Facilitated delivery of concentrated antibody formulations using hyaluronidase

Abstract

Concentrated pharmaceutical formulations of immune globulin (IG) and convenient methods for administering the pharmaceutical formulations subcutaneously in a warmed state are provided. Such products can be used in methods of treating IG-treatable diseases or conditions. Also provided are combinations, compositions, and kits that include immune globulin (IG) compositions and soluble hyaluronidase compositions formulated for subcutaneous administration.

Description

[Technical field]

[0001] Cross-reference to application This application claims priority to U.S. Provisional Application No. 63 / 243,832, filed September 14, 2021, the disclosure of which is incorporated herein by reference in its entirety for all purposes.

[0002] FIELD OF THEINVENTION The present invention is in the field of antibody therapeutics and hyaluronidase-facilitated subcutaneous delivery of therapeutic antibody viscous formulations. [Background technology]

[0003] 2. Background of the Invention Human plasma-derived immunoglobulin preparations were first used in 1952 to treat immune deficiencies. Initially, the method of choice was to administer IgG intramuscularly or subcutaneously (SC). However, to inject the large amounts of IgG required to effectively treat various diseases, intravenously administrable preparations containing lower concentrations of IgG (50 mg / mL) were developed. Typically, intravenous immunoglobulin (IVIG) contains pooled immunoglobulin G (IgG) immunoglobulins derived from the plasma of over a thousand blood donors. IVIG, which typically contains >95% unmodified IgG with intact Fc-dependent effector functions and only trace amounts of immunoglobulin A (IgA) or immunoglobulin M (IgM), is a sterile, purified IgG product primarily used to treat three major categories of conditions: 1. immunodeficiencies characterized by low antibody levels, such as X-linked agammaglobulinemia, hypogammaglobulinemia (primary immunodeficiencies), and acquired immunodeficiency states (secondary immunodeficiencies), 2. inflammatory and autoimmune diseases, and 3. acute infections.

[0004] Many IVIG manufacturers offer a variety of IVIG products. In North America and Europe, over a dozen IgG products are available, which vary in terms of IG concentration, infusion frequency, route of administration, and other considerations. Perez, et al., J Allergy Clin Immunol. (2017), 139: S1-S46. Compared to older lyophilized IVIG products that contain only 50 mg / mL of protein in solution after reconstitution, current formulations provide ready-to-use sterile liquid preparations of 100 mg / mL and 200 mg / mL of highly purified and concentrated human IgG antibodies.

[0005] More recently, IgG formulations configured for subcutaneous administration have been introduced to the IgG therapeutic market. These formulations represent a major advancement in the overall patient experience with IgG formulations. For example, a patient or caregiver trained in subcutaneous injection of an IgG formulation can inject the formulation in practically any setting. This innovation frees patients from visiting an infusion center and allows them to inject, e.g., self-inject, in the comfort of their own home or any location of their choice. Exemplary subcutaneously injected IgG formulations include HyQvia® [Immunoglobulin Infusion 10% (Human) with Recombinant Human Hyaluronidase], Hizentra® [Immunoglobulin Subcutaneous Human 20% Liquid].

[0006] European experience with rapid infusion of SCIG has shown that rates of up to 40 mL / hour using 2-4 sites to administer 40 mL (6.4 g) per infusion are well tolerated in patients with primary immunodeficiency disease ("PIDD"). In the United States, clinical trials of the first FDA-approved SCIG products (16%) used maximum rates of 15 mL per site and 20 mL / site / hour. Subsequent studies increased the dose per site to 30 mL and the infusion rate to 30 mL / hour / site. Package inserts for 10% and 20% SCIG products recommend limiting the volume of IgG to 20 mL per site for PIDD patients weighing less than 40 kg and 30 mL per site for patients weighing more than 40 kg. Suggested initial infusion rates are 15 mL / site / hour (<40 kg) or 20 mL / site / hour (>40 kg), increasing to 20 mL / site / hour and 30 mL / site / hour, respectively. Multiple sites can be injected simultaneously using abdominal, thigh, upper arm, or lumbar sites, and most injections can be completed in less than 90 minutes. Patients may choose to use more injection sites and therefore inject less volume per site, shortening the overall injection time, or patients may prefer to inject the product more slowly to tolerate more volume per site and use fewer sites. The recommended dosing interval is weekly, but more frequent dosing (daily or 2-3 times per week) may further improve serum IgG levels and result in fewer infections. Shapiro reported a retrospective analysis of 104 patients with PIDD who received SCIG using either rapid push administration or an infusion pump. 71% of patients chose to use the rapid push method and received a mean dose of 32.11 g / month given approximately three times per week. The volume of SCIG per site ranged from 3 to 20 mL and was administered over 5 to 20 minutes (1 mL / min) using a 25-gauge butterfly needle and a 12 mL syringe. Serum IgG levels and rates of systemic adverse events were similar between the two methods. Kobrynski L, Biologics (2012), 6: 277-287 (Non-Patent Document 2).

[0007] Concentrated formulations of IgG (e.g., 20% IgG) are of interest as a means of injecting smaller doses while achieving delivery of the entire prescribed dose over a potentially shortened infusion time for the entire prescribed dose, both of which would be appealing to patients and enhance compliance with prescribed dosing regimens. The design of such formulations and dosing regimens incorporating them is not a trivial task, and the feasibility of a broadly tolerated concentrated IgG formulation in a rapidly injectable format has not yet been demonstrated.

[0008] For example, recent clinical trials with 20% IgG formulations have shown that it is difficult to incorporate IgG formulations with IgG concentrations greater than 10% into dosing regimens that incorporate high infusion rates (e.g., >200 mL / hour). Anderson et al., J. Clin. Immunol. (2021) 41:458-469 (Non-Patent Document 3). When researchers increased the infusion rate of a 20% IgG formulation from 25 mL / hour / site to 75 mL / hour / site, approximately 30% of the cohort stopped infusing or reduced its rate because infusing the formulation at the selected rate was poorly tolerated (i.e., pain, discomfort). Furthermore, when the infusion rate was increased to 100 mL / min / site, approximately 40% of the cohort discontinued the infusion. Thus, although this 20% IgG formulation provides delivery of more IgG per unit volume, it does not appear to be as widely tolerated as a similar 10% IgG formulation when infused at a higher rate, such as 100 mL / hour / site.

[0009] Despite the difficulties previously encountered in designing IgG dosing regimens incorporating concentrated IgG pharmaceutical formulations administered at high subcutaneous infusion rates, such dosing regimens provide subjects receiving this treatment with the significant advantage of shorter infusion durations, providing increased convenience and tolerability at the higher infusion rates that result in this increased convenience. Such regimens, and the combination of administered components that effect this regimen, are expected to improve patient compliance due to increased convenience, shorter infusion durations, and a more satisfying overall patient infusion experience. The present invention provides such regimens, including combinations of administered components, kits that include combinations of administered components, and methods and systems for using combinations of administered components. Summary of the Invention

[0010] In various embodiments, the present invention provides dosing regimens for subcutaneous infusion of pharmaceutical formulations of IgG incorporating concentrated IgG formulations, and methods of infusion of these formulations that overcome the problems of conventional dosing regimens for subcutaneous infusion of IgG. In selected embodiments, the present invention provides kits for subcutaneous infusion of pharmaceutical formulations of IgG at high infusion rates. An exemplary kit includes a stable 20% (w / v) pharmaceutical formulation of IgG, a pharmaceutical formulation of hyaluronidase, and instructions for use to infuse IgG at an unexpectedly high rate at a high dose / volume ratio with excellent patient tolerability to a first infusion site using the formulation. The prior art does not disclose or suggest a method of infusing a concentrated (e.g., 20%) IgG formulation at a high rate to a first infusion site of a subject.

[0011] The limitations of subcutaneous injection of IgG formulations include the frequency and duration of injection. Two approaches can be taken: (1) increase the concentration of IgG in the formulation or (2) increase the injection volume per site. Concerns remain regarding the large volume injected per site, its potential effects on the body, local tolerability, and the discomfort and inconvenience associated with local site reactions. Increasing the IgG concentration in the formulation from 10% to 20% reduces the dosage by approximately 50%. However, the main challenge in increasing the concentration is the higher viscosity of the concentrated solution, which limits the achievable injection rate and requires longer injection times, partially offsetting the benefits of a more concentrated formulation.

[0012] One approach to facilitate subcutaneous infusion involves administering a pharmaceutical formulation of hyaluronidase (e.g., rHuPH20) to the first infusion site prior to infusion of the IgG formulation. Despite the promise of this approach, in studies designed to evaluate the feasibility of administering IgG formulations at high flow rates (e.g., 3-5 mL / min) using rHuPH20 based on the magnitude of tissue backpressure on IgG infusion, rHuPH20 itself was not sufficient to support IgG flow rates of 3 mL / min or greater, which are desirable for shortening the infusion time of a standard dose of IgG. Figure 12. Thus, prior to the present invention, it was unclear how to achieve high infusion rates, e.g., 3-5 mL / min subcutaneous infusion of IgG after administration of hyaluronidase to the infusion site, while maintaining the current quality and tolerability of similar 10% IgG formulations.

[0013] Recent clinical trials involving subcutaneous infusion of 20% IgG formulations have shown challenges with subcutaneous infusion of concentrated IgG formulations at high infusion rates. Anderson et al., J. Clin. Immunol. (2021) 41:458-469. The authors of this study reported that when the infusion rate of the 20% IgG formulation was 100 mL / hour / site, approximately 40% of the cohort stopped infusion. It may therefore be concluded that a dosing regimen for subcutaneous infusion of concentrated (e.g., 20%) IgG formulations such that the infusion is broadly tolerated at high flow rates (e.g., 120, 150, or even approximately 300 mL / hour / site) is neither simple nor trivial.

[0014] Injecting concentrated IgG formulations is an attractive option for many reasons, but a concern that must be addressed is that the final formulation is preferably easily loaded into an injection device by the patient (or caregiver) and equally easily released from this device through a hypodermic needle after the needle is placed at the injection site. During the manufacture of such formulations, as well as during the finishing and filling of vials containing the formulation, the complex dynamics of concentrated IgG solutions must be addressed. Given the complexity of concentrated IgG solution systems, achieving a formulation with fluid properties (e.g., acceptable viscosity and tolerability) that support rapid injection is neither a predetermined outcome nor an obvious result of a particular research course.

[0015] Antibody properties such as self-association and aggregation, solubility and viscosity pose significant challenges to develop highly concentrated antibody formulations that are easy to inject, well tolerated by patients, and pharma- ceutically and economically acceptable. Antibody properties at high concentrations can adversely affect the stability of the solution, and the viscosity of such formulations can make administration to patients and large-scale manufacturing of the formulations difficult, adversely affecting the yield of these two processes. Researchers must take these properties into account when designing novel IgG dosing regimens with concentrated IgG formulations and combinations of administration components, but given experience in the art, they would not undertake such studies where the process would be expected to be simple and / or trivial.

[0016] The present invention addresses these and other challenges by providing pharmaceutical formulations of at least about 20% (w / v) IgG in a pharma- ceutically acceptable carrier, methods that facilitate infusion of the formulation at unexpectedly high infusion rates, kits of components that facilitate infusion at high infusion rates, and systems useful for infusing the formulation at such rates.

[0017] In an exemplary embodiment, the 20% (w / v) IgG pharmaceutical formulation is configured for subcutaneous injection and is a component of a kit. The kit also includes a pharmaceutical formulation of hyaluronidase. The kit further includes instructions for injecting the hyaluronidase formulation into a first injection site followed by an IgG formulation into the site. In an exemplary embodiment, the instructions instruct the person injecting the IgG how to inject the IgG at a high rate at the first injection site. In an exemplary embodiment, the 20% (w / v) IgG is injected into the first injection site at ambient temperature (about 25° C.).

