind injection of the study drug, or up to the upper limit of the week 24 analytical window (whichever comes first).

[0442] The key secondary efficacy endpoints were: 1) Percentage change in calculated LDL-C from baseline to week 12: similar definitions and rules as the primary efficacy endpoint, except that the LDL-C calculated at week 12 was the LDL-C level obtained within the week 12 analytical window and over the 12-week efficacy period. The 12-week efficacy period was defined as the time from the first double-blind study drug injection to either the sixth visit for re-providal IVRS contact or 21 days after the last study drug injection, whichever came first. Blood samples collected on the day of the sixth visit for re-providal IVRS contact were considered pre-titration; 2) Percentage change in Apo B from baseline to week 24: using the same definitions and rules as the primary endpoint; 3) Percentage change in non-HDL-C from baseline to week 24: using the same definitions and rules as the primary endpoint; 4) Percentage change in total C from baseline to week 24: using the same definitions and rules as the primary endpoint; 5) Percentage change in Apo B from baseline to week 12.6) The same definitions and rules were used for the percentage change in LDL-C from baseline to week 12 as for the calculated percentage change in LDL-C; 7) The same definitions and rules were used for the percentage change in non-HDL-C from baseline to week 12 as for the calculated percentage change in LDL-C from baseline to week 12; 8) The same definitions and rules were used for the percentage change in total LDL-C from baseline to week 12 as for the calculated percentage change in LDL-C from baseline to week 12; 9) The same definitions and rules were used for the calculated percentage change in LDL-C from baseline to week 52 as for the primary endpoint of week 52; 10) The proportion of patients who achieved their LDL-C target at week 24, which is defined as LDL-C <70 mg / dL (1.81 mmol / L) in the case of prior CVD, or <100 mg / dL (2.59 mmol / L) in the case of no prior CVD. The patient proportion was defined as: (number of patients achieving the LDL-C target calculated at week 24 / number of patients in the modified intention-to-treat (mITT) population) * 100, using the definitions and rules used for the primary endpoint; 10) the proportion of patients achieving LDL-C <70 mg / dL (1.81 mmol / L) at week 24; 11) the percentage change in Lp(a) from baseline to week 24, using the same definitions and rules as for the primary endpoint; 12) the percentage change in HDL-C from baseline to week 24, using the same definitions and rules as for the primary endpoint; 13) the percentage change in HDL-C from baseline to week 12, using the same definitions and rules used for calculating the percentage change in LDL-C from baseline to week 12; 14) 15) Percentage change in Lp(a) from baseline to week 12, using the same definitions and rules used for calculating the percentage change in LDL-C from baseline to week 12; 16) Percentage change in fasting TG from baseline to week 24, using the same definitions and rules used for the primary endpoint; 17) Percentage change in fasting TG from baseline to week 12, using the same definitions and rules used for calculating the percentage change in LDL-C from baseline to week 12; 18) Percentage change in Apo A-1 from baseline to week 24, using the same definitions and rules used for the primary endpoint; and 19) Percentage change in Apo A-1 from baseline to week 12, using the same definitions and rules used for calculating the percentage change in LDL-C from baseline to week 12.

[0443] Other secondary efficacy endpoints were: 1) the calculated percentage change in LDL-C from baseline to week 78. The definitions and rules are similar to those used for the primary endpoints, with week 78 replacing week 24; 2) the proportion of patients who achieved their LDL-C target at weeks 12, 52, and 78, where the LDL-C target is LDL-C <70 mg / dL (1.81 mmol / L) for patients with prior CVD or <100 mg / dL (2.59 mmol / L) for patients without prior CVD; 3) the proportion of patients who achieved LDL-C <100 mg / dL (2.59 mmol / L) at week 24; 4) the proportion of patients who achieved LDL-C <100 mg / dL (2.59 mmol / L) at week 12; 5) the proportion of patients who achieved LDL-C <70 mg / dL (1.81 mmol / L) at week 12; 6) the absolute change in calculated LDL-C (mg / dL and mmol / L) from baseline to weeks 12, 24, 52, and 78; 7) Apo B) Percentage changes in non-HDL-C, total-C, Lp(a), HDL-C, fasting TG, and Apo A-1 from baseline to weeks 52 and 78; 8) Changes in the ratio ApoB / ApoA-1 from baseline to weeks 12, 24, 52, and 78; 9) Proportion of patients with ApoB <80 mg / dL (0.8 g / L) at weeks 12, 24, 52, and 78; 10) Proportion of patients with non-HDL-C <100 mg / dL at weeks 12, 24, 52, and 78; 11) Proportion of patients with calculated LDL-C <70 mg / dL (1.81 mmol / L) and / or calculated LDL-C reduction ≥50% (if calculated LDL-C ≥70 mg / dL [1.81 mmol / L]) at weeks 12, 24, 52, and 78.

[0444] Other endpoints were: 1) Anti-Alirocumab antibody status (positive / negative) and titer assessed throughout the study; 2) Percentage change in high-sensitivity C-reactive protein (hs-CRP) from baseline to weeks 24, 52, and 78; 3) Absolute change in HbA1c (%) from baseline to weeks 24, 52, and 78; and 4) Response, index score, and change in index score from baseline to week 52 for each EQ-5D item.

[0445] Research Visit

[0446] The following visits were arranged:

[0447] During the following visits: 1st visit / screening / days -14 to -8; 2nd visit / screening / day -7 (+ / -3 days); 3rd visit / baseline / week 0 / day 1; 4th visit / week 4 / day 29 (+ / -7 days); 6th visit / week 12 / day 85 (+ / -3 days); 7th visit / week 16 / day 113 (+ / -7 days); 8th visit / week 24 / day 169 ( + / - 3 days) / Primary endpoint assessment; 9th visit / Week 36 / Day 253 (+ / - 7 days); 10th visit / Week 52 / Day 365 (+ / - 5 days); 11th visit / Week 64 / Day 449 (+ / - 7 days); 12th visit / Week 78 / Day 547 (+ / - 5 days); and study completion / 13th visit / Week 86 / Day 603 (+ / - 7 days).

[0448] To determine study eligibility or characterize the baseline population, medical / surgical history, medication history, demographic characteristics, height, hepatitis B surface antigen, and serum pregnancy tests are performed.

[0449] Collect all laboratory samples before administering the study drug dose.

[0450] Blood samples for lipid panels should be collected on the morning of all clinical visits, under fasting conditions (i.e., fasting for at least 10 hours overnight, with only water and no smoking). Alcohol consumption within 48 hours, as well as strenuous physical activity and smoking within 24 hours prior to blood collection, are prohibited. Note: If the patient is not fasting, a lipid panel sample should be collected, and a new appointment should be scheduled for the following day (or as close to that date as possible), with the patient reminded to fast.

[0451] Sample size and power considerations

[0452] A total sample size of 45 patients (30 with alirocumab and 15 with placebo) would have 95% power to detect a difference in the mean percentage change in LDL-C of 30%, with a two-sided significance level of 0.05; assuming a common standard deviation of 25% and that all 45 patients had evaluable primary endpoints.

[0453] To meet regulatory requirements for the entire program, the sample size was increased to 126 patients receiving alirocumab to understand its safety in a larger population. To ensure at least 126 patients received alirocumab for 12 months in this study, and assuming a 10% dropout rate during the first 3 months and a 20% dropout rate during the remaining 9 months, the total sample size was ultimately increased and rounded to 250 patients, with a randomization ratio of 2:1 (alirocumab: 167, placebo: 83).

[0454] Analyzing the population

[0455] Intended patients

[0456] The randomized population includes all randomized patients and is analyzed based on the treatment assigned by randomization.

[0457] The ITT population (also known as the full analysis group [FAS]) is defined as all randomized patients with an evaluable primary endpoint. An endpoint is evaluable when both of the following criteria are met: 1) availability of a calculated LDL-C value at baseline; and 2) availability of at least one calculated LDL-C value within one of the analysis windows up to week 24.

[0458] Patients in the ITT population were analyzed based on the treatment groups assigned by randomization (i.e., randomized treatment groups).

[0459] Modified intention therapy

[0460] The mITT population is defined as all randomized individuals who received at least one dose or a partial dose of the study drug and had an evaluable primary endpoint. An endpoint is considered evaluable (i.e., the efficacy treatment period) when both of the following criteria are met: 1) availability of baseline calculated LDL-C values; and 2) availability of at least one calculated LDL-C value during the efficacy treatment period and within one of the analytical windows up to week 24. The efficacy treatment period is defined as the time from the first double-blind injection of the study drug to 21 days after the last double-blind injection of the study drug.

[0461] Patients in the mITT population were analyzed based on their treatment groups, which were randomly assigned.

[0462] Security Analysis Group

[0463] The safety population considered for safety analyses is a randomized population that received at least one dose or a partial dose of the investigational drug. Patients are analyzed based on the actual treatment received (i.e., the treatment group, placebo, or alirocumab).

[0464] result

[0465] Description of the study population

[0466] In this study, a total of 249 patients were randomized (82 to the placebo group and 167 to the alirocumab group). One patient in the placebo group was randomized but did not receive study treatment because they withdrew their informed consent before receiving their first IMP injection. Therefore, this patient was excluded from the safety population. Two randomized patients (one in the placebo group and one in the alirocumab group) were excluded from the ITT and mITT populations due to the lack of post-baseline LDL-C assessment.

[0467] Table 14: Analytical Population

[0468]

[0469] Note: Patients with safety and anti-alirocumab antibodies are tabulated according to their actual treatment received (e.g., treatment). For other populations, patients are tabulated according to their randomization treatment.

[0470] In the alirocumab group, of the 158 patients who received at least one injection after week 12, 61 (38.6%) received an automated titration of alirocumab 75 mg Q2W to 150 mg Q2W in a blinded manner at week 12.

[0471] Subject handling

[0472] From the data cutoff date of the first step analysis, the patient status of the 249 randomized patients is as follows: 1) 0 (0.0%) patients completed the 78-week double-blind treatment period, as ongoing patients had not yet reached the 78-week visit; 2) 234 (94.0%) patients were still under treatment: 78 (95.1%) in the placebo group and 156 (93.4%) in the alirocumab group; 3) 9 (3.6%) randomized and treated patients prematurely discontinued treatment before week 24: 1 (1.2%) in the placebo group and 8 (4.8%) in the alirocumab group. 4 (1.6%) patients prematurely discontinued treatment due to adverse events: 0 in the placebo group and 4 (2.4%) in the alirocumab group. 3 (1.2%) patients prematurely discontinued treatment due to poor protocol adherence: 1 (1.2%) in the placebo group and 2 (1.2%) in the alirocumab group. Due to various other reasons, 2 patients (0.8%) prematurely discontinued study treatment: 0 in the placebo group and 2 (1.2%) in the alirocumab group; 13 (5.2%) randomized and treated patients prematurely discontinued study treatment before week 52: 2 (2.4%) in the placebo group and 11 (6.6%) in the alirocumab group. Due to adverse events, 5 patients (2.0%) prematurely discontinued study treatment: 0 in the placebo group and 5 (3.0%) in the alirocumab group. 3 patients (1.2%) prematurely discontinued study treatment due to poor protocol adherence: 1 (1.2%) in the placebo group and 2 (1.2%) in the alirocumab group. Five patients (0.8%) prematurely discontinued treatment for various other reasons: one (1.2%) in the placebo group and four (2.4%) in the alirocumab group. Fourteen patients (5.6%) prematurely discontinued treatment before completing the 78-week treatment period: three (3.7%) in the placebo group and eleven (6.6%) in the alirocumab group. Six patients (2.4%) prematurely discontinued treatment due to adverse events: one (1.2%) in the placebo group and five (3.0%) in the alirocumab group. Three patients (1.2%) prematurely discontinued treatment due to poor protocol adherence: one (1.2%) in the placebo group and two (1.2%) in the alirocumab group. Five patients (2.0%) prematurely discontinued treatment for various other reasons: one (1.2%) in the placebo group and four (2.4%) in the alirocumab group.

