Compositions and methods for treating synucleinopathies

Abstract

The present invention relates to stable and low viscosity liquid pharmaceutical compositions comprising antibodies that bind to human alpha synuclein, as well as methods for the use of antibodies that bind to human alpha synuclein for treating synucleinopathies or presymptomatic synucleinopathies, including suitable doses and / or administration regimens. These antibodies for use in the treatment of synucleinopathies or presymptomatic synucleinopathies may be formulated in the stable and low viscosity liquid pharmaceutical compositions of the present invention.

Description

[Technical field]

[0001] The present invention relates to stable and low viscosity liquid pharmaceutical compositions comprising antibodies that bind to human alpha synuclein and methods for using antibodies that bind to human alpha synuclein for treating synucleinopathies or prodromal synucleinopathies, comprising suitable doses and / or administration regimens. These antibodies for use in the treatment of synucleinopathies or prodromal synucleinopathies may be formulated in the stable and low viscosity liquid pharmaceutical compositions of the invention.

[0002] Sequence Listing Reference This application contains one or more sequence listings disclosed on a computer-readable medium (filename: "1264-WO-PCT Seq list ST26.xml", created on Aug. 3, 2022 and having a size of 18 KB), which is incorporated herein by reference in its entirety. [Background technology]

[0003] Biological agents such as antibodies are increasingly being utilized for the diagnosis and treatment of disease. Monoclonal antibodies are attractive as active pharmaceutical ingredients (APIs) because they have high homogeneity and antigen specificity while generally having a favorable side effect profile.

[0004] Monoclonal antibodies are larger and more complex than traditional small molecule drugs. These characteristics present several challenges in the development of pharmaceutical formulations containing such monoclonal antibodies. For monoclonal antibodies to remain biologically active in clinical applications, pharmaceutical formulations containing such antibodies must preserve and keep intact the conformational integrity of the antibody's amino acid core sequence while simultaneously preventing the degradation of the antibody's numerous functional groups. Degradation pathways for antibodies can involve chemical instability (e.g., any process involving modification of the antibody by bond formation or cleavage resulting in new chemical entities) or physical instability (e.g., changes in the higher order structure of the antibody). Chemical instability can result, for example, from deamidation, racemization, hydrolysis, oxidation, beta elimination, or disulfide exchange. Physical instability can result, for example, from denaturation, aggregation, precipitation, or adsorption.

[0005] Synucleinopathies refer to disorders characterized by neuronal inclusions of pathological alpha-synuclein aggregates called Lewy bodies. Synucleinopathies include Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease) and diffuse Lewy body (DLB) disease (also known as dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's and Parkinson's disease (CAPD), pure autonomic failure (PAF), and multiple system atrophy (MSA; e.g., olivopontocerebellar atrophy, striatonigral degeneration, and Shy-Drager syndrome).

[0006] Alpha-synuclein is normally associated with synapses and is thought to play a role in controlling synaptic vesicle release, thereby affecting neuronal communication, plasticity, learning, and memory. Synucleinopathy conditions have been widely shown to be associated with aggregates of alpha-synuclein, but the exact pathological species of alpha-synuclein remains unclear. A variety of abnormally folded / aggregated / secreted species, ranging from oligomers to fibrils, and various post-translational modifications have been associated with toxicity, but there is no consensus as to which, if any single species, is actually toxic.

[0007] The antibodies disclosed in WO 2017 / 009312 bind to multiple species of alpha synuclein, including all known major species formed by alternative splicing or post-translational modifications such as truncation, as well as oligomeric and fibrillar forms. Such antibodies are believed to be useful in the treatment and / or diagnosis of diseases involving alpha synuclein, such as synucleinopathies, and / or conditions involving abnormal accumulation or deposition of alpha synuclein in the central nervous system. Methods for producing the antibodies disclosed in WO 2017 / 009312 are also disclosed for the same applications, as are various functional and structural features of these antibodies.

[0008] In order to utilize these monoclonal antibodies in a clinical setting, suitable and appropriate dosing regimens for such antibodies, as well as suitable and appropriate pharmaceutical formulations containing such antibodies, are needed.

[0009] Since the pathological target in synucleinopathies is the abnormally folded and aggregated species of alpha synuclein, an effective dosing regimen must provide sufficient targeting of such species during treatment. In a preferred scenario, experimental confirmation of such direct target engagement with aggregated forms of alpha synuclein should be confirmed during treatment. However, due to the very low abundance of pathological alpha synuclein species in CSF and plasma of patients with synucleinopathies, any such reliable experimental confirmation is currently not possible. Due to the low abundance of this pathological species of alpha synuclein (aggregated and oligomeric forms), and therefore the lack of reliable quantification of target engagement, experimentally derived dose setting based on target engagement in biological samples from patients such as plasma and CSF is prevented. Therefore, a method is needed to determine or predict such target engagement with aggregated forms of alpha synuclein in order to identify suitable and appropriate dosing regimens for such antibodies. Summary of the Invention

[0010] The inventors of the present invention have found a method for predicting target engagement in CSF against aggregated species of alpha synuclein and thus establishing a relevant dosing regimen for a specific anti-alpha synuclein antibody. Therefore, it is an object of the present invention to provide a dosing regimen for a specific anti-alpha synuclein antibody. The dosing regimen is based on a relevant model that allows establishing a dosing regimen that provides target engagement with pathological alpha synuclein species in CSF. It is also an object of the present invention to provide a pharma- ceutically acceptable and clinically useful liquid formulation comprising such a monoclonal antibody against alpha synuclein.

[0011] The present invention provides a method of utilizing the monoclonal anti-alpha synuclein antibodies described herein to treat a synucleinopathy or propathic synucleinopathy, which provides the essential elements for the clinical utility of the antibody, namely, a clinically relevant dosing regimen and a suitable liquid pharmaceutical composition comprising the antibody that can be administered to a patient suffering from a synucleinopathy or propathic synucleinopathy.

[0012] The present invention relates to a suitable dosing regimen of a monoclonal antibody against human alpha synuclein for use in the treatment of a synucleinopathy or a prosyphilitic synucleinopathy.Furthermore, the present invention relates to a liquid pharmaceutical composition comprising a monoclonal anti-alpha synuclein antibody, the liquid formulation being stable upon storage and characterized by having a low viscosity.

[0013] Proper dosing for therapeutic monoclonal antibodies is important to provide a therapeutically active dose while maintaining patient safety, and preferably the dosing regimen is also convenient for the patient to be treated.

[0014] The inventors of the present invention have been able to find a way to provide such a dosing regimen, despite the current lack of a reliable method for the measurement of target engagement between anti-alpha synuclein antibodies and oligomeric alpha synuclein in blood or CSF samples. Aggregated / oligomeric / fibril species of alpha synuclein (used interchangeably herein) are only present in very small amounts in CSF or plasma samples, and therefore target engagement cannot be reliably confirmed experimentally, for example, during treatment or clinical trials. Therefore, the establishment of a relevant dosing regimen of a specific anti-alpha synuclein antibody that ensures relevant target engagement with oligomeric forms of alpha synuclein in CSF and therefore clinical efficacy requires the use of complex modeling, based on in-depth knowledge of the specificity of each antibody, such as the elaborate binding profile of said antibody to different alpha synuclein species and human pharmacokinetics. Therefore, the object of the present invention is to provide a dosing regimen of a specific anti-alpha synuclein antibody, based on relevant modeling, that allows to establish a dosing regimen that ensures target engagement with pathological alpha synuclein species in CSF. As a result, the dosing regimens provided herein enable the clinical use of specific monoclonal antibodies against pathological (aggregated and oligomeric) forms of human alpha synuclein.

[0015] The rationale for the dosing regimen of the present invention is described in the Experimental Section and outlined in Example 1.

[0016] In one aspect, the invention provides a monoclonal anti-alpha synuclein antibody for use in treating a synucleinopathy or prosymptomatic synucleinopathy, the use comprising intravenously administering the anti-alpha synuclein antibody to a human subject suffering from or at risk of developing a synucleinopathy at a dose of more than 700 mg and less than 7000 mg, such as between 900 mg and 5000 mg, or such as between 1000 mg and 4500 mg, wherein the monoclonal anti-alpha synuclein antibody is a full length antibody which binds to an epitope within amino acids 112 to 117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

[0017] In another aspect, the invention provides a method of treating a synucleinopathy or prosymptomatic synucleinopathy, the method comprising intravenously administering to a human subject in need of treatment a dose greater than 700 mg and less than 7000 mg, such as between 900 mg and 5000 mg, or such as between 1000 mg and 4500 mg, the human subject suffering from or at risk of developing a synucleinopathy, the monoclonal anti-alpha synuclein antibody being a full length antibody that binds to an epitope within amino acids 112 to 117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

[0018] In yet another aspect, the invention provides a use of a monoclonal anti-alpha synuclein antibody for the manufacture of a medicament for the treatment of a synucleinopathy or prosyphilitic synucleinopathy, the use comprising intravenously administering the anti-alpha synuclein antibody to a human subject suffering from or at risk of developing a synucleinopathy at a dose of more than 700 mg and less than 7000 mg, such as from 900 mg to 5000 mg, or such as from 1000 mg to 4500 mg, wherein the monoclonal anti-alpha synuclein antibody is a full-length antibody that binds to an epitope within amino acids 112 to 117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

[0019] In one embodiment of these aspects, the invention provides suitable dosing regimens for treating a synucleinopathy such as Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease), Gaucher disease (GD), diffuse Lewy body disease (DLBD), dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's disease and Parkinson's disease, pure autonomic dysfunction or multiple system atrophy (MSA), e.g. possible MSA, probable MSA, MSA type C, MSA type P, clinically definite MSA (rigid MSA) or clinically probable MSA.

[0020] In another embodiment of these aspects, the invention provides suitable dosing regimens for treating a prodromal synucleinopathy in a human subject at risk of developing a synucleinopathy, identifiable by exhibiting one or more clinical markers of a prodromal synucleinopathy, such as REM sleep behavior disorder (RBD), e.g., isolated RBD (iRBD), olfactory impairment, e.g., hyposmia, abnormal cognitive performance on neuropsychological testing, subtle motor dysfunction or abnormal motor performance assessed by objective testing, abnormal color vision, autonomic dysfunction (e.g., constipation, voiding symptoms, erectile dysfunction, orthostatic hypotension, etc.), reduced nigrostriatal dopaminergic connectivity in the putamen and striatum (abnormal DAT-SPECT), seborrheic dermatitis, or a genotype associated with increased risk of phenotypic transformation, e.g., a mutation in glucocerebrosidase (encoded by the GBA gene).

[0021] In certain embodiments, the present invention provides suitable dosing regimens for monoclonal antibody GM37, and its variants; GM37 variant 1, GM37 variant 2, and GM37 variant 3, all of which antibodies, methods for their production, and their properties are disclosed in WO 2017 / 009312.

[0022] In certain embodiments of these aspects, a monoclonal anti-alpha synuclein antibody for use according to the invention is administered every 3 to 5 weeks, e.g., about every 4 weeks or once a month, e.g., every 28 to 30 days.

[0023] In certain embodiments of these aspects, a monoclonal anti-alpha synuclein antibody for use according to the invention is administered in a dose of about 750 mg, about 1050 mg, about 1400 mg, about 1750 mg, about 2100 mg, about 2450 mg, about 2800 mg, about 3150 mg, about 3500 mg, about 3850 mg, about 4200 mg, about 4550 mg, about 4900 mg, about 5250 mg, about 5600 mg, about 5950 mg, about 6300 mg, or about 6650 mg. In more specific embodiments, a monoclonal anti-alpha synuclein antibody for use according to the invention is administered in a dose of 1050 mg, 2100 mg, or 4200 mg.

[0024] In one aspect, the present invention relates to a liquid pharmaceutical composition comprising a full-length IgG1 monoclonal anti-alpha synuclein antibody at a concentration of 20-230 mg / mL, for example 25-225 mg / mL, wherein the antibody is a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. A heavy chain CDR2 having the amino acid sequence of SEQ ID NO:34; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6; The composition further comprises a buffer, a pharma- ceutically acceptable tonicity agent, and a pharma- ceutically acceptable surfactant, and the pH of the composition is 4.5 to 7.5, such as 5.0 to 7.0, such as 5.5 to 6.5, such as 6.0.

[0025] Other features and advantages of the present invention as applied to these aspects and embodiments will become apparent from the following detailed description of the invention, the experimental section, and from the claims. [Brief description of the drawings]

[0026] [Figure 1] 1 shows the predicted relationship between dose of the present invention and CSF exposure and % free alpha synuclein. [Diagram 2] Principle of the competitive ELISA assay: After preincubation with increasing concentrations of alpha-synuclein (aSN) monomer or fibrils, free IgG is bound by coated aSN monomer and detected with an anti-human IgG (H+L) HRP-labeled antibody (left). Captured IgG levels, which are inversely proportional to aSN monomer or fibril concentration, are plotted as relative luminescence units and calculated using a four-parameter nonlinear fit (right). [Diagram 3] Representative GM37 variant 2 binding curves for monomeric (R2=0.9895) and fibrillar aSN (R2=0.994) are shown. [Figure 4-a] Median (including quartiles) plasma concentrations of GM37 variant 2 (ng / mL) versus time for healthy subjects (a) and patients (b) following a single dose of GM37v2 at each dose level. [Figure 4-b] Same as above. [Diagram 5] Dose-corrected plasma concentration of GM37 variant 2 versus time (log scale) at various dose levels is shown. [Figure 6-a] Plasma concentration of free alpha synuclein versus time for healthy subjects (a) and patients (b) following a single dose of GM37v2 at each dose level. [Figure 6-b] Same as above. [Figure 7-a] Plasma concentration of free / total alpha synuclein versus time for healthy subjects (a) and patients (b) following a single dose of GM37v2 at each dose level. [Figure 7-b] Same as above. [Figure 8]Plasma concentrations of free / total alpha synuclein versus individual GM37 variant 2 plasma concentrations are shown. [Figure 9] Competitive ELISA measuring binding of four antibodies GM37wt, GM37var1, GM37var2 and GM37var3 to human alpha synuclein. Alpha synuclein coated plates are used to detect the amount of antibody remaining after pre-incubation of nuclear antibodies (0.3 μg / mL) in solution with increasing concentrations of alpha synuclein (0-1000 nM). All four antibodies show similar binding to alpha synuclein. [Figure 10] The effect of anti-alpha synuclein antibodies on phosphorylated alpha synuclein levels in murine primary neurons treated with pathological alpha synuclein fibrillar seeds is compared. Primary neurons were treated with seeds (10 ng) in the presence or absence of four antibodies for use according to the invention, GM37, GM37var1, GM37var2 and GM37var3 (2 μg). After 3 weeks, neurons were fixed, stained and analyzed for alpha synuclein phosphoserine 129 positive spots by Cellomics ARRAYSCAN™. ​​Cells treated with seeds alone or seeds + isotype control antibody (B12) show a large increase in phosphorylation levels. Cells treated with GM37wt and the three variants are able to inhibit the phosphorylation of alpha synuclein, all of which show the same level of phosphorylation as cells that did not receive seeds. Data are shown as mean ± SD determined from 7 images per well in 5 wells. N=2. [Figure 11] 1 shows CSF concentrations of % free / total alpha synuclein in patients with Parkinson's disease (PD) with GM37v2 administration on days 3 and 21 of the study described in Example 3 (N=15). DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0027] definition The term "full-length antibody" is meant to refer to a full-length (whole) antibody or a substantially full-length antibody format. This term particularly refers to an antibody having a heavy chain containing an Fc region. Naturally occurring antibodies typically comprise a tetramer, usually composed of at least two heavy (H) chains and at least two light (L) chains. Each heavy chain is composed of a heavy chain variable domain (abbreviated herein as VH) and a heavy chain constant domain, usually composed of three domains (CH1, CH2 and CH3). The heavy chains may be selected, for example, from IgG isotypes (IgG1, IgG2, IgG3 and IgG4 subtypes). Each light chain is composed of a light chain variable domain (abbreviated herein as VL) and a light chain constant domain (CL). Light chains include kappa chains and lambda chains. The VH and VL regions may be further subdivided into regions of hypervariability, called "complementarity determining regions", interspersed with regions of more conserved sequence, called "framework regions" (FR). Each VH and VL is composed of three CDR domains and four FR domains arranged from the amino terminus to the carboxy terminus in the following order: FR1-CDR1-FR2-CDR2-FR3-CDR3-FR4 (or J-region). The variable domains of the heavy and light chains contain binding domains that interact with an antigen. In some embodiments, the full-length antibodies of the present invention include antibody variants that can be classified as "product-related substances" according to International Conference on Harmonization (ICH) Q6B, which is defined as "molecular variants of the product of interest formed during manufacture and / or storage that are active, do not adversely affect the safety and efficacy of the product, and do not have comparable properties in terms of biological activity, efficacy, and safety to the product of interest."Molecular variants of such antibodies for use in accordance with the present invention are meant to include, for example, N-terminal modifications such as, for example, N-terminal pyroglutamic acid (pyroGlu), truncations, or incomplete removal of the light or heavy chain signal peptide, asparagine (Asn) deamidation, aspartic acid (Asp) isomerization, oxidation such as succinimide, oxidation, free cysteine ​​(Cys) residues, alternating disulfide bonds (scrambling), trisulfide bonds, formation of thioethers, or cysteine-related modifications such as cysteine ​​racemization, glycosylation, glycosylation, removal of the C-terminal Lys, removal of both the C-terminal Lys and Gly, or C-terminal amidation.

[0028] The term "epitope" refers to an antigenic determinant capable of specific binding to an antibody. Epitopes usually consist of surface groupings of molecules such as amino acids or sugar side chains and usually have specific three-dimensional structural characteristics as well as specific charge characteristics. Conformational and linear epitopes are distinguished in that the binding to the former is always lost in the presence of denaturing solvents, whereas the latter is not. Epitopes include amino acid residues that are directly involved in binding and other amino acid residues that are not directly involved in binding (in other words, they are specifically within the footprint of the antigen-binding peptide), such as amino acid residues that are effectively blocked by the antigen-binding peptide. The term "112-117 epitope" or "epitope within amino acids 112-117" refers to a region of human alpha synuclein that contains at least four of the six amino acid residues 112-117 of human alpha synuclein, for example, that contains all six amino acid residues 112-117 of human alpha synuclein, which epitope does not include any residues 1-111 (including any residues 106-111) of human alpha synuclein and does not include any residues 118-140 (including residues 118-120) of human alpha synuclein. As used herein, an antibody for use according to the invention that is said to bind to an "epitope within amino acids 112-117" can specifically bind human alpha synuclein by binding to at least four of the six amino acid residues of the 112-117 epitope, e.g., by binding to the six amino acid residues of the 112-117 epitope, without binding to any residues 1-111 (including any residues 106-111) of human alpha synuclein and without binding to any residues 118-140 (including residues 118-120) of human alpha synuclein.

[0029] The term "human antibody" (which may be abbreviated as "humAb" or "HuMab"), as used herein, is intended to include antibodies having variable and constant domains derived from human germline immunoglobulin sequences. The human antibodies of the invention may include amino acid residues not encoded by human germline immunoglobulin sequences (e.g., mutations introduced by random or site-specific mutagenesis in vitro, or during gene rearrangement, or by somatic mutation in vivo).

[0030] The term "humanized" refers to molecules that have an antigen-binding site derived from an immunoglobulin from a non-human species, typically prepared using recombinant techniques that maintain an immunoglobulin structure based on the structure and / or sequence of a human immunoglobulin. The antigen-binding site may comprise either a complete non-human antibody variable domain fused to a human constant domain, or only the complementarity determining regions (CDRs) of such a variable domain grafted into appropriate human framework regions of the human variable domain. The framework residues of such humanized molecules may be wild-type (e.g., fully human), or they may be modified to contain one or more amino acid substitutions not found in the human antibody whose sequence was the basis for humanization. Another approach focuses on not only providing constant domains of human origin, but also on modifying the variable domains to resemble the human form as closely as possible. Both the heavy and light chain variable domains are known to contain three complementarity determining regions (CDRs) that vary and determine the binding ability depending on the antigen under discussion, and the three complementarity determining regions (CDRs) are flanked by four framework regions (FRs) that are relatively conserved in a particular species and putatively provide an anchorage for the CDRs. When a non-human antibody is tailored to a particular antigen, the variable domains can be "reshaped" or "humanized" by bluffing the CDRs from the non-human antibody onto the FRs present in the human antibody to be modified.

[0031] In the present context, "treatment" or "treating" is intended to refer to the clinically relevant management and care of a patient for the purpose of alleviating, preventing, partially preventing, eliminating, slowing or decelerating the progression of one or more clinical signs of a disease. For the purposes of the present invention, "treatment" or "treating" further refers to an approach for obtaining a beneficial or desired clinical result, where a "beneficial or desired clinical result" includes, but is not limited to, a partial or total alleviation of symptoms, a decrease in the extent of a disorder or disease, a stabilized (i.e., not worsening) disease or disorder state, a delay or slowing of the progression of a disease or disorder state, a reduction or palliation of a disease or disorder state, or a remission of a disease or disorder. In certain embodiments, "treatment" or "therapeutic effect" consists of delaying or slowing disease progression in patients suffering from a synucleinopathy, which in certain embodiments is MSA, which may be selected from one or more of the following MSA subtypes: clinically definite MSA, clinically probable MSA, definite MSA, probable MSA, MSA type C, or MSA type P. In another embodiment, "treatment" refers to delaying disease onset in patients with a prodromal synucleinopathy. Treatment may be measured by quantifying clinical efficacy or therapeutic effect by measuring the slowing or delaying of disease progression as assessed by log change from baseline in the Unified Multiple System Atrophy Rating Scale (UMSARS) Part I and Part II Total Score (UMSARS TS), or in the modified UMSARS Part I (mUMSARS), or in the abbreviated UMSARS (aUMSARS) until the end of treatment (EoT), i.e., until the end of a treatment period of 24 weeks, 48 ​​weeks, 72 weeks, 96 weeks, or more. Treatment may also be measured by quantifying clinical efficacy or therapeutic effect by measuring the slowing or delaying of disease progression as assessed by log change from baseline in the UMSARS Part I, modified UMSARS Part I (mUMSARS), and / or UMSARS Part II scores until EoT. Such disease progression may also be measured by quantifying clinical efficacy or therapeutic effect by measuring the slowing or delaying of disease progression as assessed by log change from baseline in the UMSARS Part I, modified UMSARS Part I (mUMSARS), and / or UMSARS Part II scores until EoT.Disease progression may be assessed as the change from baseline to EoT in TS, UMSARS part I, mUMSARS and / or UMSARS part II scores. Disease progression may also be assessed by the log change from baseline to EoT in abbreviated UMSARS (aUMSARS), or as the change from baseline in brain volume measured by volumetric MRI (vMRI), or as the change from baseline in neurofilament light chain (NfL) blood levels. Treatment may also be measured by quantifying clinical efficacy or therapeutic effect by measuring the slowing or delay of disease progression as assessed by log change from baseline in one or more parameters selected from the following: Schwab and England Activities of Daily Living (SE-ADL) score; as change from baseline in Clinical Global Impression-Severity of Illness (CGI-S) score; as change from baseline in Patient Global Impression-Severity of Illness (PGI-S) score; as change from baseline in Observer-Reported Global Impression-Severity of Illness (OGI-S) score; as change from baseline in Composite Autonomic Symptom Score Select Change (COMPASS Select as change from baseline in the UMSARS Part IV score; as change from baseline in speaking, swallowing, falls, and gait as assessed by the UMSARS Part I item scores; as change from baseline in frequency, causes, and effects of falls as assessed by the Fall Diary Periods; and as change from baseline in the EQ-5D-5L scoring system (EuroQolas a change from baseline in 5-Dimension, 5-Level (EQ-5D-5L) score; as a change from baseline in brain volume as measured by volumetric MRI (vMRI); as a change from baseline in tissue integrity as measured by diffusion tensor imaging (DTI) MRI; as a change from baseline in neurofilament light chain (NfL) blood concentrations; as a change from baseline in heart rate, blood pressure and orthostatic symptoms as assessed by UMSARS Part III; as a change from baseline in gait parameters or frequency of falls as assessed by a digital wearable sensor-based device capable of tracking relevant gait parameters and / or registered falls; as a change from baseline in cerebral blood flow as measured by arterial spin labeling (ASL) MRI; as a change from baseline in CSF concentrations of t-tau and NfL; or as a change from baseline in pathological species of alpha-synuclein in the CSF. Patients to be treated may be identified or diagnosed via methods or criteria accepted in the relevant field.

[0032] The term “kd” (seconds -1 or 1 / s), as used herein, refers to the dissociation rate constant of a particular antibody-antigen interaction. This value is also referred to as the k value.

[0033] The term "ka" (M -1 × seconds -1 or 1 / M seconds), as used herein, refers to the association rate constant of a particular antibody-antigen interaction.

[0034] The term "KD" (M), as used herein, refers to the dissociation equilibrium constant of a particular antibody-antigen interaction, and is obtained by dividing kd by ka. KD can be determined by methods such as those described in Example 6A, or other methods known in the art.

[0035] The term "KA" (M -1or 1 / M), as used herein, refers to the association equilibrium constant of a particular antibody-antigen interaction and is obtained by dividing ka by kd.

[0036] The term "IC50" as used herein refers to the antibody concentration that achieves 50% of the maximum inhibitory effect. The exact IC50 value in nM usually depends on the specific assay and therefore cannot be directly compared between different assays.

[0037] The term "Emax" as used herein refers to the maximum effect of an antibody at an antibody concentration, i.e., when all alpha synuclein is bound by the antibody.

[0038] The term "avidity" as used herein refers to the cumulative strength of an antibody-antigen complex. As used herein, it encompasses the affinity of two of the individual non-covalent interactions between an IgG molecule and its antigen.

[0039] The term "Cmax," as used herein, refers to the maximum concentration of an antibody measured in the plasma of a subject following infusion of that antibody.

[0040] The term "tmax," as used herein, refers to the time it takes to reach Cmax after injection of an antibody.

[0041] The phrase "use according to the present disclosure" as used throughout this disclosure is meant to apply to all uses and methods of the present invention, including use in the treatment of synucleinopathy or pre-symptomatic synucleinopathy, methods of treating synucleinopathy or pre-symptomatic synucleinopathy, and use of the monoclonal anti-alpha synuclein antibody of the present invention for the manufacture of a medicament for the treatment of synucleinopathy or pre-symptomatic synucleinopathy. Such uses may include administering the monoclonal anti-alpha synuclein antibody of the present invention to a patient in need of treatment using a suitable dose, administration regimen, and / or suitable pharmaceutical formulation. Such formulations or compositions are also provided by the present invention.

[0042] The terms "formulation" and "composition" are used interchangeably throughout this application.

[0043] The term "stable composition" refers to a composition that can be stored under certain conditions, typical storage conditions for antibody formulations herein, for example, at about 5°C, for a certain period of time, herein at least 6 months or more, and the protein in the composition essentially retains its physical and / or chemical and / or biological stability. Various analytical techniques for measuring protein stability are available and well known in the art, some of which are also described in the experimental section herein. Stability can be measured at a selected temperature for a selected period of time. In certain embodiments, the formulation is stable at about 40°C for at least about 1, 2, 3, 4, 5, 6, 7, 14, 21, 28 days or more. In certain embodiments, the formulation is stable at about 40°C ± 3°C for at least about 1, 2, 3, 4, 5, 6, 7, 8 weeks or more. In certain embodiments, the formulation is stable for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, or more months at about 25° C. In certain embodiments, the formulation is stable for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, or more months at about 5° C.±3° C. In certain embodiments, the formulation is stable for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48 months or more at about −20° C.±3° C. Further, the formulation is preferably stable after freezing (e.g., to −20° C., −40° C., or −70° C.) and thawing the formulation, e.g., after 1, 2, 3, 4, or 5 cycles of freezing and thawing.Stability can be qualitatively and / or quantitatively assessed in a variety of different ways, including assessing aggregate formation (e.g., by measuring turbidity using size exclusion chromatography and / or by visual inspection); by assessing charge heterogeneity using cation exchange chromatography, image capillary isoelectric focusing (icIEF), or capillary zone electrophoresis; analysis of amino- or carboxy-terminal sequences; mass spectrometry, SDS-PAGE analysis to compare reduced and intact antibodies; peptide map (e.g., trypsin or LYS-C) analysis; assessing the biological activity or antigen-binding function of the antibody, etc. Instability can involve any one or more of aggregation, deamidation (e.g., Asn deamidation), oxidation (e.g., Met oxidation), isomerization (e.g., Asp isomerization), clipping / hydrolysis / fragmentation (e.g., hinge region fragmentation), succinimide formation, unpaired cysteines, N-terminal extensions, C-terminal processing, differences in glycosylation, etc.