[0018] A recent clinical trial involving administration of hyaluronidase to a first injection site followed by subcutaneous injection of a 20% (w / v) IgG formulation at this site was accompanied by surprising results. The researchers found that injecting 80 U of hyaluronidase per gram of IgG into the first injection prior to injecting the 20% (w / v) IgG formulation allowed the IgG to be infused into the first injection site at a rate similar to that typically achieved with a similar 10% IgG formulation promoted with the same dose of hyaluronidase. This result was unexpected in view of the fact that the 20% (w / v) IgG formulation is approximately four times more viscous than the corresponding 10% (w / v) IgG formulation. See Example 5. Infusion of the 20% IgG formulation was surprisingly well and broadly tolerated across the entire cohort at infusion rates up to 300 mL / hour. In preclinical dosing of 20% (w / v) IgG in hyaluronidase-accelerated pigs, it was found that a 5-10-fold increase in the amount of hyaluronidase administered did not significantly reduce tissue backpressure to levels comparable to those observed when a 10% (w / v) IgG formulation accelerated with hyaluronidase was administered. Given the number of subjects who discontinued infusions of 75 mL / hour / site and 100 mL / hour / site in the Anderson et al. study (ibid.), one skilled in the art, unaware of the preclinical studies, would be justified in concluding that the difficulties associated with the 4-fold higher viscosity of 20% (w / v) IgG may need to be at least partially counterbalanced by injecting a correspondingly increased dose of hyaluronidase per gram of IgG compared to the dose used in HyQvia® [Immunoglobulin Infusion 10% (Human) Combined with Recombinant Human Hyaluronidase], which was not the case in practice. One aware of the preclinical studies would have concluded that high infusion rates of 120–300 mL / h / site would not be possible or would not be well tolerated by subjects, or both, when administering a viscous 20% (w / v) IgG formulation, but surprisingly, none of these assumptions proved to be true during the clinical trials.It should be noted that if an infusion rate of at least about 300 mL / hour were achievable in human subjects, the viscosity of the 20% (w / v) IgG formulation would have to be overcome by warming in order to reach that rate, and that the inventors initially believed that such a high infusion rate would not be achievable with 20% (w / v) IgG at room temperature.

[0019] According to various embodiments of the invention, accelerated, warmed or non-warmed 20% (w / v) IgG allows a standard dose of IgG to be administered in 50% of the current standard volume for injecting such a dose of a 10% IgG formulation, shortening the infusion time; surprisingly, infusion rate and tolerability are not hindered by the high viscosity of non-warmed 20% (w / v) IgG formulations.

[0020] In some embodiments, the present invention provides a method of subcutaneously injecting hyaluronidase into a first injection site followed by subcutaneous injection of a 20% (w / v) IgG formulation into the site in a warmed state. In these embodiments, the 20% (w / v) IgG formulation is warmed to a temperature appropriate to reduce the viscosity of the formulation to a desired value before injection, during injection, or both, and to obtain acceptable patient tolerability. Surprisingly, a moderate increase in temperature above room temperature resulted in a significant decrease in viscosity. FIG. 1. Although it is widely understood that warming antibody and other protein solutions can degrade proteins and cause their aggregation, the 20% (w / v) IgG formulation of the present invention was not adversely affected by warming to approximately 40° C.

[0021] In various embodiments, the invention provides methods in which a pharmaceutical formulation of hyaluronidase is administered to at least a first injection site, followed by rapid injection of a warmed 20% (w / v) IgG formulation to the injection site.

[0022] Preclinical studies of infusion of a 20% (w / v) IgG formulation have shown that infusion rates as high as 7.5 mL / min can be achieved using an in-line warming device, overcoming the inherent problems of infusing a highly viscous protein solution. Pharmacokinetic results from these preclinical studies indicate that a warmed accelerated 20% (w / v) IgG formulation infused at 5 mL / min is readily dispersed from the subcutaneous space and taken up by the systemic compartment. The present invention does not require significant redesign of the formulation, other than to increase the concentration of IgG found in the formulation, and offers significant advantages over prior art IgG infusion formulations, methods, and systems.

[0023] The kits, methods, and formulations of the present invention provide an unexpected and significant improvement to the patient experience for patients requiring subcutaneous infusion of IgG formulations, with the concentration of IgG in the formulation providing subjects with a shorter duration infusion experience than previous 10% (w / v) and 20% (w / v) IgG formulations. Furthermore, in embodiments where the formulation is heated, the infusion of the 20% (w / v) IgG formulation results in lower backpressure due to the reduced viscosity of the antibody solution, is easier to inject, is infusion compatible with multiple infusion pump and infusion set combinations, and is less uncomfortable for the patient. A simple, rapid, and widely tolerated infusion procedure favors patient compliance with recommended treatment regimens, benefiting patients and the overall health economy.

[0024] In an exemplary embodiment, the present invention provides a pharmaceutical formulation contained within a system for delivering the pharmaceutical formulation by injection to a subject in need thereof. The pharmaceutical formulation comprises at least about 20% (w / v) immunoglobulin in a pharma- ceutically acceptable aqueous carrier in which the immunoglobulin is dissolved. The system includes a first container containing the pharmaceutical formulation; a first hypodermic needle having a first end configured to pierce a first injection site of the subject and an end opening disposed therein through which the pharmaceutical formulation is delivered to the first injection site; a first connecting member in fluid communication with the first container and the hypodermic needle; and a first warming device in thermal contact with a component of the system selected from the first container, the first connecting member, and combinations thereof, the first warming device configured to heat the pharmaceutical formulation to at least about 30° C., to maintain the pharmaceutical formulation at a temperature of at least about 30° C., and combinations thereof.

[0025] In an exemplary embodiment, the pharmaceutical formulation is at a temperature of at least about 30°C, preferably from about 30°C to about 40°C, for example, from about 35°C to about 40°C.

[0026] In various embodiments, the invention provides a pharmaceutical formulation of an immunoglobulin (e.g., IgG). The formulation comprises at least about 20% (w / v) immunoglobulin and a pharma- ceutically acceptable aqueous carrier in which the immunoglobulin is dissolved. The pharmaceutical formulation has a viscosity that permits injection of the pharmaceutical formulation into a first subcutaneous injection site of a subject in need of such injection at a rate of greater than about 3 mL / min, and the pharmaceutical formulation is under a first pressure of about 7000 Pa to about 47000 Pa. In an exemplary embodiment, the pressure in the tissue adjacent to the injection site is about 25 to about 200 mmHg, e.g., about 25 to about 150 mmHg. In an exemplary embodiment, the pressure in the tissue adjacent to the first injection site is insufficient to cause sufficient discomfort to cause the subject to discontinue the injection at a desired injection rate.

[0027] Exemplary formulations do not include a small molecule agent specifically incorporated to reduce the viscosity of the formulation. In various embodiments, the formulation is not a suspension of antibody in a mixture of water and an organic solvent, such as an alcohol, for example ethanol.

[0028] IgG-based therapeutics are generally administered alone in the range of about 100 mg to about 2 g of protein material / kg / patient / dose per month, e.g., about 1 g of protein material / kg / patient / dose. In an exemplary embodiment, the therapeutic of the invention is injected to treat a neuroimmunological indication, and the dose is about 1 to about 2 grams of protein material / kg / patient / dose. In an exemplary embodiment, the indication is selected from primary immunodeficiency (PID) and secondary immunodeficiency (SID). In an exemplary embodiment, when used to treat PID or SID, the therapeutic of the invention is administered in an amount of about 400 to about 800 mg / kg / patient / dose.

[0029] In various embodiments, in addition to the full dose being administered in a single infusion period, the dose can be divided and administered in stages over a selected period of time. Thus, for example, the dose can be divided into biweekly doses (1 / 2 dose) or weekly doses (1 / 4 dose).

[0030] The present disclosure recognizes the source of problems associated with highly concentrated IgG therapeutic formulations, which may present administration challenges (e.g., administration difficulties, patient discomfort) that reduce patient compliance due to high viscosity of the therapeutic formulation and / or aggregation of IgG in the formulation. In particular, the present disclosure provides pharmaceutical formulations of IgG containing at least about 20% IgG, which are temporarily less viscous, i.e., less viscous than when such formulations are at room temperature ("reference formulations"). Thus, in various embodiments, the formulations of the present invention provide subjects treated with the therapeutic agent with an injection experience that is more comfortable and tolerable than that experienced with current similar products. In various embodiments, this experience is contrasted with current regimens, for example, by a more rapid injection time relative to the required dose, and an increased or similar level of tolerability despite administering a standard dose at a reduced time.

[0031] In exemplary embodiments, the therapeutic formulations of the invention provide for infusion of a standard IgG dose over a time frame that is at least about 1.2-fold, at least about 1.4-fold, at least about 1.6-fold, at least about 1.8-fold, or at least about 2-fold, or more, relative to the time required to administer a comparable 10% (w / v) IgG formulation for a given indication.

[0032] In some embodiments, the present disclosure provides low-aggregation pharmaceutical formulations of IgG, despite a 20% (w / v) concentration of IgG in the formulation. In some embodiments, without being bound by a particular theory, the present disclosure encompasses the recognition that reduced surface adsorption and / or interfacial interactions may have beneficial effects on certain protein formulations. In particular, in some embodiments, the present disclosure provides formulations of therapeutic protein agents with relatively low surface adsorption and / or interfacial interactions (compared to those observed for an appropriate reference formulation, e.g., a 20% formulation of a different protein, e.g., a different antibody, or a 10% formulation of IgG). In some embodiments, the provided formulations can be injected subcutaneously (SC) or intramuscularly (IM). The present disclosure also provides methods of making and / or using such formulations.

[0033] In an exemplary embodiment, the present invention provides a method of injecting a pharmaceutical formulation of an immunoglobulin into a first injection site of a subject in need thereof. The formulation injected by the method comprises at least about 20% (w / v) of an immunoglobulin fraction in about 80% (w / v) of a pharma- ceutically acceptable aqueous carrier in which the immunoglobulin fraction is dissolved. The method includes delivering the pharmaceutical formulation from a first container through a first hypodermic needle into the first injection site, the first container and the first hypodermic needle being maintained in fluid communication through a first connecting member, and the pharmaceutical formulation is at an injection temperature of about 30°C to about 40°C upon entry into the first injection site. In an exemplary embodiment, the injection temperature is about 30°C, about 31, about 32, about 33, about 34, about 35, about 36, about 37, about 38, about 39, or about 40°C.

[0034] In exemplary embodiments, the invention provides methods for injecting a concentrated IgG formulation such that injection of the pharmaceutical formulation at the injection temperature does not cause greater discomfort to the subject than would be experienced by the subject upon injection, under the same injection parameters, of an otherwise identical pharmaceutical formulation comprising about 10% (w / v) immunoglobulin in an aqueous pharmaceutical carrier. In various embodiments, the injection causes less patient discomfort than administration of a 10% (w / w) IgG formulation (supra).

[0035] In exemplary embodiments, the invention provides methods for injecting a concentrated IgG formulation (e.g., greater than 20% (w / v)) such that injection of the pharmaceutical formulation at the injection temperature does not cause greater subject discomfort than the discomfort experienced by the subject upon injection, under the same injection parameters, of an otherwise identical pharmaceutical formulation that contains about 20% (w / v) immunoglobulin in an aqueous pharmaceutical carrier. In various embodiments, the injection causes less patient discomfort than injection of a similar or identical 20% (w / v) IgG formulation at a temperature below 30° C.

[0036] In various embodiments, any of the above formulations and methods are enhanced (facilitated) by injecting a dose of a pharmaceutical formulation of hyaluronidase at the site of IgG injection prior to or in combination with injection at the site of the IgG formulation of the invention. The hyaluronidase is administered at the same or a different temperature as the IgG.

[0037] Further embodiments, objects, and advantages of the present invention will become apparent from the detailed description that follows. [Brief description of the drawings]

[0038] [Figure 1A] FIG. 1 shows the dynamic viscosity as a function of temperature of an exemplary 20% (w / v) IgG formulation of the invention. [Figure 1B] 1 shows the dynamic viscosity as a function of temperature of an exemplary 20% (w / v) IgG formulation of the invention.

[0039] [Diagram 2] FIG. 1 shows an exemplary experimental set-up for an infusion warmer study aimed at determining the effect of warming on 20% (w / v) IgG.

[0040] [Diagram 3]An in vivo proof-of-concept study in pigs is presented, in which an experimental setup is provided to compare the injection pressure and local reactions of IgG 20% (w / v) vs. warmed IgG 20% (w / v) vs. warmed accelerated IgG 20% (w / v), which is based on experience with HyQvia® [immunoglobulin injection 10% (human) with recombinant human hyaluronidase] and uses pigs because it has high relevance to humans based on the similarity of skin anatomy between pigs and humans, whereby the experimental setup used a first setting of 5 mL of rHuPH20 (recombinant human hyaluronidase) or buffer at a flow rate of 2 mL / min, and a second setting of 50 mL of IgG 20% (w / v) solution at flow rates of 3 and 5 mL / min. In the experimental setup, intra-animal controls are provided laterally to compare the two treatment approaches in individual animals. The experimental setup provides in-line pressure and temperature monitoring (approximately 34-35 °C just before the needle through physiological temperature).