[0473] The table below provides the availability of LDL-C values ​​over time. At week 24, the primary efficacy endpoint was achieved in 78 patients (96.3%) in the placebo group and 157 patients (94.5%) in the alirocumab group. In the placebo group, 77 patients (95.1%) were evaluated during treatment and 1 patient (1.2%) were evaluated for treatment discontinuation, compared to 155 patients (93.4%) and 2 patients (1.2%) in the alirocumab group. At week 52, key secondary efficacy endpoints were achieved in 78 patients (96.3%) in the placebo group and 158 patients (95.2%) in the alirocumab group.

[0474] Table 15: LDL-C Availability Calculated Over Time - ITT Audience

[0475]

[0476] Values ​​during treatment are obtained after the first study treatment injection and within 21 days after the last study treatment injection.

[0477] Post-treatment values ​​were obtained more than 21 days after the last study treatment injection.

[0478] At week 24, the primary endpoint was missing in 12 patients (4.9%). The reasons for the missing values ​​at the week 24 visit were as follows: 1) 4 subjects did not have samples available due to early discontinuation of the study; 2) 2 subjects were still on treatment but did not have their week 24 LDL-C measured; 3) 6 samples were available at week 24, but LDL-C could not be calculated (5 samples had TG > 400 mg / dL and reported measured LDL-C, 1 sample had > 400 mg / dL but did not report measured LDL-C).

[0479] Demographics and baseline characteristics

[0480] Overall, demographic characteristics, baseline disease characteristics, baseline efficacy lipid parameters, LMT history, and background LMT use were homogeneous between patients randomized to the alirocumab group and those randomized to the placebo group (see Table 16). Specifically, the mean baseline LDL-C in the alirocumab group was 134.6 mg / dL (SD = 41.1 mg / dL), compared to a mean baseline LDL-C of 134.0 mg / dL (SD = 41.4 mg / dL) in the placebo group, with an overall mean of 134.4 mg / dL (SD = 41.1 mg / dL). A potentially significant exception was the difference observed in baseline BMI, with a mean BMI of 28.6 kg / m² in the alirocumab group.2 (SD=4.6 kg / m2), while it was 27.7 kg / m2 in the placebo group. 2 (SD=4.7 kg / m 2 ).

[0481] Table 16: Baseline characteristics of the FHII patient population

[0482]

[0483] Unless otherwise stated, the percentage (N) of patients. All patients were on the basis of maximum tolerated statin ± other lipid-lowering therapy. †The diagnosis of heFH must be made by genotyping or clinical criteria. For patients who have not undergone genotyping, the clinical diagnosis must be based on a score >8 on the Simon Broome criteria or the WHO / Dutch Lipid Network criteria for definite FH.

[0484] Table 17: Disease characteristics and other relevant baseline data - randomized population

[0485]

[0486] * heFH diagnosis can be confirmed through genotyping and WHO or Simon Broome criteria.

[0487] Note: p-values ​​for comparing baseline data between treatment groups are provided for descriptive purposes. Fisher's exact test was used as a screening tool for quantitative data, while the asymptotic univariate ANOVA test was used for Wilcoxon scores (Krukal-Wallis test) for continuous data.

[0488] Table 18: Background LMT at randomization point - randomized population

[0489]

[0490] Note: p-values ​​are provided for comparison of treatment groups with baseline data for descriptive purposes. Fisher's exact test was used as a screening tool.

[0491] *With or without statins.

[0492] Table 19 Classification of Cardiovascular History and Risk Factors

[0493]

[0494] Unless otherwise stated, the percentage (N) of patients. All patients were on the basis of maximum tolerated statin ± other lipid-lowering therapy.

[0495] Table 20: Lipid efficacy parameters at baseline - quantitative summary in conventional units - randomized population

[0496]

[0497]

[0498] Note: p-values ​​for comparing baseline data between treatment groups are provided for descriptive purposes. As a screening tool, an asymptotic one-way ANOVA test was used for the Wilcoxon score (Kruskal-Wallis test).

[0499] The initial protocol did not plan to collect measured LDL-C values, which were added during the revision process. Therefore, measured LDL-C values ​​were available for fewer patients compared to calculated LDL-C values.

[0500] Exposure level

[0501] Exposure to the injections was similar across treatment groups, with a mean exposure of approximately 58–60 weeks. Patients treated with alirocumab had exposures of 2–75.9 weeks, while those treated with placebo had exposures of 11.6–75.7 weeks. The majority (93.5% vs. 97.5%, alirocumab vs. placebo, respectively) of patients were treated for more than 52 weeks.

[0502] In the alirocumab group, of the 158 patients who received at least one injection after week 12, 61 (38.6%) received automated up-titer from alirocumab 75 mg Q2W to 150 mg Q2W in a blinded manner at week 12. 26 patients did not have the opportunity for up-titer at week 12 because they lacked their week 8 LDL-C values ​​at the time of the up-titer decision. Of these 26 patients lacking week 8 LDL-C values, 4 alirocumab patients should have already been up-tied based on the available week 8 LDL-C data. The remaining patients were either in the placebo group or had week 8 LDL-C levels below the cutoff value of <70 mg / dL for up-titer in alirocumab patients.

[0503] Efficacy Analysis

[0504] Analysis of the main efficacy of ITT in the population

[0505] The primary endpoint (the calculated percentage change in LDL-C from baseline to week 24) was analyzed using the MMRM model in the ITT population, estimated using the mean LS at week 24. This repeated measures approach included all LDL-C values ​​collected during and after treatment up to week 52. At week 24, LDL-C values ​​were not calculated in 3 patients (3.7%) in the placebo group and 9 patients (5.4%) in the alirocumab group (Table 15). These missing values ​​were calculated using the MMRM model.

[0506] The primary efficacy analysis showed a statistically significant reduction in the percentage change in baseline-calculated LDL-C at week 24 in the alirocumab treatment group (mean LS = 2.8%) compared to the placebo group (mean LS = -48.7%). The mean difference in LS between the alirocumab and placebo groups was -51.4% (p < 0.0001). 81.4% of HeFH patients in the alirocumab group achieved their LDL-C target at week 24, compared to 11.3% in the placebo group.

[0507] Table 21: Percentage change in LDL-C from baseline calculated at week 24 (ITT analysis): MMRM analysis - ITT population

[0508]

[0509] Note: Least squares (LS) mean, standard error (SE), and p-values ​​were obtained from MMRM (mixed effects model with repeated measures) analysis. The model included treatment groups, randomization stratified according to IVRS, time points, fixed categorical effects of treatment interactions over time points, and continuous fixed covariates of baseline calculated LDL-C values ​​and baseline values ​​of interactions over time points.

[0510] The MMRM model and baseline description are run on patients who are in at least one of the analysis windows used in the model and have baseline values ​​and values ​​after baseline.

[0511] If statistical significance is achieved according to a fixed stratification method used to ensure strong control over Type 1 errors in the population at the 0.05 level, then the p-value is followed by an asterisk (*).

[0512] LDL-C calculated over time

[0513] Figure 4This is a chart showing the percentage change from baseline in the LDL-C LS mean (+ / - SE) of the ITT population over time. Note: Least squares (LS) mean and standard error (SE) are obtained from MMRM (mixed effects model with repeated measures) analysis.

[0514] The model includes a fixed categorical effect of the treatment group, time points, and the interaction of treatments over time points, as well as a continuous fixed covariate of baseline LDL-C values ​​and the interaction of baseline LDL-C over time points.

[0515] Table 22: LDL-C Calculated Over Time - ITT Population

[0516]

[0517] The baseline is described using the mean and standard error.

[0518] Note: Least squares (LS) mean, standard error (SE), and p-values ​​were obtained from MMRM (mixed effects model with repeated measures) analysis. The model included treatment groups, randomization stratification according to IVRS, time points, fixed categorical effects of treatment interactions over time points, and continuous fixed covariates of baseline calculated LDL-C values ​​and baseline values ​​of interactions over time points.

[0519] The MMRM model and baseline description are run on patients who are in at least one of the analysis windows used in the model and have baseline values ​​and values ​​after baseline.

[0520] Sensitivity to serious GCP non-compliance

[0521] No sites with severe GCP sensitivity were found in this study.

[0522] Key secondary efficacy analysis

[0523] The table below summarizes the analysis results for all key secondary endpoints in stratified order, with statistical significance tested at the 0.05 level. This study achieved statistical significance to support all alirocumab-treated patients in all strata of the key secondary efficacy endpoints (i.e., Apo A-1 – percentage change from baseline to week 12, except the last one).

[0524] For clarity, the ITT analysis is defined for patients in the ITT population and includes all endpoint assessments within the analysis window, regardless of study treatment dosing status (i.e., including post-treatment assessments). The in-treatment analysis is defined for patients in the mITT population and includes all endpoint assessments from the first double-blind study drug injection to the last injection + 21 days (i.e., including efficacy treatment assessments).

[0525] Table 23: Summary of key secondary efficacy endpoints

[0526]

[0527]

[0528] Layered testing terminated

[0529] Apart from the percentage change in Apo A-1 from baseline to week 12 in the ITT population, all key secondary efficacy endpoints achieved statistical significance according to the stratified testing procedure, supporting patients treated with alirocumab.

[0530] In the mITT population (in-treatment analysis), key secondary power analysis of the percentage change in calculated LDL-C from baseline to week 24 showed results consistent with the ITT analysis, with a statistically significant reduction in calculated LDL-C in the alirocumab treatment group (mean LS = -49.4%) compared to the placebo group (mean LS = 2.7%). The treatment difference in mean LS between patients treated with alirocumab and those treated with placebo was -52.2% (p < 0.0001). Indeed, very few patients had LDL-C values ​​collected post-treatment (i.e., more than 21 days after the last injection) at week 24: 1 patient (1.2%) in the placebo group and 2 patients (1.2%) in the alirocumab group.

[0531] In the ITT analysis, the reduction in the percentage change of Apo A-1 from baseline to week 24 was not statistically significant: the mean LS was 0.4% in the alirocumab group and -1.9% in the placebo group (mean LS difference was 2.3% in placebo, p = 0.1475).

[0532] Ldl-C calculated over time (including observed data)

[0533] Figure 5 This is a graph showing the percentage change from baseline in mean LDL-C LS (+ / - SE) over time during efficacy treatment for the mITT population.

[0534] Overview

[0535] Overall, the demographic characteristics, baseline disease characteristics, baseline efficacy lipid parameters, LMT history, and background LMT use were comparable between patients randomly assigned to the alirocumab group and those randomly assigned to the placebo group. Specifically, the mean (SD) baseline LDL-C in the alirocumab group was 134.6 (41.1) mg / dL, compared to a mean (SD) baseline LDL-C of 134.0 (41.4) mg / dL in the placebo group.

[0536] In addition to the percentage change in Apo A-1 from baseline to week 12 in the ITT population (ITT analysis), the primary efficacy endpoint and all key secondary endpoints met the statistically significant benefit according to the stratified testing procedure, supporting the use of Alirocumab in patients.

[0537] Overview of security results

[0538] A total of 248 patients were randomized and received at least a partial dose of the study treatment (safety population). Below is a high-level overview of adverse events and events of interest.