[0044] "Low viscosity composition" is meant to describe a liquid pharmaceutical composition having a viscosity of at least about less than 20 cP, such as less than 15 cP, such as less than 14 cP, such as less than 13 cP, such as less than 12 cP, such as less than 11 cP, such as less than 10 cP, such as less than 9 cP, such as less than 8 cP, such as less than 7 cP, such as less than 6 cP, such as less than 5 cP.

[0045] In this application, "buffer" refers to a buffer solution that resists changes in pH through the action of acid-base conjugate components. The buffer solution or buffering agent (used interchangeably) of the present invention preferably maintains the pH of the composition in the range of about 4.5 to about 7.5, such as about 5.5 to about 6.5, for example, 5.7 to 6.4, 5.8 to 6.3, or 5.9 to 6.2. In one embodiment, the buffer has a pH of 5.5, 5.6, 5.7, 5.8, 5.9, 6.0, 6.1, 6.2, 6.3, 6.4, 6.5, or 7.0. Histidine buffers (such as L-histidine) are examples of buffers that control the pH in this range. Examples of buffers are acetate, citrate, tartrate, histidine (such as L-histidine), glutamate, phosphate, Tris, glycine, bicarbonate, succinate, sulfate, and nitrate buffers or mixtures thereof. In some embodiments, the buffer is selected from sodium phosphate, histidine (such as L-histidine), citric acid, sodium citrate, sodium acetate, or mixtures thereof. In one specific embodiment, the buffer is a histidine buffer (such as L-histidine) or a mixture of histidine buffers.

[0046] In this application, "surfactant" refers to a surface active agent, preferably a non-ionic surfactant. Examples of surfactants herein include polysorbates (e.g., polysorbate 20 and polysorbate 80); poloxamers (e.g., poloxamer 188); Triton; X-100; sodium dodecyl sulfate (SDS); sodium lauryl sulfate; sodium octyl glucoside; lauryl-, myristyl-, linoleyl-, or stearyl-sulfobetaine; lauryl-, myristyl-, linoleyl-, or stearyl-sarcosine; linoleyl-, myristyl-, or cetyl-betaine; lauroamidopropyl-, cocamidopropyl-, linoleamidopropyl-, myristamidopropyl-, palmidopropyl-, or isostearamidopropyl-betaine (e.g., lauroamidopropyl); myristamidopropyl-, palmidopropyl-, or isostearamidopropyl dimethylamine; sodium methyl cocoyl taurate or disodium methyl oleyl taurate; polyethyl glycol, polypropyl glycol, and copolymers of ethylene and propylene glycol. In one specific embodiment, the pharma- ceutically acceptable surfactant is polysorbate 80, also known as Tween 80.

[0047] In this application, "tonicity agent" refers to an excipient that allows for an isotonic liquid pharmaceutical composition. Isotonicity means that the formulation of interest has essentially the same osmotic pressure as human blood. An isotonic formulation will generally have an osmotic pressure of about 250-350 mOsm. Examples of tonicity agents include mannitol, sorbitol, lactose, dextrose, trehalose, sodium chloride, potassium chloride, glycerol, and glycerin. In one specific embodiment, the tonicity agent is a suitable salt, such as NaCl.

[0048] In the context of the present invention, "bulking agent" is meant to refer to an excipient that provides additional stability to a liquid pharmaceutical composition. Examples of bulking agents include these main classes of excipients: sugars and polyols (such as sucrose, trehalose, glucose, lactose, sorbitol, mannitol and glycerol); amino acids (arginine, aspartic acid, glutamic acid, lysine, glycine, glutamate, histidine, methionine or alanine); and polymers and proteins (gelatin, PVP, PLGA, PEG, dextran, cyclodextrin and derivatives, starch derivatives, HSA or BSA). In one specific embodiment, the bulking agent is sucrose.

[0049] The term "histidine buffer" or "histidine" is meant to encompass histidine buffers and mixtures thereof, such as histidine, L-histidine, L-histidine hydrochloride, L-histidine monohydrochloride, L-histidine monohydrate, and L-histidine hydrochloride monohydrate, or mixtures thereof. In one specific embodiment, the histidine buffer is a mixture of L-histidine and L-histidine monohydrochloride.

[0050] Detailed Description of the Invention The present invention relates to suitable dosing regimens for use in the treatment of synucleinopathies or presymptomatic synucleinopathies and provides suitable liquid pharmaceutical compositions of monoclonal antibodies against human alpha synuclein for use in the treatment of synucleinopathies or presymptomatic synucleinopathies.

[0051] In one aspect, the invention provides a monoclonal anti-alpha synuclein antibody for use in treating a synucleinopathy or prosymptomatic synucleinopathy, the use comprising intravenously administering the anti-alpha synuclein antibody to a human subject suffering from or at risk of developing a synucleinopathy at a dose of more than 700 mg and less than 7000 mg, such as from 900 mg to 5000 mg, or such as from 1000 mg to 4500 mg, wherein the monoclonal anti-alpha synuclein antibody is a full length antibody which binds to an epitope within amino acids 112 to 117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

[0052] In another aspect, the invention provides a method of treating a synucleinopathy or prosymptomatic synucleinopathy, the method comprising intravenously administering a monoclonal anti-alpha synuclein antibody at a dose greater than 700 mg and less than 7000 mg, such as from 900 mg to 5000 mg, or such as from 1000 mg to 4500 mg, to a human subject in need of treatment, the human subject having or at risk of developing a synucleinopathy, wherein the monoclonal anti-alpha synuclein antibody is a full-length antibody that binds to an epitope within amino acids 112 to 117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

[0053] In yet another aspect, the invention provides use of a monoclonal anti-alpha synuclein antibody for the manufacture of a medicament for the treatment of a synucleinopathy or prosyphilitic synucleinopathy, the use comprising intravenously administering the anti-alpha synuclein antibody to a human subject suffering from or at risk of developing a synucleinopathy at a dose of more than 700 mg and less than 7000 mg, such as from 900 mg to 5000 mg, or such as from 1000 mg to 4500 mg, wherein the monoclonal anti-alpha synuclein antibody is a full-length antibody that binds to an epitope within amino acids 112 to 117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

[0054] In certain embodiments, the monoclonal anti-alpha synuclein antibody has an estimated KD value for binding to oligomeric forms of alpha synuclein of about 0.1-1.0 nM, such as 0.2-0.8 nM, such as 0.4-0.6 nM, such as about 0.5 nM.

[0055] In certain embodiments, the monoclonal anti-alpha synuclein antibody has an estimated KD value for binding to the monomeric form of alpha synuclein of about 30-40 nM, such as 32-38 nM, such as 34-37 nM, such as about 36 nM, and an estimated KD value for binding to the oligomeric form of alpha synuclein of about 0.1-1.0 nM, such as 0.2-0.8 nM, such as 0.4-0.6 nM, such as about 0.5 nM. In one embodiment, the ratio between the monomeric binding value and the oligomeric binding value is approximately 60-70 fold enhanced for the oligomeric form compared to the monomeric form, such as 62-68 fold enhanced, such as 64-66 fold enhanced, such as 65 fold enhanced, such as 65 fold enhanced, such as 62-68 fold enhanced, such as 64-66 fold enhanced, such as 65 fold enhanced, such as 62-68 fold enhanced, such as 64-66 fold enhanced, such as 65 fold enhanced, such as 64-6 ... In certain embodiments, the monoclonal anti-alpha synuclein antibody has a human T1 / 2 of about 25-35 days, such as about 4 weeks, such as about 27-33 days, such as about 28 days, such as about 28-32 days, such as 30 days, such as 28-30 days.

[0056] In embodiments, the monoclonal anti-alpha synuclein antibody for use according to the invention comprises: a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. a heavy chain CDR2 having the amino acid sequence of SEQ ID NO:2; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6.

[0057] In certain embodiments, a monoclonal anti-alpha synuclein antibody for use according to the invention comprises a heavy chain consisting of the variable domain of SEQ ID NO:7 and a light chain consisting of the variable domain of SEQ ID NO:8.

[0058] In embodiments, the monoclonal anti-alpha synuclein antibody for use according to the invention comprises: a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. A heavy chain CDR2 having the amino acid sequence of SEQ ID NO:33; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6.

[0059] In certain embodiments, a monoclonal anti-alpha synuclein antibody for use according to the invention comprises a heavy chain consisting of the variable domain of SEQ ID NO:30 and a light chain consisting of the variable domain of SEQ ID NO:8.

[0060] In embodiments, the monoclonal anti-alpha synuclein antibody for use according to the invention comprises: a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. A heavy chain CDR2 having the amino acid sequence of SEQ ID NO:34; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6.

[0061] In certain embodiments, a monoclonal anti-alpha synuclein antibody for use according to the invention comprises a heavy chain consisting of the variable domain of SEQ ID NO:31 and a light chain consisting of the variable domain of SEQ ID NO:8.

[0062] In embodiments, the monoclonal anti-alpha synuclein antibody for use according to the invention comprises: a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. A heavy chain CDR2 having the amino acid sequence of SEQ ID NO:35; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6.

[0063] In certain embodiments, a monoclonal anti-alpha synuclein antibody for use according to the invention comprises a heavy chain consisting of the variable domain of SEQ ID NO:32 and a light chain consisting of the variable domain of SEQ ID NO:8.

[0064] In certain embodiments, the monoclonal anti-alpha synuclein antibody for use in accordance with the present invention is a full-length human antibody. In such embodiments, the monoclonal anti-alpha synuclein antibody may be, for example, a human IgG1 antibody.

[0065] In certain embodiments, a monoclonal anti-alpha synuclein antibody for use in accordance with the invention comprises a human IgG1 heavy chain constant region and / or a human kappa light chain constant region.

[0066] In certain embodiments, a monoclonal anti-alpha synuclein antibody for use according to the present invention comprises a constant heavy chain domain as defined in SEQ ID NO:18 and / or a kappa light chain constant domain as defined in SEQ ID NO:17.

[0067] In a particular embodiment, the monoclonal anti-alpha synuclein antibody for use according to the invention is the antibody GM37, or a variant thereof; GM37 variant 1, GM37 variant 2 or GM37 variant 3. In a preferred embodiment, the antibody is GM37v2.

[0068] In one embodiment, a monoclonal anti-alpha synuclein antibody for use according to the invention is administered at a dose of greater than 700 mg and less than 7000 mg, such as between 900 mg and 5000 mg, or such as between 1000 mg and 4500 mg. In a specific embodiment, the monoclonal anti-alpha synuclein antibody is administered at intervals of 3 to 5 weeks or in another regimen that provides substantially the same area under the curve (AUC) for exposure of the antibody or provides substantially the same putative target engagement of oligomeric alpha synuclein in the patient's CSF to a human subject.

[0069] In some embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered every 6 weeks, 5 weeks, 4 weeks, 3 weeks, 2 weeks, or every week. In some embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered every 20 days, 21 days, 22 days, 23 days, 24 days, 25 days, 26 days, 27 days, 28 days, 29 days, 30 days, 31 days, 32 days, 33 days, 34 days, 35 days, 36 days, 37 days, 38 days, 39 days, or 40 days.

[0070] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered every 3-5 weeks, every 4 weeks, or once a month, such as every 25-31 days, such as every 28-30 days.

[0071] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered at a dose of about 75 mg, about 225 mg, about 750 mg, about 2250 mg, about 4500 mg, or about 9000 mg.

[0072] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered in a dose of 1000 mg to 4500 mg, such as 2000 mg to 4500 mg, or such as 3500 mg to 4500 mg, such as 4200 mg.

[0073] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered in a dose of about 750 mg, about 1050 mg, about 1400 mg, about 1750 mg, about 2100 mg, about 2450 mg, about 2800 mg, about 3150 mg, about 3500 mg, about 3850 mg, about 4200 mg, about 4550 mg, about 4900 mg, about 5250 mg, about 5600 mg, about 5950 mg, about 6300 mg, or about 6650 mg. In more specific embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered in a dose of 1050 mg, 2100 mg, or 4200 mg.

[0074] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered at the doses specified above by intravenous infusion over 30 minutes ± 10 minutes, over 20 minutes, over 25 minutes, 30 minutes, 35 minutes or over 40 minutes, etc.

[0075] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered at the doses specified above by intravenous infusion over 15 minutes ± 5 minutes, over 10 minutes, over 15 minutes or over 20 minutes, etc.

[0076] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the present invention are administered at the doses specified above by intravenous infusion at a rate of about 30 mg / min to about 150 mg / min, such as about 35 mg / min, about 70 mg / min or about 140 mg / min.

[0077] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use in accordance with the present invention are administered at the doses specified above by intravenous infusion at a rate of about 25 mg / min to about 300 mg / min, such as 60 mg / min to about 300 mg / min, such as about 70 mg / min, about 140 mg / min or about 280 mg / min.

[0078] In embodiments, a monoclonal anti-alpha synuclein antibody for use in accordance with the invention is administered in an amount and frequency sufficient to achieve an estimated CSF average steady state concentration of the antibody of at least 0.5 nM, such as at least 1 nM, such as at least 2 nM, such as at least 3 nM, such as at least 4 nM, such as at least 5 nM, such as at least 6 nM, such as at least 7 nM, such as at least 8 nM, such as at least 9 nM, such as at least 10 nM, such as at least 11 nM, such as at least 12 nM, such as at least 13 nM, such as at least 14 nM, or such as at least 15 nM.

[0079] In another embodiment, a monoclonal anti-alpha synuclein antibody for use in accordance with the present invention is administered in an amount and frequency sufficient to achieve putative target engagement with oligomeric forms of alpha synuclein in the CSF of at least 50%, such as at least 55%, such as at least 60%, such as at least 75%, such as at least 77%, such as at least 80%, such as at least 82%, such as at least 85%, such as at least 87%, such as at least 90%, at least 92%, such as at least 95%, such as at least 97%, or such as at least 99%.

[0080] In another embodiment, the monoclonal anti-alpha synuclein antibody for use according to the present invention is for use in the treatment of synucleinopathies. Such synucleinopathies may be selected from the group including Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease), Gaucher's disease (GD), diffuse Lewy body disease (DLBD), dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's disease and Parkinson's disease, pure autonomic dysfunction and multiple system atrophy (MSA). Such treatment may consist of slowing or delaying the disease progression of synucleinopathies (such as the progression of MSA) or delaying the onset of disease if the patient has prodromal synucleinopathies.

[0081] In certain embodiments, the synucleinopathy being treated is Parkinson's disease (PD).

[0082] In yet another specific embodiment, the synucleinopathy being treated is dementia with Lewy bodies (DLB).

[0083] In yet another specific embodiment, the synucleinopathy to be treated is multiple system atrophy (MSA). In such an embodiment, the human subject suffering from MSA can be identified by being diagnosed with MSA of multiple system atrophy-predominantly parkinsonian (MSA-P) or multiple system atrophy-predominantly cerebellar (MSA-C) subtype, or by being diagnosed with definite or probable MSA, which may also be of multiple system atrophy-predominantly parkinsonian (MSA-P) or multiple system atrophy-predominantly cerebellar (MSA-C) subtype, or by being diagnosed with clinically definite MSA or clinically probable MSA, which may also be of multiple system atrophy-predominantly parkinsonian (MSA-P) or multiple system atrophy-predominantly cerebellar (MSA-C) subtype. In yet another embodiment, the diagnosis of MSA is based on the presence of one or more suitable biomarkers for MSA identified in the human subject. Such biomarkers may be selected from the group including physiological biomarkers, biological biomarkers, genetic biomarkers, molecular biomarkers, histological biomarkers, radiological biomarkers, imaging biomarkers, behavioral biomarkers, or digital biomarkers. In further such embodiments, a human subject suffering from MSA or having definite or probable multiple system atrophy (MSA), or other MSA subtypes, may be identifiable by a validated clinical evaluation and / or diagnostic method known in the art. In another such embodiment, a human subject suffering from MSA or having definite or probable multiple system atrophy (MSA), or other MSA subtypes, may be identifiable by having experienced motor and / or autonomic (orthostatic or urinary) MSA symptoms within the past 5 years, such as within the past 4 years, such as within the past 3 years, such as within the past 2 years, such as within the past 1 year, or such as within the past 6 months.In yet another such embodiment, a human subject with MSA or definite or probable multiple system atrophy (MSA), or other MSA subtypes, may be identifiable by having a UMSARS part I score (when item 11, relating to sexual function, is omitted) of ≦16. In yet another such embodiment, a human subject with MSA or definite or probable multiple system atrophy (MSA), or other MSA subtypes, may be identifiable by having cognitive ability as assessed by the Montreal Cognitive Assessment (MoCA) of a score of ≧22.

[0084] In another embodiment, the monoclonal anti-alpha synuclein antibody for use according to the invention is for use in the treatment of a prodromal synucleinopathy in a human subject at risk of developing a synucleinopathy, the human subject being identifiable by displaying one or more clinical markers of a prodromal synucleinopathy selected from the group including: REM sleep behavior disorder (RBD), e.g. isolated RBD (iRBD), olfactory impairment, e.g. hyposmia, abnormal cognitive performance on neuropsychological testing, fine motor dysfunction or abnormal motor skills assessed by objective testing, abnormal color vision, autonomic dysfunction (e.g. constipation, voiding symptoms, erectile dysfunction, orthostatic hypotension), reduced nigrostriatal dopaminergic connectivity in the putamen and striatum (abnormal DAT-SPECT), and a genotype associated with increased risk of phenotypic transformation, e.g. a mutation in glucocerebrosidase (encoded by the GBA gene). In such embodiments, a human subject at risk of developing a synucleinopathy may be identifiable by exhibiting an RBD, e.g., isolated RBD (iRBD), and at least one additional clinical marker of prodromal synucleinopathy, e.g., hypotension and / or abnormal DAT-SPECT. In yet another such embodiment, a human subject at risk of developing a synucleinopathy may be identifiable by exhibiting an RBD, e.g., isolated RBD (iRBD), and hypotension and abnormal DAT-SPECT.

[0085] In an embodiment of the invention, a monoclonal anti-alpha synuclein antibody, such as GM37v2, is formulated into one of the specific liquid pharmaceutical compositions as provided in the present application and claims.

[0086] In another aspect of the invention, there is provided a kit comprising a monoclonal anti-alpha synuclein antibody for use in accordance with the invention.

[0087] In yet another embodiment, the monoclonal anti-alpha synuclein antibodies for use according to the invention are expressed in or obtained by expression in CHO cells.

[0088] In aspects, the monoclonal anti-alpha synuclein antibodies for use in accordance with the present invention are for use in treating abnormal aggregation of alpha synuclein in a human subject, the human subject being identified as having abnormal aggregation of alpha synuclein in the CNS.

[0089] In some embodiments, treatment with a monoclonal anti-alpha synuclein antibody for use according to the invention may continue for weeks, months, a year, or even years. In further embodiments, treatment may be part of a combination therapy, in which a monoclonal antibody for use according to the invention is given in combination with or in conjunction with one or more additional medications. Such additional medications may be part of the standard of care used in certain synucleinopathies. In MSA, such standard of care includes one or more of the following drugs: drugs for reducing Parkinson's disease-like signs and symptoms, such as levodopa and / or carbidopa, or drugs known to be useful in treating autonomic symptoms (e.g., voiding symptoms or neurogenic orthostatic hypotension) (such drugs are pyridostigmine, midodrine, or droxidopa).

[0090] Specific Doses and Dosing Regimens The doses and dosing regimens of the present invention may be expressed in fixed doses, such as a specific amount in mg of monoclonal antibody for use according to the present invention (i.e., independent of the body weight of the human subject to be treated). Such doses are described in the embodiments and aspects of the present invention, including in Table 1 below. In some embodiments, the doses or dosing regimens of the present invention may be expressed in mg / kg (i.e., doses that vary based on the body weight of the human subject to be treated). It would be within the skill of a trained physician to convert between a fixed dose and a dose administered according to body weight (such as mg / kg). The outcome of the conversion would depend on the body weight of the human subject to be treated with the doses or dosing regimens of the present invention.

[0091] In one embodiment, a monoclonal anti-alpha synuclein antibody for use according to the invention is administered at a dose of 1000 mg to 4500 mg at intervals of 3 to 5 weeks, or the antibody is administered to a human subject in another regimen that provides substantially the same putative target engagement of oligomeric alpha synuclein in the patient's CSF. In a particular embodiment, the antibody is administered to a human subject in a regimen that provides substantially the same putative target engagement of oligomeric alpha synuclein in the patient's CSF as 4200 mg of GM37v2 administered approximately every 4 weeks.

[0092] In some embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered every 4 weeks. In some embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered monthly. In some embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered every 27 days, every 28 days, every 29 days, every 30 days, or every 31 days.

[0093] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered every 28-30 days, such as every 3-5 weeks, every 4 weeks, or once a month.

[0094] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered in a dose of 1000 mg to 4500 mg, such as 2000 mg to 4500 mg, or such as 3500 mg to 4500 mg, such as 4200 mg.

[0095] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered in a dose of about 1050 mg, about 1400 mg, about 1750 mg, about 2100 mg, about 2450 mg, about 2800 mg, about 3150 mg, about 3500 mg, about 3850 mg, about 4200 mg. In further specific embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered in a dose of 1050 mg, 2100 mg, or 4200 mg.

[0096] In one embodiment, a monoclonal anti-alpha synuclein antibody for use according to the invention is administered at a dose of 13 mg / kg to 71 mg / kg, or such as 14 mg / kg to 64 mg / kg, or such as 15 mg / kg to 60 mg / kg, or such as 15 mg / kg, or such as 30 mg / kg, or such as 60 mg / kg at intervals of 3 to 5 weeks, or the antibody is administered to a human subject in another regimen that provides substantially the same putative target engagement of oligomeric alpha synuclein in the CSF of the patient. In a particular embodiment, the antibody is administered to a human subject in a regimen that provides substantially the same putative target engagement of oligomeric alpha synuclein in the CSF of the patient as 60 mg / kg of GM37v2 administered approximately every 4 weeks.

[0097] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered at a dose of about 1 mg / kg, about 3 mg / kg, about 11 mg / kg, about 32 mg / kg, about 64 mg / kg, or about 129 mg / kg.

[0098] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered at a dose of 14 mg / kg to 64 mg / kg, such as 15 mg / kg to 60, such as 30 mg / kg to 60 mg / kg, such as 60 mg / kg.

[0099] In certain embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered at a dose of about 11 mg, about 15 mg, about 20 mg, about 25 mg, about 30 mg, about 35 mg, about 40 mg, about 45 mg, about 50 mg, about 55 mg, about 60 mg, about 65 mg, about 70 mg, about 75 mg, about 80 mg, about 85 mg, about 90 mg / kg, or about 95 mg / kg. In further specific embodiments, monoclonal anti-alpha synuclein antibodies for use according to the invention are administered at a dose of 15 mg / kg, 30 mg / kg, or 60 mg / kg.

[0100] In certain embodiments, the patient to be treated has a body weight of 50-110 kg, e.g., 50 kg, 55 kg, 60 kg, 65 kg, 70 kg, 75 kg, 80 kg, 85 kg, 90 kg, 95 kg, 100 kg, 105 kg, or 110 kg. In the clinical trial disclosed in Example 3, the average body weight of the human subjects included was about 70 kg.

[0101] In some embodiments, doses and dosing regimens of the invention may also be expressed as an amount and dosing frequency of a monoclonal antibody of the invention that provides a sufficient predicted CSF mean steady state concentration, sufficient AUC exposure, or sufficient predicted target engagement against oligomeric forms of alpha synuclein in the CSF to obtain clinical efficacy.

[0102] The following table sets forth the conversions between the relevant dosage forms for an exemplary human subject of weight 70 kg.

[0103] [Table 1]

[0104] [Table 2]

[0105] Exemplary dosing regimens are provided in the table below.

[0106] [Table 3]

[0107] For the purposes of this disclosure, the CSF concentration of an antibody for use according to the present invention and the brain interstitial fluid (ISF) concentration of that antibody are assumed to be equal.

[0108] In one embodiment, a monoclonal antibody for use according to the invention (e.g., GM37 or a variant thereof, such as GM37v2) is administered intravenously and is administered such that a desired therapeutic concentration of the antibody is achieved in the CSF and / or ISF of a human subject. In one embodiment, the antibody enters the brain and achieves a concentration sufficient to produce a therapeutic effect mediated, for example, by binding to aggregated alpha-synuclein and causing microglia-dependent and / or independent clearance / inactivation, and / or by reducing a-synuclein aggregation, and / or by preventing prion-like intracellular propagation.

[0109] In another embodiment, a desired therapeutic concentration of a monoclonal antibody for use according to the invention (e.g., GM37 or a variant thereof, such as GM37v2) in CSF and / or ISF can be comparable to a concentration of the antibody that can provide and maintain (after one or more administrations) at least a 10-100%, such as 20-90%, such as 30-80%, such as 40-70%, such as 50-60%, such as at least 10%, such as at least 20%, such as at least 30%, such as at least 40%, such as at least 50%, such as at least 60%, such as at least 70%, such as at least 80%, such as at least 85%, such as at least 90%, such as at least 95% reduction in aggregated alpha synuclein in the ISF and / or CSF of a subject.

[0110] In one embodiment, a dosing regimen of the invention achieves a concentration of an antibody (eg, GM37 or a variant thereof, such as GM37v2) in the ISF and / or CSF of a subject that is above the estimated IC50.

[0111] In one embodiment, a dosing regimen of the invention achieves a concentration of an antibody (e.g., GM37 or a variant thereof, such as GM37v2) that is greater than the estimated IC50 and less than the estimated IC95 for oligomeric alpha synuclein in the ISF and / or CSF of a subject.

[0112] In one embodiment, a dosing regimen of the invention achieves a concentration of an antibody (e.g., GM37 or a variant thereof, such as GM37v2) that is greater than the estimated IC85 and less than the estimated IC95 for oligomeric alpha synuclein in the ISF and / or CSF of a subject.

[0113] In one embodiment, a dosing regimen of the invention achieves a concentration of antibody (e.g., GM37 or a variant thereof, such as GM37v2) above the estimated IC85 for oligomeric alpha synuclein in the ISF and / or CSF of a subject.

[0114] In one embodiment, a dosing regimen of the invention achieves a concentration of antibody (e.g., GM37 or a variant thereof, such as GM37v2) above the estimated IC90 for oligomeric alpha synuclein in the ISF and / or CSF of a subject.

[0115] In one embodiment, a dosing regimen of the invention achieves a concentration of antibody (e.g., GM37 or a variant thereof, such as GM37v2) above the estimated IC95 for oligomeric alpha synuclein in the ISF and / or CSF of a subject.

[0116] In another embodiment, a dosing regimen of the invention achieves a concentration of an antibody (e.g., GM37 or a variant thereof, such as GM37v2) that provides an estimated greater than 50% reduction in aggregated a-synuclein in a subject's ISF and / or CSF and can be sustained (after one or more administrations).

[0117] In another embodiment, a dosing regimen of the invention achieves a concentration of an antibody (e.g., GM37 or a variant thereof, such as GM37v2) that provides an estimated greater than 80% reduction in aggregated a-synuclein in a subject's ISF and / or CSF and can be sustained (after one or more administrations).

[0118] In another embodiment, a dosing regimen of the invention achieves a concentration of an antibody (e.g., GM37 or a variant thereof, such as GM37v2) that provides an estimated greater than 90% reduction in aggregated a-synuclein in a subject's ISF and / or CSF and can be sustained (after one or more administrations).

[0119] In another embodiment, a dosing regimen of the invention achieves a concentration of an antibody (e.g., GM37 or a variant thereof, such as GM37v2) that provides an estimated greater than 95% reduction in aggregated a-synuclein in a subject's ISF and / or CSF and can be sustained (after one or more administrations).

[0120] The dosing regimen of the present invention is relevant and applicable to all types of synucleinopathies and prodromal synucleinopathies. The dosing regimen is determined based on the required estimated CSF mean steady-state concentration required to ultimately obtain the desired target engagement of oligomeric alpha-synuclein in the CSF / brain. It is unclear exactly how much aggregated alpha-synuclein needs to be removed from the CSF / ISF to alter and / or slow down disease progression, but CSF alpha-synuclein load has not been found to vary significantly between different types of synucleinopathies. Tateno et al., for example, have shown that the amount of alpha-synuclein in the CSF is comparable between patients suffering from dementia with Lewy bodies (DLB), Parkinson's disease (PD), and multiple system atrophy (MSA) (Tateno et al, Alzheimer Dis Assoc Disord 2012;26:213-216), which may predict that the dosing regimen of the present invention is suitable for synucleinopathies in general and is therefore not limited to a specific indication such as PD, DLB, or MSA.

