Use of monoclonal antibodies against epidermal growth factor receptor in the treatment of patients with hypoxemic acute respiratory failure

Abstract

The present invention relates to the fields of biotechnology and medicine and provides the use of monoclonal antibodies against the epidermal growth factor receptor in the treatment of diseases of infectious origin leading to hypoxemic acute respiratory failure.

Description

[Technical field]

[0001] The present invention relates to the fields of biotechnology and medicine, and in particular to the use of monoclonal antibodies (MAbs) against epidermal growth factor receptor in the treatment of patients with hypoxemic acute respiratory failure. [Background technology]

[0002] Hypoxemic acute respiratory failure is the leading cause of emergency hospitalization. Mortality is nearly 20%. The most frequent etiologies are pneumonia, neurological causes, non-pulmonary sepsis and chronic obstructive pulmonary disease. The disease is characterized by dyspnea at rest, arterial O2 pressure (PO2) less than 60 mmHg, and / or arterial CO2 pressure (PCO2) greater than 45 mmHg (Joao D et al. (2019) J Crit Care 49:84-91.; Piriano T et al. (2019) Respir Care. 64(6):638-646).

[0003] Respiratory failure can progress to acute respiratory distress syndrome (ARDS), a life-threatening condition whether caused by lung disease or not. (Butt Y and cols.(2016)Arch Pathol Lab Med.;140(4):345-50). It is the result of a systemic inflammatory disease resulting in pulmonary infiltration, edema and hypoxia. This process is characterized at the cellular level by loss of alveolar-capillary membrane integrity, excessive infiltration of neutrophils and release of proinflammatory cytokines and chemokines. (Shan X and cols.(2017)Oncotarget;8(16):26648-61). At the pathological level, in the acute phase there is intra-alveolar and interstitial edema, in the proliferative phase there is proliferation of type II pneumocytes and in more advanced stages there is fibrosis. (Poletti V and cols.(2010)Pathologica.102(6):453-63)

[0004] Clinically, it is manifested by hypoxemia, and bilateral opacities on chest x-ray are associated with reduced compliance. Morphologically, diffuse alveolar damage is seen in the acute phase of ARDS. Mortality from ARDS remains high, ranging from 35% to 46% (Ferguson ND y cols.(2012)Intensive Care Med.;38(10):1573-82;Huppert LA y cols.(2019)Semin Respir Crit Care Med.;40(1):31-9). Survivors may have persistent morbidity associated with significant impairment in quality of life (Butt Y y cols.(2016)Arch Pathol Lab Med.;140(4):345-50; Huppert LA y cols.(2019)Semin Respir Crit Care Med.;40(1):31-9; Fan E y cols.(2018)JAMA.;319(7):698-710).

[0005] Although some ventilation strategies have improved outcomes in acute lung injury, most treatments with corticosteroids or surfactants have shown controversial results. (Fan E and cols.(2018)JAMA.;319(7):698-710).

[0006] The epidermal growth factor receptor (EGFR) is a 170 kDa membrane glycoprotein that controls fundamental cellular processes including cell migration, cell cycle, cell metabolism and survival, and cell proliferation and differentiation. (Shan X and cols.(2017)Oncotarget;8(16):26648-61;Mendelsohn J,Baselga J.(2006)Semin Oncol.;33(4):369-85;Saba NF and cols.(2006)Oncology;20(2):153-61). The physiological role of EGFR is to regulate epithelial tissue development and homeostasis. (Mendelsohn J,Baselga J.(2006)Semin Oncol.;33(4):369-85).