[0041] [Figure 4] Shown is a graph of the average in-line pressure versus time between pooled data sets at a flow rate of 5 mL / min. Red: buffer + warmed IGSC, 20% (n=8); Green: PH20 (hyaluronidase) + warmed IGSC, 20% (n=6); Buffer + IGSC, 20% (n=8).

[0042] [Diagram 5] Graphs of mean in-line pressure versus time, comparison of treatment approaches at a flow rate of 5 mL / min, and pooled data sets for pairs of infusion conditions are shown.

[0043] [Figure 6] FIG. 6 is a table summarizing the data of FIGS. 4 and 5.

[0044] [Figure 7] 1 shows a graph of the average in-line pressure versus time among pooled data sets from multiple injection experiments in pigs injected at a flow rate of 3 mL / min.

[0045] [Figure 8] 1 shows a graph of mean in-line pressure versus time, comparing treatment approaches at a flow rate of 3 mL / min.

[0046] [Figure 9] 1 is a table showing individual data sets and statistical comparisons for a flow rate of 3 mL / min.

[0047] [Figure 10] 1 is a graph of mean in-line pressure versus time for various 20% IgG infusion regimens containing various amounts of rHuPH20.

[0048] [Figure 11] Results from injection experiments using a 19 G needle at injection rates of 3-7.5 mL / min are shown.

[0049] [Figure 12] Included are graphs showing in-line pressure versus time for IgG formulations in buffer with rHuPH20 and with rHuPH20 + warming, showing that acceleration without warming showed a slight decrease in infusion pressure. In contrast, acceleration with warming clearly reduces subcutaneous infusion pressure. Green - Formulation A (rHuPH20 + warmed IG, 20%); Red - Buffer + IG (20%). Dose, 50 mL IG (20%), 3 pigs per group.

[0050] [Figure 13] Table showing pharmacokinetic parameters for pig infusion study. Treatment group 1: in-line heated accelerated IGSC 20% (n=3); 5ml rHuPH20 at 2ml / min and 50ml*(400mg / kg) heated IgG 20% at 5ml / min (→ infusion time approx. 10 min). Treatment group 2: IGSC 20% SC (n=3); 5ml buffer at 2ml / min and 50ml*(400mg / kg) lg 20% ​​at 1ml / min (→ infusion time approx. 50 min). Sampling times: pre-dose, 5 min-28 days post-dose. Bioanalysis: ELISA assay of human IgG in pig serum.

[0051] [Figure 14] Schematic diagram of the overall study design for a Phase I, single-dose, single-center, open-label, three-arm study to evaluate the tolerability and safety of immunoglobulin subcutaneous (human), 20% solution (TAK-881) in combination with recombinant human hyaluronidase at various infusion rates in healthy adult subjects. All subjects were admitted to the Clinical Research Center (CRC) on day -1 prior to dosing and discharged on day 4. Abbreviations: ADA = anti-drug antibodies; EOS = end of study; ET = early termination; IgG = immunoglobulin G. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0052] Detailed Description of the Invention I. Introduction While early IG preparations were intended for intravenous administration, the development of preparations that allow for subcutaneous infusion of tolerated doses of IgG in outpatient settings, for example by the IgG recipient, a caregiver, or a home health care professional, has led to widespread acceptance of subcutaneous administration of IgG. The convenience of self-administration makes subcutaneous IgG therapy the preferred option for many patients. Weekly subcutaneous administration results in relatively stable serum IgG levels between doses, reducing the distinct peak and trough levels associated with intravenous administration every 3-4 weeks.

[0053] Since the first subcutaneous IgG (SCIG) product (VIVAGLOBIN® [Immunoglobulin Subcutaneous (Human)], 16%) was introduced in the United States in 2006, the only major change has been in the concentration of IgG. At least two 10% IgG products previously approved for IV administration have received FDA approval for SC administration (GAMMAGARD LIQUID® [Immunoglobulin Injection (Human)], 10%), (GAMUNEX®-C [Immunoglobulin Injection (Human) 10%]), and another 10% IgG product (GAMMAKED™ [Immunoglobulin Injection (Human), 10% Caprylate / Chromatographically Purified) have been introduced for both IV and SC administration. 20% IgG products (CUVITRU® [Immunoglobulin Subcutaneous (Human), 20% Solution]) (HIZENTRA® [Immunoglobulin Subcutaneous (Human) 20% Liquid]) for SC administration only are also now available in the United States. The 20% IgG product has the advantage that the injection volume is smaller, potentially reducing the number of sites required to administer SCIG. Alternative methods of administration, such as the rapid SC push method, have also been reported, with SCIG administered daily, biweekly, and bimonthly.

[0054] An approach to reduce infusion times, thereby increasing overall patient satisfaction with the infusion experience and, consequently, patient compliance with the infusion regimen, would be based on more rapid subcutaneous infusion of a given dose of IgG. This goal could be achieved by injecting concentrated subcutaneous IgG pharmaceutical formulations at high infusion rates. However, this approach is not trivial. Among the difficulties encountered with concentrated antibody formulations is the increased solution viscosity, which significantly complicates product handling (e.g., syringe filling) and injection. Viscosity of protein solutions is highly sensitive to the amino acid sequence of the protein, the composition of the buffer, and the presence of protein aggregates. Nicoud et al., Soft Matter, 11 (2015): 5513. Controlling aggregation and viscosity in highly concentrated antibody solutions is not a trivial matter (EP2538973). This is illustrated by the few antibody products currently on the market as highly concentrated formulations (>100 mg / mL) (EP2538973).

[0055] The high viscosity of concentrated IgG formulations can make them difficult to load into and empty from infusion devices and can make administration by injection difficult, especially for subcutaneous delivery, where larger gauge needles must be used to deliver a useful dose of the highly viscous solution in a reasonable time frame, which can make subcutaneous injections even more painful.

[0056] The US FDA does not permit subcutaneous injection of formulations with a volume greater than approximately 1.5 mL having a viscosity greater than approximately 50 centipoise (cP). Shire et al., J Pharm Sci (2004), 93:1390-1402. Viscous concentrated antibody formulations with high resistance to flow are difficult to handle and administer to patients. Reducing the viscosity of concentrated antibody formulations may prove important to fully deploy the benefits to patients.

[0057] The concentration dependence of the viscosity of aqueous solutions of gamma globulin is exponential, not linear. Thus, a small increase in antibody concentration in an aqueous formulation results in a significant increase in viscosity and the drawbacks associated with highly viscous aqueous antibody formulations. Srinivasan et al., Pharm Res (2013) 30" 1749-1757.

[0058] Given the exponential dependence between viscosity and concentration, controlling the viscosity of an antibody solution requires balancing a complex network of solution components and properties. The viscosity of an antibody solution is also dependent on shear rate. Different compositions of salts, and pH also affect the antibody solution viscosity. The viscosity of an antibody solution is highly dependent on protein concentration and increases nonlinearly with increasing antibody concentration. Under high concentration conditions, antibodies can undergo self-association, the extent of which is a function of concentration. Reversible self-association has a large impact on the physical properties of protein formulations. In fact, these multivalent low affinity interactions can result in concentrated antibody formulations with unusually high viscosity. Reducing reversible protein-protein interactions reduces viscosity. Liu et al., J Pharm Sci, 94:9(2005):1928-1940; Shire et al., J Pharm Sci, 93:6(2004):1390-1402.

[0059] The role that antibody aggregates play in the viscosity of antibody solutions has not yet been established in the art. Contrary to the above results, other researchers have found that solutions containing aggregates of proteins such as antibodies have lower viscosities than monomeric samples of similar occupied volume fractions due to the polydispersity of the aggregate distribution. See Nicoud et al., supra, noting that it is generally accepted in the art that the formation of protein aggregates and reversible self-association increases the viscosity of a solution. Thus, uncertainty remains regarding the relevance of aggregate formation to solution viscosity.

[0060] In various embodiments, the present invention addresses shortcomings of current concentrated IgG pharmaceutical formulations that arise due to the viscosity of such formulations. In one embodiment, a pharmaceutical formulation is provided that has a reduced viscosity relative to its room temperature viscosity, i.e., a warmed formulation. Also provided is a system that includes the pharmaceutical formulation and allows the viscosity to be reduced from its room temperature value, and in fact "tuned" to a desired value to minimize injection time while maximizing the comfort of the patient receiving the formulation. Also provided is a method of administering the concentrated IgG formulations of the present invention to a patient in need thereof. An exemplary IgG formulation of the present invention comprises at least about 20% IgG (w / v) in a pharma- ceutically acceptable carrier. The various delivery methods are enhanced by injecting a dose of a hyaluronidase formulation at or near the IgG injection site prior to and at about the same time as injecting the IgG at the IgG injection site.

[0061] Reference will now be made in detail to the practice of exemplary embodiments of the present disclosure, as illustrated in the accompanying drawings. The same reference indicators are used throughout the drawings and the following detailed description to refer to the same or similar parts. Those skilled in the art will understand that the following detailed description is illustrative only and is not intended to be in any way limiting. Other embodiments of the present disclosure will readily suggest themselves to such skilled artisan having the benefit of this disclosure.

[0062] For clarity, not all of the routine features of the implementations described herein are shown and described. It will be understood that in the development of any such actual implementation, numerous implementation-specific decisions will be made to achieve the particular goals of the developer, e.g., compliance with application- and business-related constraints, and that these particular goals will vary from implementation to implementation and from developer to developer. Moreover, it will be understood that such a development effort may be complex and time-consuming, but would nevertheless be within the capabilities of one of ordinary skill in the art having the benefit of this disclosure.

[0063] Many modifications and variations of the exemplary embodiments described in this disclosure can be made without departing from the spirit and scope of the exemplary embodiments, as will be apparent to those skilled in the art. The specific exemplary embodiments described herein are provided by way of example only, and the disclosure is intended to be limited only by the terms of the appended claims, along with the full scope of equivalents to which such claims are entitled.

[0064] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by those skilled in the art (e.g., cell culture, molecular genetics, nucleic acid chemistry, hybridization techniques, and biochemistry). Standard techniques are used for molecular, genetic, and biochemical methods (generally, see Sambrook et al., Molecular Cloning: A Laboratory Manual, 2d ed. (1989) Cold Spring Harbor Laboratory Press, Cold Spring Harbor, NY and Ausubel et al., Short Protocols in Molecular Biology (1999) 4.sup.th Ed, John Wiley & Sons, Inc., incorporated herein by reference) as well as chemical methods. In addition, Harlow & Lane, A Laboratory Manual Cold Spring Harbor, NY, refers to standard immunological techniques.

[0065] II. Definition Unless otherwise defined, all technical and scientific terms used herein generally have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Generally, the nomenclature used herein and the laboratory procedures in organic chemistry, pharmaceutical formulation, and medical imaging are those well known and commonly employed in the art.

[0066] As used herein, the articles "a" and "an" are used to refer to one or to more than one (i.e., to at least one) of the grammatical object of the article. By way of example, "an element" means one element or more than one element.

[0067] A "disease" is a condition in the health of an animal in which the animal is unable to maintain homeostasis and which, if not ameliorated, will result in a continuing deterioration of the animal's health.

[0068] As used herein, "pharmaceutically acceptable carrier" includes any substance that, when combined with the conjugate, retains the activity of the conjugate and is non-reactive with the subject's immune system. Examples include, but are not limited to, any of the standard pharmaceutical carriers, such as phosphate buffered saline, water, emulsions such as oil / water emulsions, and various types of wetting agents. Other carriers may also include sterile solutions. Typically, such carriers contain excipients.

[0069] Excipients can be used in the present invention for a wide variety of purposes, such as adjusting the physical, chemical, or biological properties of the formulation, such as adjusting the viscosity, and / or in the processes of the present invention to further improve efficacy and / or further stabilize such formulations, as well as in processes, for example, during manufacture, transportation, storage, preparation for use, administration, and against deterioration and spoilage due to subsequent stresses. The term "excipient" generally includes fillers, binders, disintegrants, coatings, adsorbents, anti-adherents, glidants, preservatives, antioxidants, solvents, co-solvents, buffers, chelating agents, viscosity imparting agents, surfactants, diluents, wetting agents, carriers, diluents, preservatives, emulsifiers, stabilizers, and tonicity adjusters.

[0070] Acceptable excipients preferably are pharma- ceutically acceptable, ie, non-toxic to recipients at the dosages and concentrations employed.