[0121] In addition, the dosing regimen of the present invention is also relevant to patients with prodromal synucleinopathy, as these patients have been shown to exhibit symptoms of altered alpha-synuclein processing, for example, Mollenhauer et al. demonstrated that among the prodromal synucleinopathy group, participants with hyposmia exhibited the lowest mean CSF alpha-synuclein levels, while participants with iRBD had intermediate levels between healthy subjects and patients with Parkinson's disease (Mollenhauer et al. Mov Disord. 2019 September; 34 (9): 1354-1364). These findings indicate that patients with clinical features of prodromal synucleinopathy already have reduced CSF alpha-synuclein levels, which is consistent with significant pathology already present during these prodromal stages.

[0122] Antibodies of the Invention Antibodies for use according to the invention bind to an epitope within the 112-117 epitope. In one embodiment, the invention relates to the monoclonal antibody GM37, a variant thereof (e.g., GM37 variant 1, GM37 variant 2, and GM37 variant 3), or GM285, for use in treating a synucleinopathy or a propathic synucleinopathy.

[0123] The GM37, GM37 variant 1, GM37 variant 2, and GM37 variant 3 antibodies bind to an epitope within amino acid sequence 112-117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10). Specifically, the GM37, GM37 variant 1, GM37 variant 2, and GM37 variant 3 antibodies bind to all six amino acids within this epitope.

[0124] The GM285 antibody binds to an epitope at amino acids 112-115 (ILED; SEQ ID NO: 19) of human alpha synuclein (SEQ ID NO: 10).

[0125] An "anti-alpha synuclein antibody" or "alpha synuclein antibody" (used interchangeably) is an antibody that binds to alpha synuclein or an alpha synuclein fragment. The antibodies of the present invention specifically bind within the amino acid sequence of alpha synuclein corresponding to SEQ ID NO: 9 and / or 19.

[0126] The term antibody "GM37" is intended to include antibodies comprising heavy chain CDR1-3 SEQ ID NOs: 1, 2 and 3 and light chain CDR1-3 as provided in SEQ ID NOs: 4, 5 and 6. In one embodiment, the antibody GM37 may comprise a heavy chain variable domain of SEQ ID NO: 7 and / or a light chain variable domain of SEQ ID NO: 8. For example, the antibody GM37 may be an IgG antibody comprising a heavy chain consisting of the variable domain of SEQ ID NO: 7 and the constant domain of SEQ ID NO: 18, together with a light chain consisting of the variable domain of SEQ ID NO: 8 and the kappa constant domain of SEQ ID NO: 17.

[0127] The term antibody "GM37 variant 1" is intended to include antibodies comprising heavy chain CDRs 1-3 SEQ ID NOs: 1, 33 and 3 and light chain CDRs 1-3 as provided in SEQ ID NOs: 4, 5 and 6. In one embodiment, the antibody GM37 may comprise a heavy chain variable domain of SEQ ID NO: 30 and / or a light chain variable domain of SEQ ID NO: 8. For example, the antibody GM37 may be an IgG1 antibody comprising a heavy chain consisting of the variable domain of SEQ ID NO: 30 and the constant domain of SEQ ID NO: 18, together with a light chain consisting of the variable domain of SEQ ID NO: 8 and the kappa constant domain of SEQ ID NO: 17.

[0128] The term antibody "GM37 variant 2" or "GM37v2" (used interchangeably) is intended to include antibodies comprising heavy chain CDR1-3 SEQ ID NO: 1, 34 and 3 and light chain CDR1-3 as provided in SEQ ID NO: 4, 5 and 6. In one embodiment, the antibody GM37 may comprise a heavy chain variable domain of SEQ ID NO: 31 and / or a light chain variable domain of SEQ ID NO: 8. For example, the antibody GM37 may be an IgG1 antibody comprising a heavy chain consisting of the variable domain of SEQ ID NO: 31 and the constant domain of SEQ ID NO: 18, together with a light chain consisting of the variable domain of SEQ ID NO: 8 and the kappa constant domain of SEQ ID NO: 17.

[0129] The term antibody "GM37 variant 3" is intended to include antibodies comprising heavy chain CDR1-3 SEQ ID NO: 1, 35 and 3 and light chain CDR1-3 as provided in SEQ ID NO: 4, 5 and 6. In one embodiment, the antibody GM37 may comprise a heavy chain variable domain of SEQ ID NO: 32 and / or a light chain variable domain of SEQ ID NO: 8. For example, the antibody GM37 may be an IgG1 antibody comprising a heavy chain consisting of the variable domain of SEQ ID NO: 32 and the constant domain of SEQ ID NO: 18, together with a light chain consisting of the variable domain of SEQ ID NO: 8 and the kappa constant domain of SEQ ID NO: 17.

[0130] The term antibody "GM285" is intended to include antibodies comprising heavy chain CDR1-3 SEQ ID NO: 20, 21 and 22 and light chain CDR1-3 as provided in SEQ ID NO: 23, 24 and 25. In one embodiment, the antibody GM37 may comprise a heavy chain variable domain of SEQ ID NO: 26 and / or a light chain variable domain of SEQ ID NO: 27. For example, the antibody GM37 may be an IgG1 antibody comprising a heavy chain consisting of the variable domain of SEQ ID NO: 26 and the constant domain of SEQ ID NO: 28, together with a light chain consisting of the variable domain of SEQ ID NO: 27 and the kappa constant domain of SEQ ID NO: 29.

[0131] In a preferred embodiment of the invention, the full-length GM37, GM37 variant 1, GM37 variant 2, GM37 variant 3, or GM285 antibody is in an IgG isotype format, most preferably in an IgG1 format, and even more preferably in a human or humanized IgG1 format.

[0132] [Table 4]

[0133] Specific amino acid sequences used herein: GFTFSSYAMT (SEQ ID NO: 1) AIRSN GDRTD YADSVKG (SEQ ID NO:2) AIRSS GDRTD YADSVKG (SEQ ID NO: 33) AIRSQ GDRTD YADSVKG (SEQ ID NO: 34) AIRSH GDRTD YADSVKG (SEQ ID NO: 35) AKNWAPFDS (SEQ ID NO: 3) ASQSVSSSYLA (SEQ ID NO: 4) GASSRAT (SEQ ID NO:5) QQYGSSPWT (SEQ ID NO: 6) [ka] AASGFTFSRFTMT (SEQ ID NO: 20) AISGSGGGTS YADSVKG (SEQ ID NO: 21) AKNWAPFDY (SEQ ID NO:22) RASQSVSRSYLA (SEQ ID NO: 23) GASSRAT (SEQ ID NO: 24) QQYGSSPWT (SEQ ID NO: 25)

[0134] A complete sequence listing of the present invention is provided below. [ka] [ka] [ka] [ka] [ka] [ka] [ka] [ka]

[0135] Antibodies for use according to the present invention may be obtained from any suitable source and in some embodiments may be produced in different cell lines, for example human cell lines, mammalian non-human cell lines, or insect cell lines, for example CHO cell lines, HEK cell lines, BHK-21 cell lines, murine cell lines (such as myeloma cell lines), fibrosarcoma cell lines, PER.C6 cell lines, HKB-11 cell lines, CAP cell lines or HuH-7 human cell lines.

[0136] In one embodiment, the antibodies for use according to the present invention are human antibodies. Human monoclonal antibodies directed against alpha synuclein can be generated using transgenic or transchromosomic mice carrying parts of the human immune system rather than the mouse immune system. Such transgenic and transchromosomic mice include mice that can be referred to as HuMAb mice and KM mice, respectively.

[0137] In one embodiment, the antibodies for use according to the invention, exemplified by GM37 and its variants GM37var1-3 and GM285, are capable of binding to the toxic alpha synuclein fragment consisting of residues 1-119 / 122 of alpha synuclein and neutralizing its toxicity (e.g., by extracellularly binding to the alpha synuclein fragment and thereby preventing the alpha synuclein fragment from being taken up by cells). In a further embodiment, the antibodies for use according to the invention are capable of binding to an epitope within amino acids 112-117 of alpha synuclein and bind to the toxic alpha synuclein species in the human brain. In a further embodiment, the antibodies for use according to the invention have an effect on removing extracellular alpha synuclein and normalizing synaptic transmission impairment induced by alpha synuclein in vivo. In yet another embodiment, the antibodies for use according to the invention are also capable of ameliorating the appearance of the associated motor phenotype in a rat model of Parkinson's disease. All these properties are described in detail in WO 2017 / 009312.

[0138] Pharmaceutical Formulations and Routes of Administration The invention also provides a process for producing a pharmaceutical composition comprising an antibody for use according to the invention. Such pharmaceutical compositions may be formulated according to conventional techniques using pharma- ceutically acceptable buffers, carriers or diluents, as well as any other known adjuvants or excipients.

[0139] Pharmaceutical compositions of the invention may include diluents, fillers, salts, buffers, surfactants (e.g., non-ionic surfactants such as Tween-20 or Tween-80), stabilizers (e.g., sugars or non-protein amino acids), preservatives, tissue fixatives, solubilizing agents, and / or other materials suitable for inclusion in a pharmaceutical composition.

[0140] In addition, the pharmaceutical composition or formulation may include other carriers, or nontoxic, nontherapeutic, nonimmunogenic stabilizers, etc. The compositions may also include large, slowly metabolized macromolecules such as proteins, polysaccharides such as chitosan, polylactic acids, polyglycolic acids and copolymers (e.g., latex functionalized sepharose, agarose, cellulose, etc.), polymeric amino acids, amino acid copolymers, and lipid aggregates (e.g., oil droplets or liposomes).

[0141] Pharmaceutically acceptable carriers include any and all suitable solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonicity agents, antioxidants, and absorption delaying agents, which are physiologically compatible with the antibodies for use in accordance with the present invention. Examples of suitable aqueous and non-aqueous carriers that may be employed in the pharmaceutical compositions of the present invention include water, saline, phosphate buffered saline, ethanol, dextrose, polyols (e.g., glycerol, propylene glycol, polyethylene glycol, and the like), and suitable mixtures thereof, vegetable oils, e.g., olive oil, corn oil, peanut oil, cottonseed oil, and sesame oil, carboxymethylcellulose colloidal solutions, tragacanth gum, and organic esters such as ethyl oleate, and / or various buffers. Other carriers are well known in the pharmaceutical art and may be employed in the present invention.

[0142] Pharmaceutically acceptable carriers include sterile aqueous solutions or dispersions and sterile powders for the extemporaneous preparation of sterile solutions.

[0143] The pharmaceutical compositions of the present invention may also include pharma- ceutically acceptable antioxidants, such as, for example, (1) water-soluble antioxidants, such as ascorbic acid, cysteine ​​hydrochloride, sodium bisulfate, sodium metabisulfite, sodium sulfite, and the like; (2) oil-soluble antioxidants, such as ascorbyl palmitate, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propyl gallate, alpha-tocopherol, and the like; and (3) metal chelators, such as citric acid, ethylenediaminetetraacetic acid (EDTA), sorbitol, tartaric acid, phosphoric acid, and the like.

[0144] The pharmaceutical compositions of the present invention may also contain isotonic agents, such as sugars, polyalcohols, for example, mannitol, sorbitol, glycerol, or sodium chloride in the composition.

[0145] The pharmaceutical compositions of the present invention may also contain one or more adjuvants appropriate for the selected route of administration, such as preservatives, wetting agents, emulsifying agents, dispersing agents, preservatives or buffers, which may enhance the shelf life or effectiveness of the pharmaceutical composition.

[0146] The antibody of the present invention may be prepared with a carrier that protects the antibody from rapid release, such as a controlled release formulation, including implants, transdermal patches, and microencapsulated delivery systems. Such carriers may include gelatin, glyceryl monostearate, glyceryl distearate, biodegradable, biocompatible polymers, such as ethylene vinyl acetate, polyanhydrides, polyglycolic acid, collagen, polyorthoesters, and polylactic acid, alone or with waxes, or other materials well known in the art. Methods for the preparation of such formulations are generally known to those skilled in the art.

[0147] The pharmaceutical composition for injection must be typically sterile and stable under the conditions of manufacture and storage.The composition can be formulated as a solution, microemulsion, liposome, or other ordered structure suitable for high drug concentration.The carrier can be, for example, an aqueous or non-aqueous solvent or dispersion medium containing water, ethanol, polyol (for example, glycerol, propylene glycol, polyethylene glycol, etc.) and suitable mixtures thereof, vegetable oil such as olive oil, and organic ester such as ethyl oleate.

[0148] Sterile solutions for injection can be prepared by incorporating the active antibody in the required amount in a suitable solvent, optionally with one or a combination of ingredients such as those listed above, followed by sterilization microfiltration. In general, dispersions are prepared by incorporating the active antibody into a sterile vehicle containing a basic dispersion medium and other required ingredients, such as those listed above. In the case of sterile powders for the preparation of sterile solutions, examples of the methods of preparation are vacuum drying and freeze-drying (lyophilization), which produce a powder of the active ingredient plus any additional desired ingredients from the solution previously sterile-filtered.

[0149] The composition can be formulated in dosage unit form for ease of administration and uniformity of dosage. As used herein, dosage unit form refers to a unit suitable as a single dosage for a subject to be treated, each unit containing a predetermined amount of active antibody that produces the desired therapeutic effect in association with the necessary pharmaceutical excipients.

[0150] In certain embodiments, the pharmaceutical composition is administered by intravenous infusion.

[0151] Certain Liquid Pharmaceutical Compositions of the Invention In an aspect of the invention, the antibodies for use according to the invention are formulated as a liquid pharmaceutical composition and administered by intravenous infusion.

[0152] In one aspect, the present invention provides a liquid pharmaceutical composition comprising a full-length IgG1 monoclonal anti-alpha synuclein antibody at a concentration of about 20-230 mg / mL, e.g., 25-225 mg / mL, wherein the antibody is a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. A heavy chain CDR2 having the amino acid sequence of SEQ ID NO:34; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6; The composition further comprises a buffer, a pharma- ceutically acceptable tonicity agent, and a pharma- ceutically acceptable surfactant, and the pH of the composition is 4.5 to 7.5, such as 5.0 to 7.0, such as 5.5 to 6.5, such as 6.0.

[0153] In a preferred embodiment, the liquid pharmaceutical composition of the present invention is a stable liquid pharmaceutical composition. In a preferred embodiment, the liquid pharmaceutical composition of the present invention is a low viscosity liquid pharmaceutical composition. In a preferred embodiment, the liquid pharmaceutical composition of the present invention is a stable and low viscosity liquid pharmaceutical composition. In a preferred embodiment, the liquid pharmaceutical composition of the present invention is suitable and safe for clinical use for patients requiring administration / medication of the liquid pharmaceutical composition.

[0154] In certain embodiments, the monoclonal anti-alpha synuclein antibody of the liquid pharmaceutical composition further comprises a heavy chain consisting of the variable domain of SEQ ID NO: 31 and a light chain consisting of the variable domain of SEQ ID NO: 8. In more specific embodiments, the monoclonal anti-alpha synuclein antibody further comprises a heavy chain constant domain defined in SEQ ID NO: 18 and a kappa light chain constant domain defined in SEQ ID NO: 17.

[0155] In certain embodiments, the monoclonal anti-alpha synuclein antibody of the liquid pharmaceutical composition of the present invention is GM37v2.

[0156] In some embodiments, the liquid pharmaceutical composition comprises a monoclonal anti-alpha synuclein antibody at a concentration greater than 20 mg / mL, and in some embodiments less than 230 mg / mL. In further embodiments, the concentration of the monoclonal anti-alpha synuclein antibody in the pharmaceutical composition is 20-225 mg / mL, 20-220 mg / mL, 20-215 mg / mL, 20-210 mg / mL, 20-205 mg / mL, 20-200 mg / mL, 20-195 mg / mL, 20-190 mg / mL, 20-185 mg / mL, 20-180 mg / mL, 20-175 mg / mL, 20-170 mg / mL, 20-165 mg / mL, 20-160 mg / mL, 20-155 mg / mL, 20-1 50mg / mL, 20~145mg / mL, 20~140mg / mL, 20~135mg / mL, 20~130mg / mL, 20~125mg / mL, 20~120mg / mL, 20~115mg / mL, 20~110mg / mL, 20~105mg / mL, 20~100mg / mL, 20~95mg / mL, 20~90mg / mL, 20~85mg / mL, 20~80mg / mL, 20~75mg / mL, 20~70mg / mL, 20~65mg / mL, 20~60mg / mL, 20~55mg / mL, 20~50mg / mL, 20~45mg / mL, 20~40mg / mL, 20~35mg / mL, 20~30mg / mL, 20~25mg / mL, 25~230mg / mL, 30~230mg / mL, 35~230mg / mL, 40~230mg / mL , 45~230mg / mL, 50~230mg / mL, 55~230mg / mL, 60~230mg / mL, 65~230mg / mL, 70~230mg / mL, 75~230mg / mL, 80~230mg / mL, 85~230mg / mL, 90~23 0mg / mL, 95~230mg / mL, 100~230mg / mL, 105~230mg / mL, 110~230mg / mL, 115~230mg / mL, 120~230mg / mL, 125~230mg / mL, 130~230mg / mL, 135 ~230mg / mL, 140~230mg / mL, 145~230mg / mL, 150~230mg / mL, 155~230mg / mL, 160~230mg / mL, 165~230mg / mL, 170~230mg / mL, 175~230mg / mL,180~230mg / mL, 185~230mg / mL, 190~230mg / mL, 195~230mg / mL, 200~230mg / mL, 205~230mg / mL, 210~230mg / mL, 215~230m g / mL, 220~230mg / mL, 225~230mg / mL, 25~225mg / mL, 30~220mg / mL, 35~215mg / mL, 40~210mg / mL, 45~205mg / mL, 50~200mg / mL, 55-195 mg / mL, 60-190 mg / mL, 65-185 mg / mL, 70-180 mg / mL, 75-175 mg / mL, 80-170 mg / mL, 85-165 mg / mL, 90-160 mg / mL, 95-155 mg / mL, 100-150 mg / mL, 105-145 mg / mL, 110-140 mg / mL, 115-135 mg / mL, or 120-130 mg / mL (including any values ​​between these numbers).

[0157] In certain embodiments, the liquid pharmaceutical composition comprises a monoclonal anti-alpha synuclein at a concentration of about 50 mg / mL. In another particular embodiment, the monoclonal anti-alpha synuclein antibody of the liquid pharmaceutical composition has a concentration of about 53 mg / mL. In some embodiments, the monoclonal anti-alpha synuclein antibody of the liquid pharmaceutical composition has a concentration within + / -30%, such as + / -25%, such as + / -20%, such as + / -15%, such as + / -10%, such as + / -8%, such as + / -6%, such as + / -5%, such as + / -4%, such as + / -3%, such as + / -2.5%, such as + / -2%, such as + / -1.5% of the value. etc., having a concentration within the range of + / -1%, such as + / -0.75%, such as + / -0.5%, such as + / -0.25%, such as + / -0.1%, such as + / -0.05%, such as + / -0.025%, such as + / -0.01%, such as + / -0.0075%, such as + / -0.005%, such as + / -0.0025%, such as + / -0.001%, etc. or within + / -0.0005%.

[0158] In some embodiments of the present invention, the buffer is a single buffer or a mixture of buffers. In further embodiments of the present invention, the buffer is selected from acetate, citrate, tartrate, histidine glutamate, phosphate, Tris, glycine, bicarbonate, succinate, sulfate or nitrate buffers or mixtures thereof. In further embodiments, the buffer is selected from sodium phosphate, histidine (such as L-histidine), citric acid, sodium citrate, sodium acetate or mixtures thereof. In certain embodiments, the buffer is a histidine buffer (such as L-histidine) or a mixture of histidine buffers. The histidine buffer can be selected from histidine buffers and mixtures thereof, such as histidine, L-histidine, L-histidine hydrochloride, L-histidine monohydrochloride, L-histidine monohydrate and L-histidine hydrochloride monohydrate or mixtures thereof. In one preferred embodiment, the histidine buffer is a mixture of L-histidine and L-histidine monohydrochloride. In some preferred embodiments of the liquid pharmaceutical composition of the invention, the buffer is present at a concentration of 10-60 mM, such as 15-55 mM, such as 20-50 mM, such as 20-45 mM, such as 20-40 mM, such as 25-40 mM, such as 10-40 mM, such as 15-35 mM, such as 20-30 mM or 25 mM. In some embodiments, the buffer of the liquid pharmaceutical composition may be at a concentration within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 8%, such as + / - 6%, such as + / - 5%, such as + / - 4%, such as + / - 3%, such as + / - 2.5%, such as + / - 2%, such as + / - 1.5%, such as + / - 1 %, such as + / -0.75%, such as + / -0.5%, such as + / -0.25%, such as + / -0.1%, such as + / -0.05%, such as + / -0.025%, such as + / -0.01%, such as + / -0.0075%, such as + / -0.005%, such as + / -0.0025%, such as + / -0.001%, or a concentration within + / -0.0005%.

[0159] In an embodiment, the pH of the liquid pharmaceutical composition of the present invention is in the range of about 4.5 to about 7.5, such as about 4.5 to about 6.5, such as about 5.0 to about 6.5, such as about 5.5 to about 6.5, for example, 5.7 to 6.4, 5.8 to 6.3, or 5.9 to 6.2. In one embodiment, the liquid pharmaceutical composition has a pH of 5.5, 5.6, 5.7, 5.8, 5.9, 6.0, 6.1, 6.2, 6.3, 6.4, 6.5, or 7.0. A histidine buffer (such as L-histidine) is an example of a buffer that can be included in the liquid pharmaceutical composition of the present invention to control the pH in this range. In a preferred embodiment, the pH of the liquid pharmaceutical composition of the present invention is 6.0. In some embodiments, the liquid pharmaceutical composition has a pH within + / - 30% of the value, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 8%, such as + / - 6%, such as + / - 5%, such as + / - 4%, such as + / - 3%, such as + / - 2.5%, such as + / - 2%, such as + / - 1.5%, such as + / - 1% of the value. and the like, has a pH within + / -0.75%, such as + / -0.5%, such as + / -0.25%, such as + / -0.1%, such as + / -0.05%, such as + / -0.025%, such as + / -0.01%, such as + / -0.0075%, such as + / -0.005%, such as + / -0.0025%, such as + / -0.001%, or + / -0.0005%.

[0160] In an embodiment, the surfactant of the liquid pharmaceutical composition of the present invention is a non-ionic surfactant. In a further embodiment, the surfactant is a polysorbate (e.g., polysorbate 20 and polysorbate 80); poloxamer (e.g., poloxamer 188); Triton; X-100; sodium dodecyl sulfate (SDS); sodium lauryl sulfate; sodium octyl glucoside; lauryl-, myristyl-, linoleyl-, or stearyl-sulfobetaine; lauryl-, myristyl-, linoleyl-, or stearyl-sarcosine; linoleyl-, myristyl-, or cetyl-betaine; lauroamidopropyl-, cocamidopropyl-, linoleamidopropyl-, myristamidopropyl-, palmidopropyl-, or isostearamidopropyl-betaine (e.g., lauroamidopropyl); myristamidopropyl-, palmidopropyl-, or isostearamidopropyl dimethylamine; sodium methyl cocoyl taurate or disodium methyl oleyl taurate; polyethyl glycol, polypropyl glycol, and copolymers of ethylene and propylene glycol. In one specific embodiment, the pharma- ceutically acceptable surfactant of the liquid pharmaceutical composition of the invention is polysorbate 80, also known as Tween 80. In some preferred embodiments of the liquid pharmaceutical composition of the invention, the surfactant is present in an amount of 0.001% to 0.10% (w / v), such as 0.005% to 0.08% (w / v), such as 0.008% to 0.06% (w / v), such as 0.01% to 0.05% (w / v), such as 0.015% to 0.05% (w / v), such as 0.01% to 0.05% (w / v), such as 0.01% to 0.03% (w / v), or such as 0.02% (w / v).In some embodiments, the surfactant in the liquid pharmaceutical composition may be at a concentration within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 8%, such as + / - 6%, such as + / - 5%, such as + / - 4%, such as + / - 3%, such as + / - 2.5%, such as + / - 2%, such as + / - 1.5%, such as + / - The concentration may be within, for example, 1%, + / -0.75%, + / -0.5%, + / -0.25%, + / -0.1%, + / -0.05%, + / -0.025%, + / -0.01%, + / -0.0075%, + / -0.005%, + / -0.0025%, + / -0.001%, or + / -0.0005%.

[0161] In an embodiment, the tonicity agent of the liquid pharmaceutical composition of the present invention is selected from mannitol, sorbitol, lactose, dextrose, trehalose, sodium chloride, potassium chloride, glycerol and glycerin. In one specific embodiment, the tonicity agent is a suitable salt such as NaCl. In one specific embodiment, the tonicity agent of the liquid pharmaceutical composition of the present invention is sodium chloride (NaCl). In some preferred embodiments of the liquid pharmaceutical composition of the present invention, the isotonicity agent is present at a concentration of 10-150 mM, such as 10-150 mM, such as 10-150 mM, such as 10-150 mM, such as 10-150 mM, such as 20-140 mM, such as 30-130 mM, such as 40-120 mM, such as 50-110 mM, such as 60-110 mM, such as 70-110 mM, such as 80-110 mM, such as 90-110 mM or such as about 100 mM. In some embodiments, the tonicity agent in the liquid pharmaceutical composition may be at a concentration within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 8%, such as + / - 6%, such as + / - 5%, such as + / - 4%, such as + / - 3%, such as + / - 2.5%, such as + / - 2%, such as + / - 1.5%, such as + / - The concentration may be within, for example, 1%, + / -0.75%, + / -0.5%, + / -0.25%, + / -0.1%, + / -0.05%, + / -0.025%, + / -0.01%, + / -0.0075%, + / -0.005%, + / -0.0025%, + / -0.001%, or + / -0.0005%.

[0162] In an embodiment, the liquid pharmaceutical composition of the present invention further comprises a bulking agent, which is selected from sugars and polyols (such as sucrose, trehalose, glucose, lactose, sorbitol, mannitol and glycerol); amino acids (arginine, aspartic acid, glutamic acid, lysine, glycine, glutamate, histidine, methionine or alanine); or polymers and proteins (gelatin, PVP, PLGA, PEG, dextran, cyclodextrin and derivatives, starch derivatives, HSA or BSA). In one specific embodiment, the bulking agent is selected from arginine, glutamate, sucrose, glycine or sorbitol. In one specific embodiment, the bulking agent is sucrose. In some preferred embodiments of the liquid pharmaceutical composition of the present invention, the bulking agent is present in a concentration of 20-200 mM, such as 25-180 mM, such as 30-170 mM, such as 35-160 mM, such as 40-150 mM, such as 45-140 mM, such as 50-130 mM, such as 60-130 mM, such as 65-120 mM, such as 70-120 mM, such as 75-120 mM, such as 80-110 mM, such as 85-110 mM, such as 90-110 mM, such as 95-110 mM, 95-105 mM, or such as 100 mM. In some embodiments, the bulking agent of the liquid pharmaceutical composition may be present at a concentration within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 8%, such as + / - 6%, such as + / - 5%, such as + / - 4%, such as + / - 3%, such as + / - 2.5%, such as + / - 2%, such as + / - 1.5%, such as + / - 1 %, such as + / -0.75%, such as + / -0.5%, such as + / -0.25%, such as + / -0.1%, such as + / -0.05%, such as + / -0.025%, such as + / -0.01%, such as + / -0.0075%, such as + / -0.005%, such as + / -0.0025%, such as + / -0.001%, or a concentration within + / -0.0005%.

[0163] In an embodiment, a liquid pharmaceutical composition of the invention comprises a monoclonal anti-alpha synuclein antibody, GM37v2, a histidine buffer and sodium chloride (NaCl) at a pH of 4.5 to 7.5.

[0164] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 20-230 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 10-60 mM histidine buffer, and 10-150 mM sodium chloride (NaCl), at a pH of 4.5-7.5.

[0165] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 40-60 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 20-30 mM histidine buffer, and 90-110 mM sodium chloride (NaCl), at a pH of 5.5-6.5.

[0166] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer and 100 mM sodium chloride (NaCl) at pH 6.0.

[0167] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer and 100 mM sodium chloride (NaCl), at pH 6.0 or within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 5%, such as + / - 1%, such as + / - 0.5%, such as + / - 0.25% or + / - 0.1%, etc.

[0168] In an embodiment, a liquid pharmaceutical composition of the invention comprises a monoclonal anti-alpha synuclein antibody, GM37v2, a histidine buffer and polysorbate 80 (tween80) at a pH of 4.5 to 7.5.