[0539] Table 24: Overview of Adverse Events: Treatment-Related Emergency Adverse Events – Safety Population

[0540]

[0541] TEAE: Treatment-emergent adverse event; SAE: Serious adverse event.

[0542] n(%) = Number or percentage of patients with at least one TEAE

[0543] Treatment-urgent SAEs occurred in a total of 17 patients, specifically 10 (6.0%) in the alirocumab treatment group and 7 (8.6%) in the placebo treatment group. No more than 2 cases were reported in any state of emergency (SOC) in either treatment group, and no more than one individual SAE was reported in either treatment group.

[0544] No patient deaths were reported during the first phase of analysis.

[0545] Six patients prematurely discontinued study treatment due to TEAEs. Specifically, five patients (3.0%) in the alirocumab treatment group discontinued treatment prematurely due to rectal adenocarcinoma, diarrhea, nausea, angioedema, weakness, and elevated alanine aminotransferase. One patient (1.2%) in the placebo treatment group discontinued treatment due to syncope.

[0546] TEAEs occurred in 117 (70.1%) patients in the alirocumab treatment group and 62 (76.5%) patients in the placebo treatment group. TEAEs occurring in ≥5% of patients in either treatment group were: injection site reaction (10.8% vs. 7.4% in the alirocumab and placebo groups, respectively), headache (8.4% vs. 8.6% in the alirocumab and placebo groups, respectively), myalgia (6.0% vs. 6.2% in the alirocumab and placebo groups, respectively), and diarrhea (5.4% vs. 1.2% in the alirocumab and placebo groups, respectively).

[0547] For TEAE of special interest (AESI), the results are represented by a predefined set of preferred terms in the SMQ.

[0548] Treatment emergency injection site reactions (ISRs) occurred in 18 patients (10.8%) in the alirocumab treatment group and 6 patients (7.4%) in the placebo treatment group. None of these AEs were serious.

[0549] In 17 patients (10.2%) in the alirocumab treatment group and 6 patients (7.4%) in the placebo treatment group, generalized anaphylactic TEAEs identified by the MedDRA SMQ as “hypersensitivity” occurred. None of these AEs were serious.

[0550] Treatment-related neurological events occurred in 7 patients (4.2%) in the alirocumab treatment group and 2 patients (2.5%) in the placebo group. In the alirocumab group, PT (post-traumatic stress disorder) was: hypoesthesia in 4 patients (2.4%), paresthesia in 2 patients (1.2%), and balance disorder in 1 patient (0.6%). None of these adverse events (AEs) were serious.

[0551] Treatment-emergent neurocognitive disorders occurred in 0 (0.0%) patients in the alirocumab treatment group and in 1 (1.2%) patients in the placebo treatment group. None of these adverse events were serious.

[0552] A total of 9 patients (5.4%) in the alirocumab treatment group and 0 patients (0.0%) in the placebo treatment group had two consecutive calculated LDL-C measurements below 25 mg / dL. Among those patients with two consecutive calculated LDL-C measurements below 25 mg / dL, 3 patients (33.3%) in the alirocumab treatment group experienced TEAEs. PTs were: influenza, influenza-like illness, and nasopharyngitis. These AEs were neither serious nor AESI.

[0553] in conclusion

[0554] Early evaluation of the study data leads to the following conclusions: 1) The study met its primary efficacy endpoint, with a statistically significant reduction in calculated LDL-C in patients treated with alirocumab; 2) In addition to the final endpoint (Apo A-1 at week 12 in the ITT population (ITT analysis)), the study also met all key secondary efficacy endpoints; and 3) Based on the available data at the time of this first-step analysis, subcutaneous administration of alirocumab (depending on the history of MI or stroke at baseline) is generally safe and well-tolerated in patients with heterozygous familial hypercholesterolemia and LDL-C > 70 mg / dL or LDL-C > 100 mg / dL.

[0555] Overview of summary data from FH I and FH II studies

[0556] The pooled data from the FHI and FHII studies yielded the following conclusions: 1) Self-administered alirocumab produced a significantly greater reduction in LDL-C after 24 weeks than placebo (mean difference in LS: 51.4–57.9%); 2) Most patients (>70%) achieved their LDL-C target at week 24; 3) At week 52, alirocumab resulted in a 47.1–50.3% reduction in LDL-C; 4) At week 52, alirocumab achieved a mean LDL-C level of 1.7–1.9 mmol / L (65.9–74.3 mg / dL); 5) Approximately 50% of patients did not require titration up to alirocumab 150 mg Q2W, suggesting that 75 mg Q2W may be sufficient for many patients; and 6) TEAEs occurred at similar frequencies in both the alirocumab and placebo groups.

[0557] Specifically, combined data from the FHI and FHII studies showed that alirocumab produced a significant reduction in LDL-C at week 24 compared to placebo. In the alirocumab group (N = 488), the percentage change from baseline in mean LS (SE) at week 24 was -48.8%, compared to 7.1% in the placebo group (N = 244). The difference in mean LS (SE) compared to placebo was -55.8% (2.1) (P < 0.0001). Furthermore, only 42% of patients receiving alirocumab required titration up to a 150 mg Q2W dose at week 12.

[0558] The LDL-C values ​​calculated from the LS mean (SE) of the ODYSSEY FH I and FH II studies are shown over time. Figure 8The values ​​shown in the figure are the percentage changes in the mean LS from baseline to week 24 and week 52. Figure 9 This is a graph showing the LDL-C values ​​calculated from the mean (SE) of the ODYSSEY FHII and FHII studies against time. The values ​​indicated below the graph are the number of patients analyzed at each time point.

[0559] In patients who received double-blind treatment for at least 12 weeks, 176 / 311 (56.6%) of FH I and 97 / 158 (61.4%) of FH II had LDL-C levels <1.8 mmol / L at week 8 and maintained at alirocumab 75 mg Q2W. In these patients, LDL-C levels remained stable over time. Figure 10 For patients receiving FHI (Fluid-I) with a dose escalated to 150 mg Q2W, the mean LDL-C level was 2.7 mmol / L (104.3 mg / dL) at week 12 and 2.0 mmol / L (78.5 mg / dL) at week 24. The corresponding values ​​for FHI (Fluid-II) were 2.6 mmol / L (98.6 mg / dL) at week 12 and 1.9 mmol / L (71.8 mg / dL) at week 24.

[0560] Subgroup analyses of the primary efficacy endpoint showed a consistent reduction in calculated LDL-C across a range of demographic and baseline characteristics. Figures 11A-11C The percentage reduction in LDL-C (alirocumab versus placebo) was 60.1% in men and 50.6% in women (pooled data from FH I and FH II), with an interaction p-value of 0.0267. In individual studies, the LDL-C reduction (versus placebo) was 62.6% in men and 51.9% in women in FH I, and 53.5% in men and 49.2% in women in FH II.

[0561] An overview of the interim safety data from the FH I and FH II studies is listed in Table 25A. All data were collected up to the last patient visit at week 52. The percentages of patients experiencing TEAEs, serious AEs, and TEAEs leading to treatment discontinuation were comparable between the treatment groups in each study (Table 25B). A higher proportion of patients experienced injection site reactions in the alirocumab group versus the placebo group in FH I (12.4% vs. 11.0%) and FH II (11.4% vs. 7.4%). Most injection site reactions were classified as mild in intensity. No injection site reactions led to discontinuation of the study drug. None of the reported neurological or anaphylactic events (Table 3) were serious. Pruritus was reported in two (0.6%) and three (1.8%) patients treated with alirocumab in FH I and II, respectively, compared to one patient treated with placebo in each study (0.6% vs. 1.2%, respectively). A very small number of neurocognitive events were reported in either alirocumab (2 patients [0.6%] in FH I, none in FH II) or placebo (2 patients [1.2%] in FH II, 1 patient [1.2%] in FH II; Table 3). In FH I and FH II, 85.8% and 91.6% of patients treated with alirocumab (compared to 87.7% and 90.1% with placebo, respectively) received study treatment for ≥76 weeks.

[0562] Table 25A: Mid-term safety analysis (summary data from FH I and FH II studies)

[0563]

[0564]

[0565] Table 25B: Final Safety Analysis (Summary data from FH I and FH II studies)

[0566]

[0567] Example 4: A randomized, double-blind, placebo-controlled, parallel-group study to evaluate the efficacy and safety of Alirocumab in patients with heterozygous familial hypercholesterolemia and LDL-C ≥160 mg / dL under lipid-improving therapy.

[0568] introduction

[0569] This study included patients with heterozygous familial hypercholesterolemia (heFH) with or without a recorded history of MI or ischemic stroke.

[0570] The aim of this study was to evaluate the efficacy and safety of alrocumab in heFH patients treated with maximally tolerated statins (with or without additional LMT) and whose LDL-C levels were ≥160 mg / dL (4.14 mmol / L).

[0571] Conduct this specific study ( Figure 6 This study demonstrates that in heFH patients with LDL-C levels greater than or equal to 160 mg / dL, Alirocumab 150 mg Q2W as add-on therapy to statins plus / - other LMTs produced a statistically significant and clinically meaningful reduction in LDL-C. This population with such high LDL-C levels, although the optimized LMT represents the highest-risk group with well-identified unmet medical needs that could be addressed by adding Alirocumab to their LDL-C-lowering therapy.

[0572] Research Objectives

[0573] The primary objective of this study was to demonstrate the reduction in LDL-C (compared to placebo after 24 weeks of treatment) in patients with heterozygous familial hypercholesterolemia (heFH) and LDL-C ≥160 mg / dL (4.14 mmol / L) by addition therapy with Alirocumab as a stable maximum tolerated daily statin (with or without other LMTs).

[0574] Secondary objectives are: 1) to evaluate the effect of alirocumab on LDL-C compared to placebo after 12 weeks of treatment; 2) to evaluate the effect of alirocumab on other lipid parameters (i.e., Apo B, non-HDL-C, total-C, Lp(a), HDL-C, TG, and Apo A-1 levels); 3) to evaluate the long-term effect of alirocumab on LDL-C; 4) to evaluate the safety and tolerability of alirocumab; and 5) to evaluate the development of anti-alirocumab antibodies.

[0575] Research Design

[0576] This is a randomized, double-blind, placebo-controlled, parallel-group, unbalanced (2:1, Alirocumab:placebo), multicenter, multinational study to evaluate the efficacy and safety of Alirocumab in patients with familial hypercholesterolemia (heFH) and LDL-C ≥160 mg / dL, with or without their LMT (i.e., stable maximum tolerated daily statin therapy + / - other LMT). Randomization was stratified based on a history of myocardial infarction (MI) or ischemic stroke [with / without] and statin therapy (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily, compared to any daily dose of simvastatin, atorvastatin less than 40 mg daily or rosuvastatin less than 20 mg daily). After randomization, patients received double-blind study treatment (alirocumab or placebo) every 2 weeks for a 78-week period, on top of stable maximum tolerated daily statin therapy plus / - other LMTs.

[0577] Following the completion of the 18-month double-blind treatment period, all patients who successfully completed the ODYSSEY High FH study were eligible to participate in the open-label extension study. Therefore, regardless of the study treatment received during the 18-month double-blind treatment period, all patients received Alirocumab upon entry into the open-label extension study.

[0578] The study consisted of three phases: screening, double-blind treatment, and follow-up.

[0579] The screening period lasted up to 3 weeks, including an interim visit, during which patients (or another designated person, such as a spouse, relative, etc.) were trained to self-inject / inject with a placebo of Alirocumab. Eligibility assessments were conducted to allow patients to be randomized into the study.