[0071] Exemplary excipients include, but are not limited to, amino acids such as glycine, alanine, glutamine, asparagine, threonine, proline, 2-phenylalanine, including charged amino acids, preferably lysine, lysine acetate, arginine, glutamate, and / or histidine; preservatives, including antimicrobial agents such as antibacterial and antifungal agents; antioxidants, such as ascorbic acid, methionine, sodium sulfite, or sodium bisulfite; and antioxidants to maintain the composition at or slightly below physiological pH, typically within a pH range of about 5 to about 8 or 9. buffers, buffer systems, and buffering agents used for the preparation of pharmaceutical compositions (examples of buffers are borate, bicarbonate, Tris-HCl, citrate, phosphate, or other organic acids, succinate, phosphate, histidine, and acetate, e.g., Tris buffer at about pH 7.0-8.5, or acetate buffer at about pH 4.0-5.5); non-aqueous solvents such as propylene glycol, polyethylene glycol, vegetable oils such as olive oil, and injectable organic esters such as ethyl oleate; water, alcohol / aqueous solutions, emulsions or suspensions, including saline and buffered media. The carrier may be an aqueous carrier, such as a biodegradable polymer, such as polyester; a bulking agent, such as mannitol or glycine; a chelating agent, such as ethylenediaminetetraacetic acid (EDTA); an isotonicity agent and an absorption retarding agent; a complexing agent, such as caffeine, polyvinylpyrrolidone, β-cyclodextrin, or hydroxypropyl-β-cyclodextrin; a bulking agent; monosaccharides; disaccharides; and other carbohydrates, such as glucose, mannose, or dextrin; the carbohydrate may be a non-reducing sugar, preferably trehalose, sucrose, octasulfate, sorbitol, or xylitol. (low molecular weight) proteins, polypeptides or proteinaceous carriers, e.g. human or bovine serum albumin, preferably gelatin or immunoglobulins of human origin; colouring and flavouring agents; sulphur-containing reducing agents, e.g. glutathione, thioctic acid, sodium thioglycolate, thioglycerol, α-monothioglycerol and sodium thiosulfate diluents; emulsifiers; hydrophilic polymers such as polyvinylpyrrolidone), salt-forming counterions such as sodium; preservatives such as antimicrobial agents, antioxidants, chelating agents, inert gases and the like;Examples are benzalkonium chloride, benzoic acid, salicylic acid, thimerosal, phenethyl alcohol, methylparaben, propylparaben, chlorhexidine, sorbic acid, or hydrogen peroxide; metal complexes such as Zn-protein complexes; solvents and co-solvents (such as glycerin, propylene glycol, or polyethylene glycol); sugars and sugar alcohols including polyols, trehalose, sucrose, octasulfate, mannitol, sorbitol, or xylitol, stachyose, mannose, sorbose, xylose, ribose, myo-initose, galactose, lactitol, ribitol, myo-initose, galactitol, glycerol, cyclitols (e.g., inositol), polyethylene glycol; and polyhydric sugar alcohols; suspending agents; pluronic, surfactants or wetting agents such as PEG, sorbitan esters, polysorbates such as polysorbate 20, polysorbates, triton, tromethamine, lecithin, cholesterol, tyloxapol; surfactants may be detergents, preferably with a molecular weight of >1.2KD and / or polyethers, preferably with a molecular weight of >3KD, non-limiting examples of preferred detergents are Tween 20, Tween 40, Tween 60, Tween 80, and Tween 85; non-limiting examples of preferred polyethers are PEG 3000, PEG 3350, PEG 4000, and PEG 5000; stability enhancers such as sucrose or sorbitol; tonicity agents, e.g. alkali metal halides, preferably sodium chloride or potassium chloride, mannitol. sorbitol; parenteral delivery vehicles including sodium chloride solution, Ringer's dextrose, dextrose and sodium chloride, lactated Ringer's, or fixed oils; intravenous delivery vehicles including fluid and nutrient replenishers, electrolyte replenishers (such as those based on Ringer's dextrose);

[0072] It will be apparent to one skilled in the art that different excipients of a pharmaceutical composition (e.g., those listed above) may have different effects, e.g., amino acids can act as buffers, stabilizers, and / or antioxidants, mannitol can act as a bulking agent and / or tonicity enhancer, sodium chloride can act as a delivery vehicle and / or tonicity enhancer, etc.

[0073] Polyols are useful stabilizers in both liquid and lyophilized formulations to protect proteins from physical and chemical degradation processes, and are also useful for adjusting the tonicity of the formulation. Polyols include sugars, such as mannitol, sucrose, and sorbitol, and polyhydric alcohols, such as glycerol and propylene glycol, and for the purposes of discussion herein, polyethylene glycol (PEG) and related substances. Mannitol is commonly used to ensure the structural stability of the cake in lyophilized formulations. Mannitol provides structural stability to the cake. Mannitol is commonly used with lyophilization protection agents, such as sucrose. Sorbitol and sucrose are commonly used agents to adjust tonicity and are used as stabilizers to protect against freeze-thaw stress during transportation or bulk preparation during manufacturing processes. PEG stabilizes proteins and is useful as a cryoprotectant.

[0074] Surfactants are routinely used to prevent, minimize, or reduce surface adsorption. Protein molecules can be susceptible to adsorption on surfaces, as well as denaturation and resulting aggregation at air-liquid, solid-liquid, and liquid-liquid interfaces. These effects are generally inversely proportional to protein concentration. These deleterious interactions are generally inversely proportional to protein concentration and are usually exacerbated by physical agitation, such as that occurring during product transportation and handling. Commonly used surfactants include polysorbate 20, polysorbate 80, other fatty acid esters of sorbitan polyethoxylate, and poloxamer 188. Surfactants are also commonly used to control protein conformational stability. The use of surfactants in this regard is protein specific, as any given surfactant will usually stabilize some proteins and destabilize others.

[0075] Antioxidants can prevent the harmful oxidation of proteins in pharmaceutical formulations, in part, by maintaining appropriate levels of ambient oxygen and temperature, and by avoiding exposure to light. Antioxidant excipients can also be used to prevent oxidative degradation of proteins. Useful antioxidants in this regard include reducing agents, oxygen / free radical scavengers, and chelating agents. Antioxidants for use in therapeutic protein formulations are preferably water-soluble and maintain activity throughout the shelf life of the product. EDTA is a useful example.

[0076] Metal ions can act as protein cofactors, forming protein coordination complexes. Metal ions can also inhibit some processes that degrade proteins.

[0077] Salts may be used in accordance with the present invention, for example, to adjust the ionic strength and / or tonicity of the pharmaceutical formulation and / or to further improve the solubility and / or physical stability of the antibody construct or other components. As is well known, ions can stabilize the native state of proteins by binding to charged residues on the surface of the protein, as well as by shielding charged and polar groups in the protein, reducing the strength of their electrostatic, attractive, and repulsive interactions. In addition, ionic interactions with charged and polar groups in proteins may also reduce intermolecular electrostatic interactions, thereby preventing or reducing protein aggregation and insolubility. Ionic species differ in their effects on proteins. Numerous classification rankings of ions and their effects on proteins have been developed that can be used in formulating pharmaceutical compositions in accordance with the present invention. One example is the Hofmeister series, which ranks ionic and polar non-ionic solutes by their effect on the conformational stability of proteins in solution. Stabilizing solutes are termed "cosmotropic". Destabilizing solutes are termed "chaotropic". Kosmotropes are commonly used in high concentrations (e.g., >1 molar ammonium sulfate) to precipitate proteins from solution. Chaotropes are commonly used to denature and / or solubilize proteins ("salting in"). The relative effectiveness of an ion for "salting in" and "salting out" defines its position in the Hofmeister series.

[0078] Free amino acids can be used in pharmaceutical compositions as stabilizers and antioxidants, as well as other standard uses. Lysine, proline, serine, and alanine can be used to stabilize proteins in the formulation. Glycine is useful for ensuring correct cake structure and properties in lyophilization. Arginine can be useful for inhibiting protein aggregation in both liquid and lyophilized formulations. Methionine is useful as an antioxidant.

[0079] Exemplary useful excipients for formulating pharmaceutical compositions include sucrose, trehalose, mannitol, sorbitol, arginine, lysine, polysorbate 20, polysorbate 80, poloxamer 188, pluronic, and combinations thereof. The excipients may be present in the pharmaceutical composition at different concentrations, so long as the composition exhibits the desired properties as exemplified herein, and in particular promotes stabilization of the bispecific single chain antibody construct contained therein. For example, sucrose may be present in the pharmaceutical composition at a concentration of 2% (w / v) to 12% (w / v), i.e., 12% (w / v), 11% (w / v), 10% (w / v), 9% (w / v), 8% (w / v), 7% (w / v), 6% (w / v), 5% (w / v), 4% (w / v), 3% (w / v), or 2% (w / v). The preferred sucrose concentration is in the range of 4% (w / v) to 10% (w / v), more preferably 6% (w / v) to 10% (w / v). Polysorbate 80 may be present in the pharmaceutical composition at a concentration of 0.001% (w / v) to 0.5% (w / v), i.e., 0.5% (w / v), 0.2% (w / v), 0.1% (w / v), 0.08% (w / v), 0.05% (w / v), 0.02% (w / v), 0.01% (w / v), 0.008% (w / v), 0.005% (w / v), 0.002% (w / v), or 0.001% (w / v). A preferred concentration of polysorbate 80 is in the range of 0.002% (w / v) to 0.5% (w / v), preferably 0.005% (w / v) to 0.02% (w / v).

[0080] The pharmaceutical compositions provided herein may include, among others, one or more preservatives. Preservatives useful for formulating pharmaceutical compositions generally include antimicrobial agents (e.g., antibacterial or antifungal agents), antioxidants, chelating agents, inert gases, and the like, examples of which are benzalkonium chloride, benzoic acid, salicylic acid, thimerosal, phenethyl alcohol, methylparaben, propylparaben, chlorhexidine, sorbic acid, or hydrogen peroxide). Antimicrobial preservatives are substances used to extend the shelf life of drugs by reducing microbial growth. Preservatives particularly useful for formulating pharmaceutical compositions of the present invention include benzyl alcohol, chlorobutanol, phenol, meta-cresol, methylparaben, phenoxyethanol, propylparabenthiomerosal. The structures and typical concentrations for the use of these preservatives are described in Table 1 of Meyer et al. J Pharm Sci.96(12),3155. Compositions containing such carriers are formulated by well-known conventional methods.

[0081] "Infusion system," as used herein, refers to a system that includes one or more component(s) that allows an individual (also referred to herein as a user or patient) to self-administer a dose of a drug. An exemplary infusion system includes a reservoir for storing and deploying IgGSC. An exemplary device includes one or more wearable components for improved subject convenience. An exemplary infusion system includes a warming device that can bring the pharmaceutical formulation to a desired injection temperature, e.g., about 30°C to about 40°C. In an exemplary embodiment, the system includes a syringe warmer. In an exemplary system, the warming device is an in-line warmer. In an exemplary embodiment, the system includes components intended to compensate for the viscosity of the pharmaceutical formulation and reduce the injection force required to administer a dose of the pharmaceutical formulation (e.g., U.S. Patent Publication 2020 / 0268987). In various embodiments, the infusion system includes structural elements for diverting the flow of the pharmaceutical formulation to two or more sites. In various embodiments, the infusion system includes at least one needle (e.g., a subcutaneous needle). Exemplary needles are configured for one or more injection sites (eg, bifurcated, etc.).

[0082] "Warming device," as the term is used herein, refers to any device or configuration of a device capable of warming a volume of a pharmaceutical formulation, such that a dose (or two or more doses, if administered simultaneously) can be warmed to a desired administration temperature, e.g., about 30°C to about 40°C prior to administration. A warming device can warm the pharmaceutical formulation in its resting state, during flow, or both. Exemplary devices include syringe warmers and in-line warmers. See, e.g., U.S. Patent Publications 2014 / 0207063; 20110166517; 2008 / 0262409; 2008 / 0119782; 2008 / 0269663; 20060153549; 2005 / 0008354; U.S. Patent Nos. 7,316,666; 5,250,032; 4,680,445; and 4,532,414. An exemplary warming device is a component of an infusion system utilized to infuse IgGSCs.

[0083] When using a warmed syringe, the syringe to be warmed can be a standard syringe that is preheated using a syringe warmer. A syringe warmer generally has one or more openings that can each receive a syringe containing a pharmaceutical formulation, and a means for heating and maintaining the syringe at a particular temperature before use. This is referred to herein as a preheated syringe. Suitable heated syringe warmers include those available from Vista Dental Products and Inter-Med. Warmers can accommodate syringes of various sizes and can be heated to any temperature, typically within 1°C, from about 25°C to about 40°C. In some embodiments, the syringe is preheated in a heating bath, such as a water bath, maintained at the desired temperature.