[0007] EGFR and its ligands are upregulated in multiple tumors of epithelial origin, including non-small cell lung cancer, gliomas, head and neck, cervical and esophageal tumors (Mendelsohn J, Baselga J. (2006) Semin Oncol.; 33(4): 369-85). Overexpression of EGFR in tumors correlates with increased metastasis, decreased survival and poor prognosis. Its intracellular domain is associated with specific protein tyrosine kinase activity, and its overexpression by cells alters cell cycle regulation, blocks apoptosis, promotes angiogenesis, increases motility, increases cell adhesion and metastasis. (Mendelsohn J, Baselga J. (2006) Semin Oncol.; 33(4): 369-85, Saba NF and cols. (2006) Oncology; 20(2): 153-61). Several drugs have been developed to block EGFR-mediated signaling, such as tyrosine kinase inhibitors (TKIs), including gefitinib, erlotinib, and osimertinib, and anti-EGFR MAbs, such as cetuximab, panitumumab, and nimotuzumab. (Mendelsohn J, Baselga J. (2006) Semin Oncol.; 33(4): 369-85, Saba NF and cols. (2006) Oncology; 20(2): 153-61; Perez R and cols. (2011) Clinical Effects. Cancers (Basel); 3(2): 2014-31; Smith D and cols. (2009) Bull Cancer.; 96 Suppl: S31-40).

[0008] Acute respiratory failure leads to upregulation and overexpression of EGFR. Essentially, EGFR activation leads to more severe lung pathology. A key node in pulmonary fibrosis is the EGFR pathway, which controls many cascades of cell proliferation, mucus secretion, inflammatory responses, and tissue repair. (Venkataraman T, Frieman MB. (2017) Antiviral Res.; 143: 142-50).

[0009] Despite this evidence, there are conflicting reports on the effect of EGFR TKIs on fibrosis in mice. Suzuki et al. reported an increase in fibrosis after gefitinib treatment (Suzuki H and cols. (2003) Cancer Res.; 63(16): 5054-9), whereas Ishii et al. reported a decrease in fibrosis (Ishii Y, Fujimoto S, Fukuda T. (2006) Am J Respir Crit Care Med.; 174(5): 550-6). The cause of this discrepancy is unclear, but variations in mouse strains and duration of gefitinib treatment may explain the differences. (Suzuki H and cols. (2003) Cancer Res.; 63(16): 5054-9; Ishii Y, Fujimoto S, Fukuda T. (2006) Am J Respir Crit Care Med.; 174(5): 550-6).

[0010] In lung cancer patients, TKIs can induce acute hypoxemic respiratory failure secondary to interstitial pneumonia. This adverse event occurs at a low frequency of 1.1-2.2% but can be fatal, accounting for 58% of all EGFR-TKI treatment-related deaths. (Ohmori T and cols.(2021)Int J Mol Sci.;22(2):792). Japanese patients have a significantly higher incidence of interstitial pneumonia of unknown etiology at this time point (Suh CH and cols.(2018)Lung Cancer;123:60-9).

[0011] Surprisingly, the inventors observed an improvement in lung pathology, inflammation, ventilation parameters and increased survival when nimotuzumab was administered to patients suffering from hypoxemic acute respiratory failure or ARDS. Summary of the Invention

[0012] In one embodiment, the invention relates to the use of MAbs against EGFR in the treatment of diseases resulting in hypoxemic acute respiratory failure of infectious origin, in particular diseases classified as ARDS.

[0013] In a particular embodiment of the invention, the acute respiratory failure is of infectious origin and is selected from the group consisting of coronavirus, rhinovirus, cytomegalovirus, Epstein-Barr, influenza virus, respiratory syncytial virus, Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenza, Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis, Enterobacter spp, Klebsiella spp, Acinetobacter spp, Staphylococcus spp, Serratia spp, Cryptococcus neoformans, Rhizopus It may be caused by a microorganism selected from the group comprising: Aspergillus spp, Pneumocystis spp, Mucor spp and Rhizomucor spp.

[0014] Among the anti-EGFR MAbs contemplated by the present invention that may be used in the treatment of hypoxemic acute respiratory failure or ARDS are nimotuzumab, cetuximab and panitumumab.