[0580] The double-blind treatment period is an 18-month randomized, double-blind study treatment period. The first injection during the double-blind period is given at the location on the day of randomization (week 0 [D1] - V3) and as soon as possible after being called to the IVRS / IWRS to randomize into the study. Subsequent injections are given by the patient (self-injection) or another designated person (e.g., spouse, relative, etc.) at the patient's preferred location (home...). Patients randomized to Alirocumab receive a dose of 150 mg IMP from randomization (V3) until week 76 (i.e., weeks 0, 2, 4, 6, 8... to 76).

[0581] For patients who did not consent to participate in the open-label extended study or who discontinued study treatment prematurely, the follow-up period (if applicable) is 8 weeks after the end of DBTP.

[0582] Lipid parameters were measured in the laboratory during the study.

[0583] Patients who achieved two consecutive calculated LDL-C levels <25 mg / dL (0.65 mmol / L) during the study period were monitored and managed.

[0584] Statins and other LMTs (if applicable) should remain stable (including dosage) during the first 24 weeks of DBTP unless exceptional circumstances arise, with the primary considerations being (including, but not limited to, a TG alert issued by the central laboratory) to ensure such changes are made in the investigator's judgment. From week 24 onwards, background LMTs may be modified only under certain conditions described below.

[0585] As described in Example 2 above (see Table 1), patients should maintain a stable diet (NCEP-ATPIII TLC diet or equivalent) throughout the entire study duration from the start of screening. A properly trained dietitian or field staff member will check the patients' diet during the screening visit and periodically throughout the study.

[0586] The study duration includes a screening period of up to 3 weeks, a 78-week double-blind treatment process (DBTP) for efficacy and safety assessment, and an 8-week post-treatment follow-up period following the last visit of the DBTP for patients who do not agree to participate in the open-label extended study or who discontinue treatment prematurely. Therefore, the maximum study duration per patient is approximately 89 weeks (20 months) (up to 3 weeks of screening + 78 weeks of double-blind treatment + 8 weeks of follow-up). The study ends for each patient either at the last visit scheduled in the protocol or at the resolution / stabilization of all SAEs and AESIs, whichever comes last.

[0587] Patient selection

[0588] Inclusion criteria were: 1) patients with heterozygous familial hypercholesterolemia (heFH)* who were poorly controlled with the maximum tolerated daily dose of statins, **with or without other lipid-modified therapy (LMT), and who were at a stable dose prior to the screening visit (week 3).

[0589] A diagnosis of heFH must be made through genotyping or clinical criteria. For patients who have not undergone genotyping, a clinical diagnosis can be based on a score of ≥8 points on the Simon Broome criteria or the WHO / Dutch Lipid Network criteria for definite FH. See the criteria described in Example 2 above.

[0590] Maximum tolerated dose definition: Any of the following is acceptable: 1) Rosuvastatin 20 mg or 40 mg daily; 2) Atorvastatin 40 mg or 80 mg daily; 3) Simvastatin 80 mg daily (if this dose has been used for >1 year - see Exclusion Criterion E 06); or 4) Patients who cannot use any of the above statin doses should be treated with a daily dose of atorvastatin, rosuvastatin, or simvastatin deemed appropriate for the patient, based on the investigator's judgment or consideration. Some examples of acceptable reasons for patients taking lower statin doses include, but are not limited to: adverse effects of higher doses, advanced age, low body mass index, regional practice, local prescribing information, concomitant medications, and comorbidities such as impaired glucose tolerance / impaired fasting glucose.

[0591] Patients who met all of the above inclusion criteria were screened for exclusion criteria as follows, which were classified and numbered in three sub-sections: exclusion criteria related to the study method, exclusion criteria related to background treatment, and exclusion criteria related to Alirocumab.

[0592] Exclusion criteria related to the study methods were: 1) patients were not diagnosed with heFH by genotyping or clinical criteria; 2) at the screening visit (week-3) <160 mg / dL (<4.14 mmol / L); 3) patients had not received a stable dose of LMT (including statins) for at least 4 weeks prior to the screening visit (week-3) or from screening to randomization and / or fenofibrate for at least 6 weeks, if applicable; 4) patients were currently receiving a statin other than simvastatin, atorvastatin, or rosuvastatin; 5) patients were not receiving simvastatin, atorvastatin, or rosuvastatin daily or at the registered dose; 6) patients received doses higher than 80 mg of atorvastatin, 40 mg of rosuvastatin, or 40 mg of simvastatin. 7) Use of a fibrates other than fenofibrate within 6 weeks of the screening visit (week-3) or between the screening and randomization visits; 8) Use of nutritional supplements or over-the-counter treatments that may affect lipids, which were not used at a stable dose / volume for at least 4 weeks before the screening visit (week-3) or between the screening and randomization visits; 9) Use of red yeast rice products within 4 weeks of the screening visit (week-3) or between the screening and randomization visits; 10) Received plasma extraction therapy or planned investigational therapy within 2 months prior to the screening visit (week-3). Patients who received plasma collection therapy during the study period; 11) recent (within 3 months prior to the screening visit [week -3] or between the screening and randomization visits) MI, unstable angina leading to hospitalization, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), uncontrolled arrhythmia, stroke, transient ischemic attack (TIA), carotid revascularization, endovascular or surgical intervention for peripheral vascular disease; 12) patients scheduled to undergo PCI, CABG, carotid or peripheral vascular revascularization during the study period; 13) patients with systolic blood pressure >160 mmHg at the screening or randomization visits. 14) A history of New York Heart Association (NYHA) Class III or IV heart failure within the past 12 months; 15) A known history of hemorrhagic stroke; 16) Age <18 years or legal age of adulthood at the screening visit (week-3), whichever is greater; 17) Patients who have not previously received cholesterol-lowering dietary guidance prior to the screening visit (week-3); 18) Newly diagnosed (within 3 calendar months prior to randomization visit [week 0]) or poorly controlled (glycosylated hemoglobin A1c [HbA1c] >9% at the screening visit [week-3]); 19) The presence of any clinically significant uncontrolled known endocrine disorder affecting serum lipids or lipoproteins.Note: Patients receiving thyroid replacement therapy may be included if the dose is stable for at least 12 weeks between screening and randomization visit, and TSH is within the normal range in a central laboratory at the time of screening visit; 20) History of surgery for obesity treatment within 12 months prior to screening visit (week-3); 21) Unstable weight, defined as a change of >5 kg within 2 months prior to screening visit (week-3); 22) Known history of heterozygous FH; 23) Known history of PCSK9 loss of function (i.e., genetic mutation or sequence variation); 24) Use of systemic corticosteroids, unless they are used as replacement therapy for pituitary / adrenal disorders and have been used in a stable regimen for at least 6 weeks prior to randomization visit (week-0). Note: Topical, intra-articular, nasal, inhaled, and ocular steroid therapy is not considered "systemic" and is permitted; 25) Use of continuous estrogen or testosterone replacement therapy unless the therapy has been stable for the past 6 weeks prior to the screening visit (week-2) and there are no plans to change the treatment regimen during the study; 26) History of cancer within the past 5 years, excluding adequately treated basal cell carcinoma, squamous cell carcinoma, or cervical cancer in situ; 27) Known history of a positive HIV test; 28) The patient has received any investigational drug other than the Alirocumab training placebo kit within 1 month or 5 half-lives (whichever is longer); 29) The patient has previously received at least one dose of Alirocumab or any other anti-PCSK9 monoclonal antibody in other clinical trials; 30) The patient withdrew informed consent during screening (the patient did not wish to continue or was unable to return); 31) Conditions / circumstances such as: any clinically significant abnormalities identified at screening, which, according to the investigator... Or any secondary investigator's judgment that would impede the safe completion of the study or constrain the endpoint assessment, such as major systemic diseases, short life expectancy, or patients deemed unsuitable for the study by the investigator or any secondary investigator for any reason, for example: a) patients deemed unable to meet the requirements of a specific experimental protocol (e.g., scheduled visits); b) patients deemed unable to administer or tolerate long-term injections as prescribed by the investigator or patient; c) the investigator or any secondary investigator, pharmacist, research collaborator, other research staff directly involved in implementing the experimental protocol, or their relatives, etc.; d) any other actual or anticipated circumstances that the investigator believes would limit or restrict the patient's participation in the study process (e.g., geographical or social...); 32) Laboratory findings during screening (excluding randomization week 0 laboratory): a) positive test for hepatitis B surface antigen or hepatitis C antibody; b) positive serum β-hCG or urine pregnancy (including week 0) in women with potential delivery; c) triglycerides >400 mg / dL (>4.52 mmol / L) (one laboratory repeat allowed); d) eGFR <30 mL / min / 1.73 m according to the four-variable MDRD study formula.2 (Calculated by the central laboratory); e) ALT or AST > 3 x ULN (1 replicate laboratory allowed); f) CPK > 3 x ULN (1 replicate laboratory allowed); g) TSH < lower limit of normal (LLN) or > upper limit of normal (ULN) (1 replicate laboratory allowed).

[0593] Exclusion criteria related to background treatment are: 1) all contraindications or warnings / precautions for use of the background treatment (where applicable), as listed in the respective national product label.

[0594] Exclusion criteria related to Alirocumab are: 1) known hypersensitivity to monoclonal antibodies or any component of the drug product; 2) pregnant or lactating women; and 3) women with a potential for delivery who are not protected by an effective method of birth control (as defined in the informed consent form and / or the appendix to the local operating protocol) and / or who are unwilling or unable to undergo pregnancy testing. Note: Women with a potential for delivery must have a confirmed negative pregnancy test result at the time of screening and randomization visit. They must use an effective method of contraception throughout the duration of study treatment and for 10 weeks after their last IMP intake, and consent to repeat urine pregnancy testing at the designated visit. The method of contraception used must meet the criteria for highly effective methods of contraception, which are based on the “Notes on the Guidelines for Conducting Nonclinical Safety Studies of Human Clinical Trials of Drugs (CPMP / ICH / 286 / 95)”. Postmenopausal women must have been amenorrhea for at least 12 months.

[0595] Research on treatment

[0596] The sterile Alirocumab drug product is administered at a concentration of 150 mg / mL in histidine, pH 6.0, polysorbate 20, and sucrose. The drug product is administered in 1 mL volumes using an auto-injector.

[0597] The sterile placebo against Alirocumab was prepared in the same formulation as Alirocumab, without adding 1 mL of protein to the autoinjector.

[0598] During the double-blind treatment period, either Alirocumab or placebo was administered subcutaneously every two weeks, starting from week 0 and continuing until the last injection two weeks before the end of the double-blind treatment period (week 76). If the injection was scheduled for the same date as the field visit, IMP should be administered after blood sampling was completed.

[0599] Ideally, IMP should be administered subcutaneously every two weeks at approximately the same time of day; however, a window of ±3 days is acceptable. The specific time of day depends on the patient's preference.

[0600] The following categories of drugs are identified as non-investigational medicine products (NIMPs) because they are background therapies or potential salvage agents: statins (rosuvastatin, atorvastatin, simvastatin); cholesterol absorption inhibitors (ezetimibe); bile acid binding polyvalent chelators (such as cholestyramine, colestipol, colesvelam); niacin; fenofibrate; omega-3 fatty acids (≥1000 mg daily).

[0601] Patients who achieved two consecutive calculated LDL-C levels <25 mg / dL (0.65 mmol / L) were monitored.

[0602] Patients with an anti-Alirocumab antibody titer of 240 or higher at follow-up received additional antibody samples 6 to 12 months after their last dose, and then approximately every 3 to 6 months thereafter, until the titer returned to below 240.