[0084] The heated syringe can be a self-heating syringe, i.e., the liquid formulation in the syringe can be heated and maintained at a certain temperature. The self-heating syringe can be a standard medical syringe with a heating device attached. Suitable heating devices that can be attached to the syringe include syringe heaters or syringe heater tapes available from Watlow Electric Manufacturing Co., St. Louis, Mo., and syringe heater blocks, stage heaters, and in-line perfusion heaters available from Warner Instruments, Hamden, Conn., such as the SW-61 type syringe warmer. The heater can be controlled through a central controller, such as the TC-324B or TC-344B type heater controller available from Warner Instruments.

[0085] The heated syringe maintains the liquid protein formulation at a specific temperature of about 30° C. to about 40° C. By maintaining the pharmaceutical formulation at an elevated temperature during injection, the viscosity of the liquid formulation is reduced, the solubility of the antibody in the formulation is increased, or both.

[0086] Heat may also be provided to the pharmaceutical formulation using an in-line heater, see, e.g., U.S. Patent No. 10,933,200, U.S. Patent Publication Nos. 2014 / 0091083 and 2011 / 0184501.

[0087] Infusion systems for use in the present invention include systems with a pump that drives a pharmaceutical formulation from a reservoir in the system to a subcutaneous needle or through a connection between a reservoir and a subcutaneous needle, see, e.g., U.S. Patent Publication 2004 / 0073161, U.S. Patent Nos. 6,554,791 and 5,782,805.

[0088] As used herein, the term "injection" generally means administering a composition to a subject or system to achieve delivery of an agent that is or is contained in the composition. Those skilled in the art will recognize the various routes that may be utilized for administration to a subject, e.g., a human, in the appropriate circumstances. For example, in some embodiments, administration may be ocular, oral, parenteral, topical, and the like. In some specific embodiments, administration may be bronchial (e.g., by bronchial instillation), buccal, transdermal (e.g., may be or may include one or more of topical, such as dermal, intradermal, interdermal, transdermal, etc.), enteral, intraarterial, intradermal, intragastric, intramedullary, intramuscular, intranasal, intraperitoneal, intrathecal, intravenous, intraventricular, in a particular organ (e.g., in the liver), mucosal, nasal, oral, rectal, subcutaneous, sublingual, topical, tracheal (e.g., by intratracheal instillation), intravaginal, vitreous, and the like. Subcutaneous injection is an exemplary mode of administration. In some embodiments, injection may include only a single dose. In some embodiments, the injection may include a fixed number of doses. In some embodiments, the injection may involve dosing that is intermittent (e.g., multiple doses spaced apart by time) and / or periodic (e.g., individual doses separated by a period of time) dosing. In some embodiments, the injection may involve continuous dosing (e.g., perfusion) for at least a selected period of time. In some embodiments, the injection includes administration of multiple doses at multiple sites. In some embodiments, the injection is a predetermined dose at one, two, or more sites, where the predetermined dose is divided over multiple sites. The use of one, two, or more sites for injection is suitable for subcutaneous injection.

[0089] Injectability or Injectability: As generally used herein, the term "injectability" or "injectability" refers to the ability to inject (inject) a pharmaceutical formulation through a syringe with a needle of a selected gauge, e.g., an 18-32 gauge needle, optionally with a thin-walled needle (in which case the needle is a hypodermic needle). Injectability generally depends on factors such as the pressure or force required for injection, uniformity of flow, aspiration characteristics, and freedom from needle clogging. The injectability of a liquid pharmaceutical formulation may be evaluated by comparing the injection force of a reduced-viscosity formulation with a standard formulation without added viscosity-reducing agent. A reduced injection force of a formulation of the invention reflects an improved injectability of the formulation. The formulations of the invention have improved injectability. For various formulations, the injection force is reduced by about 10%, 20%, 30%, 50%, 75%, or more when compared to a formulation with the same concentration of protein under otherwise identical conditions while obtaining the same injection force. In some embodiments, the amount by which the injection force is reduced is within a range bounded by a lower limit and an upper limit, the upper limit being greater than the lower limit. In some embodiments, the lower limit may be about 5%, about 10%, or about 15%. In some embodiments, the upper limit may be about 50% or about 75%. In some embodiments, the range may be about 10% to about 30%. In some embodiments, the range may be about 10% to about 50%. In some embodiments, the range may be about 10% to about 75%. Alternatively, the injectability of a liquid pharmaceutical formulation may be evaluated by comparing the time required to inject the same volume, for example 0.5 mL to about 1 mL, of the liquid protein formulation when the syringe is depressed with the same force.

[0090] As generally used herein, the term "injection force" refers to the force required to push a given liquid formulation through a given syringe with a given needle gauge at a given injection rate. Injection force is usually reported in Newtons. For example, injection force may be measured as the force required to push a liquid formulation through a 1 mL plastic syringe (e.g., plastic, glass, metal) with an inner diameter of 0.25 inches and a 0.50 inch, 27 gauge needle at an injection rate of 250 mm / min. Testing equipment can be used to measure injection force. When measured under the same conditions, formulations with lower viscosity, such as those of the present invention, generally require lower overall injection force.

[0091] Exemplary "tissue back pressure", as the term is used herein, refers to the force exerted by the tissue of the subcutaneous compartment that opposes the force exerted by the IgGSC as it is injected by the infusion system and enters the subcutaneous compartment, providing resistance to the infusion and distribution of the IgGSC into the subcutaneous compartment. In various embodiments, the infusion methods of the invention do not involve sufficient tissue back pressure to cause a subject receiving the IgG formulation to terminate the infusion or slow it down due to the perception of discomfort or pain.

[0092] IgG-based therapeutics are generally administered alone in the range of about 100 mg to about 2 g / kg / patient / dose of protein material per injection. The present disclosure recognizes the source of problems associated with highly concentrated IgG therapeutic formulations, which may present administration challenges due to high viscosity and / or aggregation. In particular, the present disclosure provides pharmaceutical formulations of IgG containing at least about 20% IgG, which are temporarily low viscous, i.e., less viscous than when such formulations are at room temperature ("reference formulations"). The present invention further provides "facilitated" formulations, "facilitated" infusions of these formulations, and systems containing and used for infusion of the "facilitated" formulations. As used herein, "facilitated" refers to the co-administration or simultaneous administration of a hyaluronidase formulation (e.g., rHuPH20) and a 20% IgG formulation.

[0093] "Enhanced IGSC(20%)" refers to injecting IGSC(20%) and hyaluronidase to enhance infusion of the antibody formulation. In an exemplary embodiment, the Enhanced IGSC(20%) is infused into the first infusion site at a rate of at least about 100 mL / hour, at least about 120 mL / hour, at least about 140 mL / hour, at least about 160 mL / hour, at least about 180 mL / hour, at least about 200 mL / hour, at least about 220 mL / hour, at least about 240 mL / hour, at least about 260 mL / hour, at least about 280 mL / hour, or at least about 300 mL / hour.

[0094] Kinematic Viscosity: As used herein, kinematic viscosity refers to a measure of the rate at which momentum is transferred through a fluid. It is measured in Stokes (St). Kinematic viscosity is a measure of the resistive flow of a fluid under the influence of gravity. If two fluids of equal volumes but different viscosities are placed in the same capillary viscometer and allowed to flow by gravity, the more viscous fluid will usually take longer to flow through the capillary than the less viscous fluid. Kinematic viscosity has dimensions of length / time. Kinematic viscosity is generally expressed in centistokes (cSt). The SI unit of kinematic viscosity is mm 2 / s, which is equal to 1 cSt.

[0095] As used herein, the terms "improve," "increase," "inhibit," "reduce," "decrease," or grammatical equivalents thereof refer to a value compared to a baseline or other reference measurement. In some embodiments, a suitable reference measurement may be or include a measurement in a particular system (e.g., an individual) under otherwise comparable conditions in the absence (e.g., before and / or after) of a particular agent or treatment, or in the presence of a suitable comparable reference agent. In some embodiments, a suitable reference measurement may be or include a measurement in a comparable system known or expected to respond in a particular way, in the presence of the relevant agent or treatment.

[0096] As generally used herein, the term "low-viscosity formulation" refers to a liquid formulation containing a high concentration of a high molecular weight protein, e.g., IgG, that is modified by injection using a system described herein, resulting in a reduced viscosity of the injected formulation compared to a corresponding formulation injected at a lower temperature.

[0097] As used herein, "membrane-anchored HASEGP" refers to a family of membrane-anchored hyaluronidases that share common structural features as described herein. As described and illustrated herein, hyaluronidases that are normally membrane-anchored (i.e., glycosaminoglycanases that can degrade hyaluronan, preferably those that exhibit at least some activity in the neutral pH range) can be converted to soluble HASEGPs or sHASEGPs by removing or modifying one or more of the regions associated with anchoring the hyaluronidase in the membrane.

[0098] As used herein, "soluble hyaluronidase" refers to a polypeptide characterized by its solubility under physiological conditions.Soluble HASEGP can be identified, for example, by partitioning into the aqueous phase of a Triton X-114 solution warmed to 37°C (Bordier et al J Biol Chem.1981 Feb.25;256(4):1604-7).On the other hand, lipid-anchored HASEGP partitions into detergent-rich phase, but partitions into detergent-poor phase or aqueous phase after treatment with phospholipase-C.

[0099] As used herein, "sHASEGP", whenever referenced herein, refers to the soluble PH20 polypeptide described in U.S. Patent No. 10,588,983, the contents of which are incorporated herein by reference in their entirety for all purposes. In particular, HASEGP polypeptides are provided. The polypeptides are single-chain or two-chain polypeptides. Smaller portions thereof that retain hyaluronidase activity are also provided. Hyaluronidase domains derived from sHASEGP vary in size and composition, including insertions and deletions in surface loops. Thus, for purposes herein, the catalytic domain is a portion of sHASEGP as defined herein and is homologous to domains of other hyaluronidase-like sequences, such as HYAL1, HYAL2, HYAL3, previously identified, however, it was not recognized that isolated single-chain forms of human hyaluronidase domains could function in in vitro assays. The aspartic acid and glutamic acid residues required for activity are present in conserved motifs.

[0100] In particular, sHASEGP polypeptides are provided. The polypeptides are single-chain or double-chain polypeptides. Smaller portions thereof that retain hyaluronidase activity are also provided. Hyaluronidase domains derived from sHASEGP vary in size and organization, including insertions and deletions in surface loops. Thus, for purposes herein, the catalytic domain is the portion of sHASEGP defined herein and is homologous to domains of other hyaluronidase-like sequences, such as HYAL1, HYAL2, HYAL3, previously identified, although it was not recognized that isolated single-chain forms of human hyaluronidase domains could function in in vitro assays. The aspartic acid and glutamic acid residues required for activity are present in conserved motifs.

[0101] As used herein, "soluble sHASEGP neutral hyaluronidase domain" refers to a β-1,4 endoglucosaminidase domain of a sHASEGP that exhibits hyaluronidase activity at neutral pH, is soluble under the conditions described, and shares homology and structural characteristics with the hyaluronidase glycosyl hydrolase family domain, but contains additional sequences at the carboxy terminus required for neutral activity. Thus, at least the minimal portion of the domain that exhibits hyaluronidase activity and remains soluble as assessed by standard in vitro assays. Such hyaluronidase domains and catalytically active portions thereof are contemplated herein. Also provided are truncated forms of the hyaluronidase domain, including the minimal fragment thereof that acts catalytically as a single chain form. As used herein and in the art, neutral or neutral activity refers to a protein that exhibits activity at neutral pH (e.g., exhibits activity at about pH 7) and is therefore active in the pH range characteristic of many physiological tissues. As will be appreciated by those skilled in the art, proteins generally exhibit an activity range around their optimum pH. The optimum pH for a neutrally active protein is within one to several pH units above or below pH 7, but the activity range can extend over many pH units.

[0102] Thus, for exemplary purposes herein, a Hyaluronidase domain is a portion of a sHASEGP as defined herein that is homologous to domains of other sHASEGPs. As with the larger class of enzymes in the Hyaluronidase family, the sHASEGP catalytic domain shares a high degree of amino acid sequence identity. The Asp and Glu residues required for activity are present in conserved motifs.

[0103] As used herein, "catalytically active domain of a sHASEGP" refers to the neutral active endoglucosaminidase domain as defined by in vitro activity against glycosaminoglycan substrates.