[0015] In another embodiment, the invention relates to a method of treating a subject comprising administering an anti-EGFR mAb intravenously or subcutaneously at a dose range of 1 mg / kg body weight to 6 mg / kg body weight at least twice and up to 5 times over a 72 to 168 hour period. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0016] Pharmaceutical Compositions The mAbs against EGFR used in the present invention are administered as part of a pharmaceutical composition containing the mAb as an active ingredient and in a pharmacologically suitable excipient for parenteral use. Among these MAbs are in particular nimotuzumab, whose sequence is described in US Patent No. 5,891,996, cetuximab, whose sequence is described in US Patent No. 6,217,866, and panitumumab, whose sequence is described in US Patent No. 5,558,864.

[0017] Therapeutic Applications and Methods The present invention describes the use of anti-EGFR antibodies in the treatment of acute hypoxic respiratory failure or ARDS. In particular, the use is described in patients whose acute respiratory failure or respiratory distress syndrome is caused by infectious agents, such as viruses, bacteria, or fungi. In particular, anti-EGFR can be used to treat acute respiratory failure or ARDS induced by viruses, such as coronavirus, rhinovirus, cytomegalovirus, Epstein-Barr virus, influenza virus, and respiratory syncytial virus. In the case of bacterial infections, those caused by streptococci, pneumococci or staphylococci, Haemophilus influenzae, Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis, Enterobacter spp, Klebsiella spp, Acinetobacter spp and Serratia spp. If the infectious agent is a fungus, this may be Cryptococcus neoformans, Rhizopus spp, Aspergillus spp, Pneumocystis spp, Mucor spp, or also Rhizomucor spp.

[0018] The use of anti-EGFR antibodies according to the invention ameliorates the symptoms and signs of acute hypoxemic respiratory failure or acute respiratory distress syndrome.

[0019] The reduction of these symptoms allows the patient to improve and be better managed by the medical team. A particular advantage of the proposed treatment is the non-induction of immunodeficiency in the patient, unlike other conventional treatments based on steroids or other immunosuppressants. The maintenance of immune competence in treated patients reduces the likelihood of the appearance of other opportunistic infections, which are very common in severe or critically ill patients.

[0020] Patients undergoing anti-EGFR antibody therapy are preferably admitted to an intensive care unit or intermediate care unit, but may be in a conventional care unit. They present at least the following symptoms: dyspnea at rest, arterial O2 pressure (PO2) less than 60 mmHg and / or arterial CO2 pressure (PCO2) greater than 45 mmHg, lower oxygen saturation (SO2) < 94% on room air at sea level, or the need for oxygen therapy to maintain SO2 > 93%, ratio of arterial pressure of oxygen / inspiratory fraction of oxygen (PaO2 / FiO2) < 300 mmHg, respiratory rate > 30 inspirations / min, or the presence of infiltrates in more than 50% of both lung fields. A confirmatory diagnosis is established taking into account arterial blood gas parameters and radiological findings, either X-ray, lung ultrasound or computed axial tomography.

[0021] Other signs and symptoms include dyspnea, high respiratory rate, tachycardia, cyanosis, confusion, fatigue, hypotension, dry cough, fever, 38°C, headache, and neurological symptoms.Alterations in various laboratory parameters are observed, including increased levels of D-dimer, ferritin, LDH, C-reactive protein, and IL-6 above the normal range.

[0022] Anti-EGFR MAbs are administered intravenously or subcutaneously to patients in the dose range of 1 mg / kg body weight to 6 mg / kg body weight, which corresponds to approximately a total of 50 mg to 600 mg, respectively. Preferably, for the anti-EGFR antibody nimotuzumab, a dose of 1.42 mg / kg to 2.85 mg / kg is used. These MAbs will be administered to patients at least twice and up to 5 times. The time between two successive doses is 72 hours to 168 hours. For nimotuzumab, the preferred schedule is 2 to 3 doses spaced 72 hours apart, using a loading dose of 200 mg followed by a dose of 100 mg. The doses and schedules used for the various anti-EGFR MAbs can be adjusted by evaluating their ability to recognize EGFR.