[0603] During the double-blind study treatment, patients were randomized in a 1:2 ratio to receive either placebo or Alirocumab, with replacement block randomization. Randomization was stratified based on a history of myocardial infarction (MI) or ischemic stroke [yes / no], and statin therapy (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily, compared to any daily dose of simvastatin, atorvastatin less than 40 mg daily or rosuvastatin less than 20 mg daily).

[0604] Concomitant medications are any treatments a patient receives during the study (up to follow-up). Concomitant medications should be kept to a minimum during the study. However, if these are deemed necessary for the patient's well-being and unlikely to interfere with IMP, they may be administered at the investigator's discretion at a stable dose (if possible). Any other concomitant medications are permitted except for the specific information regarding concomitant medications provided in this section. If a patient's LDL-C at the screening visit (week 3) is > or equal to 160 mg / dL (4.14 mmol / L) and is being treated with statins only, i.e., without additional LMT, the investigator will report the reason why the patient did not receive a second LMT. For background LMTs, including statins, the location must follow the national product label for patient safety monitoring and management.

[0605] Nutritional products or over-the-counter therapies that may affect lipids are permitted only if used at a stable dose for at least 4 weeks prior to the screening visit, during the screening period, and maintained throughout the first 24 weeks of the double-blind treatment period. Modifications to these nutritional products or over-the-counter medications are permitted after the 24-week visit, but should generally be avoided. Examples of such nutritional products or over-the-counter medications include omega-3 fatty acids at doses <1000 mg, and phytosterols, such as those found in Benecol, flaxseed oil, and psyllium.

[0606] Patients must have been on a stable maximum tolerated daily dose of statin, with or without other LMTs, for at least 4 weeks prior to the screening visit (6 weeks for fenofibrate). During the study, patients should maintain these stable maximum tolerated daily doses of statin, with or without other LMTs. Lipid profile values ​​from samples obtained after randomization are blinded. However, triglyceride alerts and salvage thresholds for LDL-C values ​​are used to make decisions regarding a patient's background LMT. Background LMT should not be changed from the screening visit (week -3) of the double-blind treatment period until week 24. During this period, no dose adjustments, discontinuation, or initiation of other statins or other LMTs should be made, unless there are exceptional circumstances, with primary consideration (including, but not limited to, triglyceride alerts issued by the central laboratory) to ensure that such changes are justified in the investigator's judgment.

[0607] For triglyceride alerts confirmed by repeated testing (TG ≥ 500 mg / dL (5.65 mmol / L)), the investigator conducts an investigation, manages the patient, and modifies the background LMT based on his / her medical judgment.

[0608] For salvage notifications of LDL-C occurring at the week 24 visit and in two subsequent consecutive visits (i.e., an increase of >25% in LDL-C compared to the randomized visit), investigators should ensure there is no reasonable explanation for the inadequate LDL-C control (e.g., alternative medical reasons such as corticosteroid use). Specifically, this means: adherence to the diet is appropriate; background LMT is appropriate; and study treatment is administered as planned. If any of the above can reasonably explain the inadequate LDL-C control, investigators should take appropriate action, emphasizing the absolute need for treatment adherence, and if necessary, organizing specific consultations with qualified nutrition professionals, emphasizing the absolute need for dietary adherence, and conducting a blinded LDL-C assessment within 1 to 2 months. If no cause is found, or if appropriate action fails to reduce LDL-C below the alarm threshold, salvage medication may be introduced. The effectiveness of any such change is based on the absence of a salvage notification of LDL-C in the blinded lipid test at the next lab draw.

[0609] If no cause for LDL-C exceeding the threshold is found, or if appropriate action fails to lower LDL-C below the threshold, a rescue medication may be introduced. The effectiveness of any such change will be determined based on the absence of a rescue threshold from a blinded lipid test at the next routinely scheduled lab draw. Patients on each regimen are already receiving the maximum tolerated dose of statins, so statin uptiing or switching will not be considered. To further lower LDL-C, investigators may consider adding: a cholesterol absorption inhibitor (ezetimibe) or a bile acid conjugating chelator (resin-based cholestyramine and colestipol or colesvelam, a non-absorbable polymer). Other lipid modifiers to consider include: fibrates (Note: When combining fibrates with other cholesterol-lowering drugs (e.g., statins), caution should be exercised due to the risk of myopathy. Fenofibrate is the preferred fibrate when combined with statins because it does not affect statin glucuronidation. The only fibrate permitted under the regimen is fenofibrate); niacin (Note: Niacin raises blood sugar, but it has been shown to effectively improve lipid profiles in diabetic patients if glucose control is maintained).

[0610] In summary, background LMT should not be modified from screening to follow-up. However, modification of background LMT is permitted up to week 24 if a confirmed TG alert is reached or if there is a definitive clinical concern (at the investigator's discretion). From week 24 onwards, modification of background LMT is permitted if a confirmed TG alert is reached, or if the salvage threshold for LDL-C is reached (and there is no other reasonable explanation), or if there is a definitive clinical concern (at the investigator's discretion).

[0611] Women who have a potential risk of childbirth must use effective contraception throughout the study treatment and for 10 weeks after the last IMP injection (e.g., follow-up).

[0612] The following concomitant medications are prohibited from use from the initial screening visit to the follow-up visit: statins other than simvastatin, atorvastatin and rosuvastatin; fibrates other than novice; and red yeast rice products.

[0613] Study endpoints

[0614] The primary efficacy endpoint is the percentage change in calculated LDL-C from baseline to week 24, defined as: 100 × (calculated LDL-C value at week 24 - calculated LDL-C value at baseline) / calculated LDL-C value at baseline. The baseline calculated LDL-C value is the last LDL-C level obtained prior to the first double-blind IMP injection. The week 24 calculated LDL-C level is the LDL-C level obtained within the week 24 analysis window and during the primary efficacy period. The primary efficacy period is defined as the time from the first double-blind IMP injection up to 21 days after the last double-blind IMP injection or up to the upper limit of the week 24 analysis window (whichever comes first). Where appropriate, all calculated LDL-C values ​​(planned or unplanned, fasting or non-fasting) may be used to provide a value for the primary efficacy endpoint, according to the above definition.

[0615] The key secondary efficacy endpoints were: 1) Percentage change in calculated LDL-C from baseline to week 12: similar definitions and rules as the primary efficacy endpoint, except that the LDL-C calculated at week 12 was the LDL-C level obtained within the week 12 analytical window and over the 12-week efficacy period. The 12-week efficacy period was defined as the time from the first double-blind IMP injection until the sixth visit to provide IVRS contact or until 21 days after the last double-blind IMP injection, whichever came first. Blood samples collected on the day of the sixth visit to provide IVRS contact were considered pre-titration; 2) Percentage change in Apo B from baseline to week 24: using the same definitions and rules as the primary endpoint; 3) Percentage change in non-HDL-C from baseline to week 24: using the same definitions and rules as the primary endpoint; 4) Percentage change in total C from baseline to week 24: using the same definitions and rules as the primary endpoint; 5) Percentage change in Apo B from baseline to week 12. The same definitions and rules are used for the percentage change in LDL-C from baseline to week 12 as for the calculated LDL-C; 6) The same definitions and rules are used for the percentage change in non-HDL-C from baseline to week 12 as for the calculated LDL-C; 7) The same definitions and rules are used for the percentage change in total-C from baseline to week 12 as for the calculated LDL-C; 8) The same definitions and rules are used for the calculated LDL-C from baseline to week 52 as for the calculated LDL-C from baseline to week 24 as for the calculated LDL-C; The 52-week efficacy period is defined as the time from the first double-blind IMP injection to 21 days after the last double-blind IMP injection or up to the upper limit of the 52-week analysis window, whichever comes first; 9) The proportion of patients who achieved their LDL-C target at week 24, defined as LDL-C <70 mg / dL (1.81 mmol / L) in the case of prior CVD, or <100 mg / dL (2.59 mmol / L) in the case of no prior CVD, defined as: (Number of patients who achieved their LDL-C target at week 24 / Number of patients in the mITT population) * 100, using the definitions and rules used for the primary endpoint; 10) Percentage change in Lp(a) from baseline to week 24. Using the same definitions and rules as for the primary endpoint; 11) Percentage change in HDL-C from baseline to week 24.The following definitions and rules apply as to the primary endpoint: 12) Percentage change in HDL-C from baseline to week 12, using the same definitions and rules as for the calculated percentage change in LDL-C from baseline to week 12; 13) Percentage change in Lp(a) from baseline to week 12, using the same definitions and rules as for the calculated percentage change in LDL-C from baseline to week 12; 14) Percentage change in fasting TG from baseline to week 24, using the same definitions and rules as the primary endpoint; 15) Percentage change in fasting TG from baseline to week 12, using the same definitions and rules as for the calculated percentage change in LDL-C from baseline to week 12; 16) Percentage change in Apo A-1 from baseline to week 24, using the same definitions and rules as the primary endpoint; and 17) Percentage change in Apo A-1 from baseline to week 12, using the same definitions and rules as for the calculated percentage change in LDL-C from baseline to week 12.

[0616] Other secondary efficacy endpoints were: 1) the percentage change in LDL-C from baseline to week 78, using similar definitions and rules as those used for the primary endpoint of replacing week 24 with week 78; 2) the proportion of patients who achieved their LDL-C target at weeks 12, 52, and 78, i.e., LDL-C <70 mg / dL (1.81 mmol / L) for patients with prior CVD or <100 mg / dL (2.59 mmol / L) for patients without prior CVD; 3) the proportion of patients who achieved LDL-C <100 mg / dL (2.59 mmol / L) at week 24; 4) the proportion of patients who achieved LDL-C <100 mg / dL (2.59 mmol / L) at week 12; 5) the proportion of patients who achieved LDL-C <70 mg / dL (1.81 mmol / L) at week 24; and 6) the proportion of patients who achieved LDL-C <70 mg / dL (1.81 mmol / L) at week 12. 7) Proportion of patients with <80 mg / dL (1.81 mmol / L); 8) Absolute changes in calculated LDL-C (mg / dL and mmol / L) from baseline to weeks 12, 24, 52, and 78; 9) Percentage changes in Apo B, non-HDL-C, total-C, Lp(a), HDL-C, fasting TG, and Apo A-1 from baseline to weeks 52 and 78; 10) Change in the Apo B / Apo A-1 ratio from baseline to weeks 12, 24, 52, and 78; 11) Proportion of patients with <80 mg / dL (0.8 g / L) Apo B at weeks 12, 24, 52, and 78; 12) Proportion of patients with <100 mg / dL non-HDL-C at weeks 12, 24, 52, and 78; and 13) Calculated LDL-C <70 mg / dL at weeks 12, 24, 52, and 78. (1.81 mmol / L) and / or the proportion of patients with a calculated LDL-C reduction of ≥50% (if the calculated LDL-C is ≥70 mg / dL [1.81 mmol / L]).

[0617] Total LDL-C, HDL-C, TG, Apo B, Apo A-1, and Lp(a) were measured directly by the central laboratory. LDL-C was calculated using the Friedewald formula at all visits (except for week-1 and follow-up). If the TG value exceeded 400 mg / dL (4.52 mmol / L), LDL-C was measured by the central laboratory (using a beta-quantitative method) instead of being calculated. Non-HDL-C was calculated by subtracting HDL-C from total LDL-C. The Apo B / Apo A-1 ratio was calculated.