[0104] sHASEGPs of interest include those that are active in vivo and in vitro against chondroitin sulfate and chondroitin sulfate proteoglycans (CSPGs), as well as those that are active against hyaluronan. As used herein, human sHASEGPs are those encoded by nucleic acids, such as DNA, present in the human genome, and include all allelic variants and conservative variations, unless they are variants found in other mammals.

[0105] As used herein, "a nucleic acid encoding a hyaluronidase domain or catalytically active portion of a sHASEGP" is intended to refer to a nucleic acid that encodes only the described single chain hyaluronidase domain or an active portion thereof, and does not encode other continuous portions of the sHASEGP as a contiguous sequence.

[0106] As used herein, a statement that a glycoprotein consists essentially of a "Hyaluronidase domain" means that the only sHASEGP portion of the polypeptide is the Hyaluronidase domain or a catalytically active portion thereof. The polypeptide may optionally, and generally, include additional, non-sHASEGP-derived sequences of amino acids.

[0107] As used herein, a "domain" refers to a portion of a molecule, e.g., a glycoprotein or encoding nucleic acid, that is structurally and / or functionally distinct from other portions of the molecule.

[0108] As used herein, "hyaluronidase" refers to an enzyme that catalyzes the hydrolysis of glycosaminoglycans, including hyaluronan. This definition includes naturally occurring hyaluronidases, as well as recombinant hyaluronidases of both human and other sources.

[0109] For clarity, reference to hyaluronidase refers to all forms, with particular forms being specifically named. For purposes herein, the hyaluronidase domain includes membrane-bound and soluble forms of sHASEGP proteins.

[0110] "HuPH20" refers to human hyaluronidase, e.g., human recombinant hyaluronidase (rHuPH20).

[0111] As used herein, a "conventional infusion rate" is up to about 60 mL / hour / site, which is the typical label value for currently approved subcutaneous IgG formulations.

[0112] As used herein, a "higher infusion rate" is about 60 to about 100 mL / hour / site.

[0113] As used herein, a "high infusion rate" is about 100 to about 300 mL / hour / site, e.g., at least about 120, at least about 140, at least about 160, at least about 180, at least about 200, at least about 220, at least about 240, at least about 260, at least about 280, at least about 300 mL / hour / site, or more.

[0114] III. Embodiment A. Kit As a means of improving and enhancing the overall patient experience of subjects injecting concentrated IgG formulations, in various embodiments, the present invention provides: A first container containing a pharmaceutical formulation of hyaluronidase, e.g., human hyaluronidase, e.g., recombinant human hyaluronidase, in a pharma- ceutically acceptable carrier; a second container containing a pharmaceutical formulation of 20% (w / v) IgG in a pharma- ceutically acceptable carrier; (i) a first aliquot of a predetermined dose of the pharmaceutical formulation of recombinant human hyaluronidase, and (ii) instructions providing guidance for sequentially subcutaneously injecting, at a first injection site, a first aliquot of a predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG following (i). A kit comprising:

[0115] In various embodiments, the pharmaceutical formulation of recombinant human hyaluronidase contains 160 U / mL of hyaluronidase, for example, recombinant human hyaluronidase. In an exemplary embodiment, the recombinant human hyaluronidase is rHuPH20.

[0116] In various embodiments, the kit further comprises (i) a pharmaceutical formulation of recombinant human hyaluronidase, and (ii) an injection device for sequentially or simultaneously subcutaneously injecting (i) followed by a pharmaceutical formulation of 20% (w / v) IgG. In various embodiments, the kit further comprises a set of hypodermic needles.

[0117] In various embodiments, the instructions are a component of the Dosage and Administration section of Complete Prescribing Information. In an exemplary embodiment, the instructions provide guidance for subcutaneously injecting a pharmaceutical formulation of rHuPH20 into a first injection site. In one embodiment, the instructions provide guidance for subcutaneously injecting about 50 U / g to about 100 U of rHuPH20 per gram of IgG into a first injection site.

[0118] In some embodiments, the instructions provide guidance for subcutaneously injecting up to at least about 100 mL, up to at least about 150 mL, up to at least about 200 mL, up to at least about 250 mL, or up to at least about 300 mL of the pharmaceutical formulation of 20% (w / v) IgG into a first injection site. In exemplary embodiments, the instructions provide guidance for subcutaneously injecting a first predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG into a first injection site at a rate of at least about 120 mL / hour, at least about 150 mL / hour, at least about 200 mL / hour, at least about 250 mL / hour, or at least about 300 mL / hour. In various embodiments, the instructions provide guidance to subcutaneously inject at least about 120 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first infusion site at a rate of at least about 120 mL / hour, at least about 150 mL / hour, at least about 200 mL / hour, at least about 250 mL / hour, or at least about 300 mL / hour. In various embodiments, the instructions provide guidance to (b) subcutaneously inject at least about 300 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first infusion site. In an exemplary embodiment, the instructions provide guidance to (a) subcutaneously inject at least about 300 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first infusion site at a rate of at least about 300 mL / hour.

[0119] In various embodiments, the instructions provide guidance for subcutaneous injection of a pharmaceutical formulation of 20% (w / v) IgG warmed to a temperature of about 30° C. to about 41° C., the pharmaceutical formulation being warmed to that temperature prior to injection, during injection, and combinations thereof.

[0120] In various embodiments, the instructions further provide guidance for simultaneously or sequentially (i) subcutaneously injecting a second aliquot of the predetermined dose of the pharmaceutical formulation of recombinant human hyaluronidase at a second injection site, and (ii) following (i), subcutaneously injecting a second aliquot of the predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG at the second injection site.

[0121] In various embodiments, the instructions provide guidance for subcutaneously injecting the pharmaceutical formulation of rHuPH20 into a first infusion site, and then injecting the pharmaceutical formulation of 20% (w / v) IgG into the first infusion site using a member selected from: (i) a set of subcutaneous needles, (ii) a pooling bag, (iii) a gravity fill set with a vent spike, (iv) a syringe, (v) a pump, (vi) a warming device, (vii) tubing, and combinations thereof.

[0122] B. Preparation Highly concentrated formulations of macromolecules such as therapeutic protein substances, including whole antibodies or fragments thereof, with low viscosity are of great value for ease of storage and delivery in vivo. However, there are few techniques for preparing high concentration, low viscosity protein substance formulations of more than 200 mg of protein substance per mL of solution that are also stable and do not form any appreciable or interfering amount of aggregates. The present disclosure specifically identifies the source of the problems associated with high concentration protein substance compositions. In particular, the present disclosure recognizes that such compositions may pose many challenges, such as high viscosity, low stability, and handling and manufacturing difficulties. Furthermore, the present disclosure recognizes that certain viscosity-reducing agents sometimes proposed for use in the art may be required in large quantities to sufficiently reduce viscosity, and in some cases, these agents may be toxic or pharma- ceutical unacceptable.

[0123] The present disclosure recognizes that high concentration protein substances must often be handled with great care, as they are highly susceptible to aggregation and high protein-protein interactions. Solutions with high protein substance concentrations have a tendency to aggregate and form particles during processing and / or storage, which makes them difficult to manipulate during further processing and / or delivery. Concentration-dependent degradation and / or aggregation can present a major challenge to the development of high concentration protein substance formulations.

[0124] The present disclosure provides, inter alia, high concentration formulations (e.g., greater than 200 mg / mL) of reduced viscosity proteinaceous agents comprising therapeutic agents. Generally, the formulations provided are suitable for parenteral administration (e.g., by injection), and in many embodiments, parenteral administration without injection and / or other than intravenous administration. In particular, in many embodiments, the present disclosure provides formulations suitable for administration by subcutaneous injection (SC) and / or intramuscular (IM) injection. In many embodiments, the formulations provided are suitable for administration through an 18-32 gauge needle.

[0125] In an exemplary embodiment, the present invention provides a pharmaceutical formulation contained within a system for delivering the pharmaceutical formulation by injection to a subject in need thereof. The pharmaceutical formulation comprises at least about 20% (w / v) immunoglobulin in a pharma- ceutically acceptable aqueous carrier in which the immunoglobulin is dissolved. The system includes a first container containing the pharmaceutical formulation; a first hypodermic needle having a first end configured to pierce a first injection site of the subject and a distal opening disposed therein through which the pharmaceutical formulation is delivered to the first injection site; a first connecting member in fluid communication with the first container and the hypodermic needle; and a first warming device in thermal contact with a component of the system selected from the first container, the first connecting member, and combinations thereof, the first warming device configured to heat the pharmaceutical formulation to at least about 30° C., to maintain the pharmaceutical formulation at a temperature of at least about 30° C., and combinations thereof.

[0126] In exemplary embodiments, the pharmaceutical formulation, when injected, is at a temperature of at least about 30° C., at least about 32, at least about 34, at least about 36, at least about 38, or at least about 40° C. In various embodiments, the formulation is at at least one of these temperatures before, after, or during injection into the injection site.

[0127] In some embodiments, the first injection site is a first subcutaneous injection site.

[0128] In various embodiments, the present invention provides a pharmaceutical formulation of an immunoglobulin. The formulation comprises at least about 20% (wt / v) immunoglobulin and a pharma- ceutically acceptable aqueous carrier in which the immunoglobulin is dissolved. The pharmaceutical formulation has a viscosity that allows for injection of the pharmaceutical formulation into a first subcutaneous injection site of a subject in need of such injection at a rate of greater than about 3 mL / min (e.g., about 3 to about 7.5 mL / min, e.g., about 3 to about 45 mL / min), and the pharmaceutical formulation is under a first pressure of about 7000 Pa to about 47000 Pa. Exemplary formulations do not include a small molecule agent specifically incorporated to reduce the viscosity of the formulation. In various embodiments, the formulation is not a suspension of an antibody in a mixture of water and an organic solvent, such as an alcohol, e.g., ethanol. Exemplary formulations have a viscosity of about 10 mPa / sec or less at about 30 to about 40°C.

[0129] In some embodiments, the present disclosure provides low-aggregation pharmaceutical formulations of antibodies. In some embodiments, the present disclosure encompasses the recognition that reduced surface adsorption and / or interfacial interactions may have beneficial effects on certain protein formulations. In particular, in some embodiments, the present disclosure provides formulations of therapeutic protein agents that have relatively low surface adsorption and / or interfacial interactions (compared to those observed for appropriate reference formulations). The provided formulations can be injected subcutaneously (SC) or intramuscularly (IM).

[0130] In an exemplary embodiment, the present invention provides an infusion system, wherein the first container is selected from an infusion bag and a syringe.

[0131] In various embodiments, the first connecting member of the system is a length of hollow tubing attached to both the first container and the hypodermic needle.

[0132] In various embodiments, the system further includes a means for pressurizing the first container sufficiently to drive the pharmaceutical formulation from the first container through the first connecting member into the first hypodermic needle, from where it exits the system through its distal opening. If pressure is not provided in the course of manually operating the syringe, an exemplary pressurizing means is a pump.

[0133] In exemplary embodiments, the warming means of the system is configured to warm the IgG formulation while it resides in the first container, while it passes through the system, e.g., while it resides in the first connecting member, or both. Exemplary systems are configured to provide the pharmaceutical formulation exiting the distal opening of the first hypodermic needle at a first flow rate, the first flow rate being selected to allow the pharmaceutical formulation to be heated or maintained at at least about 30° C. while passing through the first connecting member at the first flow rate. In some embodiments, the formulation is heated or maintained at about 30° C. to about 40° C.

[0134] In various embodiments, the system is configured to provide a pharmaceutical formulation passing through the first connecting member and / or exiting the distal opening of the first hypodermic needle at a first flow rate, the first flow rate selected such that the pharmaceutical formulation can be heated or maintained at a temperature between about 28° C. and at least about 40° C., e.g., about 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40° C., during passage through the first connecting member at the first flow rate.

[0135] In exemplary embodiments, the connecting member is a length of tubing, which in some embodiments is maintained within a heating means to heat the IgG formulation as it passes through the connecting means.

[0136] In an exemplary embodiment, the pharmaceutical formulation contained in the first container is configured as a single unit dose formulation.

[0137] It is within the scope of the present invention to administer multiple, for example, two, three, four, five or more unit doses to a subject at two, three, four or more sites to achieve a desired dose. In an exemplary embodiment, the unit dose is administered to two or more sites and a branched connecting member, where each branch terminates in a hypodermic needle and each hypodermic needle is inserted into a unique administration site. Thus, in some embodiments, a single unit dose formulation is configured to deliver a pharmaceutical formulation to a first injection site. In various embodiments, a single unit dose formulation is configured to deliver a pharmaceutical formulation to a first injection site and a second injection site.