[0023] Another object of the invention is the combination, sequentially or concomitantly, of anti-EGFR antibodies with antiviral therapy or antibiotics. Antibiotics that can be combined include, inter alia, cephalosporins such as ceftriaxone, macrolides such as azithromycin, glycopeptides such as vancomycin, beta-lactams such as meropenem and oxazolidinones such as linezolid. Among the antiviral drugs that can be combined are, inter alia, type 1 and type 2 interferons, antiretroviral drugs used in the treatment of HIV such as remdesivir. The antibiotic or antiviral regimens used are those conventionally used for each drug, and the regimens for the use of anti-EGFR antibodies correspond to those mentioned above.

[0024] Further, an object of the present invention is the sequential or concomitant combination of anti-EGFR antibodies with other anti-inflammatory or anticoagulant therapies, such as steroids, or other immunomodulatory agents, and anticoagulant therapies, such as low molecular weight fractionated heparin or heparin, sodium heparin, unfractionated, etc. [Brief description of the drawings]

[0025] [Figure 1] Axial chest computed tomography scans of three patients treated with nimotuzumab. Sequential images A) at admission (columns, B) at discharge and C) follow-up (30-60 days after discharge). [Diagram 2] FIG. 1 shows the time course of the PaO2 / FiO2 ratio before and after administration of nimotuzumab. [Diagram 3] FIG. 1 shows the change in lactate dehydrogenase (LDH) enzyme concentration before and after administration of nimotuzumab. [Figure 4] Diagram of the radiological evolution of three patients before and after treatment with nimotuzumab: A) patient JMTR, B) patient JHV, C) patient MESS. [Diagram 5] FIG. 1: Overall evolution of COVID-19 patients treated with nimotuzumab. [Figure 6] FIG. 13. D-dimer levels in patients treated with nimotuzumab.

[0026] example Example 1. The use of nimotuzumab reduces SARS-CoV-2 mortality in patients with hypoxemic acute respiratory failure. Fourteen patients diagnosed with SARS-CoV-2 and with clinical, radiological or laboratory evidence of hypoxemic acute respiratory failure or respiratory distress syndrome were given a 200 mg dose of the monoclonal antibody nimotuzumab intravenously. All patients received a second dose equivalent to 100 mg 72 hours after the first dose.

[0027] To assess the impact on the use of the investigational drug, a group of SARS-CoV-2-positive patients classified as severe and receiving concurrent steroid and anticoagulant treatment in 20 Cuban hospitals was selected as controls. [Table 1]

[0028] Table 1 shows that the use of nimotuzumab reduced mortality by 16% compared to the control group. Internationally, survival rates in severe COVID-19 patients range from 77% to 81% after the use of best supportive care, including anticoagulant therapy and steroids as well as anti-IL6 receptor antibodies in some patients (tocilizumab) (Group RC (2021) Lancet;397(10285):1637-45; Rosas IO y cols. (2021) N Engl J Med.;384(16):1503-16). The recovery data of nimotuzumab in combination with treatment established in the Cuban protocol (92.85%) compare very favorably with Cuban control patients (77%) and international trials (77-81%).

[0029] Axial chest computed tomography scans were performed on three patients treated with nimotuzumab. Figure 1A and Figure 1B show extensive areas of ground-glass opacity, solidification of air spaces in the exudative phase, and reduced lung volume in the organizing and fibrotic phases. In contrast, Figure 1C shows that three patients showed resolution of pulmonary inflammatory lesions and no signs of fibrosis.

[0030] Example 2. The use of nimotuzumab improves ventilatory parameters in treated patients. In 10 severely ill COVID-19 patients, the ratio between arterial oxygen pressure (PaO2) and inspired fraction of oxygen (FiO2) was calculated as one of the ventilation parameters. Figure 2 shows the behavior of this ratio over time, before nimotuzumab and after two doses of the antibody, 72 hours apart. As can be seen in the figure, the patients showed an improvement in pulmonary ventilation over time.