[0618] Clinical laboratory data include urinalysis, hematology (red blood cell count, hemoglobin, red blood cell distribution width (RDW), reticulocyte count, hematocrit, platelets, white blood cell count with differential hematocrit), standard chemistry (glucose, sodium, potassium, chloride, bicarbonate, calcium, phosphorus, blood urea nitrogen, creatinine, uric acid, total protein, LDH, albumin, gamma-glutamyl transferase [γGT]), hepatitis C antibody, liver panel (ALT, AST, ALP, and total bilirubin), and CPK.

[0619] Vital signs include: heart rate, systolic blood pressure and diastolic blood pressure in a sitting position.

[0620] Other endpoints included: anti-Alirocumab antibody assessment, hs-CRP, and HbA1c. 1c EQ-5D questionnaire and pharmacogenetic samples.

[0621] Anti-Alirocumab antibodies include antibody status (positive / negative) and antibody titer. Serum samples were periodically drawn throughout the study for anti-Alirocumab antibody determination. The first predetermined sample was obtained at the randomized visit prior to IMP injection (pre-dose administration). Additional samples were collected from patients with an anti-Alirocumab antibody titer equal to or greater than 240 at follow-up, 6 to 12 months after the last dose, and thereafter approximately every 3 to 6 months until the titer returned to below 240. Anti-Alirocumab antibody samples were analyzed using a validated non-quantitative, titer-based bridging immunoassay. This involved initial screening, a drug-specific confirmatory assay, and a measurement of the anti-Alirocumab antibody titer in the sample. The limit of detection was approximately 1.5 ng / mL. Samples positive in the ADA assay were evaluated using a validated non-quantitative competitive ligand binding assay for neutralizing antibodies. The limit of detection for neutralizing antibodies based on monoclonal positive control was 390 ng / mL.

[0622] The percentage change of hs-CRP from baseline to weeks 24, 52, and 78.

[0623] Absolute change of HbA1c (%) from baseline to weeks 24, 52 and 78.

[0624] EQ-5D is a standardized measure of health status developed by the EuroQol Group to provide a simple, universal measure of health for clinical and economic assessments. As a standard for measuring health-related quality of life, EQ-5D defines health across five dimensions: mobility, self-care, daily activities, pain / discomfort, and anxiety / depression. Each dimension can take one of three responses (three sequential levels of severity): “No problems” (1); “Some problems” (2); “Severe problems” (3). Overall health status is defined as a five-digit number. The health status defined by the five-dimensional classification can be converted into a corresponding index score quantifying health status, where 0 represents “death” and 1 represents “complete health”.

[0625] Research Steps

[0626] For all visits after Day 1 / Week 0 (randomized visits), a certain number of days of time frame is allowed. The window is ±3 days for visits at weeks 12 and 24, ±5 days for weeks 52 and 78, and ±7 days for all other field visits during the double-blind treatment and follow-up periods. A +3-day window is allowed for randomized visits (Day 1 / Week 0), and a ±7-day window is allowed for injection training visits at screening time (Week -1).

[0627] Samples used to determine lipid parameters (i.e., total C, LDL-C, HDL-C, TG, non-HDL-C, Apo B, Apo A-1, Apo B / Apo A-1 ratio, Lp[a]) should be collected in the morning and under fasting conditions (i.e., overnight, at least 10–12 hours fasting and avoiding smoking) for all field visits throughout the study period. Alcohol consumption within 48 hours and vigorous physical activity within 24 hours prior to blood collection are discouraged. Note: If a patient is not fasting, a blood sample will not be collected, and a reschedule will be made for the following day (or as close as possible to that date) for patients with fasting instructions (see conditions above).

[0628] Only patients meeting the inclusion criteria are screened. The screening period lasts up to 3 weeks or 21 days (and as short as possible upon receipt of laboratory eligibility criteria) prior to randomization / day 1 visit. The first screening visit (week -3) takes place 21 to 8 days prior to the randomization visit. If another designated person is planned to administer the injection to the patient during the study, that person should be present at the injection training visit (week -1).

[0629] The following visits were scheduled: Screening visits (1st visit / Week -3 / Day -21 to Day -8); Screening (2nd visit / Week -1 / Day -7 ± 7 days); Randomized visits (3rd visit / Week 0 / Day 1 + 3 days); 4th visit / Week 4 / Day 29 ± 7 days; 5th visit / Week 8 / Day 57 ± 7 days; 6th visit / Week 12 / Day 85 ± 3 days; 7th visit / Week 16 / Day 113 ± 7 days). 8th visit / week 24 / day 169 ± 3 days; 9th visit / week 36 / day 253 ± 7 days; 10th visit / week 52 / 12 months / day 365 ± 5 days; 11th visit / week 64 / day 449 ± 7 days; 12th visit / week 78 / 18 months / day 547 ± 5 days (end of treatment visit); and 13th visit / week 86 / day 603 ± 7 days (follow-up).

[0630] Security

[0631] The safety events monitored were treatment-emergent adverse events (TEAEs) reported by patients or discovered by investigators, serious adverse events (SAEs), TEAEs leading to treatment discontinuation, AEs of particular interest (injection site reactions, anaphylactic events, selected neurological events, and cardiovascular events with definitive outcomes), occurrence of PCSA (potentially clinically significant abnormality) in laboratory parameters, specific analysis of diabetes or impaired glycemic control, and patients with two consecutive LDL-C < 25 mg / dL.

[0632] Statistical methods

[0633] Sample quantity determination

[0634] A total sample size of 45 patients (30 in alirocumab and 15 in placebo) had 95% power to detect the difference in the 30% mean percentage change in LDL-C, with a two-sided significance level of 0.05, and assumed a common standard deviation of 25%. All 45 patients had evaluable primary endpoints. A final total sample size of 105 patients was selected, with a randomization ratio of 2:1 (70 in alirocumab: 35 in placebo) to provide at least 50 patients exposed to alirocumab for 12 months in the first step of the analysis, and assumed a dropout rate of 10% during the first 3 months and 20% during the 3–12 months period.

[0635] Timing of analysis:

[0636] The first-step analysis included the efficacy endpoint up to week 52 (final efficacy analysis) and the interim safety analysis, which reviewed all safety data up to the co-study cutoff date (week 52 visit of the last patient). Analysis of lipid data beyond week 52 was descriptive. The results of the first-step analysis are presented in this paper.

[0637] The second (final) analysis will be conducted at the end of the study and will include a final analysis of efficacy endpoints up to week 78 and a final safety analysis.

[0638] Analyst population:

[0639] The primary efficacy analysis population is the intention-to-treat (ITT) population, defined as all randomized patients with an evaluable primary efficacy endpoint, namely those with an available baseline calculated LDL-C value and at least one available calculated LDL-C value within one of the analysis windows up to week 24 (including all calculated LDL-C values ​​during and after treatment).

[0640] The secondary efficacy analysis population was the modified intention-to-treat (mITT) population, defined as all such randomized patients who received at least one dose or partial dose of a double-blind investigational drug product (IMP) and had a usable, calculated LDL-C value at baseline and within one of the analysis windows during the efficacy treatment period up to week 24. The efficacy treatment period was defined as the time from the first double-blind IMP administration to 21 days after the last double-blind injection.

[0641] The safety population includes all randomized patients who received at least one dose or a partial dose of double-blind IMP.

[0642] Efficacy analysis:

[0643] The initial analysis of efficacy endpoints was performed using the ITT method (based on the ITT population as defined above), including all lipid data regardless of whether patients continued treatment. This corresponds to the ITT estimate, which is defined for the primary and key secondary endpoints. Additionally, the in-treatment method (based on the mITT population as defined above) was used for analysis, including lipid data collected during efficacy treatment. This corresponds to the in-treatment estimate of key secondary endpoints.

[0644] The ITT method analyzed all patients, regardless of their treatment adherence; it assessed the benefit of the treatment strategy and reflected the effects across the patient population as comprehensively as possible. The in-treatment method analyzed treatment effects, limited to the period during which patients actually received treatment. It assessed the benefits of treatment in patients who adhered to treatment up to the identified time point.

[0645] Efficacy analysis was conducted based on randomization of treatment.

[0646] All measurements (arranged or unarranged, fasting or non-fasting) are assigned to the analysis window to provide assessments at time points from week 4 to week 78.

[0647] For the primary efficacy analysis (ITT method), a mixed-effects model with repeated measures (MMRM) was used to analyze the calculated percentage change in LDL-C from baseline to week 24. All post-baseline data were used, with the analysis window from week 4 to week 52, and missing data were accounted for by the MMRM. The model included the treatment group (placebo vs. alirocumab), randomization strata (according to IVRS), time points (weeks 4 to 52), fixed categorical effects of treatment interactions and strata interactions at time points, and continuous fixed covariates of baseline LDL-C values ​​and interactions with baseline values ​​at time points. The model provided baseline-adjusted least-squares mean (LS mean) estimates and their corresponding 95% confidence intervals for both treatment groups at week 24. To compare alirocumab versus placebo, these estimates were tested for differences at the 5% alpha level using appropriate contrast statements.

[0648] A stratification procedure was defined to test key secondary endpoints while controlling for multiplicity (using the order of the key secondary endpoints described above). The first key secondary endpoint was the percentage change in LDL-C from baseline to week 24, calculated using the in-treatment method.

[0649] Continuous secondary variables (i.e., lipids other than TG and Lp(a)) expected to have a normal distribution were analyzed using the same MMRM model as the primary endpoint. Continuous endpoints expected to have a non-normal distribution (i.e., TG and Lp(a)) were analyzed using multiple estimation methods to handle missing values, followed by a robust regression model with the target endpoint as the response variable using M-estimation (using the SAS ROBUSTREG procedure), where the treatment group, randomization layer (according to IVRS), and corresponding baseline values ​​were used as effects for comparing treatment outcomes. Means for the two treatment groups, differences between these estimates, and combined estimates of their corresponding SE, 95% CI, and p-values ​​are provided (via the SAS MIANALYZE procedure).

[0650] The binary secondary efficacy endpoint was analyzed using a multiple attribution approach to handle missing values, followed by stratified logistic regression with the treatment group as the main effect and the corresponding baseline value as a covariate, stratified by a randomization factor (according to IVRS). Combined estimates of the advantage ratio versus placebo, 95% CI, and p-value are provided (via the SAS MIANALYZE procedure).

[0651] Security Analysis:

[0652] Safety analyses are descriptive and performed on the safety population based on actual treatment received. Safety analyses focus on the TEAE period, defined as the time from the first double-blind administration of the first dose to 70 days after the last double-blind injection. TEAEs or PCSAs that occurred, worsened, or became severe after patient enrollment in the open-label extended study (LTS13643) are not considered part of the TEAE period. The TEAE period is truncated at the co-study cutoff date.

[0653] result

[0654] study patients

[0655] Patient responsibility

[0656] Of the 107 randomized patients (72 in the alirocumab group and 35 in the placebo group), one patient in the alirocumab group had no baseline calculated LDL-C value and was therefore excluded from the ITT and mITT populations.

[0657] Two randomized patients in the alirocumab group were excluded from the mITT population (one patient was excluded from the ITT population, and the other patient had no LDL-C value during efficacy treatment up to one of the analysis windows up to week 24).

[0658] Table 26 – Analytical Population

[0659]

[0660] Research and handling

[0661] The study treatment, exposure, and safety analyses were evaluated using all data up to the study's common cutoff date (defined as the date of the last patient's week 52 visit). Therefore, this first-step analysis included efficacy data up to week 52 and safety data beyond week 52 and up to week 78 (or, for some patients, follow-up). Patient treatment is shown in... Figure 12 middle.