[0169] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 20-230 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 10-60 mM histidine buffer and polysorbate 80 (tween 80) in an amount of 0.001%-0.10% (w / v), at a pH of 4.5-7.5.

[0170] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 40-60 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 20-30 mM histidine buffer and polysorbate 80 (tween 80) in an amount of 0.01%-0.03% (w / v), at a pH of 5.5-6.5.

[0171] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer and polysorbate 80 (tween80) in an amount of 0.02% (w / v), at pH 6.0.

[0172] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer and polysorbate 80 (tween80) in an amount of 0.02% (w / v), at pH 6.0 or within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 5%, such as + / - 1%, such as + / - 0.5%, such as + / - 0.25% or + / - 0.1% of said value.

[0173] In an embodiment, a liquid pharmaceutical composition of the invention comprises a monoclonal anti-alpha synuclein antibody, GM37v2, a histidine buffer, sodium chloride (NaCl) and polysorbate 80 (tween 80) at a pH of 4.5 to 7.5.

[0174] In an embodiment, a liquid pharmaceutical composition of the present invention comprises 20-230 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 10-60 mM histidine buffer, 10-150 mM sodium chloride (NaCl) and polysorbate 80 (tween 80) in an amount of 0.001%-0.10% (w / v), at a pH of 4.5-7.5.

[0175] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 40-60 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 20-30 mM histidine buffer, 90-110 mM sodium chloride (NaCl) and polysorbate 80 (tween 80) in an amount of 0.01%-0.03% (w / v), at a pH of 5.5-6.5.

[0176] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer, 100 mM sodium chloride (NaCl) and polysorbate 80 (tween80) in an amount of 0.02% (w / v), at pH 6.0.

[0177] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer, 100 mM sodium chloride (NaCl) and polysorbate 80 (tween 80) in an amount of 0.02% (w / v), at pH 6.0 or within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 5%, such as + / - 1%, such as + / - 0.5%, such as + / - 0.25% or + / - 0.1% of said value.

[0178] In an embodiment, a liquid pharmaceutical composition of the invention comprises a monoclonal anti-alpha synuclein antibody, GM37v2, a histidine buffer, sodium chloride (NaCl) and sucrose at a pH of 4.5 to 7.5.

[0179] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 20-230 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 10-60 mM histidine buffer, 10-150 mM sodium chloride (NaCl) and 20-200 mM sucrose, at a pH of 4.5-7.5.

[0180] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 40-60 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 20-30 mM histidine buffer, 90-110 mM sodium chloride (NaCl) and 90-110 mM sucrose, at a pH of 5.5-6.5.

[0181] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer, 100 mM sodium chloride (NaCl) and 100 mM sucrose at pH 6.0.

[0182] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer, 100 mM sodium chloride (NaCl) and 100 mM sucrose, at pH 6.0 or within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 5%, such as + / - 1%, such as + / - 0.5%, such as + / - 0.25% or + / - 0.1%, etc.

[0183] In an embodiment, a liquid pharmaceutical composition of the invention comprises a monoclonal anti-alpha synuclein antibody, GM37v2, a histidine buffer, sucrose and polysorbate 80 (tween80) at a pH of 4.5 to 7.5.

[0184] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 20-230 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 10-60 mM histidine buffer, 20-200 mM sucrose and polysorbate 80 (tween 80) in an amount of 0.001%-0.10% (w / v), at a pH of 4.5-7.5.

[0185] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 40-60 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 20-30 mM histidine buffer, 90-110 mM sucrose and polysorbate 80 (tween 80) in an amount of 0.01%-0.03% (w / v), at a pH of 5.5-6.5.

[0186] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer, 100 mM sucrose and polysorbate 80 (tween80) in an amount of 0.02% (w / v), at pH 6.0.

[0187] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer, 100 mM sucrose and polysorbate (tween 80) in an amount of 0.02% (w / v), at pH 6.0 or within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 5%, such as + / - 1%, such as + / - 0.5%, such as + / - 0.25% or + / - 0.1%, etc.

[0188] In an embodiment, a liquid pharmaceutical composition of the invention comprises a monoclonal anti-alpha synuclein antibody, GM37v2, histidine buffer, sodium chloride (NaCl), sucrose and polysorbate 80 (tween 80) at a pH of 4.5 to 7.5.

[0189] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 20-230 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 10-60 mM histidine buffer, 10-150 mM sodium chloride (NaCl), 20-200 mM sucrose and polysorbate 80 (tween 80) in an amount of 0.001%-0.10% (w / v), at a pH of 4.5-7.5.

[0190] In an embodiment, the liquid pharmaceutical composition of the present invention comprises 40-60 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 20-30 mM histidine buffer, 90-110 mM sodium chloride (NaCl), 90-110 mM sucrose and polysorbate 80 (tween 80) in an amount of 0.01%-0.03% (w / v), at a pH of 5.5-6.5.

[0191] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer, 100 mM sodium chloride (NaCl), 100 mM sucrose and polysorbate 80 (tween80) in an amount of 0.02% (w / v), at pH 6.0.

[0192] In an embodiment, a liquid pharmaceutical composition of the invention comprises 53 mg / mL of a monoclonal anti-alpha synuclein antibody, GM37v2, 25 mM histidine buffer, 100 mM sodium chloride (NaCl), 100 mM sucrose and polysorbate 80 (tween 80) in an amount of 0.02% (w / v), at pH 6.0 or within + / - 30%, such as + / - 25%, such as + / - 20%, such as + / - 15%, such as + / - 10%, such as + / - 5%, such as + / - 1%, such as + / - 0.5%, such as + / - 0.25% or + / - 0.1% of said value.

[0193] In certain embodiments, liquid pharmaceutical compositions of the invention are present in vials in a volume of 20 mL, with each vial containing about 1000-1060 mg of GM37v2, for example, about 1060 mg of GM37v2.

[0194] Synucleinopathy and prosyndromic synucleinopathy Synucleinopathies refer to disorders characterized by neuronal inclusions of pathological alpha-synuclein aggregates called Lewy bodies. Synucleinopathies include Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease) and diffuse Lewy body (DLB) disease (also known as dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's and Parkinson's disease (CAPD), pure autonomic failure (PAF), and multiple system atrophy (MSA; e.g., olivopontocerebellar atrophy, striatonigral degeneration, and Shy-Drager syndrome).

[0195] In one aspect, the present invention provides suitable dosing regimens for treating synucleinopathies such as Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease), Gaucher's disease (GD), diffuse Lewy body disease (DLBD), dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's disease and Parkinson's disease, pure autonomic failure or multiple system atrophy (MSA). In a preferred embodiment, the synucleinopathy is PD. In another preferred embodiment, the synucleinopathy is DLB. In yet another preferred embodiment, the synucleinopathy is MSA.

[0196] In another aspect, the present invention provides a suitable dosing regimen for treating prodromal synucleinopathy in a human subject at risk of developing synucleinopathy, which can be identified by showing one or more clinical markers of prodromal synucleinopathy. Such clinical markers of prodromal synucleinopathy can be selected from REM sleep behavior disorder (RBD), such as isolated RBD (iRBD), olfactory disorder, such as hyposmia, abnormal cognitive performance in neuropsychological tests, subtle motor dysfunction or abnormal motor performance assessed by objective tests, abnormal color vision, autonomic dysfunction (e.g., constipation, voiding symptoms, erectile dysfunction, orthostatic hypotension, etc.), reduced nigrostriatal dopaminergic binding in putamen and striatum (abnormal DAT-SPECT), seborrheic dermatitis, or a genotype associated with increased risk of phenotypic transformation, such as a mutation in glucocerebrosidase (encoded by GBA gene).

[0197] In some embodiments of these aspects, the human subject is identified as having a symptom of a synucleinopathy or prodromal synucleinopathy in the form of abnormal accumulation or deposition of alpha synuclein in the central nervous system. In certain embodiments, the human subject is identified by in vivo imaging of alpha synuclein (e.g., in the brain) by methods including positron emission tomography (PET), single photon emission computed tomography (SPECT), near infrared (NIR) light imaging, magnetic resonance imaging (MRI), dopamine transporter (DAT) imaging, or transcranial ultrasound.

[0198] In some embodiments, a human subject is identified as having symptoms of a synucleinopathy or prosymptomatic synucleinopathy by assaying the level of alpha synuclein in a sample of blood, plasma, or cerebrospinal fluid (CSF) obtained from the subject and comparing the level of alpha synuclein assayed in the subject to a reference standard, and a difference or similarity between the level of alpha synuclein in the blood, plasma, or CSF sample and the reference standard correlates with the level of alpha synuclein in the subject's brain. Levels of alpha synuclein can be assessed by methods known in the art, including, for example, analyzing alpha synuclein by one or more techniques selected from Western blot, immunoprecipitation, enzyme-linked immunosorbent assay (ELISA), immunoradiometric assay (RIA), fluorescence-activated cell sorting (FACS), two-dimensional gel electrophoresis, mass spectrometry (MS), matrix-assisted laser desorption / ionization (MALDI-TOF), surface-enhanced laser desorption / ionization-time of flight mass spectrometry (SELDI-TOF), high performance liquid chromatography (HPLC), fast protein liquid chromatography (FPLC), multidimensional liquid chromatography (LC) followed by tandem mass spectrometry (MS / MS), and laser densitometry.

[0199] In some embodiments, the human subject has been identified as having symptoms of a synucleinopathy or propathic synucleinopathy via art-recognized methods and criteria.

[0200] Recently, new diagnostic criteria for MSA, "The Movement Disorder Society Criteria for the Diagnosis of Multiple System Atrophy," have been published by Wenning et al., which are incorporated herein by reference (Wenning et al., Movement Disorders, 2022, Volume 37, Issue 6, Pages 1131-1148). These new criteria describe "Research criteria for possible prodromal MSA," which can be used to identify patients with prodromal synucleinopathy.

[0201] [Table 5]

[0202] Parkinson's Disease (PD) Parkinson's disease (PD) is a synucleinopathy disorder. There are no clearly defined diagnostic criteria for PD, but there are various symptoms and diagnoses that can be used in combination to support a PD diagnosis. Although an accurate diagnosis of Parkinson's disease is difficult to make, especially in its early stages, a skilled practitioner can reach a reasonable conclusion that a human subject suffers from PD by using clinical assessment tools. In some embodiments, a PD diagnosis can be based on the presence of at least two of the four major symptoms of PD: a) Tremor or tremor b) Slowness of movement, also known as bradykinesia c) Rigidity or stiffness of the arms, legs, or trunk d) Poor balance, also known as postural instability, and potential for falls.

[0203] Imaging techniques such as, for example, MRI, brain ultrasound, PET scan, and / or single photon emission computed tomography (SPECT) scan to analyze dopamine transport (DaTscan) may also be useful to support a diagnosis of PD.

[0204] Dementia with Lewy Bodies (DLB) Dementia with Lewy bodies is a type of synucleinopathy with progressive dementia that leads to decline in thinking, reasoning and independent functioning. Dementia with Lewy bodies is often difficult to diagnose because its early symptoms resemble those of Alzheimer's disease or psychosis. Although there are no definitive diagnostic criteria, some core clinical symptoms of DLB ​​are dementia, movement disorder / parkinsonism, cognitive fluctuations, visual hallucinations and REM sleep behavior disorder. Some supportive clinical symptoms are extreme sensitivity to antipsychotics, falls or fainting, serious problems with involuntary functions (maintaining blood pressure, incontinence, constipation, loss of smell), personality changes and mood disorders (depression, loss of motivation, anxiety).

[0205] A diagnosis of Lewy body dementia requires a progressive decline in thinking ability and at least two of the following: a) Fluctuations in alertness and mental function b) Recurring visual hallucinations c) Symptoms of Parkinson's disease d) REM sleep behavior disorder

[0206] Autonomic dysfunction, along with instability in blood pressure and heart rate, poor regulation of body temperature, sweating, and associated signs and symptoms, further support a diagnosis of Lewy body dementia, as well as hypersensitivity to antipsychotic medications.

[0207] Physical and neurological examinations, as well as various tests, can help distinguish DLB from other diseases and support the diagnosis of DLB. Such specific tests include a positron emission tomography (PET) or single photon emission computed tomography (SPECT) scan, which shows reduced dopamine transporter (DAT) uptake in the basal ganglia (brain regions), and a pulmonary embolism scan, which shows reduced cardiac nerve conduction. 123This may be iodine-MIBG myocardial scintigraphy or a sleep study to confirm REM sleep behavior disorder without loss of muscle tone.

[0208] Multiple system atrophy (MSA) Multiple system atrophy (MSA) is the most rapidly progressing group of synucleinopathies and is characterized by abnormal deposition of the protein alpha-synuclein in the central and peripheral autonomic nervous systems. In this context, the term MSA is meant to refer to all types of MSA, such as multiple system atrophy-predominantly parkinsonian (MSA-P) or multiple system atrophy-predominantly cerebellar (MSA-C). MSA is sometimes also referred to as olivopontocerebellar atrophy, progressive autonomic failure with multiple system atrophy, striatonigral degeneration or Shy-Drager syndrome. The present invention provides dosing regimens for the treatment of MSA in the prodromal, early, moderate and advanced stages and all stages in between.

[0209] Diagnosing multiple system atrophy (MSA) can be difficult because certain signs and symptoms of MSA, such as muscle rigidity and unsteady gait, occur together with other disorders, such as Parkinson's disease. Appropriate clinical testing with various autonomic nervous system tests and imaging tests can assist in determining whether the diagnosis is probable or definite MSA. Examples of clinical methods that may be useful in supporting the diagnosis of MSA in patients with suspected MSA are structural and functional brain imaging, cardiac sympathetic nerve imaging, cardiovascular autonomic nervous system tests, olfactory tests, sleep studies, urological evaluation, and dysphagia, cognitive function evaluation, skin biopsy, retinal biomarkers, blood and / or cerebrospinal fluid biomarkers, and genetic testing. The diagnosis of definite or probable MSA can be facilitated, for example, by the so-called Gilman classification (Gilman et al., Neurology. 2008 Aug 26; 71(9): 670-676).

[0210] In some embodiments, the human subject to be treated has probable MSA, which can be identified by: a) autonomic nervous system failure accompanied by urinary incontinence or an orthostatic fall in blood pressure within 3 minutes of standing to at least 30 mmHg systolic blood pressure or 15 mmHg diastolic blood pressure, and b) Levodopa-unresponsive parkinsonism (bradykinesia with rigidity, tremor, or postural instability), or c) Cerebellar syndrome (cerebellar dysarthria, limb ataxia or gait ataxia with cerebellar oculomotor dysfunction).

[0211] In some embodiments, the human subject to be treated has a confirmed MSA, which can be identified by: a) Parkinsonism (bradykinesia with rigidity, tremor or postural instability) or b) cerebellar syndrome (cerebellar dysarthria, limb ataxia or gait ataxia with cerebellar oculomotor dysfunction), and c) at least one feature suggestive of autonomic dysfunction (erectile dysfunction in men with otherwise unexplained frequent urgency or residual urine, or marked orthostatic hypotension below the level required for probable MSA), and d) At least one of the following characteristics: For certain MSA-P or MSA-C: i. Bambisky sign with hyperreflexia ii. Wheezing For a surefire MSA-P: iii. Rapidly progressive parkinsonism iv. Poor response to levodopa v. Postural instability within 3 years of movement onset vi. Gait ataxia, cerebellar dysarthria, limb ataxia, or cerebellar ocular dysmetria; vii. Dysphagia within 5 years of motor onset viii. Atrophy of the putamen, middle cerebellar peduncle, pons, or cerebellum on MRI ix. Hypometabolism in the putamen, brainstem, or cerebellum on fluorodeoxyglucose positron emission tomography (FDG-PET) For a definite MSA-C: x. Parkinsonism (bradykinesia and rigidity) xi. Atrophy of the putamen, middle cerebellar peduncle, or pons on MRI xii. Hypometabolic changes in the putamen as determined by FDG-PET xiii. Presynaptic nigrostriatal dopaminergic denervation in single photon emission computed tomography (SPECT) or PET. Currently, a definitive MSA diagnosis can only be confirmed postmortem by the following tests: a) widespread and abundant brain alpha-synuclein-positive glial cytoplasmic inclusions, and / or b) Neurodegenerative changes in the striatonigral or olivopontocerebellar regions.

[0212] Recently, new diagnostic criteria for MSA, "The Movement Disorder Society Criteria for the Diagnosis of Multiple System Atrophy", were published by Wenning et al. (Wenning et al., Movement Disorders, 2022, Volume 37, Issue 6, Pages 1131-1148).

[0213] These criteria include the diagnoses of clinically definite MSA and clinically probable MSA.

[0214] [Table 6]

[0215] [Table 7]

[0216] REM Sleep Behavior Disorder (RBD) Rapid eye movement (REM) sleep behavior disorder (RBD) is thought to be an early manifestation of synucleinopathy. RBD is characterized by "acting out" dream content and is diagnosed by video polysomnography (vPSG) showing loss of muscle tone normally associated with REM sleep. RBD, including clinically isolated RBD (iRBD) (previously sometimes referred to as idiopathic RBD), is the most reliable clinical marker for a group of neurodegenerative disorders including prodromal synucleinopathies, Parkinson's disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). The vast majority of individuals with REM sleep behavior disorder, including iRBD, are diagnosed with a synucleinopathy within 20 years, such as within 3 years, such as within 5 years, such as within 8 years, or such as within 16 years of onset of iRBD. Thus, the REM sleep behavior disorder (RBD) population may serve as an ideal group to administer antibodies for use in accordance with the present invention to modify the progression of synuclein-specific neurodegenerative diseases, i.e., to obtain disease-modifying treatments that delay or prevent phenotypic conversion to overt synucleinopathy.

[0217] The diagnosis of RBD may be based on specific consensus criteria such as those established by the International Classification of Sleep Disorders (ICSD-3), the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-V), or the American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events. A confirmatory RBD diagnosis may require confirmation by vPSG analysis. The diagnosis of RBD can be further supported by evaluation using various imaging techniques that are also useful for identifying synucleinopathies, such as positron emission tomography (PET), single photon emission computed tomography (SPECT), near-infrared (NIR) light imaging, magnetic resonance imaging (MRI), dopamine transporter (DAT) imaging, or transcranial ultrasound.

[0218] Unified Multiple System Atrophy Rating Scale (UMSARS) The UMSARS is a well-known composite clinician and patient caregiver-reported scale for assessing disease progression in patients with MSA. The UMSARS scale can be used in clinical practice to assess MSA patients both for monitoring disease progression and / or quantifying response to treatment.

[0219] UMSARS consists of four parts: Part I assesses medical history information based on symptoms and activities of daily living over the past 2 weeks as reported by the patient and caregiver (12 items), rated on a scale ranging from 0 = no disability to 4 = incapacity (Note: each item uses a different anchor descriptor that corresponds to the question being addressed).

[0220] Part II consists of a clinical examination of key motor signs and symptoms (14 items) rated on a scale ranging from 0=normal to 4=marked / severe impairment (Note: each item uses different anchor descriptors that correspond to the question being addressed).

[0221] Part III includes an autonomic nervous system test (4 items), individual measurements of systolic and diastolic blood pressure, heart rate, and orthostatic symptoms (yes / no).

[0222] Part IV assesses overall disability (1 item), rated on a scale ranging from 1 = completely independent to 5 = incapacitated / bedridden with total assistance.

[0223] The total UMSARS score (UMSARS TS) is obtained by summing items from Part I and Part II. Part I scores range from 0 to 48 and Part II scores range from 0 to 56. Higher scores indicate greater impairment. Experienced neurologists can use the UMSARS after a short training session.

[0224] The modified UMSARS (mUMSARS) score in this context consists of the UMSARS Part I1, where response choice scores of 0 and 1 are expected to result in one classification in the analysis.

[0225] The simplified UMSARS (aUMSARS) score may be derived from a subset of items from UMSARS Parts I and II that have been shown to be patient-centered and sensitive to progression in MSA. The simplified UMSARS may be developed to be patient-centered (patient-relevant) and sensitive to detecting changes in patients diagnosed with definite MSA, probable MSA, clinically definite MSA, or clinically probable MSA. The simplified UMSARS score is based on a subset of items from Parts I and II in the original UMSARS score. Items included in the aUMSARS score may be identified, for example, by 1) finding items that are sensitive to gradient and / or patient-centered / focused changes based on correlation with QoL scales, and 2) combining them into a simplified version of the UMSARS, i.e., excluding items that are less patient-centered / focused and less capable of detecting changes over time. Data used to develop the aUMSARS may be obtained, for example, from the European MSA Study Group Natural History Study and the MSA-Ras trial. The sensitivity to change of the subitems of the Integrated MSA Scale can be assessed by calculating the sensitivity to change ratio using the mean slope of its progression divided by the standard deviation of the slope when its progression over time is modeled with a linear mixed model. The degree of patient-centeredness can be assessed based on the correlation between the Integrated MSA Scale items and quality of life measures.

[0226] An example of such an aUMSARS is provided below, and this particular aUMSARS includes the following 19 Part I and Part II UMSARS items:

[0227] [Table 8]

[0228] Specific embodiments The following embodiments will explain the present invention in further detail.

[0229] In one embodiment, the invention provides a monoclonal alpha synuclein antibody for use in treating a synucleinopathy or propathic synucleinopathy, the use comprising intravenously administering the monoclonal alpha synuclein antibody to a human subject suffering from or at risk of developing a synucleinopathy at a dose of more than 700 mg and less than 7000 mg, such as between 900 mg and 5000 mg, or such as between 1000 mg and 4500 mg, wherein the monoclonal alpha synuclein antibody is a full length antibody which binds to an epitope within amino acids 112 to 117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

[0230] In one embodiment, the invention provides a monoclonal alpha synuclein antibody for use in the treatment of a synucleinopathy, the use comprising intravenously administering the monoclonal alpha synuclein antibody to a human subject suffering from or at risk of developing a synucleinopathy at a dose greater than 700 mg and less than 7000 mg, such as between 900 mg and 5000 mg, or such as between 1000 mg and 4500 mg, wherein the monoclonal alpha synuclein antibody is a full length antibody which binds to an epitope within amino acids 112 to 117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

[0231] In one embodiment, the invention provides a monoclonal alpha synuclein antibody for use in the treatment of a propathic synucleinopathy, the use comprising intravenously administering the monoclonal alpha synuclein antibody to a human subject suffering from or at risk of developing a synucleinopathy at a dose of more than 700 mg and less than 7000 mg, such as between 900 mg and 5000 mg, or such as between 1000 mg and 4500 mg, wherein the monoclonal alpha synuclein antibody is a full length antibody which binds to an epitope within amino acids 112 to 117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

[0232] In certain embodiments, the monoclonal anti-alpha synuclein antibody has a predicted KD value for binding to oligomeric forms of alpha synuclein of about 0.5 nM.

[0233] In a further embodiment, the monoclonal alpha synuclein antibody has a KD value for binding to the monomeric form of alpha synuclein of about 36 nM.

[0234] In a further embodiment, the monoclonal alpha synuclein antibody has a KD value for binding to the monomeric form of alpha synuclein of about 36 nM and an estimated value for binding to the oligomeric form of alpha synuclein of about 0.5 nM.

[0235] In one embodiment, the ratio between monomeric and oligomeric binding values ​​is approximately 65-fold enhanced for the oligomeric form compared to the monomeric form.

[0236] In further embodiments, the monoclonal alpha synuclein antibody has a human T1 / 2 of about 25-35 days, such as about 4 weeks, such as about 27-33 days, such as 28-32 days, such as 28-30 days, such as 28 days, such as 29 days, such as 30 days.

[0237] In a further embodiment, the monoclonal alpha synuclein antibody has a KD value for binding to the monomeric form of alpha synuclein of approximately 36 nM and an estimated KD value for binding to the oligomeric form of alpha synuclein of 0.5 nM, thereby enhancing the ratio between monomeric and oligomeric binding by approximately 65-fold.

[0238] In a further embodiment, the monoclonal alpha synuclein antibody has a KD value for binding to the monomeric form of alpha synuclein of about 36 nM and an estimated Kd value for binding to the oligomeric form of alpha synuclein of 0.5 nM, such that the ratio between monomeric and oligomeric binding is enhanced by approximately 65-fold, and the antibody has a T1 / 2 of about 28-30 days, e.g., 29 days.

[0239] In a further embodiment, the monoclonal alpha synuclein antibody is a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. a heavy chain CDR2 having the amino acid sequence of SEQ ID NO:2; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6.

[0240] In a further embodiment, the monoclonal alpha synuclein antibody comprises a heavy chain consisting of the variable domain of SEQ ID NO:7 and a light chain consisting of the variable domain of SEQ ID NO:8.

[0241] In a further embodiment, the monoclonal alpha synuclein antibody is a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. A heavy chain CDR2 having the amino acid sequence of SEQ ID NO:33; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6.

[0242] In a further embodiment, the monoclonal alpha synuclein antibody comprises a heavy chain consisting of the variable domain of SEQ ID NO:30 and a light chain consisting of the variable domain of SEQ ID NO:8.

[0243] In a further embodiment, the monoclonal alpha synuclein antibody is a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. A heavy chain CDR2 having the amino acid sequence of SEQ ID NO:34; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6.

[0244] In a further embodiment, the monoclonal alpha synuclein antibody comprises a heavy chain consisting of the variable domain of SEQ ID NO:31 and a light chain consisting of the variable domain of SEQ ID NO:8.

[0245] In a further embodiment, the monoclonal alpha synuclein antibody is a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. A heavy chain CDR2 having the amino acid sequence of SEQ ID NO:35; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6.

[0246] In a further embodiment, the monoclonal alpha synuclein antibody comprises a heavy chain consisting of the variable domain of SEQ ID NO:32 and a light chain consisting of the variable domain of SEQ ID NO:8.

[0247] In a further embodiment, the monoclonal alpha synuclein antibody is a fully-length human antibody.

[0248] In a further embodiment, the monoclonal alpha synuclein antibody is a human IgG1 antibody.

[0249] In a further embodiment, the monoclonal alpha synuclein antibody is GM37.

[0250] In a further embodiment, the monoclonal alpha synuclein antibody is GM37 variant 1.

[0251] In a further embodiment, the monoclonal alpha synuclein antibody is GM37 variant 2.

[0252] In a further embodiment, the monoclonal alpha synuclein antibody is GM37 variant 3.

[0253] In a further embodiment, the monoclonal alpha synuclein antibody further comprises a heavy chain constant domain defined in SEQ ID NO:18 and a kappa light chain constant domain defined in SEQ ID NO:17.

[0254] In a further embodiment, the monoclonal alpha synuclein antibody is administered every 4 weeks or every 28 days.

[0255] In a further embodiment, the monoclonal alpha synuclein antibody is administered once a month.

[0256] In further embodiments, the monoclonal alpha synuclein antibody is administered at doses greater than 700 mg and less than 7000 mg, such as 900 mg to 5000 mg, or such as 1000 mg to 4500 mg, at intervals of 3 to 5 weeks.

[0257] In further embodiments, the monoclonal alpha synuclein antibody is administered in a dose of 750 mg, 2250 mg, or 4500 mg.

[0258] In further embodiments, the monoclonal alpha synuclein antibody is administered in a dose of 1000 mg to 4500 mg, such as 2000 mg to 4500 mg, or such as 3500 mg to 4500 mg.

[0259] In further embodiments, the monoclonal alpha synuclein antibody is administered at a dose of 750 mg, 1050 mg, 1400 mg, 1750 mg, 2100 mg, 2450 mg, 2800 mg, 3150 mg, 3500 mg, 3850 mg, 4200 mg, 4550 mg, 4900 mg, 5250 mg, 5600 mg, 5950 mg, 6300 mg, or 6650 mg.

[0260] In further embodiments, the monoclonal alpha synuclein antibody is administered at a dose of 1050 mg, 2100 mg or 4200 mg.

[0261] In a further embodiment, the monoclonal alpha synuclein antibody is administered at a dose of 4200 mg.

[0262] In one embodiment, the dose is a fixed dose.

[0263] In further embodiments, the monoclonal alpha synuclein antibody is administered at a dose of 1050 mg, 2100 mg, or 4200 mg every 28 to 30 days.

[0264] In a further embodiment, the monoclonal alpha synuclein antibody is administered at a dose of 4200 mg every 4 weeks or every 28 to 30 days, for example, every 28 days, every 29 days or every 30 days.

[0265] In a further embodiment, the monoclonal alpha synuclein antibody is administered by intravenous infusion over 30 minutes ± 10 minutes.

[0266] In a further embodiment, the monoclonal alpha synuclein antibody is administered by intravenous infusion over 15 minutes ± 5 minutes.