[0031] Example 3: Treatment with nimotuzumab improves inflammatory parameters in treated patients. LDH and IL-6, as measures of inflammation, were measured before and after treatment with nimotuzumab in eight severe COVID-19 patients, the latter measured by ELISA (Quantikine). All patients had received steroid treatment before administration of the monoclonal antibody.

[0032] FIG. 3 shows that a reduction in LDH occurs after two doses of MAb nimotuzumab.

[0033] Table 2 shows the concentrations of IL-6 before and at different time points of treatment with nimotuzumab. [Table 2]

[0034] In 5 of 8 patients, the decrease in serum IL-6 concentrations on days 0 and 7 was significant (p=0.048 Friedman test, day 0 vs. day 7 p=0.03 Dunn test). In patients MVH, IL-6 increases at 48 hours (although remains below the mean) and then decreases, whereas in RGR patients, IL-6 concentrations remain stable. In these 7 patients, the evolution is classified as favorable, considering the marked increasing trend as part of the natural history of the disease. In MAST patients, IL-6 was increased, which correlated with the indolent course of the disease.

[0035] Example 4. Nimotuzumab treatment improves areas affected by multifocal interstitial pneumonia. The percentage of affected areas in both lung fields (right and left lung) was calculated in 8 patients with different time evolution of COVID-19 after two doses of nimotuzumab. The results are shown in Table 3. [Table 3]

[0036] Overall, the use of nimotuzumab improved disease in 62.5% of treated patients 168 hours after the first dose of the monoclonal antibody. In one patient, disease in both lung fields remained unchanged, while in two patients, disease increased by only 10% on the seventh day of evolution. Figure 4 shows the radiological evolution of three of these patients before and after treatment with nimotuzumab.

[0037] Example 4. Patients with ARDS caused by COVID-19 have clinical improvement after treatment with nimotuzumab. Evaluation of their overall evolution (clinical, radiological and laboratory), taking into account the improvement of some of the parameters routinely measured at each of these evaluations. Figure 5 shows that, overall, 75% of patients showed signs of clinical improvement 1 week after the first dose of nimotuzumab.

[0038] Example 5. Nimotuzumab treatment leads to a decrease in D-dimer in severe COVID-19 patients. Two COVID-19 patients treated with nimotuzumab and the rest of the drugs included in the Cuban protocol to manage the disease have D-dimer measurements. Figure 6 shows that both patients had a significant reduction in D-dimer after the combination of nimotuzumab with the rest of the therapy provided for COVID-19 in the Cuban protocol. It should be clarified that both patients reached high levels of D-dimer even under treatment with anticoagulants (fractionated heparin), steroids and other immunomodulatory drugs.

Claims

1. A composition comprising the monoclonal antibody nimotuzumab for the treatment of diseases resulting in hypoxemic acute respiratory failure.

2. The composition of claim 1, wherein the hypoxemic acute respiratory failure is acute respiratory distress syndrome.

3. The composition according to any one of claims 1 to 2, wherein the disease has an infectious origin.

4. The infection, Coronavirus, Rhinovirus, Cytomegalovirus, Epstein-Barr, Influenza virus, Respiratory syncytial virus, Streptococcus pyogenes, Streptococcus pneumoniae, Haemophilus influenzae, Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis, Enterobacter spp, Acinetobacter spp, Staphylococcus spp), Klebsiella Serratia spp, Cryptococcus neoformans, Rhizopus spp, Aspergillus spp, Pneumocystis spp, Mucor spp and Rhizomucor spp. The composition of claim 3, wherein the infection is caused by a microorganism selected from the group consisting of:

5. A composition for the treatment of hypoxemic acute respiratory failure comprising an anti-EGFR MAb by intravenous or subcutaneous route in the range of 1-6 mg / Kg body weight.

6. 6. The composition of claim 5, wherein the anti-EGFR MAb is administered to the subject at least twice and up to five times, with the time elapsing between two successive administrations being between 72 hours and 168 hours.

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