[0662] In this study, seven patients were randomized at the first site and six patients at the second site were identified as having serious GCP non-compliance, and the sites were closed. For the first closed site, one key finding was related to IMP injections, which were reported to have been received by some patients, with the corresponding kits found in the refrigerator. These injection reports were corrected in the database, but other injection issues could not be ruled out. For the second site, continued attention to study-related practices and relevant documentation was observed during routine monitoring.

[0663] Of the 13 patients, one was still in progress by the deadline, one was discontinued due to an adverse event, one was transferred, three were discontinued due to poor adherence to the protocol, and seven were discontinued due to the decision to close the location.

[0664] A total of 10 (9.3%) randomized patients completed the 78-week double-blind study treatment period, and 76 (71.0%) randomized patients were still on treatment at the cutoff date of the first-step analysis. Six patients (17.1%) in the placebo group and 15 patients (20.8%) in the alirocumab group prematurely discontinued the double-blind IMP before week 78. All of these patients actually discontinued prematurely before week 52. The primary reasons for study treatment discontinuation were "other reasons," poor adherence, and adverse events. These "other reasons" included 7 patients who discontinued due to the site closure decision as described above, 1 patient who withdrew without further specification, 1 patient who withdrew due to independently obtained cholesterol results, and 1 patient who moved.

[0665] In the first step of the analysis, the final results were available for the primary efficacy endpoint at week 24 and key secondary efficacy endpoints assessed at weeks 12, 24, and 52. The table below provides the availability of LDL-C over time. At week 24, the primary efficacy endpoint was available for 33 (94.3%) in the placebo group and 63 (88.7%) in the alirocumab group.

[0666] Table 27 – LDL-C Availability Calculated Over Time – ITT Population

[0667]

[0668] At week 24, 10 patients were missing the primary endpoint (2 in the placebo group and 8 in the alirocumab group). The reasons for the missing endpoint at the week 24 visit (based on CRF monitoring) were as follows: 3 samples were not performed due to early study termination; 3 samples were completed outside the analytical time window; 2 samples were not completed due to incomplete week 24 visit; and 2 samples were available but could not be measured (lipemia, insufficient quantity, TG > 400 mg / dL [> 4.52 mmol / L], sample loss, etc.).

[0669] The high number of missing data in week 52 was mainly due to the decision to close two sites due to serious GCP non-compliance.

[0670] Of the 106 patients, 25 were missing the LDL-C endpoint at week 52. The reasons for the missing results are as follows: 17 samples were not completed due to early discontinuation of the study, including 11 patients from two closed sites; 3 samples were completed outside the analysis time window; 1 sample was not completed because it was not completed at week 52; 1 sample was lost but the week 52 visit was completed; and 3 samples were available but could not be measured (TG > 400 mg / dL [ > 4.52 mmol / L] and hemolysis).

[0671] Demographic and baseline characteristics

[0672] Overview of population characteristics

[0673] One hundred and seven patients with HeFH diagnosed by genotyping (17.8%) and the WHO / Dutch Lipid Network criteria (a score >8) or the Simon Broome criteria (82.2%) for definitive FH were randomized in a 2:1 ratio to alirocumab (150 mg Q2W) or placebo.

[0674] The baseline demographic characteristics, disease characteristics, and lipid parameters in the alirocumab group were substantially similar to those in the placebo group: HeFH was diagnosed in the alirocumab group (19.4%) compared to the placebo group (14.3%) by genotyping; HeFH was diagnosed in the alirocumab group (80.6%) and the placebo group (85.7%) by clinical criteria; the mean age (SD) in the alirocumab group was 49.8 years (14.2%) compared to the mean age in the placebo group (52.1 years (11.2%); the percentage of Caucasians in the alirocumab group (88.9%) compared to the placebo group (85.7%); and the mean BMI (SD) in the alirocumab group was 28.8 kg / m². 2 (5.2) The mean BMI in the placebo group was 28.9 kg / m². 2(4.2). Due to the small sample size, some imbalances were observed: a higher proportion of female patients in the alirocumab group (51.4%) compared to the placebo group (37.1%); a more recent diagnosis of hypercholesterolemia in the alirocumab group (median 9.8 years) compared to the placebo group (median 17.4 years); a lower proportion of patients considered to have very high CV risk in the alirocumab group (52.8%) compared to the placebo group (65.7%), primarily driven by a history of coronary revascularization surgery; and a lower proportion of patients receiving ezetimibe at randomization in the alirocumab group (19.4%) compared to the placebo group (34.3%). Cardiovascular history and risk factors for patients in the alirocumab and placebo groups are shown in Table 28.

[0675] Table 28 – Cardiovascular history and risk factors

[0676]

[0677] At randomization, all patients received statin therapy, with 72.9% receiving high-intensity statins (atorvastatin 40 to 80 mg daily or rosuvastatin 20 to 40 mg daily) and 6.5% receiving simvastatin 80 mg. In addition to statins, 19.4% and 34.3% of patients in the alirocumab and placebo groups, respectively, received ezetimibe. Table 30 shows the background lipid-modifying therapy (LMT) in the alirocumab and placebo groups at randomization, as well as the background lipid-modifying therapy (LMT) in the overall randomized population.

[0678] Table 31 shows the lipid efficacy parameters at baseline in the alirocumab and placebo treatment populations, as well as in the total randomized population. The mean (SD) calculated LDL-C at baseline was 197.8 (53.4) mg / dL (5.123 (1.38) mmol / L). The mean (SD) non-HDL-C at baseline was 226.4 (55.3) mg / dL. The mean total-C at baseline was 274.4 (54.0) mg / dL. The mean (SD) HDL-C at baseline was 48.1 (13.3) mg / dL. The mean (SD) total-C / HDL-C ratio at baseline was 6.135 (2.119). The mean (SD) fasting triglycerides (TG) at baseline was 149.8 (86.6) mg / dL. The baseline mean (SD) lipoprotein-(a) was 41.2 (46.6) mg / dL. The baseline mean (SD) Apo-B was 140.9 (31.0) mg / dL. The baseline mean (SD) Apo-A1 was 137.5 (23.3) mg / dL. The baseline mean (SD) Apo-B / Apo-A1 ratio was 1.061 (0.323) mg / dL.

[0679] Exposure to the injection was similar between the treatment groups, with a mean exposure of 60.7 weeks in the placebo group and 58.3 weeks in the alirocumab group.

[0680] Table 29 – Disease characteristics and other relevant baseline data – randomized population

[0681]

[0682] Table 30 – Background LMT at Randomization – Randomized Population

[0683]

[0684] Table 31 - Lipid efficacy parameters at baseline - Routine quantitative summary in standard units - Randomized population

[0685]

[0686]

[0687] Dosage and duration

[0688] Exposure to the injection was similar across treatment groups, with a mean exposure of 60.7 weeks in the placebo group and 58.3 weeks in the alirocumab group. The duration of injection exposure could not be calculated for one patient in the alirocumab group because the date of the last injection was unknown.

[0689] effect

[0690] Primary efficacy endpoint

[0691] The ITT analysis included all calculated LDL-C values ​​collected during and after treatment up to week 52. The primary endpoint (the percentage change in calculated LDL-C from baseline to week 24) was analyzed on the ITT population using MMRM models, with estimates of the mean LS at week 24. Nine patients (11.3%) in the alirocumab group and two patients (5.7%) in the placebo group did not have calculated LDL-C values ​​at week 24. These missing values ​​were considered using MMRM models.

[0692] The results of the primary endpoint analysis are shown in Table 32, expressed in mmol / L and mg / dL.

[0693] Analysis of main efficacy

[0694] A statistically significant reduction in the percentage change of LDL-C from baseline to week 24 was observed in the alirocumab group (mean LS vs. baseline -6.6%) compared to the placebo group (mean LS vs. baseline -45.7%) (mean LS difference (SE) = -39.1% (6.0%), p < 0.0001) (see Table 31). This represents an absolute reduction of -90.8 (6.7) mg / dL in the alirocumab group and an absolute reduction of -15.5 (9.5) mg / dL in the placebo group (see Table 33). The percentage change of LDL-C from baseline to week 24 for individual patients is shown in... Figure 13 All patients were on background statins (at maximum tolerated level). Some patients also received further lipid-lowering therapy.

[0695] In the alirocumab group, a decrease in LDL-C from baseline was observed from week 4 to week 52 (see [link to study]). Figure 7 , Figures 14A-14B (See Table 33). A slight decrease in LDL-C reduction over time was observed in the alirocumab group (mean LS was -42.1 against baseline at week 52, compared to -45.7 at week 24), although the total reduction remained the same (75 mg / dL; see Table 33). Figures 14A-14BFurthermore, a significant number of alirocumab patients achieved LDL levels of <100 mg / dL (57% vs. 11% in placebo patients) and <70 mg / dL (<1.81 mmol / L; 32% vs. 3% in placebo patients) at week 24, despite baseline LDL-C levels >190 mg / dL (mean (SD) baseline calculated LDL-C in the alirocumab group was 196.3 (57.9) mg / dL; in the placebo group it was 201 (43.4) mg / dL). At week 12, 31.0% of patients in the alirocumab group (compared to 0.0% in the placebo group; ITT analysis) achieved a calculated LDL-C level of <70 mg / dL (<1.81 mmol / L). Similarly, at week 52, 31% of patients in the alirocumab group (compared to 5.7% in the placebo group; ITT analysis) achieved a calculated LDL-C level of <70 mg / dL (<1.81 mmol / L).

[0696] Sensitivity analysis of the primary efficacy endpoint was performed, excluding 13 patients from two sites with serious GCP non-compliance. The percentage change in LDL-C from baseline to week 24 in the alirocumab group (mean LS vs. baseline -2.3%) remained statistically significant compared with the placebo group (mean LS vs. baseline -50.3%) (mean difference in mean LS (SE) compared with placebo was -48.0% (5.8%), p < 0.0001) (see Table 34).

[0697] Table 32 - Percentage change in LDL-C from baseline calculated at week 24: MMRM-ITT analysis - ITT population

[0698]

[0699] Table 33 – LDL-C-ITT Analysis Calculated Over Time – ITT Population

[0700]

[0701]

[0702] Sensitivity analysis of the primary endpoint

[0703] Table 34 - Percentage change in LDL-C from baseline calculated at week 24: MMRM-ITT analysis - ITT population excluded from locations with severe CGP non-compliance.

[0704]

[0705] Key secondary efficacy endpoints

[0706] The table below summarizes the analysis results of key secondary endpoints arranged in stratified order. All key secondary endpoints were statistically significant based on the stratified testing procedure for the Lp(a) endpoint at week 24 (ITT estimate).

[0707] Statistical significance for HDL-C was not reached at week 24 (ITT estimate), therefore the testing procedure was discontinued, and the p-values ​​provided from this endpoint are for descriptive purposes only.

[0708] Table 35

[0709]

[0710] In-treatment analysis of the percentage change in LDL-C from baseline to week 24 showed results very consistent with the ITT analysis (the mean difference in LS values ​​between the in-treatment analysis and placebo was -38.9%, compared to -39.1% in the ITT analysis). In fact, at week 24, only 3 patients (2 in the placebo group and 1 in the alirocumab group) had LDL-C values ​​collected after treatment (i.e., more than 21 days after the last injection).

[0711] Key secondary endpoints, including Apo B, non-HDL-C, total LDL-C, and Lp(a), at multiple time points, and the proportion of patients achieving their LDL-C target at week 24, were statistically significant according to the stratified test procedure. Significant reductions in non-HDL-C, Apo B, and Lp(a) levels were observed at week 24. For non-HDL-C, the mean change in LS from baseline to week 24 with alirocumab versus placebo was -41.9 vs. -6.2 (p < 0.0001), for Apo B it was -39.0 vs. -8.7 (p < 0.0001), and for Lp(a) it was -23.5 vs. -8.7 (p = 0.0164).