[0267] In a further embodiment, the monoclonal alpha synuclein antibody is administered by intravenous infusion at a rate of 25 mg / min to 300 mg / min.

[0268] In a further embodiment, the monoclonal alpha synuclein antibody is administered by intravenous infusion at a rate of 30 mg / min to 150 mg / min, e.g., 35 mg / min, 70 mg / min or 140 mg / min.

[0269] In a further embodiment, the monoclonal alpha synuclein antibody is administered by intravenous infusion at a rate of 60 mg / min to 300 mg / min, e.g., 70 mg / min, 140 mg / min or 280 mg / min.

[0270] In further embodiments, the monoclonal alpha synuclein antibody is administered in an amount and frequency sufficient to achieve an estimated CSF average steady state concentration of the antibody of at least 0.5 nM, such as at least 1 nM, such as at least 2 nM, such as at least 3 nM, such as at least 6 nM, or such as at least 12 nM.

[0271] In a further embodiment, the monoclonal alpha synuclein antibody is administered in an amount and frequency sufficient to achieve an estimated CSF average steady state concentration of the antibody of at least 3 nM.

[0272] In a further embodiment, the monoclonal alpha synuclein antibody is administered in an amount and frequency sufficient to achieve an estimated CSF average steady state concentration of the antibody of at least 6 nM.

[0273] In a further embodiment, the monoclonal alpha synuclein antibody is administered in an amount and frequency sufficient to achieve an estimated CSF average steady state concentration of the antibody of at least 12 nM.

[0274] In further embodiments, the monoclonal alpha synuclein antibody is administered in an amount and frequency sufficient to achieve putative target engagement with oligomeric forms of alpha synuclein in the CSF of at least 50%, such as at least 60%, such as at least 75%, such as at least 80%, such as at least 85%, such as at least 90%, such as at least 95%, or such as at least 99%.

[0275] In a further embodiment, the monoclonal alpha synuclein antibody is administered in an amount and frequency sufficient to achieve putative target engagement with at least 85% of the oligomeric forms of alpha synuclein in the CSF.

[0276] In a further embodiment, the monoclonal alpha synuclein antibody is administered in an amount and frequency sufficient to achieve putative target engagement with at least 90% of the oligomeric forms of alpha synuclein in the CSF.

[0277] In a further embodiment, the monoclonal alpha synuclein antibody is administered in an amount and frequency sufficient to achieve putative target engagement with at least 95% of the oligomeric forms of alpha synuclein in the CSF.

[0278] In further embodiments, the synucleinopathy to be treated is selected from the list consisting of Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease), Gaucher disease (GD), diffuse Lewy body disease (DLBD), dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's disease and Parkinson's disease, pure autonomic failure, and multiple system atrophy (MSA).

[0279] In further embodiments, the synucleinopathy being treated is selected from Parkinson's disease (PD), dementia with Lewy bodies (DLB), or multiple system atrophy (MSA).

[0280] In further embodiments, the synucleinopathy treated is multiple system atrophy (MSA) or an MSA subtype selected from definite MSA, probable MSA, MSA type C, MSA type P, clinically definite MSA, or clinically probable MSA.

[0281] In further embodiments, the synucleinopathy being treated is selected from Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease), Gaucher disease (GD), diffuse Lewy body disease (DLBD), dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's disease and Parkinson's disease, pure autonomic failure, and multiple system atrophy (MSA), and the treatment comprises administering a monoclonal alpha synuclein antibody to the patient in an amount and frequency sufficient to achieve a CSF steady state concentration of the antibody of at least 0.5 nM, such as at least 1 nM, such as at least 2 nM, such as at least 3 nM, such as at least 6 nM, or such as at least 12 nM.

[0282] In further embodiments, the synucleinopathy being treated is selected from Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease), Gaucher disease (GD), diffuse Lewy body disease (DLBD), dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's disease and Parkinson's disease, pure autonomic failure and multiple system atrophy (MSA), and the treatment comprises administering a monoclonal alpha synuclein antibody to the patient in an amount and frequency sufficient to achieve a CSF steady state concentration of the antibody of at least 3 nM, such as at least 6 nM, or such as at least 12 nM.

[0283] In further embodiments, the synucleinopathy being treated is selected from Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease), Gaucher disease (GD), diffuse Lewy body disease (DLBD), dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's disease and Parkinson's disease, pure autonomic dysfunction, and multiple system atrophy (MSA), and the treatment comprises administering a monoclonal alpha synuclein antibody to the patient in an amount and frequency sufficient to achieve putative target engagement with oligomeric forms of alpha synuclein in the CSF of at least 50%, such as at least 60%, such as at least 75%, such as at least 80%, such as at least 85%, such as at least 90%, such as at least 95%, or such as at least 99%.

[0284] In further embodiments, the synucleinopathy being treated is selected from Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease), Gaucher disease (GD), diffuse Lewy body disease (DLBD), dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's disease and Parkinson's disease, pure autonomic failure and multiple system atrophy (MSA), and the treatment comprises administering a monoclonal alpha synuclein antibody to the patient in an amount and frequency sufficient to achieve putative target engagement against oligomeric forms of alpha synuclein in the CSF of at least 85%, such as at least 90%, such as at least 95%.

[0285] In a further embodiment, the invention provides a method of treating a synucleinopathy selected from Parkinson's disease (PD) (including idiopathic and genetic forms of Parkinson's disease), Gaucher disease (GD), diffuse Lewy body disease (DLBD), dementia with Lewy bodies (DLB), Lewy body variant of Alzheimer's disease (LBV), mixed Alzheimer's disease and Parkinson's disease, pure autonomic failure, or multiple system atrophy (MSA).

[0286] In a further embodiment, the invention provides a method of treating a synucleinopathy selected from Parkinson's disease (PD), dementia with Lewy bodies (DLB), or multiple system atrophy (MSA).

[0287] In a further embodiment, the invention provides a method of treating multiple system atrophy (MSA), e.g., a synucleinopathy that is an MSA subtype selected from definite MSA, probable MSA, MSA type C, MSA type P, clinically definite MSA, or clinically probable MSA.

[0288] In a further embodiment, the invention provides a monoclonal alpha synuclein antibody for treating a human subject suffering from multiple system atrophy (MSA), identifiable by a diagnosis of multiple system atrophy-predominantly parkinsonian (MSA-P) or multiple system atrophy-predominantly cerebellar (MSA-C) subtypes of MSA.

[0289] In a further embodiment, the invention provides a monoclonal alpha synuclein antibody for treating a human subject suffering from multiple system atrophy (MSA), identifiable by the onset of motor and / or autonomic (orthostatic or urinary) MSA symptoms within the past 5 years, such as within the past 4 years, such as within the past 3 years, such as within the past 2 years, such as within the past year.

[0290] In a further embodiment, the invention provides a monoclonal alpha synuclein antibody for treating a human subject suffering from multiple system atrophy (MSA), as identifiable by having a UMSARS part I score of ≦16 (omitting question 11 regarding sexual function).

[0291] In a further embodiment, the invention provides a monoclonal alpha synuclein antibody for treating a human subject suffering from multiple system atrophy (MSA), identifiable by having cognitive ability as assessed by the Montreal Cognitive Assessment (MoCA) of a score of ≧22.

[0292] In an embodiment, treating a synucleinopathy consists of slowing disease progression.

[0293] In further embodiments, treating a synucleinopathy consists of slowing the progression of the disease by at least 5%, such as at least 10%, such as at least 15%, such as at least 20%, such as at least 25%, such as at least 30%, such as at least 35%, such as at least 40%, such as at least 45%, such as at least 50%, such as at least 55%, such as at least 60%, such as at least 65%, such as at least 70%, such as at least 75%, such as at least 80%, such as at least 85%, or such as at least 90%.

[0294] In further embodiments, treating a synucleinopathy consists of slowing the progression of the disease by at least 25%, such as at least 30%, such as at least 35%, or such as at least 40%.

[0295] In further embodiments, a therapeutic effect against a synucleinopathy is observed following administration of at least 10 doses, such as at least 11 doses, such as at least 12 doses, such as at least 13 doses, such as at least 14 doses, such as at least 15 doses, such as at least 16 doses, such as at least 17 doses, such as at least 18 doses, such as at least 19 doses, or at least 20 doses of the monoclonal alpha synuclein antibody.

[0296] In further embodiments, the therapeutic effect against synucleinopathy is observed after at least 24 weeks, such as at least 48 weeks, such as at least 72 weeks, or such as at least 96 weeks of treatment with the monoclonal alpha synuclein antibody.

[0297] In further embodiments, the therapeutic effect against synucleinopathy is observed after at least 44 weeks or at least 48 weeks of treatment with the monoclonal alpha synuclein antibody.

[0298] In further embodiments, the therapeutic effect for synucleinopathy is observed following administration of at least 10 doses, such as at least 11 doses, or such as at least 12 doses of the monoclonal alpha synuclein antibody.

[0299] In embodiments, the delay in disease progression is quantified by the log change from baseline in any of the relevant Unified Multiple System Atrophy Rating Scale (UMSARS) scores described herein, or the relevant parts of any of these scales, e.g., part I, part II, part III, or part IV, or the change from baseline in any combination of these parts of the UMSARS.

[0300] In further embodiments, the delay in disease progression is quantified by the log change from baseline in the Unified Multiple System Atrophy Rating Scale (UMSARS) part I and / or part II, or in the modified UMSARS part I (mUMSARS), or in the abbreviated UMSARS (aUMSARS) score.

[0301] In a further embodiment, the delay in disease progression is quantified by the log change from baseline in the Unified Multiple System Atrophy Rating Scale (UMSARS) part I or part II score.

[0302] In a further embodiment, the delay in disease progression is quantified by the log change from baseline in Unified Multiple System Atrophy Rating Scale (UMSARS) part I and part II scores.

[0303] In a further embodiment, the delay in disease progression is quantified by the log change from baseline in the Unified Multiple System Atrophy Rating Scale (UMSARS) part I, modified UMSARS part I (mUMSARS) and / or UMSARS part II score.

[0304] In a further embodiment, the delay in disease progression is quantified by the log change from baseline in UMSARS TS, UMSARS part I, mUMSARS and / or UMSARS part II scores.

[0305] In a further embodiment, the delay in disease progression is quantified by the log change from baseline in the abbreviated UMSARS (aUMSARS) score.

[0306] In a further embodiment, the delay in disease progression is quantified by the log change from baseline in modified UMSARS (mUMSARS) score.

[0307] In a further embodiment, the delay in disease progression is quantified by the log change from baseline in the Total Unified Multiple System Atrophy Rating Scale (UMSARS TS) score.

[0308] In a further embodiment, the delay in disease progression is quantified by log change from baseline in brain volume as determined by volumetric MRI (vMRI).

[0309] In a further embodiment, the delay in disease progression is quantified by the log change from baseline in neurofilament light chain (NfL) blood levels.

[0310] In further embodiments, the delay in disease progression is quantified by a log change from baseline in one or more parameters selected from the following: Schwab England Activities of Daily Living (SE-ADL) score; as a change from baseline in the Clinical Global Impression-Severity (CGI-S) score; as a change from baseline in the Patient Global Impression-Severity (PGI-S) score; as a change from baseline in the Observer Reported Global Impression-Severity score; as a change from baseline in the Composite Autonomic Symptom Score Select Change (COMPASS Select Change) score; as a change from baseline in the UMSARS Part IV score; as a change from baseline in speaking, swallowing, falls, and gait as assessed by the UMSARS Part I item scores; as a change from baseline in the frequency, causes, and effects of falls as assessed by the Fall Diary Periods; as a change from baseline in the EQ-5D-5L scoring system (EuroQol as change from baseline in 5-Dimension, 5-Level (EQ-5D-5L) score; as change from baseline in brain volume as measured by volumetric MRI (vMRI); as change from baseline in tissue integrity as measured by diffusion tensor imaging (DTI) MRI; as change from baseline in neurofilament light chain (NfL) blood concentrations; as change from baseline in heart rate, blood pressure and orthostatic symptoms as assessed by UMSARS Part III; as change from baseline in gait parameters or frequency of falls as assessed by a digital wearable sensor-based device capable of tracking relevant gait parameters and / or registered falls; as change from baseline in cerebral blood flow as measured by arterial spin labeling (ASL) MRI; as change from baseline in CSF concentrations of t-tau and NfL; or as change from baseline in concentrations of pathological species of alpha-synuclein in the CSF.

[0311] In further embodiments, a human subject at risk of developing a synucleinopathy or suffering from a prodromal synucleinopathy can be identified by exhibiting one or more clinical markers of a prodromal synucleinopathy selected from the group comprising REM sleep behavior disorder (RBD), e.g., isolated RBD (iRBD), olfactory impairment, e.g., hyposmia, abnormal cognitive performance in neuropsychological testing, subtle motor dysfunction or abnormal motor performance assessed by objective testing, abnormal color vision, autonomic dysfunction (e.g., constipation, voiding symptoms, erectile dysfunction, orthostatic hypotension, etc.), reduced nigrostriatal dopaminergic connectivity in the putamen and striatum (abnormal DAT-SPECT), seborrheic dermatitis, and a genotype associated with increased risk of phenotypic transformation, e.g., a mutation in glucocerebrosidase (encoded by the GBA gene).

[0312] In a further embodiment, a human subject at risk of developing a synucleinopathy or suffering from a propathic synucleinopathy can be identified by exhibiting RBD, e.g., isolated RBD (iRBD), and at least one additional clinical marker of a propathic synucleinopathy, e.g., hyposmia and / or an abnormal DAT-SPECT.

[0313] In a further embodiment, treating the propathic synucleinopathy consists of delaying disease onset.

[0314] In further embodiments, treating a prosymptomatic synucleinopathy comprises delaying the time to disease onset or disease diagnosis by at least 5%, such as at least 10%, such as at least 15%, such as at least 20%, such as at least 25%, such as at least 30%, such as at least 35%, such as at least 40%, such as at least 45%, such as at least 50%, such as at least 55%, such as at least 60%, such as at least 65%, such as at least 70%, such as at least 75%, such as at least 80%, such as at least 85%, or such as at least 90%.

[0315] In further embodiments, treating a propathic synucleinopathy consists of delaying the time to disease onset or disease diagnosis by at least 6 months, such as at least 8 months, such as at least 10 months, such as at least 12 months, such as at least 14 months, such as at least 16 months, such as at least 18 months, such as at least 20 months, such as at least 22 months, such as at least 24 months, such as at least 2 years, such as at least 3 years, such as at least 4 years, such as at least 5 years.

[0316] In a further embodiment, the invention provides a method of treating a prosyndromic synucleinopathy, wherein the treatment comprises administering a monoclonal alpha synuclein antibody in an amount and frequency sufficient to achieve a CSF steady state concentration of the antibody of at least 0.5 nM, such as at least 1 nM, such as at least 2 nM, such as at least 3 nM, such as at least 6 nM, or such as at least 12 nM.

[0317] In a further embodiment, the invention provides a method of treating a prosymptomatic synucleinopathy, wherein the treatment comprises administering a monoclonal alpha synuclein antibody in an amount and frequency sufficient to achieve a CSF steady state concentration of the antibody of at least 3 nM, such as at least 6 nM, or such as at least 12 nM.

[0318] In a further embodiment, the invention provides a method of treating a prosymptomatic synucleinopathy, wherein the treatment comprises administering a monoclonal alpha synuclein antibody in an amount and frequency sufficient to achieve putative target engagement with oligomeric forms of alpha synuclein in the CSF of at least 50%, such as at least 60%, such as at least 75%, such as at least 80%, such as at least 85%, such as at least 90%, such as at least 95%, or such as at least 99%.

[0319] In a further embodiment, the invention provides a method of treating a prosymptomatic synucleinopathy, wherein the treatment comprises administering a monoclonal alpha synuclein antibody in an amount and frequency sufficient to achieve putative target engagement with oligomeric forms of alpha synuclein in the CSF of at least 85%, such as at least 90%, or such as at least 95%.

[0320] In an embodiment, the present invention also provides a liquid pharmaceutical composition comprising a full-length IgG1 monoclonal anti-alpha synuclein antibody at a concentration of 25-225 mg / mL, the antibody comprising: a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO:1; b. A heavy chain CDR2 having the amino acid sequence of SEQ ID NO:34; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO:3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6; The composition further comprises a histidine buffer, a pharma- ceutically acceptable tonicity agent, a pharma- ceutically acceptable surfactant, and the pH of the composition is 5.5 to 6.5, and this liquid pharmaceutical composition is suitable for use in administering a monoclonal alpha synuclein antibody in any of the treatments, methods of treatment and uses described in the aspects, embodiments or claims of the present application.

[0321] In an embodiment of the invention, the monoclonal antibody of the liquid pharmaceutical composition comprises a heavy chain consisting of the variable domain of SEQ ID NO:31 and a light chain consisting of the variable domain of SEQ ID NO:8.

[0322] In an embodiment of the invention, the monoclonal antibody of the liquid pharmaceutical composition is a human antibody.

[0323] In an embodiment of the invention, the monoclonal antibody of the liquid pharmaceutical composition is a human IgG1 antibody.

[0324] In an embodiment of the invention, the monoclonal antibody of the liquid pharmaceutical composition is GM37 variant 2.

[0325] In a further embodiment of the invention, the monoclonal antibody of the liquid pharmaceutical composition comprises a heavy chain constant domain defined in SEQ ID NO:18 and a kappa light chain constant domain defined in SEQ ID NO:17.

[0326] In embodiments, the tonicity agent of the liquid pharmaceutical composition is selected from mannitol, sorbitol, lactose, dextrose, trehalose, sodium chloride (NaCl), potassium chloride (KCl), glycerol, or glycerin.

[0327] In embodiments, the tonicity agent of the liquid pharmaceutical composition is sodium chloride (NaCl).

[0328] In embodiments, the tonicity agent of the liquid pharmaceutical composition is sodium chloride (NaCl) at a concentration of about 70-140 mM.

[0329] In embodiments, the tonicity agent of the liquid pharmaceutical composition is sodium chloride (NaCl) at a concentration of about 50-150 mM.

[0330] In embodiments, the tonicity agent of the liquid pharmaceutical composition is sodium chloride (NaCl) at a concentration of about 100 mM.

[0331] In embodiments, the surfactant of the liquid pharmaceutical composition is selected from Polysorbate 20 (Tween 20), Polysorbate 80 (Tween 80), Poloxamer 188, or Triton X-100.

[0332] In an embodiment, the surfactant of the liquid pharmaceutical composition is polysorbate 80 (Tween 80) in an amount of 0.02% to 0.05% (w / v).

[0333] In embodiments, the surfactant of the liquid pharmaceutical composition is Polysorbate 80 (Tween 80) in an amount of about 0.02% (w / v).

[0334] In embodiments, the tonicity agent of the liquid pharmaceutical composition is sodium chloride (NaCl) and the surfactant is polysorbate 80 (Tween 80).

[0335] In an embodiment, the concentration of the histidine buffer in the liquid pharmaceutical composition is 25 to 40 mM.

[0336] In embodiments, the concentration of the histidine buffer in the liquid pharmaceutical composition is about 25 mM.

[0337] In an embodiment, the liquid pharmaceutical composition has a pH of 6.0.

[0338] In an embodiment, the concentration of the monoclonal anti-alpha synuclein antibody in the liquid pharmaceutical composition is about 30-225 mg / mL.

[0339] In an embodiment, the concentration of the monoclonal anti-alpha synuclein antibody in the liquid pharmaceutical composition is about 30-200 mg / mL.

[0340] In an embodiment, the concentration of the monoclonal anti-alpha synuclein antibody in the liquid pharmaceutical composition is about 30-150 mg / mL.

[0341] In an embodiment, the concentration of the monoclonal anti-alpha synuclein antibody in the liquid pharmaceutical composition is about 30-100 mg / mL.

[0342] In an embodiment, the concentration of the monoclonal anti-alpha synuclein antibody in the liquid pharmaceutical composition is about 45-55 mg / mL.

[0343] In embodiments, the concentration of the monoclonal anti-alpha synuclein antibody in the liquid pharmaceutical composition is about 50 mg / mL.

[0344] In embodiments, the concentration of the monoclonal anti-alpha synuclein antibody in the liquid pharmaceutical composition is about 53 mg / mL.

[0345] In embodiments, the liquid pharmaceutical composition of any of the preceding embodiments further comprises at least one bulking agent selected from sucrose, trehalose, glucose, lactose, sorbitol, mannitol, glycerol, arginine, aspartic acid, glutamic acid, glutamate, lysine, glycine, histidine, methionine, alanine, gelatin, PVP, PLGA, PEG, dextran, cyclodextrin and derivatives, starch derivatives, HSA, or BSA.

[0346] In embodiments, the bulking agent of the liquid pharmaceutical composition is arginine, glutamate, sucrose, glycine or sorbitol at a concentration of 100-200 mM.

[0347] In an embodiment, the bulking agent of the liquid pharmaceutical composition is sucrose at a concentration of 100 mM.

[0348] In an embodiment, the liquid pharmaceutical composition comprises 53 mg / mL of monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl) and 0.02% polysorbate 80 (Tween 80) (w / v) at pH 6.0.

[0349] In an embodiment, the liquid pharmaceutical composition consists essentially of 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl), 0.02% polysorbate 80 (Tween 80) (w / v) and water at a pH of 6.0.

[0350] In an embodiment, the liquid pharmaceutical composition comprises 53±5 mg / mL monoclonal anti-alpha synuclein antibody, 1.40 mg / mL L-histidine, 3.34 mg / mL L-histidine monohydrochloride, 34.16 mg / mL sucrose, 5.83 mg / mL sodium chloride (NaCl), 0.20 mg / mL polysorbate 80 (Tween 80) at pH 6.0.

[0351] In an embodiment, the liquid pharmaceutical composition consists essentially of 53±5 mg / mL monoclonal anti-alpha synuclein antibody, 1.40 mg / mL L-histidine, 3.34 mg / mL L-histidine monohydrochloride, 34.16 mg / mL sucrose, 5.83 mg / mL sodium chloride (NaCl), 0.20 mg / mL polysorbate 80 (Tween 80) and water at a pH of 6.0.

[0352] In an embodiment, the liquid pharmaceutical composition comprises 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl) and 0.02% polysorbate 80 (Tween 80) (w / v), or has amounts of each component within + / - 10% of said values, and has a pH of 6.0 or within + / - 10% of said values.

[0353] In embodiments, the liquid pharmaceutical composition consists essentially of 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl), 0.02% polysorbate 80 (Tween 80) (w / v) and water, or has amounts of each component within + / - 10% of said values, and has a pH of 6.0 or within + / - 10% of said value.

[0354] In an embodiment, the liquid pharmaceutical composition contains 53 mg / mL of a monoclonal anti-alpha synuclein antibody, 1.40 mg / mL of L-histidine, 3.34 mg / mL of L-histidine monohydrochloride, 34.16 mg / mL of sucrose, 5.83 mg / mL of sodium chloride (NaCl), 0.20 mg / mL of polysorbate 80 (Tween 80), or has amounts of each component within + / - 10% of said values, and has a pH of 6.0 or within + / - 10% of said values.

[0355] In embodiments, the liquid pharmaceutical composition consists essentially of 53 mg / mL monoclonal anti-alpha synuclein antibody, 1.40 mg / mL L-histidine, 3.34 mg / mL L-histidine monohydrochloride, 34.16 mg / mL sucrose, 5.83 mg / mL sodium chloride (NaCl), 0.20 mg / mL polysorbate 80 (Tween 80) and water, or has an amount of each component within + / - 10% of said values, and has a pH of 6.0 or within + / - 10% of said value.

[0356] In an embodiment, the liquid pharmaceutical composition comprises 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl) and 0.02% polysorbate 80 (Tween 80) (w / v), or has amounts of each component within + / - 5% of said values, and has a pH of 6.0 or within + / - 5% of said values.

[0357] In embodiments, the liquid pharmaceutical composition consists essentially of 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl), 0.02% polysorbate 80 (Tween 80) (w / v) and water, or has amounts of each component within + / - 5% of said values, and has a pH of 6.0 or within + / - 5% of said value.

[0358] In an embodiment, the liquid pharmaceutical composition contains 53 mg / mL of a monoclonal anti-alpha synuclein antibody, 1.40 mg / mL of L-histidine, 3.34 mg / mL of L-histidine monohydrochloride, 34.16 mg / mL of sucrose, 5.83 mg / mL of sodium chloride (NaCl), 0.20 mg / mL of polysorbate 80 (Tween 80), or has amounts of each component within + / - 5% of said values, and has a pH of 6.0 or within + / - 5% of said values.

[0359] In embodiments, the liquid pharmaceutical composition consists essentially of 53 mg / mL monoclonal anti-alpha synuclein antibody, 1.40 mg / mL L-histidine, 3.34 mg / mL L-histidine monohydrochloride, 34.16 mg / mL sucrose, 5.83 mg / mL sodium chloride (NaCl), 0.20 mg / mL polysorbate 80 (Tween 80) and water, or has an amount of each component within + / - 5% of said values, and has a pH of 6.0 or within + / - 5% of said values.

[0360] In an embodiment, the liquid pharmaceutical composition comprises 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl) and 0.02% polysorbate 80 (Tween 80) (w / v), or has amounts of each component within + / - 1% of said values, and has a pH of 6.0 or within + / - 1% of said values.

[0361] In embodiments, the liquid pharmaceutical composition consists essentially of 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl), 0.02% polysorbate 80 (Tween 80) (w / v) and water, or has amounts of each component within + / - 1% of said values, and has a pH of 6.0 or within + / - 1% of said value.

[0362] In an embodiment, the liquid pharmaceutical composition contains 53 mg / mL of a monoclonal anti-alpha synuclein antibody, 1.40 mg / mL of L-histidine, 3.34 mg / mL of L-histidine monohydrochloride, 34.16 mg / mL of sucrose, 5.83 mg / mL of sodium chloride (NaCl), 0.20 mg / mL of polysorbate 80 (Tween 80), or has amounts of each component within + / - 1% of said values, and has a pH of 6.0 or within + / - 1% of said values.

[0363] In an embodiment, the liquid pharmaceutical composition consists essentially of 53 mg / mL monoclonal anti-alpha synuclein antibody, 1.40 mg / mL L-histidine, 3.34 mg / mL L-histidine monohydrochloride, 34.16 mg / mL sucrose, 5.83 mg / mL sodium chloride (NaCl), 0.20 mg / mL polysorbate 80 (Tween 80) and water, or has an amount of each component within + / - 1% of said value, and has a pH of 6.0 or within + / - 1% of said value.

[0364] In an embodiment, the liquid pharmaceutical composition comprises 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl) (or having an amount of each component within + / - 20% of said value), and 0.02% polysorbate 80 (Tween 80) (w / v) (or having a concentration within + / - 30% of said value), and has a pH of 6.0 or within + / - 20% of said value.

[0365] In an embodiment, the liquid pharmaceutical composition comprises 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl) (or having an amount of each component within + / - 15% of said value), and 0.02% polysorbate 80 (Tween 80) (w / v) (or having a concentration within + / - 25% of said value), and has a pH of 6.0 or within + / - 15% of said value.

[0366] In an embodiment, the liquid pharmaceutical composition comprises 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl) (or having an amount of each component within + / - 10% of said value), and 0.02% polysorbate 80 (Tween 80) (w / v) (or having a concentration within + / - 20% of said value), and has a pH of 6.0 or within + / - 10% of said value.

[0367] In embodiments, the liquid pharmaceutical composition is a stable liquid pharmaceutical composition.

[0368] In embodiments, the liquid pharmaceutical composition is a low viscosity liquid pharmaceutical composition.

[0369] It will be appreciated that one or more features of any of the embodiments disclosed herein may be combined and / or rearranged within the scope of the invention to produce further embodiments that are within the scope of the invention, and all embodiments are intended to apply to all aspects of the invention.

[0370] In specific embodiments of the invention, the monoclonal alpha synuclein antibody of any of the preceding embodiments is administered to a patient in any one of the liquid pharmaceutical compositions of any of the preceding embodiments.

[0371] Those skilled in the art will recognize, or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments of the invention described herein, which equivalents are intended to be within the scope of the present invention. EXAMPLES

[0372] Experimental Section - Dosing Regimen The examples provided below serve to facilitate a more complete understanding of the invention, however, the scope of the invention is not limited to the specific embodiments disclosed in these examples, which are for illustrative purposes only, since alternative methods may be utilized to achieve similar results.