[0138] The pharmaceutical formulation may include components other than or in addition to IgG and a pharma- ceutically acceptable carrier, or may consist essentially of these two components, thereby providing a pharmaceutical formulation that is essentially free of proteins other than immunoglobulins. In an exemplary embodiment, the pharmaceutical formulation includes albumin.

[0139] In accordance with the present invention, pharmaceutical formulations achieve a viscosity and injectability suitable for subcutaneous administration without the need to add small organic molecules to the formulation that are incorporated into the formulation and that appreciably reduce its viscosity. The present invention contemplates exemplary formulations in which small organic or inorganic molecules are included in the formulation, but these additives are incorporated for purposes other than reducing the viscosity of the formulation.

[0140] In exemplary embodiments, the viscosity of the IgG formulation at a temperature of about 30° C., 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40° C. is about 7 mPa-s to about 10 mPa-s.

[0141] The present invention provides a pharmaceutical formulation of a predetermined and controlled viscosity and therefore a predetermined and controlled flow rate through a system containing the pharmaceutical formulation. In an exemplary embodiment, the system containing the pharmaceutical formulation is configured such that the pharmaceutical formulation has a flow rate of about 3 mL / min to about 7.5 mL / min at about 30° C. as it exits the distal opening of a first hypodermic needle, which is a 21-24 gauge hypodermic needle.

[0142] In various embodiments, the invention provides a pharmaceutical formulation according to any of the previous embodiments and further includes a system, an exemplary system including a pump configured to facilitate dispensing the pharmaceutical formulation of immune globulin under pressure from a first container to a first infusion site of a subject.

[0143] In some embodiments, the invention provides a pharmaceutical formulation, wherein injection of the pharmaceutical formulation into a first injection site at the injection temperature does not result in the subject experiencing greater discomfort than the subject would experience upon injection of an otherwise identical pharmaceutical formulation, comprising about 10% (w / v) immunoglobulin and about 90% (w / v) aqueous pharmaceutical carrier, into a first injection site under the same injection parameters. In various embodiments, the subject would experience even less discomfort under this scenario.

[0144] In an exemplary embodiment, the formulation does not include a viscosity-reducing agent, e.g., an agent that is added to the formulation for the express purpose of reducing the viscosity of the formulation and has no other significant purpose in the formulation other than viscosity reduction. Exemplary viscosity-reducing agents not present in the formulation include, but are not limited to, nicotinic acid (acid form) and / or caffeine, nicotinic acid and / or caffeine citrate, nicotinic acid and / or caffeine nicotinate, or nicotinic acid and / or aspirin; further, nicotinamide (niacinamide), nicotinic acid sodium salt, benzyl nicotinate, inositol hexanicotinate, nicotinyl alcohol (β-pyridyl carbinol), xanthine nicotinate, methyl nicotinate, nicotine nicotinic acid ethyl, propyl, isopropyl, butyl, isoamyl, hexyl, phenyl, nicotinic acid guaiacyl, xanthinol, nicotinic acid nicametate, nicotinic acid uric acid, nicotinyl hydroxamate, tocopheryl, trigonelline, nicotinoyl-dl-alpha-alanine, nicotinoyl-L-alanine, nicotinoyl-dl-valine, nicotinoyl-L-leucine, and nicotinoyl-dl-phenylalanine, ethionyl mido, niceritrol, nicofuranose, piperocaine, N-ethylpiperidine, caffeine hematin, ethoxycaffeine, methoxycaffeine, 7-benzyltheophylline, theophylline, paraxanthine, theobromine, 7-[(4-methoxyphenyl)methyl]-1,3-dimethyl-2,3,6,7-tetrahydro-1H-purine-2,6-dione, 1,3-dimethyl-7-[(4-methylphenyl)methyl]-2,3,6,7-tetrahydro-1H-purine-2,6-dione, 7-[(4- chlorophenyl)methyl]-1,3-dimethyl-2,3,6,7-tetrahydro-1H-purine-2,6-dione, 7-[(3,5-dimethylphenyl)methyl]-1,3-dimethyl-2,3,6,7-tetrahydro-1H-purine-2,6-dione, 7-benzyl-1,3-dimethyl-2,3,6,7-tetrahydro-1H-purine-2,6-dione, 1,3-dimethyl-7-{[4-(propan-2-yl)phenyl]methyl}-2,3,6,7-tetrahydro-1H-purine-2,6-dione,1,3-Dimethyl-7-[(2-methylphenyl)methyl]-2,3,6,7-tetrahydro-1H-purine-2,6-dione, 4-[(1,3-dimethyl-2,6-dioxo-2,3,6,7-tetrahydro-1H-purine-7-yl)methyl]benzonitrile, 7-[(4-bromophenyl)methyl]-1,3-dimethyl-2,3,6,7-tetrahydro-1H-purine-2,6-di 1,3-dimethyl-7-{[4-(methylthio)phenyl]methyl}-2,3,6,7-tetrahydro-1H-purine-2,6-dione, methyl 4-[(1,3-dimethyl-2,6-dioxo-2,3,6,7-tetrahydro-1H-purine-7-yl)methyl]benzoate, 1,3-dimethyl-7-{[4-(trifluoromethyl)phenyl]methyl}-2,3,6,7-tetrahydro-1H-purine-2,6-dione, 1,3-dimethyl-7-{[4-(methylthio)phenyl]methyl}-2,3,6,7-tetrahydro- 7-[(3-bromophenyl)methyl]-1,3-dimethyl-2,3,6,7-tetrahydro-1H-purine-2,6-dione; 7-(cyclohexylmethyl)-1,3-dimethyl-2,3,6,7-tetrahydro-1H-purine-2,6-dione; 1,3-dimethyl-7-[(4-nitrophenyl)methyl]-2,3,6,7-tetrahydro -1H-purine-2,6-dione, 1,3-dimethyl-7-[(3-nitrophenyl)methyl]-2,3,6,7-tetrahydro-1H-purine-2,6-dione, 1,3-dimethyl-7-(1-phenylethyl)-2,3,6,9-tetrahydro-1H-purine-2,6-dione, 8-[(pyrrolidin-1-ylcarbonothioyl)sulfanyl]caffeine, 8-hydrazino-caffeine 8-Chlorocaffeine, 8-(3-Butyl-4-phenyl-2,3-dihydrothiazol-2-ylidene)hydrazino-3,7-dihydro-1,3,7-trimethyl-1H-purine-2,6-dione, acetylsalicylic acid, salicylic acid, phenylacetic acid, 2-amino-cyclohexane-carboxylic acid, gentisic acid, phthalic acid, anthranilic acid, tetracaine, proxymethacaine, metoclopramide, procaine, chloroprocaine, benzocaine, octisalic acid, propylparaben, thimerosal, vanillin, cyclomethylcaine, mandelic acid, metoclopramide, L-pantothenic acid hemicalcium salt, L-ascorbic acid, thiamine.HCl, rutin hydrate,Riboflavin, folic acid, pyridoxine, biotin, pantoic acid, S-benzoylthiamine, pyridoxal, pyridoxamine, L-histidine, L-lysine, L-arginine, L-2-amino-3-guanidinopropionic acid hydrochloride, 4-guanidinobutyric acid, L-homoarginine·HCl, aspartame, glycine, L-alanine, proline, trans-4-hydroxy-L-proline, L-valine, L-leucine, L-isoleucine, L-methionine, L-serine, tyramine HCl, histamine, imidazole, L-phenylalanine, tyrosine, trypsin, tryptophan, threonine, L-glutamic acid, L-aspartic acid, L-valine, 5-fluoro-L-tryptophan, 5-fluoro-DL-tryptophan, 5-hydroxy-L-tryptophan, 5-methoxy-DL-tryptophan, tryptamine, arginine A and B, granisetron, selenomethionine, carnitine, asparagine, glutamine, arginine-HCl, arginine succinate, arginine dipeptide, arginine tripeptide, polyarginine, 2-amino-3-guanidinopropionic acid, guanidine, ornithine, agma arginine, guanidobutyric acid, citrulline, N-hydroxy-L-norarginine, nitroarginine methyl ester, argininamide, arginine methyl ester, arginine ethyl ester, lysinamide, lysine methyl ester, histidine methyl ester, alaninamide, alanine methyl ester, putrescine, cadaverine, spermidine, spermine, adenine, guanine, cytosine, uracil, thymine, adenosine, guanosine, cytidine, uridine, inosine, thymidine, xanthine, hypoxanthine, 2'-deoxycytidine, 2'-deoxycytidine xylidine, orotic acid, ribothymidine, 1-methylxanthine, 7-methylxanthine, and 3-methylxanthine, D-sucrose, D-(+)-trehalose dehydrate, D-(-)-fructose, D-mannitol, L-(+)-arabinose, D-sorbitol, lactose, maltose, D-ribose, D-galactose, glucosamine, hydroxyalkyl starch, hyaluronic acid, pullulan, chitosan, dextran, dextran sulfate, starch, chondroitin sulfate, carboxymethyl dextran, and hydroxyethyl starch,2-Aminopyrimidine, sodium acetate, sodium pyruvate, potassium acetate, α-ketoglutaric acid, oxaloacetic acid, fumaric acid, DL-malic acid, methyl acetoacetate, DL-isocitric acid trisodium salt, succinic acid, procaine, · HCl, creatinine, thiazole, citric acid, 3-pyridinesulfonic acid, ethylenediaminetetraacetic acid (EDTA), ethanolamine, diethanolamine, triethanolamine, dimethylcyclohexylamine · HCl, p-hydroxybenzoic acid, sodium benzoate, malonic acid, maleic acid, oxalosuccinate, pyrroline-5-carboxylic acid, ethanol, DMSO, benzyl alcohol, and 1,5-pentanediol, sodium chloride, ammonium chloride, ammonium acetate, ammonium sulfate, calcium chloride, sodium thiocyanate, polysorbate 80, polysorbate 20, n-dodecyl β-D-maltoside, octyl β-D-glucopyranoside, aspirin, calcium carrageenan, calcium cyclamate, calcobutrol, caroxetic acid, camphorusulfonic acid, creatinine, dalfampridine, dehydrated acetic acid, diazolidinyl urea, dichlorobenzyl alcohol, dimethyl isosorbide, epitetracycline, ethyl maltol, Ethyl vanillin, ornidazole, ethanolamide, HEPES (4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid), iodoxamic acid, menthol, medronic acid, m-cresol, glutathione, lactobionic acid, maltitol, oxyquinoline, pentetic acid, piperazine, propenyl guaethol, propylene carbonate, protamine sulfate, quaternium-15, quaternium-52, satialgine 11, 1,Sodium 2-ethanedisulfonate, sodium cocoyl sarcosinate, lauroyl sarcosinate, sodium polymetaphosphate, sodium pyrophosphate, pyroglutamic acid, sodium trimetaphosphate, sodium tripolyphosphate, sorbitan, tartaric acid, lactic acid, iofetamine, sucralose, 1-(4-pyridyl)pyridinium chloride, aminobenzoic acid, sodium sulfacetamide, naphthalene 2-sulfonic acid, tert-butylhydroquinone, trolamine, tromantadine, versetamide, nioxime, methylisothiazolinone , mannose, lidofenine, lactitol, isomalt, imidurea, gluconolactone, methanesulfonic acid, xylenesulfonic acid, sulfobutylether-β-cyclodextrin, caffeic acid, caffeic acid phenethyl ester, zileuton, leukotriene inhibitors, tropane N-heterocycles, atropine, hyoscyamine, scopolamine, tiotropium, ipratropium salts, allithiamine, prosultiamine, fursultiamine, benfotiamine, sulbutiamine, 1-(3-aminopropyl)-2-methyl-1H-imidazolium dihydrochloride, cimetidine, piperocaine, cyclomethylcaine, moxifloxacin, chloroquine, mepivacaine, levetriacetam, bupivacaine, cinchocaine, clindamycin, colistin, altican, tetracaine, etidocaine, cyclomethylcaine, piperocaine, phenylephrine, and bupivacaine, polyethylene glycol, branched PEG, and PolyPEG®, lactobionic acid, glucuronic acid, biotin, broclinate, cyclopentanepropionic acid, hydroxynaphthoic acid, phenylpropionic acid, Camphoric acid, mandelic acid, sulfosalicylic acid, hydroxybenzoylbenzoic acid, cinnamic acid, t-butylacetic acid, phthalic acid, trimethylacetic acid, N-methylglucamine, morpholine, piperidine, isopropylamine, trimethylamine, diethylamine, triethylamine, tripropylamine, 2-diethylaminoethanol, trimethamine, dicyclohexylamine, lidocaine, hydrabamine, choline, betaine, ethylenediamine, purine, piperazine, N-methylpiperidine polyamine, 2-amino-2-hydroxymethyl-propane-1,3-Diol (TRIS), 4-aminopyridine, aminocyclohexanecarboxylic acid, 1-o-tribiguanide, urea, benzethonium chloride, 5-amino-1-pentanol, 2-(2-aminoethoxy)ethanol, trans-cyclohexane-1,4-diamine, trans-cyclohexane-1R,2R-diamine, propane-1,3-diamine, butane-1,4-diamine, pentane-1,5-diamine, hexane-1,6-diamine, octane-1,8-diamine, 2-(2-aminoethoxy)ethanamine, 2-(2-(2-aminoethoxy)-ethoxy)ethanamine, 3-(4-(3-aminopropoxy)-butoxy)propan-1-amine, 3-(2-(2-(3-aminopropoxy)-ethoxy)-ethoxy N-(2-(2-aminoethylamino)ethyl)propan-1-amine, N-(2-(2-aminoethylamino)ethyl)ethane-1,2-diamine, N-(2-aminoethyl)ethane-1,2-diamine, N-1-(2-(2-(2-aminoethylamino)ethylamino)-ethyl)ethane-1,2-diamine, N,N-dimethylhexane-1,6-diamine, N,N,N,N-tetramethylbutane-1,4-diamine, phenyltrimethylammonium salts, choline, 1-(3-aminopropyl)-2-methyl-1H-imidazole, 1-(2-aminoethyl)piperazine, 1-[3-(dimethylamino)propyl]piperazine, 1-(2-aminoethyl)piperidine, 2-(2-aminoethyl-1-methylpyrrolidine, and combinations thereof.