[0712] The proportion of patients with very high cardiovascular (CV) risk who reached calculated LDL-C <70 mg / dL (1.81 mmol / L) or high CV risk who reached calculated LDL-C <100 mg / dL (2.59 mmol / L) at week 24 was significantly higher in the alirocumab group than in the placebo group (combined estimate of proportion: 41.0% in the alirocumab group vs. 5.7% in the placebo group, p = 0.0016).

[0713] The analyses performed using methods employed during treatment are consistent with these analyses.

[0714] In the ITT analysis, the differences in the percentage changes of HDL-C and fasting TG from baseline to week 24 were not statistically significant: HDL-C at week 24: the mean LS in the alirocumab group was +7.5% compared to baseline, while it was +3.9% in the placebo group (the difference in mean LS compared to placebo was +3.7%, p = 0.2745); and fasting TG at week 24: the mean LS in the alirocumab group was -10.5% compared to baseline, while it was -1.1% in the placebo group (the difference in mean LS compared to placebo was -9.4%, p = 0.1299).

[0715] Four patients (5.6%) experienced two consecutive calculated LDL-C values ​​<25 mg / dL. No particular safety issues were observed in these patients.

[0716] Overview of security results:

[0717] In this study, the proportion of patients experiencing treatment-emergent adverse events (TEAEs) was lower in the alirocumab group (61.1%) compared to the placebo group (71.4%). The proportion of patients experiencing serious TEAEs was similar between the treatment groups. A similar proportion of patients experienced TEAEs leading to treatment discontinuation (1 patient (2.9%) in the placebo group and 3 patients (4.2%) in the alirocumab group). These results are consistent with the proportion of patients experiencing TEAEs in previous alirocumab phase 2 / 3 placebo-controlled studies (results from 2476 and 1276 patients in the alirocumab and placebo groups, respectively). Specifically, in this study, for alirocumab versus placebo, the rates of TEAEs were 75.8% vs. 76.4%, treatment-emergent SAEs were 13.7% vs. 14.3%, fatal TEAEs were 0.5% vs. 0.9%, and TEAEs leading to discontinuation were 5.3% vs. 5.1%.

[0718] The most frequently reported SOCs (and PTs) in both treatment groups of this study were: "Infections and lesions": 40.3% in the alirocumab group versus 34.3% in the placebo group (11.1% vs. 2.9% for influenza and 6.9% vs. 0% for urinary tract infections in the alirocumab group versus placebo group); "Heart disease": 12.5% ​​in the alirocumab group versus none in the placebo group. Among the events sent to judgment, the following events were confirmed in 6 patients: 4 MIs, 1 heart failure requiring hospitalization, and 5 ischemia-driven coronary revascularization procedures; "Neurological symptoms": 11.1% in the alirocumab group versus 8.6% in the placebo group (5.6% vs. 0 for headache and 4.2% vs. 0 for dizziness in the alirocumab group versus placebo group, respectively). "Musculoskeletal and connective tissue disorders": 16.7% in the alirocumab group, compared to 28.6% in the placebo group. No deaths were reported during the study period in either group.

[0719] In the alirocumab group, 11.1% of patients reported SAEs, compared to 11.4% in the placebo group. There was no specific clinical pattern among the preferred terms for separately reported SAEs. The most frequently reported SOC (system organ class) for SAEs was "cardiac disease".

[0720] Seven patients (6 in the alirocumab group, 8.3%) and one in the placebo group (2.9%) experienced treatment-emergent local injection site reactions. These events were of mild intensity, except for one which was moderate. Two patients (1 in the alirocumab group, 1.4%) and one in the placebo group (2.9%) experienced neurocognitive impairment. Five patients (3 in the alirocumab group, 4.2%) and one in the placebo group (2.9%) experienced ALT > 3 × ULN. Two patients in 71 analyses (2.8% compared to 0 in the placebo group) experienced creatine kinase levels > 3 × ULN. None of these events were serious or led to treatment discontinuation. TEAEs occurring in both the alirocumab and placebo groups were collected up to the last patient visit at week 52 and categorized in Table 36.

[0721] Table 36 - TEAE Safety Analysis Up to Week 52

[0722]

[0723] In the events of interest, no specific signals of TEAE associated with neurological events, general allergic events, or diabetes were detected.

[0724] No related PCSA anomalies were observed.

[0725] The scope of this invention is not limited to the specific embodiments described herein. In fact, various modifications to the invention, in addition to those described herein, will become apparent to those skilled in the art from the foregoing description and drawings. Such modifications are intended to fall within the scope of the appended claims.

[0726] in conclusion:

[0727] For patients with HeFH and high baseline LDL-C (despite having maximum tolerated statin levels (with or without another LLT)), the ODYSSEY HIGH FH study yielded the following conclusions: 1) Self-administered alirocumab produced a significantly greater LDL-C reduction after 24 weeks compared to placebo. At week 24, the absolute mean reduction in LDL-C from baseline with alirocumab was -90.8 mg / dL, compared to -15.5 mg / dL with placebo, and the LDL-C level achieved with alirocumab at week 24 was 107 mg / dL, compared to 182 mg / dL with placebo; 2) Despite baseline LDL-C > 190 mg / dL, 32% of patients receiving alirocumab achieved LDL-C < 70 mg / dL; 3) 57% of patients receiving alirocumab achieved LDL-C < 100 mg / dL at week 24; 4) alirocumab is generally well tolerated, and TEAEs occurred at similar frequencies in both the alirocumab and placebo groups.

[0728] Example 5: Efficacy and safety of PCSK9 monoclonal antibody alirocumab versus placebo in 1254 patients with heterozygous familial hypercholesterolemia (heFH): Analysis up to week 78 from 4 ODYSSEY trials

[0729] background:

[0730] Previous studies have shown that only ~20% of patients with heterozygous familial hypercholesterolemia (heFH) achieve a predefined LDL-C target of ≤2.5 mmol / L [97 mg / dL] with lipid-lowering therapies (LLTs). In the maximally tolerated statin ± other LLTs from four 18-month, placebo-controlled ODYSSEY trials (FHI, FHII, HIGH FH, LONG TERM), the efficacy and safety of alirocumab versus placebo were investigated in 1254 HeFH patients (pts). This represents the largest single patient cohort with HeFH studied in a phase 3 clinical trial program. A description of the LONG TERM study is shown in Robinson et al., (2015) NEJM 372:16 pg 1489-99, which is incorporated herein by reference in its entirety.

[0731] method:

[0732] Data were pooled based on initial alirocumab dosage. In FH I / II, patients with LDL-C levels ≥1.81 / 2.59 mmol / L [70 / 100 mg / dL] received either placebo (N=244) or alirocumab 75 mg Q2W (N=488) based on CV risk; if LDL-C ≥1.81 mmol / L [70 mg / dL] at week 8, the alirocumab dose was increased to 150 mg Q2W at week 12 (41.8% of patients). Additionally, data were pooled from HIGH FH (LDL-C ≥4.14 mmol / L [160 mg / dL]) and a subgroup of HeFH patients from LONG TERM (LDL-C ≥1.81 mmol / L [70 mg / dL]), where patients received either placebo (N=180) or alirocumab 150 mg Q2W (N=342). All administrations were 1 mL subcutaneous (SC) injections. Data on changes in LDL-C from baseline up to week 52 were collected.

[0733] result:

[0734] Baseline LDL-C levels and changes from baseline are shown in Table 37. Compared with placebo, alirocumab at doses of 75 and 150 mg Q2W reduced LDL-C by 49% and 61%, respectively, at week 12 (p < 0.0001). At week 24, the LDL-C reductions with alirocumab compared to placebo were 56% (alirocumab 75 mg Q2W, with possible dose increase at week 12) and 59% (alirocumab 150 mg Q2W) (p < 0.0001). For both dosing regimens, despite high baseline LDL-C levels, mean LS LDL-C levels of ~2 mmol / L [77 mg / dL] were achieved by week 12 (Table 37) and maintained the reduction until week 52. Additional beneficial effects were observed in other parameters, including non-HDL-C and Apo B.

[0735] In individual studies to date, substantially similar rates of treatment-emergent adverse events (TEAEs) have been observed in patients treated with alirocumab and placebo. In the placebo-controlled studies of the ODYSSEY project (patients with and without HeFH), TEAEs (preferred term) reported in ≥5% of patients receiving alirocumab or placebo included nasopharyngitis (11.3% vs. 11.1% in patients treated with alirocumab and placebo), upper respiratory tract infection (URI) (6.1% vs. 7.0%), injection site reaction (6.7% vs. 4.8%), influenza (5.7% vs. 4.6%), headache (4.8% vs. 5.2%), and arthralgia (4.0% vs. 5.5%).

[0736] Table 37: LDL-C calculated from the least squares (LS) mean (SE) at weeks 12 (W12), 24 (W24), and 52 (W52) (Intention-to-treat analysis)

[0737]

[0738] in conclusion:

[0739] In this large cohort of 1254 patients with HeFH, alirocumab reduced mean LDL-C levels to <2 mmol / L [77 mg / dL] during weeks 24–52 of treatment, a level that has not been achieved to date with current LLTs.

Claims

1. A method for treating a patient with heterozygous familial hypercholesterolemia (heFH) who has inadequate control of hypercholesterolemia with or without the maximum tolerated dose of statins, with or without other lipid-lowering therapy, the method comprising administering one or more doses of a proprotein convertase subtilisin / kexin type 9 (PCSK9) inhibitor to the patient, wherein the patient exhibits inadequate control of hypercholesterolemia despite treatment with the maximum tolerated dose of statins, with or without other lipid-lowering therapy, in the absence of a PCSK9 inhibitor.

2. The method of claim 1, wherein the diagnosis of heFH is made by genotyping or clinical criteria.

3. The method of claim 2, wherein the clinical criteria are the Simon Broome Register Diagnostic Criteria for heterozygous familial hypercholesterolemia, or the WHO / Dutch Lipid Network criteria, with a score >8.

4. The method of any one of claims 1-3, wherein the PCSK9 inhibitor is an antibody that specifically binds to PCSK9 or an antigen-binding fragment thereof.

5. The method of claim 4, wherein the antibody or its antigen-binding fragment comprises a heavy chain and a light chain complementarity-determining region (CDR) of a heavy chain variable region / light chain variable region (HCVR / LCVR) amino acid sequence pair selected from SEQ ID NO: 1 / 6 and 11 / 15.

6. The method of claim 5, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18.

7. The method of claim 6, wherein the antibody or its antigen-binding fragment comprises an HCVR having the amino acid sequence of SEQ ID NO: 11 and an LCVR having the amino acid sequence of SEQ ID NO:

15.

8. The method of claim 5, wherein the antibody or its antigen-binding fragment comprises heavy chain and light chain CDR amino acid sequences having SEQ ID NO: 2, 3, 4, 7, 8 and 10.

9. The method of claim 8, wherein the antibody or its antigen-binding fragment comprises an HCVR having the amino acid sequence of SEQ ID NO: 1 and an LCVR having the amino acid sequence of SEQ ID NO:

6.

10. The method of claim 4, wherein the antibody or its antigen-binding fragment binds to the same epitope on PCSK9 with another antibody, the other antibody comprising heavy and light chain CDR amino acid sequences having SEQ ID NO: 12, 13, 14, 16, 17 and 18 or SEQ ID NO: 2, 3, 4, 7, 8 and 10.

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