[0373] Example 1 - Model for establishing a dosing regimen for antibodies for use according to the invention exemplified by GM37 variant 2 This example provides an overview of the inventive efforts undertaken by the inventors to enable the establishment of clinically relevant human dosing regimens required to obtain neutralization of oligomeric / aggregated pathological species of alpha synuclein in the CSF of patients with synucleinopathies. The dosing regimens are based on a model that requires extensive and in-depth knowledge of GM37v2 and its binding properties to different alpha synuclein species, as well as the PK properties of GM37v2, including exposure in the CSF and target engagement between GM37v2 and alpha synuclein (Example 3), as exemplified by the following experiments (Examples 2, 6, 6A, 7 and 7A).

[0374] The inventors of the present invention have been able to arrive at the claimed dosing regimen by establishing a specific relationship for GM37v2 between binding to monomeric alpha synuclein and binding to oligomeric forms of alpha synuclein. This specific relationship is unique to each alpha synuclein antibody and is essential to establish a clinically relevant dosing regimen that provides the desired target engagement with pathological forms of alpha synuclein in the CSF of patients. In vitro, the KD value of binding to the monomeric form of alpha synuclein for GM37v2 was measured to be 36nM (5,400ng / mL) (see Example 6A), and the avidity-mediated KD enhancement to the oligomeric form for GM37v2 was estimated to be approximately 65-fold (64.1+ / -5.2) lower (i.e., 0.5nM; 83ng / mL) (see Example 2).

[0375] In addition to this fold change between monomeric and oligomeric binding, detailed PK knowledge of GM37v2 was also required to obtain the dosing regimen of the present invention. The PK profile was obtained through the experiments disclosed in Example 3. GM37 variant 2 was found to have a clearance of approximately 0.25 L / day, e.g., 0.24 L / day, and a T1 / 2 of approximately 30 days, e.g., 29 days.

[0376] Target engagement of GM37 variant 2 to alpha synuclein can be calculated from the percentage of free alpha synuclein (not bound to GM37 variant 2) in plasma or CSF.

[0377] Figure 6 shows the median free alpha synuclein plasma concentration over time for healthy subjects and patients. A clear dose-related inhibition was observed. The same was observed for % free / total alpha synuclein (Figure 7). A good correlation between plasma concentration of % free / total alpha synuclein and GM37 variant 2 was also seen in Figure 8, where the Emax model (see below) was fitted to the data.

[0378] Notably, the observed IC50 values ​​were similar to the KD values ​​measured in vitro, providing experimental validation of the maximal inhibition Emax model described below.

[0379] Simple maximum inhibition E max According to the model, the % free / total associated with target engagement of monomeric alpha synuclein is given by: Free / total alpha synuclein mono %=E max (Css / (KD+Css)) where Emax is set to 100%, Css is the estimated average steady-state concentration of GM37v2, and KD is the in vitro measured binding to monomeric alpha-synuclein (36 nM for GM37v2).

[0380] In order to establish the relevant clinical dose of GM37v2 for treating synucleinopathies where aggregated alpha-synuclein is the primary target for treatment and not the monomeric form, this model needs to be adapted to take into account the 65-fold increase in avidity between the binding of monomeric GM37v2 and oligomeric GM37v2 (this increase in avidity is obtained when targeting aggregates versus monomers, as described in Example 2 and displayed in Figure 1). For GM37v2, the increase in avidity is 65-fold, and therefore the model for aggregated species of alpha-synuclein as the primary target should adopt a KD proxy value that is 65-fold lower than the monomeric KD of 36 nM (36 nM / 65 = 0.5 nM). In the following model, this estimated KD enhancement is displayed as "(KD-avidity-increase)".

[0381] Therefore, E max The % free / total associated with target engagement of the model aggregated form of alpha synuclein is given by: Free / total alpha synuclein agg %=E max (Css / (KD-Avidity-Increase+Css)) The Css value can be calculated based on the results obtained in Example 3: For example, these parameters: dose = 4200 mg; dosing interval = 28 days; clearance = 0.25 L / day gives an estimated mean plasma Css of (4200 mg / 28 days) / 0.25 L / day = 600 mg / L = 600 μg / mL. Correspondingly, the mean CSF Css is 0.3% of 600 μg / mL = 1.8 μg / mL, which is equivalent to 12 nM (since 1 μg / mL = 6.67 nM, see below).

[0382] If Emax is set to 100% and the KD-avidity-increase is 0.5 nM, following this specific example where GM37v2 CSF Css=12 nM, the estimated CSF target engagement for oligomeric / aggregated alpha-synuclein is 96% according to the following calculation: Free / total alpha synuclein agg %=E max (Css / (KD-Avidity-Increase+Css))=100% (12nM / (0.5nM+12nM))=96%.

[0383] Based on the data summarized above and the values ​​for the fold difference in affinity / avidity for alpha synuclein monomeric vs. oligomeric forms found in Target; Example 2, doses of GM37 variant 2 that result in a predicted 85%-95% target engagement in the CSF at steady state to alpha synuclein oligomeric forms at the following fixed doses (70 kg body weight): 1050 mg (15 mg / kg), 2100 mg (30 mg / kg), and 4200 mg (60 mg / kg) every 4 weeks are modeled and presented in Figure 1. In Figure 1, the plot is based on the predicted mean CSF Css of GM37 variant 2 (calculated as dose / dosing interval / clearance, as illustrated above) and a CSF fraction of 0.3% CSF Css. Binding is assumed to follow a simple sigmoidal model with Emax type: 1 nM GM37v2 = 0.15 μg / mL (1 μg / mL = 6.67 nM).

[0384] Based on these calculations, we predict: A single IV infusion of 1050 mg every 4 weeks is predicted to maintain concentrations of GM37 variant 2 in CSF and brain interstitial fluid (ISF) near the IC85, the mean concentration at which 85% of oligomeric alpha-synuclein is bound.

[0385] A 2100 mg IV infusion once every 4 weeks is predicted to maintain concentrations of GM37 variant 2 in CSF and brain interstitial fluid (ISF) near the IC90, the mean concentration at which 90% of oligomeric alpha-synuclein is bound.

[0386] A 4,200 mg IV infusion once every four weeks is predicted to maintain concentrations of GM37 variant 2 in CSF and brain interstitial fluid (ISF) near the IC95, the mean concentration at which 95% of oligomeric alpha-synuclein is bound.

[0387] Example 2 - Competitive ELISA - Monomeric vs. Oligomeric Target Engagement Illustrated by GM37 Variant 2 The binding profile of GM37 variant 2 to monomeric and fibrillar forms of alpha synuclein was characterized in this assay, also referred to as a competitive ELISA, to determine the fold difference between binding to monomeric and fibrillar alpha synuclein.

[0388] The assay principle is based on a high density coating of monomeric alpha synuclein to capture unbound anti-alpha synuclein mAb after pre-incubation with increasing concentrations of either monomeric alpha synuclein or alpha synuclein fibrils. The observed IC50 values ​​for either alpha synuclein monomer or alpha synuclein fibrils are therefore a relative measure of the differential binding strengths to two representative biologically active species of alpha synuclein. The assay principle is illustrated in Figure 2.

[0389] Production of preformed fibrils Preformed fibril (PFF) alpha-synuclein monomers were produced from a eukaryotic cell source and fibrillated according to the protocol published in Polinski et al. J Parkinsons Dis. 2018;8(2):303-322.

[0390] Briefly, 400 μL of monomeric alpha synuclein at 4 mg / mL in PBS was stirred in a 2 mL round-bottom tube with a thermomixer at 1000 rpm at 37° C. for a period of 5 days. Protein fibrillization was verified by an increase in fluorescence in response to Thioflavin T and an increase in hydrodynamic diameter measured by dynamic light scattering (DLS). Sonication was performed with a QSonica R800 (amplitude 50, 20 sec on, 10 sec off, 10 min) to obtain a monodisperse particle size distribution (Z-average) of less than 100 nm as measured by DLS. The PFF was then aliquoted into a volume of 10 μL and stored at −80° C. until use.

[0391] On the first day, 384-well plates are coated with alpha synuclein monomer, 1.4 μg / ml, 50 μl per well. Plates are incubated at 4° C. All solutions and plates are kept on ice and transferred directly to the refrigerator. The assay was continued until the next day.

[0392] Serial two-fold dilutions of alpha synuclein monomer and fibrils ranging from 60 μM to 7.15 pM were prepared in blocking buffer in low-attachment polypropylene plates. Alpha synuclein fibril preparations were thawed at RT, while alpha synuclein monomer preparations were thawed on ice. Immediately before use, the monomer and fibril stock solutions were gently mixed by pipetting half the total volume three times. An equal volume of mAb (40 ng / ml) was added to all wells containing serial dilutions of alpha synuclein, and the low-attachment plate was incubated for 2 h at RT with gentle agitation (300 rpm) on a vertical plate shaker to allow antibody-antigen complexes to form. Two wells with blocking buffer were included as blanks, and two wells with mAb + blocking buffer were included as positive controls. One hour before the preincubation described above was completed, the alpha-synuclein-coated assay plates were washed three times with PBS-T using a 384-well automated plate washer, 100 μl of blocking buffer was added to each well, and the plates were incubated at RT for 1 hour.

[0393] Prior to use, the assay plate was emptied over a sink and tapped thoroughly on a paper towel to ensure that the wells were completely emptied. Pre-incubated samples were added to the assay plate in duplicate at 50 μl per well and the plate was incubated at RT for 10 min.

[0394] Plates were washed 3 times with PBS-T using a 384-well automated plate washer. 50 μl of secondary goat anti-human-HRP antibody diluted 1:15.000 in blocking buffer was added per well followed by incubation for 1 h at RT.

[0395] Plates were washed three times with PBS-T using a 384-well automated plate washer. The two ELISA substrate components were mixed 1:1 in the appropriate volume and 50 μl was added to all wells. Immediately after addition, the luminescent signal was quantified in an Evision microtiter plate reader.

[0396] IgG binding curves were fitted and IC50 values ​​calculated using the equation: Sigmoidal, 4PL, X is log(concentration) Y=Bottom+(Top-Bottom) / (1+((X^HillSlope) / (IC50^Hillslope))).

[0397] result Binding of GM37 variant 2 to monomeric and fibrillar alpha synuclein was characterized by competitive ELISA. The assay was performed in two independent replicates per day using one monomeric alpha synuclein preparation and three different alpha synuclein fibril batches, and was repeated for another three days. The antibody concentration used (20 ng / ml final or 133 pM) was shown prior to this assay to be in the dynamic range of the antibody measurement curve when a 1.4 μg / ml monomer solution was used to coat the wells, allowing differentiation of free antibody levels.

[0398] Based on six independent competitive ELISA assays, GM37 variant 2 has an average IC50 value for monomeric alpha-synuclein of 183.9±20.5 nM and an average IC50 for fibrillar alpha-synuclein of 2.9±4 nM (see table below). Based on these values, GM37 variant 2 has an average preference of 64.1±5.2-fold, approximately 65-fold, for binding to fibrillar alpha-synuclein.

[0399] The table shows six specific experiments on the binding properties of GM37 variant 2 to monomeric and fibrillar alpha-synuclein.

[0400] [Table 9]

[0401] As shown in Figure 3, the IC50 value of GM37 variant 2 is calculated from accurate curve fitting and full titration curves of both monomeric and alpha synuclein fibrils. In addition, the reproducibility of the assay across measurements was good with IC50 CV(%) values ​​of 11.2% (monomeric alpha synuclein) and 12.3% (fibrillar alpha synuclein). Similarly, the calculated fold preference for binding of GM37 variant 2 to aSN fibrils presented a low CV value of 8.1%. Of note, the values ​​are based on the analysis of three different batches, demonstrating the stability of the assay.

[0402] Similar analysis was performed using Fab fragments derived from GM37v2 to distinguish between avidity contributions due to the IgG format or due to the presence of fibril-induced conformational epitopes. Fab fragments have no preference for binding to fibrillar alpha-synuclein. Taken together, these data indicate that the preference of GM37v2 for binding to fibrillar alpha-synuclein is driven solely by avidity, with no indication of fibrillar selectivity or specific conformational fibril epitopes.

[0403] In summary, the competition ELISA experiments show that GM37 variant 2 has approximately 65-fold preferential binding to fibrils compared to monomeric alpha-synuclein, which can be referred to as the avidity increase in binding and was used to develop the dosing regimen model described in Example 1.

[0404] Furthermore, we also assessed the binding affinity / avidity of GM37var2 to MSA and PD brain homogenates enriched for aggregated insoluble alpha-synuclein by ELISA (data not shown). The EC50 of GM37var2 for brain-derived alpha-synuclein oligomers and fibrils in these samples was shown to be approximately 0.09-0.16 nM, supporting the clinical relevance of the sub-nanomolar binding to fibrils seen with the recombinant material in the experimental setup described above.

[0405] Example 3 - Single Ascending Dose (SAD) Study of Antibodies for Use According to the Invention Exemplifying by G37 Variant 2 This was an interventional, randomized, double-blind, group-sequential, placebo-controlled, single-ascending dose study conducted to determine the safety, tolerability, PK, and pharmacodynamic properties of GM37 variant 2 in healthy non-Japanese and Japanese subjects (Part A) and patients with PD (Part B).

[0406] Part A consisted of six sequential arms (cohorts A1-A6): -Cohorts A1-A3: 8 healthy subjects per cohort: 6 randomized to GM37v2 and 2 randomized to placebo. - Cohorts A4-A6: 11-12 healthy subjects per cohort stratified by ethnicity aiming for equal numbers of non-Japanese and Japanese; per ethnic group: 4 subjects randomized to GM37v2 and 1-2 subjects randomized to placebo.

[0407] Part B consisted of two cohorts (Cohorts B1 and B2): -Cohorts B1 and B2: 7-8 patients with Parkinson's disease (PD): 6 patients randomized to GM37v2 and 1-2 patients randomized to placebo. Dose range was 75-9000mg; exact dose increments were determined at dosing conferences. Part A: 6 doses tested in healthy subjects; 75mg-225mg-750mg-2250mg-4500mg-9000mg. Part B: 2 doses tested in PD patients; 2250mg and 9000mg. · GM37v2 and placebo doses were administered by intravenous (IV) infusion over a 60 minute period (± 10 minutes). Within each cohort, the first 2 subjects / patients received either GM37v2 or placebo (1:1) and therefore served as sentinel subjects / patients to assess safety and tolerability before dosing the remaining subjects / patients. In cohorts A1, A2, A3, B1, and B2, up to six subjects received GM37v2 or placebo (5:1) for at least 14 days after the sentinel subjects were dosed and their safety data reviewed. The six subjects were dosed in a staggered interval, with up to three subjects starting on the same day (with a maximum overlap of 30 minutes between each infusion) and with a minimum of one day interval before the start of the next staggered group. In cohorts A4, A5, and A6, 9-10 subjects received GM37v2 or placebo for at least 14 days after the sentinel subjects were dosed and their safety data reviewed (7:2 in cohort A4, 7:3 in cohort A5, and 6:3 in cohort A6). The 10 subjects were dosed in a staggered interval, with a maximum of 3 subjects starting on the same day (with a maximum overlap of 30 minutes between each infusion) and with a minimum of 1 day interval before the start of the next staggered group. Parts A and B were run in parallel. However, in cohort B1, the dose administered to patients with PD did not exceed the dose tested in healthy subjects in part A. Initiation of cohort B1 was based on the safety and tolerability evaluation of the first 6 subjects in cohort A4 (i.e., at the same dose). All subjects / patients were screened within 3 and 7 weeks, respectively, prior to dosing with GM37v2. Eligible subjects / patients were kept in the clinic 2 days before dosing (day -2) until 3 days after dosing (afternoon of day 4). Subjects / patients then had regular outpatient visits until the final evaluation at 12 weeks after dosing with IMP. Safety and tolerability were evaluated throughout the study. Blinded safety and tolerability data, preliminary pharmacokinetic data, and preliminary peripheral blood and CSF pharmacodynamics (target engagement) data for Part A were reviewed and discussed at a dosing conference prior to dose escalation and initiation of each cohort in Part A. Dose escalation for the second cohort in Part A (Cohort A2) was based on a 4-week evaluation of safety data from the first cohort (Cohort A1), and for each subsequent cohort in Part A, dose escalation was based on at least a 2-week evaluation of safety data from the previous cohort in Part A.

[0408] Pharmacokinetic results: Following IV infusion of GM37v2, in non-Japanese subjects, median tmax occurred within 8-90 minutes after the end of the infusion (individual range of 1.00-5.00 hours after the start of the infusion), in Japanese subjects, median tmax occurred within 15-150 minutes after the end of the infusion (individual range of 1.00-5.00 hours after the start of the infusion), and in patients with PD, median tmax occurred within 38-45 minutes after the end of the infusion (individual range of 1.00-5.00 hours after the start of the infusion). By the end of the infusion (1 hour after administration), Cmax was not reached in the majority of subjects / patients (i.e., 35 of 41 subjects who received GM37v2 in Part A and 10 of 12 patients who received GM37v2 in Part B). There was no clear effect of GM37v2 dose on tmax for healthy subjects (Japanese or non-Japanese) or patients with PD, with similar medians and overlapping ranges between dose groups. Following Cmax, the "free" concentration of GM37v2 in plasma declined in a multi-step manner and was quantifiable up to the last pharmacokinetic sample collected for all subjects / patients in both Parts A and B (Day 84 for all except one subject in Cohort A5, whose last sample was collected on Day 63). Clearance was found to have an approximate overall mean CL of 0.01 L / hour (0.24 L / day) (range 0.00883-0.0121 L / hour) for all dose groups and parts of the study, with an approximate overall mean t1 / 2 of approximately 700 hours (29 days; range 565-843 hours); for comparison, endogenous immunoglobulin G1 has a CL of 0.21 L / day and a t1 / 2 of 21 days. GM37v2 exposure (Cmax and AUC) was comparable between Japanese and non-Japanese subjects, and between healthy subjects and patients with PD. Half-life, clearance, and volume of distribution were comparable across all doses and between Japanese and non-Japanese subjects, and between healthy subjects and patients with PD. The pharmacokinetics of "free" GM37v2 were linear, resulting in an approximately dose-proportional increase in exposure with increasing dose over the dose range of 75 to 9000 mg in Part A and the dose range of 2250 to 9000 mg in Part B. "Free" GM37v2 crossed the blood-brain barrier and was detectable in all CSF samples collected on Days 3 and 21 from subjects / patients in Parts A and B, except for one subject (75 mg GM37v2) who had "free" GM37v2 below the limit of quantification in CSF on both Days 3 and 21. CSF:plasma ratios ranged from 0.0955% to 0.137% on Day 3 and 0.164% to 0.512% on Day 21. CSF:plasma ratios were comparable at all doses and between healthy subjects and patients with PD. Median (including quartiles) plasma concentrations of GM37 variant 2 (ng / mL) for healthy subjects (cohorts A1–A6) and patients (cohorts B1–B2) at each dose level versus time are displayed in Figure 4a and b.

[0409] Pharmacodynamic results In parts A and B, a dose-dependent decrease in plasma "free" alpha synuclein as a result of GM37v binding was observed beginning immediately after infusion of GM37v2. A similar pattern was evident for free:total alpha synuclein, although with significantly less variability (Figures 6 and 7). Following every dose of GM37v2, there was a transient increase in "total" alpha synuclein concentrations, likely due to binding to GM37v2, returning to baseline before day 84. There were no significant differences in "free" or "total" plasma alpha-synuclein levels between Japanese and non-Japanese subjects in the 2250, 4500, and 9000 mg dose groups. Mean plasma "free" alpha-synuclein levels did not return to baseline by the last sampling on Day 84 for healthy subjects in Part A or patients with PD in Part B. · At the highest doses of GM37v2 (4500 and 9000 mg), there was a small, dose-dependent decrease in the mean free:total alpha-synuclein CSF ratio on day 3 in both healthy subjects in Part A and patients with PD in Part B. In Part A, the mean change from baseline in the free:total alpha-synuclein CSF ratio at day 3 ranged from -27.9% to 8.06%, with the greatest decreases (-6.56% and -27.9%) occurring at the highest doses of 4500 and 9000 mg. At day 21, the mean free:total ratio of alpha-synuclein decreased from baseline in placebo (-2.15%) and by -1.7% to -15.1% in the 225 to 4500 mg GM37v2 dose groups. In Part B, this ratio changed from baseline by -8.08% at day 3 for the 2250 mg dose of GM37v2 and by -38.8% at day 3 and -36.6% at day 21 for the 9000 mg dose of GM37v2. "Free" plasma alpha synuclein and plasma free:total alpha synuclein could be fitted to a maximum inhibition (Emax) model, where increasing concentrations of GM37v2 were associated with lower plasma "free" synuclein levels and free:total plasma alpha synuclein ratios. The estimated drug concentrations required to produce 50% of the maximum inhibition values ​​were 11049ng / mL for "free" plasma alpha synuclein and 6917ng / mL for the free:total plasma alpha synuclein ratio (Figure 8).

[0410] Targeted engagement results: In addition to target engagement of monomeric alpha synuclein in plasma (Figure 8), the inventors of the present invention were also surprisingly able to demonstrate target engagement of monomeric alpha synuclein in the CSF of Parkinson's disease patients after a single dose with GM37v2 (Figure 11). To our knowledge, this is the first time that such target engagement has been demonstrated in a clinical trial with an antibody against alpha synuclein, although other such antibodies with similar or stronger monomer binding have been tested in clinical settings. For example, prasinezumab (PRX002 or 9E4) has been reported to have 20 nM binding to monomeric alpha-synuclein, but clinical trials of this antibody, including in Parkinson's disease patients, and at doses of 0.3 mg / kg to 60 mg / kg, have shown no effect on free alpha-synuclein in CSF (Jankovic et al., JAMA Neurol. 2018 Oct;75(10):1206-1214).

[0411] The high dose in the SAD study above (9000 mg) was chosen to reach concentrations in the CSF comparable to those expected after multiple administrations at 4500 mg doses following accumulation of the antibody. Figure 11 shows the change from baseline in free / total alpha synuclein measured in CSF samples obtained on days 3 and 21 from patients with Parkinson's disease, in %, with a reduction from baseline of approximately 36% in free / total monomeric alpha synuclein at the 9000 mg dose. Since the binding of GM37v2 to oligomeric forms is approximately 65 times higher, this supports the inventor's estimation that even higher target engagement of aggregated oligomeric alpha synuclein in the CNS can be achieved, up to 95%, as predicted by the model (see Figure 1 and Example 1). These data support that the dosing regimen of the present invention can slow down disease progression in synucleinopathies by neutralizing and clearing oligomeric alpha synuclein bound by antibodies in the extracellular matrix.

[0412] Example 4 - Population PK (PopPK) analysis from data collected in Example 3 The objective of the PopPK analysis was to obtain PK data to support the dose selected for clinical trials in patients with synucleinopathy. A PopPK model was developed to describe the PK time course of GM37 variant 2 after a single dose in healthy subjects and to explore the effect of covariates on relevant PK parameters.

[0413] In total, 694 PK measurements from 41 subjects from part A (cohorts A1–A6) were included in the PopPK analysis. Plasma concentrations of GM37 variant 2 were analyzed using a nonlinear mixed-effects method. Starting with a simple one-compartment model, structural models were developed with increasing complexity. Different interindividual variability (IIV) models and different residual variability models were considered to arrive at a stable structural model. Covariate relationships were then examined in a stepwise manner (forward inclusion phase using a significance criterion of p<0.01 and backward exclusion phase using a significance criterion of p<0.005) to explore the effects of individual subject characteristics (weight [WT], height [HT], age, sex, race, and baseline alpha-synuclein) on model parameters. Model selection was informed by numerical checks (e.g., parameter estimates and respective precision), graphical goodness-of-fit checks, and assessment of scientific and physiological plausibility using objective function values.

[0414] PopPK Results Dose-normalized plasma concentrations of GM37 variant 2 versus time (log scale) are presented in Figure 5 (all subjects), where the solid line is the mean value and the grey lines and circles are individual data. No clear deviation from dose linearity was observed.

[0415] The overall PK profile of GM37 variant 2 is described by a three-compartment model with first-order elimination from the central compartment. CL (clearance) and Vss (volume of distribution) were estimated to be 0.254 L / day and 8.64 L, respectively. The geometric mean terminal elimination half-life t1 / 2 of GM37 variant 2 was estimated to be 30.5 days (CV of 17.5%). IIV was estimated to be CV of 16.1% for CL and 10.1% for V1 (volume of distribution of the central compartment). Residual variability was low (6.91%). There was no significant relationship between predicted individual CL and dose, confirming the dose-proportional PK of GM37 variant 2. ADA was detected in 3 of 41 subjects receiving GM37 variant 2, and no obvious differences were seen in the PK of GM37 variant 2 in these subjects. Among the major covariates (WT, HT, age, sex, race (including Japanese), albumin, and baseline alpha-synuclein), only WT and HT had a statistically significant effect on PK parameters.

[0416] The WT had the greatest effect on PK parameters, with a 25% decrease in CL in reference subjects with the 5th percentile of baseline covariate values ​​and a 24% higher CL in reference subjects with the 95th percentile of baseline covariate values. The effect of the WT on steady-state exposure (AUCss and Cmax;ss) appeared to be modest (approximately 0.8-1.3-fold for AUCss) in the 5th and 95th percentiles of the baseline covariate distribution compared with the reference subject (74.6 kg and 171 cm), supporting a flat fixed dosing regimen.

[0417] The final model showed a good agreement between the predicted and observed data values.

[0418] Example 6 - Antibodies for use according to the invention and their binding to human alpha synuclein Using competitive ELISA experiments, we assessed the impact of the change at residue 54 on the ability of GM37wt to bind alpha synuclein in solution. By assessing the concentration of synuclein that can inhibit antibody binding to synuclein-coated ELISA plates, we showed that the GM37 variants maintained the same binding properties and bound to alpha synuclein in this specific assay design with IC50s of 1-2 nM (Figure 9). Competitive assays were performed using a fixed concentration (0.3 μg / ml) of each of the following antibodies: GM37 (designated GM37wt), GM variant 1, GM variant 2, and GM37 variant 3, pre-incubated with human alpha synuclein ranging from 0-1000 nM for 60 minutes at room temperature. Remaining unbound antibody was captured and measured by electrochemiluminescence (MSD, Gathersburg, MD) on ELISA plates coated with 100 ng / ml recombinant human alpha synuclein using an anti-human detection antibody. The IC50 of the interaction was 1.9 nM, 1.6 nM, 2.1 nM and 1.4 nM for GM37, GM variant 1, GM variant 2 and GM37 variant 3, respectively, in this specific assay (determined using Prism Graphpad®).

[0419] Example 6A - Determination of the exact KD for binding of GM37v2 to monomeric alpha synuclein The exact KD value for binding of GM37 variant 2 to monomeric α-synuclein was determined using repeated SPR analysis in a standardized setup.

[0420] The SPR setup was as follows: anti-human IgG antibody equivalent to approximately 3000RU was amine-coupled to alpha-synuclein antibody on a CM4 chip (Cat#BR1008-39 from GE Healthcare) following the protocol from GE. The alpha-synuclein antibody was diluted to 1 μg / ml and injected with a contact time of 30 seconds using either PBS-P with additive: 1 mg / ml BSA (A7979-Sigma Aldrich) and additional 0.05% P20 (total 0.1%) or HBS-P with additive: 5 mg / ml BSA and additional 0.05% P20 (total 0.1%) as running buffer, resulting in capture levels of approximately 50-200RU.

[0421] Monomeric α-synuclein was used in a 3-fold dilution series starting at 600 nM. Removal of captured antibody (regeneration) was achieved by injection of 3M MgCl2 regeneration buffer provided in the Capture Ab kit (GE Healthcare). Assays were run in either PBS-P with additive: 1 mg / ml BSA (A7979-Sigma Aldrich) and additional 0.05% P20 (total 0.1%) or HBS-P with additive: 5 mg / ml BSA and additional 0.05% P20 (total 0.1%).

[0422] Data was analyzed using Biacore S200 Evaluation software 1.1. KD and kinetic parameters were determined by global fitting of sensorgrams to a 1:1 kinetic model. Results of replicate analyses are shown in the table below.

[0423] [Table 10]

[0424] Based on repeated SPR analyses using a standardized setup, binding of GM37 variant 2 to monomeric α-synuclein has an average measured KD of 36 nM (SD 7 nM).

[0425] Similar KDs were found for binding of GM37 variant 2 to human, rabbit and rodent monomeric alpha-synuclein (data not shown), thus this parameter was stable and reproducible for measurements from different species. These data confirm that the underlying modeling performed to arrive at the dosing regimen of the present invention is based on the well-established binding properties of GM37v2, thus supporting the validity of the estimates of CSF / ISF target engagement of, for example, aggregated alpha-synuclein.

[0426] Example 7 - Ability of antibodies for use according to the invention to block synuclein seeding activity in primary neuronal cultures The level of seeding was measured using an antibody specific for phospho-synuclein. GM37 (named GM37wt), GM37 variant 1, GM37 variant 2 and GM37 variant 3 were all able to block seeding as measured by phospho-synuclein signal (Figure 10). Furthermore, the level of inhibition was the same for all four antibodies. This cell-based data further confirms that amino acid 54 in the VH domain is not required for binding affinity to human alpha synuclein or inhibition of seeding in primary cell-based assays. Furthermore, we found that all three of these antibodies are producible using standard expression and purification methods. Interestingly, one of the variants, N54Q, showed an improvement in production over the other variants, which is very important when antibodies are commercially manufactured on a large scale. These data support the possibility of reducing the potential risk of deamidation by replacing asparagine (N) with another amino acid without considering the loss of potency.

[0427] Several studies have shown that exogenous addition of recombinant alpha-synuclein fibrillar aggregates enters cells, recruits endogenous alpha-synuclein, and induces aggregation and phosphorylation of alpha-synuclein in vitro and in vivo, which resembles LB (Volpicelli-Daley et al. 2011, Luk et al. 2012a, Luk et al. 2012b, Recasens et al. 2013, Peelaerts et al. 2015). To study the seeding of endogenous mouse alpha-synuclein with recombinant alpha-synuclein seeds, mouse primary cortical neurons prepared as described above are seeded in 96-well plates (15,000 cells per well). On day 5 of in vitro culture (DIV), 50% of the medium is replaced and supplemented with cytosine arabinoside (1 uM final concentration). At day 6 DIV, half of the medium was replaced with alpha synuclein fibrillar material, either crude fibril seeds or pure seeds, along with glial cell conditioned medium. Crude fibril seeds were made from recombinant monomeric human alpha synuclein isolated from bacteria, the monomer was filtered through an Amicon Ultra 100.000 cut-off filter (Millipore Cat. No. UFC510096) and adjusted to a concentration of 1 mg / ml in PBS, pH 7.4. To make fibril crude seeds, the monomer solution was incubated in a thermomixer at 37 °C with continuous mixing (800 rpm) until steady state was reached (assessed by daily measurements with Thioflavin S). A drop of mineral oil was added to cover the solution to minimize evaporation. The total incubation time was 5-7 days. Pure seeds were made from total fibril seeds, which were purified by centrifugation of them, and the aggregated pellet was resuspended in fresh PBS and sonicated. Antibodies are added together with alpha synuclein crude seeds once at DIV 6. Half of the medium in primary neurons is replaced with glial cell conditioned medium every week to maintain them until DIV 21.Neurons were fixed and stained for phospho-synuclein using a rabbit antibody specific for phosphorylation of alpha-synuclein at amino acid S129 (Abcam 51253) followed by a fluorescently labeled anti-rabbit antibody, and fluorescence was quantified using an automated fluorescence microscope, Cellomics Arrayscan. In one channel, nuclei were detected and the number of valid cells was defined. Phosphorylated alpha-synuclein spots were detected in another channel in a predefined ring-like region around the nucleus (representing the cell cytoplasm). The average number of spots per cell was calculated.

[0428] For fractionation studies, cells were harvested in phosphate-buffered saline (PBS) and centrifuged. The pellet was resuspended in 1% Triton buffer containing protease inhibitors. Samples were kept on ice for 15 min and subsequently sonicated. Samples were centrifuged at 100,000×g for 30 min at 4C. The supernatant is collected and labeled as the soluble fraction. The pellet was washed once with Triton buffer, resuspended in 1% SDS buffer and then sonicated. Samples were centrifuged again at 100,000×g for 30 min. The supernatant was collected as the insoluble fraction. Protein concentration was measured, samples were run on a 4-12% SDS_PAGE gel, blotted onto a membrane, and alpha synuclein and phosphorylated alpha synuclein (S129P) were detected by 4B12 / 1904 antibody (Thermo scientific: MA1-90346-human synuclein), S129P-asyn antibody (Abcam 51253), and mouse synuclein antibody (Cell Signaling-D37A6), respectively.

[0429] To test whether antibodies can inhibit seeding, alpha-synuclein seeds were used at a concentration of 6.6 nM (10 ng / well). Different concentrations of antibodies and alpha-synuclein seeds were added together on DIV day 6 to perform a dose response (starting with a highest antibody concentration of 133 nM and decreasing to 133 pM). Neurons were fixed again and stained for phospho-synuclein (Abcam 51253) and fluorescence from cells was quantified using an automated fluorescence microscope, Cellomics arrayscan. Spots / puncta per cell were counted in a Cellomics arrayscan. Both antibodies GM37, GM37v2 and antibody GM285 reduced phosphorylation of alpha-synuclein in neurons in a dose-dependent manner, with similar maximal inhibition (approximately 70-75%) for GM37, GM37v2 and 285 and IC50s of approximately 5 nM. Fractionation of cellular proteins into soluble and insoluble fractions following treatment with antibodies at the highest concentration (133 nM) shows that both antibodies, GM37, GM37v2 and GM285, inhibited cleavage of recombinant crude seeds and accumulation of C-terminal truncated fragments (CTa-syn) and reduced accumulation of phosphorylated endogenous mouse alpha-synuclein and aggregated forms of mouse alpha-synuclein in the insoluble fraction.

[0430] Example 7A - Quantification of free and total alpha-synuclein in human CSF and plasma Free (unbound) and total alpha synuclein levels were measured in CSF and plasma using the ECLIA (MSD) quantification assay. MSD Gold streptavidin plates were washed three times with wash buffer (300 μl / well) and then the wells were emptied. For the assay of free alpha synuclein, all wells were then blocked with 150 μl of Superblock T20 for 1 hour at room temperature, 500 RPM, followed by the addition of 50 μl of coating antibody (GM37v2) at 1 ng / ml in PBS. For the assay of total alpha synuclein, plates were simultaneously blocked and coated with 25 uL of coating antibody (GM37v2) at 1 ng / ml in diluent 49. After 1 hour incubation at room temperature, 500 RPM, plates were washed again three times with wash buffer (300 uL / well) and then the wells were emptied. Next, 25ul of detection antibody was added to all wells along with 25uL of diluted samples to generate alpha synuclein calibration curves (4ng / mL to 0.030ng / ml) and QC samples were run in duplicate. For free alpha synuclein assays, samples were prediluted 5x in Diluent 49, whereas for total alpha synuclein assays, samples were prediluted 500x in Diluent 49, followed by heat treatment at 95°C, 500RPM, and samples were centrifuged at 13.000RPM for 10 minutes at room temperature before being transferred to the assay plate. Samples, calibrators, QC samples and detection mAb were incubated at room temperature for 2 hours at 500RPM. The plate was then washed 3 times with wash buffer (300μL / well), followed by emptying the wells and adding 150μl of Read Buffer T (1x) to all wells of the plate. ELC responses were measured within 5 minutes after adding read buffer to the MSD streptavidin plate using a QuickPlex SQ 120. Alpha synuclein sample levels were interpolated using a 4PL curve fit of the standard curve.

[0431] Example 8 - Methods for confirming the clinical efficacy of dosing regimens provided by the present invention for treating synucleinopathy or propathic synucleinopathy The clinical efficacy or therapeutic effect of the dosing regimen provided by the present invention can be confirmed, for example, by performing a randomized, double-blind, placebo-controlled clinical trial. Such a study can investigate the efficacy or therapeutic effect of the antibody of the present invention administered by intravenous infusion at a dose of 700 mg or more and less than 7000 mg every 3-5 weeks. The infusion can be for a period of 15 minutes ± 5 minutes, 30 minutes ± 10 minutes or another suitable time frame. The dosing regimen to be tested can be a fixed dose of the present invention, such as 1050 mg, 2100 mg and / or 4200 mg, administered intravenously about every 4 weeks for 24 weeks, 48 ​​weeks, 72 weeks, 96 weeks or more for a period of 24 weeks, 48 ​​weeks, 72 weeks, 96 weeks or more for a period of 24 weeks, 48 ​​weeks, 72 weeks, 96 weeks or more for a period of 24 weeks, 48 ​​weeks, 72 weeks, 96 weeks or more for a period of 24 weeks, 48 ​​weeks, 72 weeks, 96 weeks or more for a period of 24 weeks, 48 ​​weeks, 72 weeks, 96 weeks or more for a period of 24 weeks, 48 ​​weeks, 72 weeks, 96 weeks, 96 weeks, or more for a period of 24 weeks, 48 ​​weeks, 72 ... In such clinical trials, the control group, i.e. the inactive arm of the trial, may be a classical placebo arm in which a group of patients is included in the trial and receives a suitable placebo treatment. However, data from the active arm of such trials may also be compared against historical data on disease progression obtained from relevant patients suffering from the type of synucleinopathy treated in the trial. Finally, the therapeutic effect in the active arm of such trials can be quantified by comparing disease progression in treated patients with a group of placebo control patients, which control group is further strengthened by historical data on disease progression obtained from patients with synucleinopathy. An example of such a clinical trial is NCT05104476 (National Clinical Trial Number), the protocol of which is incorporated herein by reference.

[0432] Patients to be included in such studies are those suffering from a synucleinopathy or prodromal synucleinopathy as defined by current consensus diagnostic criteria. Such patients may be diagnosed with MSA, e.g., definite MSA, probable MSA, clinically definite MSA, clinically probable MSA, MSA type C or MSA type P; PD; or DLB according to known diagnostic methods and criteria or exhibiting clinical markers for prodromal synucleinopathy such as RBD or other prodromal markers described herein.

[0433] The outcome measure for quantifying clinical efficacy or treatment effect can be any suitable method that measures a slowing or delay in disease progression as assessed, for example, by log change in Unified Multiple System Atrophy Rating Scale (UMSARS) Part I and Part II Total Score (UMSARS TS), or in modified UMSARS (mUMSARS), or in abbreviated UMSARS (aUMSARS) from baseline to end of treatment (EoT), i.e., by the end of a treatment period of 24 weeks, 48 ​​weeks, 72 weeks, 96 weeks or more.

[0434] An outcome measure for quantifying clinical efficacy or therapeutic effect can also be measuring the deceleration or delay in disease progression, for example, as assessed by the logarithmic change from baseline to EoT in UMSARS Part I, modified UMSARS (mUMSARS) and / or UMSARS Part II scores. Such disease progression can also be assessed, for example, as the change from baseline to EoT in UMSARS TS, UMSARS Part I, mUMSARS and / or UMSARS Part II scores. Disease progression can also be assessed by the logarithmic change from baseline to EoT in simplified UMSARS (aUMSARS), or as the change from baseline in brain volume measured by volumetric MRI (vMRI), or as the change from baseline in neurofilament light chain (NfL) blood levels.

[0435] Clinical efficacy or therapeutic effect may be assessed at the EoT, for example, as the change from baseline in one or more parameters selected from the following: Schwab and England Activities of Daily Living (SE-ADL) score; as the change from baseline in the Clinical Global Impression-Severity of Illness (CGI-S) score; as the change from baseline in the Patient Global Impression-Severity of Illness (PGI-S) score; as the change from baseline in the Observer-Reported Global Impression-Severity of Illness (OGI-S) score; as the change from baseline in the Composite Autonomic Symptom Score Select Change (COMPASS Select as change from baseline in the UMSARS Part IV score; as change from baseline in speaking, swallowing, falls, and gait as assessed by the UMSARS Part I item scores; as change from baseline in the frequency, causes, and effects of falls as assessed by Fall Diary Periods; as change from baseline in the EuroQol 5-Dimension, 5-Level (EQ-5D-5L) score; as change from baseline in brain volume as measured by volumetric MRI (vMRI); as change from baseline in tissue integrity as measured by diffusion tensor imaging (DTI) MRI; as change from baseline in neurofilament light chain (NfL) blood levels; as change from baseline in heart rate, blood pressure, and orthostatic symptoms as assessed by the UMSARS Part III;as change from baseline in gait parameters or frequency of falls assessed by a digital wearable sensor-based device capable of tracking relevant gait parameters and / or registered falls; as change from baseline in cerebral blood flow measured by arterial spin labeling (ASL) MRI; as change from baseline in CSF concentrations of t-tau and NfL; or as change from baseline in pathological species of α-synuclein in the CSF.

[0436] During the study, plasma and CSF samples will be collected at various time points, for example at baseline and one or more of 4, 6, 8, 12, 24, 36, 48, 60, 72, 88 and 96 weeks, to examine biological markers and exposure levels of the administered antibodies.

[0437] Experimental Section - Formulation Development The pharmaceutical formulations of the present invention may be prepared and / or analyzed and / or characterized by methods such as the analytical methods described below, which are well known in the pharmaceutical arts.

[0438] The examples and studies described below present work carried out by the inventors of the present invention to identify clinically stable pharmaceutical formulations comprising the antibody GM37 variant 2 (GM37v2).

[0439] A general description of the analytical methods used in Studies 1A, 1B, and 1C is presented below. GP-HPLC Gel permeation HPLC was performed on an Agilent 1200 HPLC system using a standardized TSK SWXL G3000 column. The mobile phase used was 0.2 M sodium phosphate (pH 7.0) at a flow rate of 1.0 mL / min. Sample injection volume was 50 uL. Approximately 250 ug of protein load was analyzed using a single measurement. Results were expressed to two decimal places as % monomer, % aggregates and % fragments in each sample.

[0440] Differential Scanning Calorimetry (DSC) DSC was performed according to the instrument's operating procedures. Samples were heated to 120° C. and the melting temperature was measured to determine formulation stability.

[0441] Dynamic Light Scattering (DLS) DLS was performed according to the instrument's operating procedure. DLS was used to determine the hydrodynamic radius of the sample by applying the Stokes-Einstein relationship. Particles present in the sample produce time-dependent scattering of light due to Brownian motion, and DLS monitors the light scattering using a highly sensitive detector.

[0442] The analysis was carried out on a Viscoteck 802DLS with associated OminiSIZE 2.0 software. Samples were analyzed in 10 replicates.

[0443] fine particles The absorbance of each sample at 340 nm and 620 nm was recorded as an indication of particulate levels and turbidity. Measurements were performed using 1 mL of undiluted product alone. Product formulation buffer was used as a blank and product absorbance readings were taken at 340 nm and 620 nm by a single operator. Results were reported to three decimal places.

[0444] Subvisible Particle Analysis Count particles by light-obscuring the test strips and measuring the results as required by USP <788> The results were reported according to the 1 mL principle. A 1 mL sample was used as a wash-through and discarded. Three readings were taken using 1 mL sample each and cumulative results were reported.

[0445] SDS-PAGE (reduced and non-reduced) Analysis using Novex Pre-cast Minigels, SimplyBlue SafeStain and Bio-Rad GS-800 Imaging Densitometry Samples were denatured by heating and treatment with sodium dodecyl sulfate. For reducing condition analysis, disulfide bonds were broken with 2-mercaptoethanol.

[0446] Polypeptides were separated based on molecular size by electrophoresis through 4%-20% gradient SDS PAGE gels. After separation, protein binding was visualized with SimplyBlue™ SafeStain (Coomassie Blue G-250). Polypeptide binding was quantified by white light densitometry using a Bio-Rad GS-800 densitometer. Standard loading masses were 3ug (non-reducing conditions) or 5ug (reducing conditions).

[0447] Example A - pH of formulation and buffer type Example A focuses on identifying the most preferred pH range and buffer type for the GM37v2 formulation and consists of two separate studies, hereafter denoted Study 1A, which tests eight formulation candidates, and Study 2A, which tests 16 formulation candidates.

[0448] Study 1A: Formulation pH and Buffer Type Eight formulation candidates, Formulation 1 to Formulation 8, were investigated and designated F1 to F8 (Table 1).

[0449] [Table 11]

[0450] The stability of GM37v2 was evaluated in eight formulation candidates at a target storage temperature of 5° C.±3° C. and at an elevated temperature of 40° C.±2° C. with RH up to 30%. The concentration of GM37v2 in each formulation buffer was 30 mg / ml.

[0451] The stability of each formulation was measured by various well-known methods at baseline (time zero, week 0; T=0) and one week later (T=1, week 1). Additionally, stability studies for each formulation included application of the following analytical methods (Table 2).

[0452] [Table 12]

[0453] The results of this stability study are summarized below.

[0454] [Table 13]

[0455] Initial aggregate levels were pH dependent. Starting aggregate levels were higher in 25 mM sodium phosphate buffer at pH 7.5 and pH 7.0 compared to other formulations at T=0 week (F8 (Test 1A) and F7 (Test 1A) respectively). Aggregate levels were also higher in 25 mM sodium citrate buffer at pH 6.0 and pH 6.5 compared to other formulations at T=0 week (F4 (Test 1A) and F6 (Test 1A) respectively).

[0456] The formulation containing 25 mM sodium acetate buffer at pH 5.5 (F3, Test 1A) also demonstrated higher aggregate levels at T=0 week compared to the other 25 mM sodium acetate buffer formulations (F1 (Test 1A) and F2 (Test 1A)). No notable differences in fragment levels were observed between the formulations at T=0 week. All formulations demonstrated no significant changes in % monomer, % aggregates and % fragments upon 1 week storage at +5°C compared to their respective results at T=0 week. Aggregation at +40°C was pH and buffer dependent. Formulations F7 (Test 1A) and F8 (Test 1A) (25 mM sodium phosphate at pH 7.0 and 7.5, respectively) demonstrated the highest increase in aggregates upon 1 week storage at +40° C. compared to their results at T=0 week. Formulations F6 (Test 1A) (25 mM sodium citrate at pH 6.5), F3 (Test 1A) (25 mM sodium acetate at pH 5.5) and F4 (Test 1A) (25 mM sodium citrate at pH 6.0) also demonstrated an increase in aggregates after 1 week at +40° C., but to a lesser extent than Formulations F7 (Test 1A) and F8 (Test 1A). Formulations F1 (Test 1A), F2 (Test 1A) and F5 (Test 1A) demonstrated no significant change in aggregate levels after 1 week storage at +40°C compared to their respective T=0 week results. Formulation F1 (Test 1A) (25 mM sodium acetate, pH 4.5) demonstrated a significant change in fragment levels after 1 week of storage at +40°C, from 0.02% to 0.45%, compared to the T=0 week results. All other formulations demonstrated a slight increase (approximately 0.1%) in fragment levels after 1 week of storage at +40°C compared to their T=0 week results.

[0457] By GP HPLC, formulations F2 (Test 1A) (25 mM sodium acetate buffer at pH 5.0) and F5 (Test 1A) (25 mM histidine buffer at pH 6.0) were presented as the most suitable formulation candidates for further development.

[0458] Summary of Thermal Stability Results for Test 1A

[0459] [Table 14]

[0460] Four unfolding events were observed for formulations F1 (Test 1A), F2 (Test 1A), F3 (Test 1A), F4 (Test 1A) and F5 (Test 1A) at week T=0. Three unfolding events were observed for formulations F6 (Test 1A), F7 (Test 1A) and F8 (Test 1A). DSC profiles for IgG1 antibodies are typically expected to present three unfolding events. In this case, a slightly more complex pattern was observed at low pH, pH 4.5-6.0, resulting in four unfolding events, which were not observed in the higher pH formulations, pH 6.5-7.5. This may be due to different conformations of the product that are stabilized at different pHs. Formulation F1 (Test 1A) (25 mM sodium citrate at pH 4.5) had the lowest melting temperatures for the 1st, 2nd and 3rd unfolding event at T=0 weeks. Formulations at pH 6.0 (F5, Test 1A), pH 6.5 (F6, Test 1A) and pH 7.0 (F7, Test 1A), pH 7.5 (F8, Test 1A) had the highest melting temperatures for the first and second melting events detected in the measurements. The melting temperatures for all unfolding events were pH dependent. The melting temperatures increased with pH from pH 4.5 to pH 7.5. It was concluded that pH 6.0, 6.5, 7.0 and 7.5 demonstrated the highest predicted thermal stability by DSC.

[0461] Summary of results for high molecular weight species in Test 1A

[0462] [Table 15]

[0463] No high molecular weight species were detected in any of the formulations at T=0 week or after 1 week of storage at +5°C and +40°C. There were no significant differences between any of the formulations.

[0464] Study 2A: Formulation pH and buffer type In Study 2A of the second part of Example A, 16 different formulation candidates were prepared, labeled Formulation Nos. 1-16 (Table 6), covering a pH range of 4-7. This study investigated the effect of pH and buffer when different buffers were used for a given formulation candidate. In addition, the concentration of GM37v2 was varied from 25mg / ml to 150mg / ml. Finally, different tonicity adjusters / stabilizers were evaluated, including the arginine / glutamate combination, which has been shown to modify viscosity at high protein concentrations. The actual pH values, GM37v2 concentrations, viscosities, and osmolalities are listed in Table 7.

[0465] [Table 16]

[0466] [Table 17]

[0467] Osmolality measurement The osmolality of the solutions was measured using a freezing point depression instrument. The calibration of the osmometer is checked using Clinitrol 290 (3MA029).

[0468] Viscosity measurement Viscosity was measured using a m-VROC™ viscometer by Rheosense equipped with an AlO tip. The shear rate employed is specified by the results. The viscometer was temperature controlled using a ThermoCube thermoelectric cooler and samples were delivered using a Hamilton 100uL syringe (81060). Viscosity was calibrated using neat isopropyl alcohol and measured at 25°C.

[0469] Summary of viscosity results for test 2A Viscosity values ​​were roughly grouped by GM37v2 concentration. At about 25 mg / mL, the viscosity values ​​averaged 1.2 cP. Around 50 mg / mL, the values ​​increased to about 1.5 cP. At GM37v2 concentrations around 100 mg / mL, the average value increased to about 2.3. Finally, at about 150 mg / mL, the viscosity values ​​ranged from 3.8 to 4.3. These viscosity levels are fairly low for formulations containing monoclonal antibodies, especially at high antibody concentrations. Thus, colloidal stability and tendency to self-associate appear to be fairly low for GM37v2 in the formulation candidates tested. These data also indicate to the inventors that clinically suitable high concentration formulations (>200 mg / mL) may be possible for GM37v2, which were further investigated.

[0470] Size Exclusion Chromatography (SEC) Measurements SEC analysis was performed on a Dionex UltiMate 3000 HPLC system equipped with a quaternary pump system and a variable wavelength detector. Briefly, the SE-HPLC method employs an isocratic flow rate at 1 mL / min, a column temperature of 20° C., and a detection wavelength of 220 nm with a Tosoh TSK gel G3000SWxL (#08541) HPLC column and a mobile phase of 50 mM sodium phosphate, 0.3 M sodium chloride, and a pH of 7.0. System suitability was assessed for the SE-HPLC method for each sequence over the course of these studies. The %CVs for the chromatographic attributes (retention time, peak area, and relative area) of the main peak (MP) were all less than 2%CV, and the relative areas sum to 100%.

[0471] Cation exchange chromatography (CEX) measurement CEX HPLC analysis was performed on a Dionex UltiMate 3000 HPLC system equipped with a quaternary pump system and a variable wavelength detector. Briefly, the CEX HPLC method employs a Dionex MabPac SCX-10, 4 x 250 mm (#074625) HPLC column with a flow rate of 1.5 mL / min, a column temperature of 35°C, and a detection wavelength of 220 nm. Samples for analysis were pre-diluted to approximately 7 mg / mL in 0.2 M NaH2PO4. The gradient program for the CEX HPLC method uses mobile phases A, B, and C. The gradient program is outlined below. Mobile phase A: 20 mM sodium phosphate, 2 mM sodium chloride, pH 5.8, 2.1 millisiemens. Mobile phase B: 20 ​​mM sodium phosphate, 2 mM sodium chloride, pH 8.0, 3.75 millisiemens. Mobile phase C: 10 mM sodium phosphate, 1 M sodium chloride, pH 6.0 Gradient conditions for CEX HPLC.

[0472] [Table 18]

[0473] System suitability was assessed for the CEX HPLC method for each sequence over the course of these studies. The %CVs for the chromatographic attributes (retention time, peak area, and relative area) of the main peak (MP) were all less than 2%CV.

[0474] Summary of Stability Results from Study 2A The stability of 16 formulation candidates was monitored using well-known SEC and CEX chromatographic techniques: T0 at baseline, T2 at 2 weeks, and T4 at 4 weeks (Tables 8 and 9).

[0475] [Table 19]

[0476] [Table 20]

[0477] Formulation F1 (Test 2A, pH 4, acetate) showed significant degradation at elevated temperatures, especially after 4 weeks. In addition, formulation F13 (Test 2A, pH 7, phosphate) also exhibited reduced stability compared to the other compositions. CEX test formulation 2 (Test 2A, pH 4, acetate) also demonstrated signs of accelerated degradation at 40° C. The optimum pH appeared to be around 6 based on this SEC and CEX data.

[0478] Conclusions / Summary of pH and Buffer Type Tests Test 1A: In Example A, Study 1A, two buffer and pH pairs were found to be suitable for proceeding into further formulation development and optimization, based on well-established physical and chemical stability ranges representative of the methods described above. The two buffer / pH pairs are: F5 (Test 1A) - about 25 mM histidine and a pH of about 6.0, and F2 (Test 1A) - about 25 mM acetate and a pH of about 5.0.

[0479] Histidine (Formulation 5, Test 1A) demonstrated better stability than citric acid at pH 6.0 as increased aggregates were observed by GP-HPLC with sodium citrate (Formulation 4, Test 1A) at pH 6.0.

[0480] pH 6.5 (Formulation 6, Test 1A) was deemed suitable by visual analysis, however GP-HPLC showed increased aggregates that were not seen at pH 5.0 (Formulation 2, Test 1A) and pH 6.0 (Formulation 5, Test 1A).

[0481] As noted above, the buffer ions selected for further development were histidine at pH 6.0 and sodium acetate at pH 5.0. In addition to these most preferred formulation candidates, a single formulation containing sodium citrate at pH 5.0 was also included in further development.

[0482] Test 2A: In summary, the well-established physical and chemical stability showing methods described above in Example A Test 2A indicate that the optimum pH is likely around 5.5-6.0. Viscosity remains very low even at GM37v2 concentrations of 150 mg / ml. The best buffer appears to be histidine, given this pH range. Among the excipients tested, NaCl may have some protective effect against chemical degradation, but arginine / glutamate may also be useful to improve physical stability.

[0483] Example B - Formulation excipients Example B focuses on identifying the most preferred excipients for clinically acceptable formulation of GM37v2 and consists of two separate studies, hereafter designated Study 1B, testing 11 formulation candidates, and Study 2B, testing 20 formulation candidates.

[0484] Test 1B: Formulation Excipients The stability of GM37v2 was evaluated in 11 formulations containing various excipients at target storage temperatures of 5±3° C. and elevated temperatures of 40±2° C. and following agitation and freeze / thaw treatments. The concentration of GM37v2 in each formulation was approximately 50 mg / mL.

[0485] The stability of each formulation was measured for each formulation candidate at baseline (time zero, month 0; T=0) and after one month (T=1, month 1).

[0486] [Table 21]

[0487] The stability tests for each formulation included the application of the following analytical methods.

[0488]

Table 22

[0489] Stirring measurement: The stirring protocol was started at T = 0 months. The samples were stirred at +5°C for 48 hours using a rotary stirrer set at 30 rpm. After stirring, the samples were stored at +5°C until tested.

[0490] Freezing / thawing measurement: The freezing / thawing protocol was started at T = 0 months. The samples were subjected to three freezing / thawing cycles consisting of approximately 18 hours at -70°C followed by approximately 4 - 6 hours at room temperature. After the third freezing, the samples were maintained in the freezer until tested.

[0491] Summary of the stability results for Test 1B:

[0492]

Table 23

[0493] · Low levels of aggregates were observed for all formulations at T = 0 months and after 1 month at +5°C. · Fragment levels < LOQ (0.01%) were observed for all formulations at T = 0 months and after 1 month at +5°C. · There were no changes in monomer purity, peak area, or height for any of the formulations after stirring at +5°C. · Except for F10 (Test 1B), there were no changes in monomer purity, peak area, or height for any of the formulations after freezing / thawing at -70°C. The aggregate level increased up to 3.05%. There were no changes in fragment levels. · At T = 1 month, formulations F1 (Test 1B), F4 (Test 1B), F6 (Test 1B), and F9 (Test 1B) demonstrated significant changes in aggregate % at +40°C. At T=1 month, all formulations demonstrated a significant change in % fragments at +40°C, with the highest percentage of fragments in formulations F5 (Test 1B), F6 (Test 1B), F9 (Test 1B) and F11 (Test 1B). Formulations containing PS80 (F4 (Test 1B), F6 (Test 1B), and F8 (Test 1B)) were observed to have a higher percentage of aggregates at both T=0 and T=1 months compared to formulations without PS80 (F3 (Test 1B), F5 (Test 1B), and F7 (Test 1B)). However, F11 (Test 1B), which also had PS80, showed the lowest amount of aggregates at T=1 month storage at +40°C. · Sodium chloride has a positive effect on aggregate levels (F3-F8 (trial 1B) vs. F9 (trial 1B)). Arginine had a negative effect on the levels of fragments (F5 (Test 1B), F6 (Test 1B) and F9 (Test 1B)), however F11 (Test 1B) without arginine also presented high levels of fragments. Citrate buffer has a positive effect on aggregate levels compared to acetate buffer at pH 5.0 (F11 (Test 1B) vs. F4 (Test 1B)). The lowest amount of aggregates and fragments was observed in formulation F2 (Test 1B) after storage at +40°C for T=1 month.

[0494] [Table 24]

[0495] At T=0 months, A340 was higher in the test control than in the other formulations. · F10 (Test 1B) demonstrated a significant increase in A340 after agitation and after freeze / thaw. · F1 (Test 1B) demonstrated a significant increase in A340 and A620 after agitation and after freeze / thaw. · F1 (Test 1B), F2 (Test 1B), F3 (Test 1B) and F5 (Test 1B) demonstrated a slight increase in A340 after storage for T = 1 month at +5°C. · F1 (Test 1B) and F11 (Test 1B) demonstrated a significant increase in A340 after storage for T = 1 month at +40°C. · F7 (Test 1B) demonstrated the smallest change in A340 after storage for T = 1 month at +40°C.

[0496] [Table 25]

[0497] [Table 26]

[0498] At T=0 months, the formulations showing the highest number of particles per container were F2 (Test 1B), F3 (Test 1B), F5 (Test 1B) and F7 (Test 1B). At T=1 month, the formulations stored at +5°C that showed the highest number of particles per container were F3 (Test 1B), F5 (Test 1B), F7 (Test 1B) and F8 (Test 1B). At T=1 month, the formulations stored at +5°C that showed the lowest number of particles per container were F6 (Test 1B), F10 (Test 1B) and F11 (Test 1B). Formulations containing PS80 consistently demonstrated lower SVP levels than formulations without it. Formulation F2 (Test 1B), the only other formulation in the study that did not contain PS80, showed fewer visible particles at T=0 and T=1 months compared to F3 (Test 1B), F5 (Test 1B) and F7 (Test 1B), suggesting that pH 6.0 may be more preferable than pH 5.0.

[0499] [Table 27]

[0500] No differences in band numbers were observed between formulations at T=0 months. After 1 month of storage at +5°C, no changes in band numbers were noted for any of the formulations. After 1 month of storage at +40°C, additional fragment bands were observed in all formulations. The highest number of additional bands was observed in formulations 5 (Test 1B), F6 (Test 1B) and F9 (Test 1B) after 1 month storage at +40°C. F5 (Test 1B), F6 (Test 1B) and F9 (Test 1B) are all formulated with arginine. No change in band number was observed after agitation or freeze / thawing in any formulation.

[0501] [Table 28]

[0502] At T=0 months, no significant differences were observed between the formulations. After storage at +5°C for 1 month, no significant changes in percentage purity were noted in any of the formulations. After 1 month of storage at +40°C, additional fragments and higher molecular weight bands were observed in all formulations, with a corresponding slight decrease in percentage IgG purity. The greatest decrease in purity was observed for formulations F4 (Test 1B), F5 (Test 1B), F6 (Test 1B) and F9 (Test 1B) after 1 month storage at +40°C. F5 (Test 1B), F6 (Test 1B) and F9 (Test 1B) are all formulations containing arginine. Formulation F2 (Study 1B) demonstrated minimal change in purity after 1 month storage at +40°C compared to the start of the study. No significant changes in the results of reducing SDS PAGE were observed in any formulation after agitation or freeze / thawing.

[0503] [Table 29]

[0504] Three melting temperatures were observed for all formulations at T=0 months, which is consistent with IgG molecules. Formulations F5 (Test 1B), F6 (Test 1B) and F9 (Test 1B) had the lowest temperature unfolding event at T=0 months, all formulated with arginine. Formulations F1 (Test 1B) and F10 (Test 1B) had the highest melting temperatures at T = 0 months (70.10°C and 71.42°C, respectively).

[0505] [Table 30]

[0506] No high molecular weight species were observed in any formulations stored at T=0 months and T=1 month at +5°C. Higher molecular weight species were detected in formulations F1 (Test 1B), F4 (Test 1B), F8 (Test 1B), F10 (Test 1B) and F11 (Test 1B) after 1 month at +40°C. F1 (Test 1B), F4 (Test 1B), F10 (Test 1B) and F11 (Test 1B) were all formulated with glycine. Higher molecular weight species were observed in formulations F1 (Test 1B) and F8 (Test 1B) after freeze / thaw. Higher molecular weight species were observed in formulations F6 (Test 1B) and F8 (Test 1B) after stirring.

[0507] Study 2B: Formulation Excipients In Study 2B, 20 different compositions were evaluated, all targeted to have a GM37v2 concentration of 225 mg / mL. This concentration was selected based on the low viscosity observed for the formulations tested in Study 2A. Actual GM37v2 concentrations ranged from approximately 216 mg / mL to 233 mg / mL. The pH range covered 5.1 to 6.4. Measured viscosities were consistently very low, ranging from 10.1 to 16.2 cP.

[0508] [Table 31]

[0509] [Table 32]

[0510] Summary of stability results from Study 2B The monomer content (or % of main peak, MP) at week T0 and various time points and temperatures are tabulated in Table 22. Initial samples displayed monomer content of 99.0-99.3%, with small amounts of dimer and fragments present. Storage at 5°C showed little change over 4 weeks, and a slight decrease when stored for the same period at 25°C. At 40°C, after 4 weeks the monomer content drops to about 96%. These losses were primarily due to an increase in dimer and HMW aggregates, with only minor changes in fragmentation.

[0511] [Table 33]

[0512] The relative area of ​​the main peak (MP) at week T0 and various time points and temperatures are tabulated in Table 23. The main peak was initially 74% or the relative area of ​​the chromatogram. There is little, if any, change during storage at 5° C. However, at 25° C., there is a significant decrease to about 71% after 4 weeks, and 50-60% upon storage at 40° C. for that length of time. Thus, even at these very high concentrations of GM37v2, the formulation appears to be chemically and physically stable with very little loss when stored at 5° C. and higher temperatures.

[0513] [Table 34]

[0514] Conclusions / Summary of Excipient Studies Test 1B: Based on all analytical methods described in Study 1B, the most suitable formulation candidates are Formulations F2 (Study 1B) and F3 (Study 1B).

[0515] Data were evaluated for each formulation, but trends were also evaluated by identifying consistent effects for specific excipients.

[0516] Formulation F3 (Test 1B) exhibited more sub-visible particles compared to formulation F2 (Test 1B), both at the start of the study and at T=1 month when stored at +5° C.

[0517] In comparing all formulations, the presence of PS80 reduced the overall number of subvisible particles and resulted in fewer visible particles. Formulation F4 (Test 1B), which differed in composition from F3 (Test 1B) by the presence of 0.02% PS80, was not a preferred formulation candidate since it had fewer subvisible particles than F3 (Test 1B), but also demonstrated poor purity by SDS PAGE and GP HPLC and the presence of aggregates by DLS and fines as determined by A340.

[0518] Therefore, the most promising formulation candidate is formulation F2 (Test 1B) (25 mM histidine, 100 mM sodium chloride, pH 6.0 and 100 mM sucrose). The rationale for selecting this candidate as optimal for further development is that the data for F2 (Test 1B) was the most favorable since it demonstrated the least amount of variation across all assays.

[0519] Test 2B: SEC data show that stability is optimal at pH 4.5 and 6.5, depending on storage temperature. Histidine buffers can be stabilizing, especially at concentrations >20 mM. NaCl has only a minor effect on stability. Higher GM37v2 concentrations result in a more rapid loss of monomer, presumably due to aggregation, but the loss is small over the time course tested. CEX data show that maintaining the relative amount of the main peak is optimal at pH 5.5-7.0. Again, histidine is preferred to maintain stability. NaCl can also be beneficial up to approximately 100 mM.

[0520] Considering these overall findings, the optimal pH is likely to be around 6.0, using a histidine buffer concentration of 20-40 mM. The nature of the tonicity modifier does not appear to be critical to obtaining a suitable clinical formulation, although NaCl appears to be the optimal of those tested in Study 2B.

[0521] Example C - Formulation Surfactant Finally, the present inventors investigated the effect of adding polysorbate 80 to the most promising formulation candidates derived from Examples A and B.

[0522] Test 1C: Nonionic surfactant (polysorbate 80) The stability of GM37v2 was evaluated in two identical formulations, one with polysorbate 80 (F2 (Test 1C)) and one without it (F1 (Test 1C)), with the other excipients being identical. The formulations were tested at the intended storage temperature of 5±3°C and at an elevated temperature of 40°C±2°C at RH ≤25%, and after agitation. The GM37v2 concentration in each formulation was 50.0mg / mL+ / -5.0.

[0523] [Table 35]

[0524] Both formulations were subjected to the stirring protocol beginning at T=0 months. Samples were stirred for 48 hours at +5° C. using a rotary stirrer set at 30 RPM. After stirring, samples were stored at +5° C. until examined.

[0525] The stability of each of the two formulations was then measured at baseline (time zero, 0 months; T=0), after 3 months (T=3, 3 months), and after 6 months (T=6, 6 months), as described in Table 25.

[0526] [Table 36]

[0527] Summary results of Study 1C

[0528] [Table 37]

[0529] [Table 38]

[0530] [Table 39]

[0531] [Table 40]

[0532] [Table 41]

[0533] [Table 42]

[0534] The formulation without polysorbate 80 exhibited more sub-visible particles of all sizes at both the start of the study and at T=6 months when stored at +5° C. compared to the formulation with polysorbate 80, however both formulations showed no significant change at T=6 compared to their corresponding T=0 month results.

[0535] Both formulations with and without polysorbate 80 stored at +5°C contained no visible particles at T=6 months and showed no significant changes by GP HPLC, reduced and non-reduced CE SDS at T=6 months compared to the T=0 month measurements.

[0536] At 6 months, the formulations (with and without polysorbate 80) were determined to have no significant differences between them at +40° C. However, at 6 months, both of these formulations demonstrated comparable trends of decreased percent IgG monomer and increased percent aggregates and fragments by GP HPLC, and decreased purity by reduced and non-reduced CE SDS, compared to the start of the study.

[0537] For formulations subjected to the agitation protocol, the formulations without polysorbate 80 were found to exhibit more sub-visible particles of all sizes compared to the formulations with polysorbate 80.

[0538] Test 2C: Nonionic surfactants (Polysorbate 80 / Poloxamer 188) We set out to investigate the effect of adding a surfactant to the most promising formulation candidates emerging from Studies 2A and 2B.

[0539] Formulations were tested and their compositions are listed in Table 32.

[0540] [Table 43]

[0541] These formulations were separately exposed to multiple freeze-thaw cycles and agitation stress.The formulations were tested by A280, SE-HPLC, and subvisible particle analysis (selected samples).

[0542] Stirring stress measurement in test 2C The formulations were filled into Schott, Fiolax, clear blowback type I glass (target volume of 1 mL in 2 mL vials) stoppered with Flurotec serum stoppers and sealed with crimp caps. The vials were agitated at room temperature using an orbital shaker (3 mm orbit) in a horizontal position at a speed of 590 rpm (revolutions per minute). Samples were taken and tested at 5 and 24 hours. An unagitated control sample was kept at room temperature in a sample box.

[0543] Five (5x) freeze-thaw stress measurements in study 2C The formulations were packaged (0.65 mL) in polypropylene tubes and subjected to five freeze-thaw cycles. Samples were frozen at -80°C for at least 12 hours. During thawing, the tubes were placed at room temperature and allowed to thaw for less than 3 hours. All thawed formulations were mixed by inversion several times and then refrozen. Samples were analyzed after five freeze-thaw cycles.

[0544] Summary results of Test 2C: Agitation stress experiments showed that there was no significant variation in the measured GM37v2 concentrations between any of the formulation candidates at any of the time points tested. The physical stability of the agitated samples was assessed by SE-HPLC. The results indicate that formulations containing poloxamer 188 may become unstable upon agitation, although the changes observed were small.

[0545] Sub-visible particle counts were evaluated for the selectively stirred samples. The particle counts and size ranges were all below the required specifications of USP788.

[0546] Similar measurements were performed on the freeze / thaw samples. These results showed that no significant changes in GM37v2 concentration were observed after multiple freeze-thaw cycles.

[0547] Upon evaluation of the SE-HPLC data, F04 (Test 2C) and F05 (Test 2C), histidine buffer formulations containing poloxamer 188, appear to show the greatest increases after multiple freeze-thaw cycles, although the changes are small.

[0548] Also, for the freeze-thaw samples, the particle counts and size ranges were all below the required specifications of USP788.

[0549] Surfactant Test Conclusions / Summary Test 1C: Overall, based on the results of all analytical methods utilized in this study (visible particles, reduced and non-reduced CE SDS, GP-HPLC and sub-visible particles), the inventors concluded that including 0.02% (w / v) polysorbate 80 in the formulation reduced the overall number of sub-visible particles and therefore, the addition of polysorbate 80 to the candidate formulation would create an optimal clinically suitable formulation.

[0550] Test 2C: The formulation candidates tested show that in these formulations, GM37v2 does not appear to exhibit significant changes in physical stability upon exposure to agitation or freeze-thaw stress. In general, however, surfactants appear to be beneficial to the performance of the formulation in terms of physical stability. Furthermore, polysorbate 80 (Polysorbate 80) appears to be slightly preferred over poloxamer 188, which appears to be slightly less stable compared to polysorbate 80. Thus, the addition of polysorbate 80 to the formulation candidates would likely be beneficial to maintain interfacial stability at the target concentration, likely to be around 0.02% (w / v).

[0551] Example D - Long-term storage stability The two formulations were evaluated for their performance in terms of long-term storage stability. The study collected stability data over a six-month time course at 5° C. and 25° C.

[0552] [Table 44]

[0553] Summary Results of Example D Both the lead and back-up formulations displayed good stability up to 6 months storage at 5° C. and up to 3 months storage at 25° C. However, in terms of subvisible particle formation and chemical stability by CEX-HPLC, the lead formulation (25 mM histidine, 100 mM sucrose, 100 mM sodium chloride, 0.02% polysorbate 80, pH 6.0, 200 mg / mL GM37v2) performed better than the back-up formulation (40 mM histidine, 100 mM sodium chloride, 0.02% polysorbate 80, pH 6.0, 200 mg / mL GM37v2) as distinguished primarily by the trends observed under accelerated conditions at 25° C. Both were comparable in terms of stability measured by SE-HPLC, and both exhibited an estimated loss of <2% over the 2-year time course. Neither formulation showed any significant loss of protein over the course of the study, and the pH remained constant for all of the stored samples.

[0554] A particular liquid pharmaceutical composition of the invention containing 25 mM histidine / histidine hydrochloride, 100 mM sucrose, 100 mM sodium chloride, 0.02% polysorbate 80, pH 6.0, with a concentration of GM37v2 of 53.0±5 mg / mL and a nominal volume of 20 mL was also tested for stability. These tests showed that the composition is suitable for long-term storage at suitable conditions, such as 5° C.±3° C., and maintains the physical and chemical integrity of antibody GM37v2 for at least 36 months.

[0555] Furthermore, a particular liquid pharmaceutical composition of the present invention containing 25 mM histidine / histidine hydrochloride, 100 mM sucrose, 100 mM sodium chloride, 0.02% polysorbate 80, pH 6.0, with a concentration of GM37v2 of 53.0±5 mg / mL was tested under accelerated stress conditions at 25° C. and showed that the formulation was stable under such conditions for at least 6 months.

[0556] Overall conclusions from Examples A-C and D: From Studies 1A, 1B and 1C, the formulation containing GM37v2, 25 mM L-histidine, 100 mM NaCl, 100 mM sucrose and 0.02% polysorbate 80 at pH 6.0 was found to be the most suitable formulation to proceed to clinical development.

[0557] Studies 2A, 2B and 2C revealed that the optimal pH is likely to be near 6.0, using a histidine buffer concentration of 20-40 mM. The nature of the tonicity modifier does not appear to be important, although NaCl is preferred due to the observed viscosity reducing effect. Polysorbate 80, at a target concentration near 0.02% (w / v), is beneficial for maintaining interfacial stability. Thus, a formulation containing 30-225 mg / mL GM37v2, 20-40 mM histidine, 100 mM NaCl, 100 mM sucrose and 0.02% polysorbate 80 at pH 6.0 is the optimal formulation candidate.

[0558] Example D revealed that formulations containing 25 mM histidine, 100 mM sucrose, 100 mM sodium chloride, 0.02% polysorbate 80 (at pH 6.0), and 53 or 200 mg / mL GM37v2 were stable upon long-term storage by using accelerated stress conditions for 3 to 6 months at 25° C. This also applies to the relatively high GM37v2 concentration of 200 mg / mL, and even at this elevated concentration, the formulations exhibit low viscosity of <10 cP.

[0559] Thus, the inventors have identified formulation candidates suitable for clinical use, as they exhibit desirable properties in the field of pharmaceutical compositions, such as high stability and low viscosity, over a wide range of GM37v2 concentrations (30-225 mg / mL), particularly those that include a histidine buffer at about pH 6.0, and even more specifically those compositions that further include NaCl, sucrose and polysorbate 80. Thus, the inventors have identified formulation candidates that are highly flexible and useful in the clinical setting to administer various dosing regimens of GM37v2 to patients.

Claims

1. 1. A monoclonal anti-alpha synuclein antibody for use in the treatment of a synucleinopathy or prosyndromic synucleinopathy, said use comprising intravenously administering the monoclonal anti-alpha synuclein antibody at a dose of 1000 mg to 4500 mg to a human subject suffering from or at risk of developing a synucleinopathy, wherein the monoclonal anti-alpha synuclein antibody is a full-length antibody capable of binding to an epitope within amino acids 112-117 (SEQ ID NO: 9 (ILEDMP)) of human alpha synuclein (SEQ ID NO: 10).

2. 2. The monoclonal antibody for use according to claim 1, wherein the treatment is treatment of a synucleinopathy and the human subject is afflicted with a synucleinopathy.

3. 2. The monoclonal antibody for use according to claim 1, wherein the treatment is treatment of a presymptomatic synucleinopathy and the human subject is at risk of developing a synucleinopathy.

4. 2. The monoclonal antibody for use according to claim 1, wherein the antibody has an estimated KD value for binding to oligomeric forms of alpha synuclein of about 0.1-1.0 nM, for example about 0.5 nM.

5. 2. The monoclonal antibody for use according to claim 1, wherein the antibody has an estimated KD value for binding to the monomeric form of alpha synuclein of about 30-40 nM and a KD value for binding to the oligomeric form of alpha synuclein of about 0.1-1.0 nM, whereby the ratio between monomeric and oligomeric binding is an enhancement of about 60-70 fold.

6. 2. The monoclonal antibody for use according to claim 1, wherein the antibody has an estimated KD value for binding to the monomeric form of alpha synuclein of about 36 nM and a KD value for binding to the oligomeric form of alpha synuclein of about 0.5 nM, thereby providing a ratio between monomeric and oligomeric binding of about 65-fold enhancement.

7. The monoclonal antibody for use according to claim 1, wherein the antibody has a human T1 / 2 of about 28 to 30 days.

8. 2. The monoclonal antibody for use according to claim 1, wherein the antibody has an estimated KD value for binding to the monomeric form of alpha synuclein of about 36 nM and a Kd value for binding to the oligomeric form of alpha synuclein of 0.5 nM, such that the ratio between monomeric and oligomeric binding is an enhancement of about 65-fold, and the antibody has a T1 / 2 of about 28-30 days, for example 29 days.

9. The antibody a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO: 1; b. a heavy chain CDR2 having the amino acid sequence of SEQ ID NO: 34; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO: 3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO: 6; 2. The monoclonal antibody for use according to claim 1, comprising:

10. 2. A monoclonal antibody for use according to claim 1, wherein the antibody comprises a heavy chain consisting of the variable domain of SEQ ID NO: 31 and a light chain consisting of the variable domain of SEQ ID NO:

8.

11. The monoclonal antibody for use according to claim 1, wherein the antibody is a human antibody.

12. The monoclonal antibody for use according to claim 1, wherein the antibody is a human IgG1 antibody.

13. The monoclonal antibody for use according to claim 1, wherein the antibody is GM37 variant 2.

14. 2. The monoclonal antibody for use according to claim 1, wherein the antibody comprises a heavy chain constant domain defined in SEQ ID NO: 18 and a kappa light chain constant domain defined in SEQ ID NO:

17.

15. 2. The monoclonal antibody for use according to claim 1, wherein the antibody is administered every four weeks.

16. The monoclonal antibody for use according to claim 1, wherein the antibody is administered every 28 to 30 days.

17. 2. The monoclonal antibody for use according to claim 1, wherein the antibody is administered once a month.

18. 2. The monoclonal antibody for use according to claim 1, wherein the antibody is administered at a dose of 1050 mg, 2100 mg or 4200 mg.

19. 2. The monoclonal antibody for use according to claim 1, wherein the antibody is administered at a dose of 4200 mg.

20. 2. The monoclonal antibody for use according to claim 1, wherein the antibody is administered by intravenous infusion over 30 minutes ± 10 minutes.

21. 2. The monoclonal antibody for use according to claim 1, wherein the antibody is administered in an amount and frequency sufficient to achieve an estimated CSF mean steady-state concentration of the antibody of at least 3 nM, such as at least 6 nM, or such as at least 12 nM.

22. 2. The monoclonal antibody for use according to claim 1, wherein the antibody is administered in an amount and frequency sufficient to achieve predicted target engagement with oligomeric forms of alpha synuclein in the CSF of at least 85%, at least 90%, etc. or at least 95%, etc.

23. The monoclonal antibody for use according to any one of claims 1 to 2, wherein the synucleinopathy is Parkinson's disease (PD), dementia with Lewy bodies (DLB), or multiple system atrophy (MSA).

24. 3. The monoclonal antibody for use according to any one of claims 1 to 2, wherein the synucleinopathy is multiple system atrophy (MSA), such as an MSA subtype selected from possible MSA, probable MSA, MSA type C, MSA type P, clinically established MSA or clinically probable MSA.

25. The monoclonal antibody for use according to any one of claims 1 to 2, wherein the treatment of synucleinopathy consists in slowing the progression of the disease.

26. 4. The monoclonal antibody for use according to claim 1 or 3, wherein the treatment of a prosymptomatic synucleinopathy consists in delaying the onset of the disease.

27. 1. A liquid pharmaceutical composition comprising a full-length IgG1 monoclonal anti-alpha synuclein antibody at a concentration of 25-225 mg / mL, said antibody comprising: a. a heavy chain CDR1 having the amino acid sequence of SEQ ID NO: 1; b. a heavy chain CDR2 having the amino acid sequence of SEQ ID NO: 34; c. a heavy chain CDR3 having the amino acid sequence of SEQ ID NO: 3; d. a light chain CDR1 having the amino acid sequence of SEQ ID NO:4; e. a light chain CDR2 having the amino acid sequence of SEQ ID NO:5; f. a light chain CDR3 having the amino acid sequence of SEQ ID NO:6; A liquid pharmaceutical composition, wherein the composition further comprises a histidine buffer, a pharmaceutically acceptable tonicity agent, and a pharmaceutically acceptable surfactant, and wherein the pH of the composition is 5.5 to 6.

5.

28. 28. The liquid pharmaceutical composition of claim 27, wherein the tonicity agent is selected from mannitol, sorbitol, lactose, dextrose, trehalose, sodium chloride (NaCl), potassium chloride (KCl), glycerol, or glycerin.

29. 28. The liquid pharmaceutical composition of claim 27, wherein the tonicity agent is sodium chloride (NaCl).

30. 28. The liquid pharmaceutical composition of claim 27, wherein the tonicity agent is sodium chloride (NaCl) at a concentration of about 100 mM.

31. 28. The liquid pharmaceutical composition of claim 27, wherein the surfactant is selected from polysorbate 20, polysorbate 80, poloxamer 188, or Triton X-100.

32. 28. The liquid pharmaceutical composition of claim 27, wherein the surfactant is polysorbate 80 in an amount of about 0.02%.

33. 28. The liquid pharmaceutical composition of claim 27, wherein the concentration of the histidine buffer is about 25 mM.

34. 28. The liquid pharmaceutical composition of claim 27, having a pH of 6.

0.

35. 28. The liquid pharmaceutical composition of claim 27, wherein the monoclonal anti-alpha synuclein antibody concentration is about 30 to 220 mg / mL.

36. 28. The liquid pharmaceutical composition of claim 27, wherein the monoclonal anti-alpha synuclein antibody concentration is about 45 to 55 mg / mL.

37. 28. The liquid pharmaceutical composition of claim 27, wherein the monoclonal anti-alpha synuclein antibody concentration is about 50-55 mg / mL.

38. 28. The liquid pharmaceutical composition of claim 27, wherein the monoclonal anti-alpha synuclein antibody concentration is about 53 mg / mL.

39. 28. The liquid pharmaceutical composition of claim 27, wherein the composition further comprises at least one bulking agent selected from sucrose, trehalose, glucose, lactose, sorbitol, mannitol, glycerol, arginine, aspartic acid, glutamic acid, glutamate, lysine, glycine, histidine, methionine, alanine, gelatin, PVP, PLGA, PEG, dextran, cyclodextrins and derivatives, starch derivatives, HSA, or BSA.

40. 40. The liquid pharmaceutical composition of claim 39, wherein the bulking agent is arginine, glutamate, sucrose, glycine or sorbitol at a concentration of 100-200 mM.

41. 40. The liquid pharmaceutical composition of claim 39, wherein the bulking agent is sucrose at a concentration of 100 mM.

42. 42. The liquid pharmaceutical composition of any one of claims 27-41, comprising 53±5 mg / mL monoclonal anti-alpha synuclein antibody, 1.40 mg / mL L-histidine, 3.34 mg / mL L-histidine monohydrochloride, 34.16 mg / mL sucrose, 5.83 mg / mL sodium chloride (NaCl), 0.20 mg / mL polysorbate 80 at pH 6.

0.

43. 42. The liquid pharmaceutical composition of any one of claims 27 to 41, comprising 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl) and 0.02% polysorbate 80, or having an amount of each component within + / - 10% of said values, and having a pH of 6.0 or within + / - 10% of said value.

44. 42. The liquid pharmaceutical composition of any one of claims 27 to 41, comprising 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl), or with the amounts of each component within + / - 20% of said values, and 0.02% polysorbate 80, or with a concentration within + / - 30% of said concentration, and having a pH of 6.0 or within + / - 20% of said value.

45. 42. The liquid pharmaceutical composition of any one of claims 27 to 41, comprising 53 mg / mL monoclonal anti-alpha synuclein antibody, 25 mM histidine buffer, 100 mM sucrose, 100 mM sodium chloride (NaCl), or with the amounts of each component within + / - 10% of said values, and 0.02% polysorbate 80, or with a concentration within + / - 20% of said concentration, and having a pH of 6.0 or within + / - 10% of said value.

46. 28. The liquid pharmaceutical composition of claim 27, wherein the liquid pharmaceutical composition is a stable liquid pharmaceutical composition.

47. 28. The liquid pharmaceutical composition of claim 27, wherein the liquid pharmaceutical composition is stable for at least 12 months when stored at 5°C ± 3°C.

48. 28. The liquid pharmaceutical composition of claim 27, wherein the liquid pharmaceutical composition is stable for at least 24 months when stored at 5°C ± 3°C.

49. 28. The liquid pharmaceutical composition of claim 27, wherein the liquid pharmaceutical composition is stable for at least 36 months when stored at 5°C ± 3°C.

50. 28. The liquid pharmaceutical composition of claim 27, wherein the liquid pharmaceutical composition is a low viscosity liquid pharmaceutical composition.

51. 28. The liquid pharmaceutical composition of claim 27, wherein the liquid pharmaceutical composition is a low-viscosity liquid pharmaceutical composition having a viscosity of less than 20 cP.

52. 28. The liquid pharmaceutical composition of claim 27, wherein the liquid pharmaceutical composition is a low-viscosity liquid pharmaceutical composition having a viscosity of less than 10 cP.

53. 28. The monoclonal alpha synuclein antibody for use according to claim 1, wherein the antibody is formulated in any one of the liquid pharmaceutical compositions according to claim 27.

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