[0145] B. Method Proteinaceous-based therapeutics are often administered through intravenous infusion, which can be costly and require a high level of patient compliance. Some proteinaceous-based therapeutics may be administered via subcutaneous or intramuscular injection. Although these routes may offer distinct advantages in ease of administration and cost when compared to intravenous infusion, these routes may also present challenges that may result, for example, from limited injection volume tolerance. Typically, the injection volume is preferably less than about 2 mL for subcutaneous injection and less than about 5 mL for intramuscular injection. Furthermore, it is often preferred that preparations for subcutaneous or intramuscular injection have a viscosity of about 20 centipoise (cP) or less.

[0146] If it is desirable to administer a comparable (or identical) dose by a different route, for example by subcutaneous (SC) injection, highly concentrated formulations are useful, given that the allowable volumes for such routes are significantly smaller than those for IV injection. Such highly concentrated formulations may present significant problems in administration, particularly due to high viscosity, as discussed herein. Also, efforts to concentrate proteinaceous materials to achieve smaller volumes for injection run the risk of damage to the proteinaceous materials, for example as a result of chemical and / or physical instability. Furthermore, subjects may report pain at the injection site when the viscosity is high. Reported antibody concentrations formulated for SC injection can be up to about 100 mg / mL (Wang et al., J. Pharm. Sci. 96:1-26, 2007), and in some cases 150-200 mg / mL.

[0147] In various embodiments, the invention provides a method of subcutaneously injecting a pharmaceutical formulation of 20% (w / v) IgG to a first injection site in a subject in need thereof, the method comprising: (a) injecting a first aliquot of a predetermined dose of hyaluronidase to the first injection site by injecting a predetermined volume of the pharmaceutical formulation of hyaluronidase to the first injection site; and (b) following (a), injecting a first aliquot of a predetermined dose of IgG to the first injection site by injecting a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG to the first injection site. In an exemplary embodiment, the method further includes (c) injecting a second aliquot of the predetermined dose of hyaluronidase at the second injection site by injecting a second predetermined volume of the pharmaceutical formulation of hyaluronidase at the second injection site, and (d) following (c), injecting a second aliquot of the predetermined dose of IgG at the second injection site by injecting a second predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG at the second injection site.

[0148] In various embodiments, the first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is at least about 120 mL, at least about 150 mL, at least about 180 mL, at least about 200 mL, at least about 220 mL, at least about 250 mL, at least about 280 mL, or at least about 300 mL.

[0149] In various embodiments, the first final predetermined rate is at least about 120 mL / hour, at least about 150 mL / hour, at least about 180 mL / hour, at least about 200 mL / hour, at least about 220 mL / hour, at least about 250 mL / hour, at least about 280 mL / hour, or at least about 300 mL / hour.

[0150] In various embodiments, the first predetermined volume of the 20% (w / v) IgG pharmaceutical formulation is about 100 mL to about 300 mL, for example, about 150 mL to about 200 mL, about 200 mL to about 250 mL, or about 250 mL to about 300 mL, which is injected into a first injection site at a first final rate of about 100 mL / hour to about 300 mL / hour, for example, about 150 mL / hour to about 200 mL / hour, about 200 mL / hour to about 250 mL / hour, or about 250 mL / hour to about 300 mL / hour.

[0151] In an exemplary embodiment, a first intermediate infusion rate of less than 300 mL / hour is maintained for a selected time before achieving the first final rate of 300 mL / hour and then increased to the first final predetermined rate.

[0152] In some embodiments, a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is infused into a first injection site at a rate of at least about 300 mL / hour without reducing the rate of infusion or ceasing the infusion due to subject discomfort, pain, or a combination thereof.

[0153] In one embodiment, a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is infused into a first injection site at a rate that includes an ascending phase followed by a terminal phase, the rate of the terminal phase being about 200 to about 300 mL / hour, e.g., about 220 mL / hour, about 240 mL / hour, about 260 mL / hour, about 280 mL / hour, the terminal phase ending upon infusion of the last of the first predetermined volume into the first injection site, and the terminal phase proceeding without reducing the rate of infusion or ceasing the infusion due to the subject's discomfort, pain, or a combination thereof.

[0154] An example of a weight-based infusion rate escalation schedule is shown in Table 1. [Table 1]

[0155] In various embodiments, at least about 60% of the first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is infused into the first infusion site during the terminal phase at a first final rate of at least about 200 mL / hour to about 300 mL / hour, e.g., about 220 mL / hour, about 240 mL / hour, about 260 mL / hour, about 280 mL / hour, without reducing the rate of infusion or ceasing the infusion due to subject discomfort, pain, or a combination thereof.

[0156] In various embodiments, the first predetermined volume is about 200 mL to about 300 mL, e.g., about 220 mL, about 240 mL, about 260 mL, or about 280 mL, and the first final rate is about 200 mL / hour to about 300 mL / hour, e.g., about 220 mL / hour, about 240 mL / hour, about 260 mL / hour, or about 280 mL / hour.

[0157] In an exemplary embodiment, the second final predetermined rate is approximately 300 mL / hour, and the second intermediate infusion rate is maintained for a selected time before achieving the second final predetermined rate and then increased to the second final predetermined rate.

[0158] In various embodiments, the prescribed dose of the pharmaceutical formulation of hyaluronidase is essentially similar between a method injecting a pharmaceutical formulation of 20% (w / v) IgG and a method injecting an otherwise identical pharmaceutical formulation containing 10% (w / v) IgG.

[0159] In an exemplary embodiment, a first predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG is injected into a first injection site at a rate that is about 2 to about 3 times faster than the rate at which the pharmaceutical formulation of 20% (w / v) IgG would be injected without injecting a predetermined dose of hyaluronidase into the first injection site prior to injecting the pharmaceutical formulation of 20% (w / v) IgG into the first injection site.

[0160] In some embodiments, the method is performed using a system configured to perform the method. An exemplary system includes (a) a first container containing a pharmaceutical formulation of recombinant human hyaluronidase in a pharma- ceutical acceptable carrier, (b) a second container containing a pharmaceutical formulation of 20% w / v IgG in a pharma- ceutical acceptable carrier, and (c) (i) a first aliquot of a predetermined volume of the pharmaceutical formulation of recombinant human hyaluronidase, and (ii) (i) followed by a first aliquot of a predetermined volume of the pharmaceutical formulation of 20% IgG, at a first injection site.

[0161] In various embodiments, the means for continuous subcutaneous infusion at the first infusion site includes (i) a subcutaneous needle set, (ii) a pooling bag, (iii) a gravity filling set with a vent spike, (iv) a syringe, (v) a pump, (vi) a warming device, (vii) tubing, and combinations thereof.

[0162] The method of any of the preceding paragraphs can be practiced using any combination of the kits described in any of the preceding paragraphs. It will be apparent to one of skill in the art that each of the above elements can be combined in any useful combination.

[0163] In an exemplary embodiment, the invention provides a method of injecting a pharmaceutical formulation of an immunoglobulin into a first injection site of a subject in need thereof. The formulation injected by the method comprises at least about 20% (w / v) of an immunoglobulin fraction in a pharma- ceutically acceptable aqueous carrier in which the immunoglobulin fraction is dissolved. The method includes delivering the pharmaceutical formulation from a first container through a first hypodermic needle into the first injection site, the first container and the first hypodermic needle being maintained in fluid communication through a first connecting member, and the pharmaceutical formulation is at an injection temperature of about 30° C. to about 40° C., about 30° C. to about 37° C., about 30° C. to about 35° C., or about 33° C. to about 35° C. upon entry into the first injection site.

[0164] In exemplary embodiments, the invention provides methods for administering a concentrated IgG formulation such that administration of the pharmaceutical formulation at injection temperatures is not associated with greater discomfort to the subject than would be experienced by the subject upon administration of an otherwise identical pharmaceutical formulation comprising about 10% (w / v) immunoglobulin in an aqueous pharmaceutical carrier under the same administration parameters, in various embodiments, the administration is associated with less discomfort to the patient compared to administration of a 10% (w / v) formulation.

[0165] In exemplary embodiments, the invention provides methods for administering a concentrated IgG formulation such that administration of the pharmaceutical formulation at injection temperatures does not cause greater discomfort to the subject than would be experienced by the subject upon administration of an otherwise identical pharmaceutical formulation comprising about 20% (w / v) immunoglobulin in an aqueous pharmaceutical carrier, under the same administration parameters. In various embodiments, administration causes less patient discomfort than administration of a similar or identical 20% (w / v) formulation at a temperature below 30° C.

[0166] In exemplary embodiments, the invention provides methods for administering a concentrated IgG formulation such that administration of the pharmaceutical formulation at injection temperatures does not cause greater discomfort to the subject than the discomfort experienced by the subject upon administration of an otherwise identical pharmaceutical formulation comprising about 20% (w / v) immunoglobulin in an aqueous pharmaceutical carrier at 25° C. In various embodiments, administration causes less patient discomfort compared to administration of a 20% (wt / v) formulation at 25° C.

[0167] In various embodiments, the blebs produced upon injection are regularly shaped, demonstrate increased dispersion of the injected formulation, and are essentially completely degraded within about 8 to about 24 hours after injection.

[0168] It should be appreciated that in some embodiments, the flow rate of the IgG formulation will slow as the formulation contacts tissue within the administration site. According to this embodiment, the pharmaceutical formulation is injected into the subject at a first injection site at a second flow rate that is different from the flow rate that exits the distal end of the needle, and this flow rate can change as the formulation occupies the subcutaneous space.

[0169] In exemplary embodiments, the second flow rate is at least about 3 mL / min, e.g., at least about 5 mL / min, with flow rates as high as about 7.5 mL / min being achievable using the formulations, methods, and systems of the present invention.

[0170] C. System In various embodiments, the present invention provides a system for subcutaneously injecting a pharmaceutical formulation of 20% (w / v) IgG. The system is configured to subcutaneously inject the pharmaceutical formulation at a first injection site in a subject in need thereof. The pharmaceutical formulation comprises at least about 20% (w / v) IgG and a pharma- ceutical acceptable aqueous carrier in which the IgG is dissolved. An exemplary system includes a first container containing a pharmaceutical formulation of 20% (w / v) IgG; a second container containing a pharmaceutical formulation of hyaluronidase; a first hypodermic needle including a first end configured to pierce a first injection site of a subject and a distal opening disposed therein through which the pharmaceutical formulation of 20% (w / v) IgG is delivered to the first injection site; optionally a first connecting member configured to be in fluid communication with the first container and the hypodermic needle; and a first warming device configured to be in thermal contact with a component of the system selected from the first container, the first connecting member, and combinations thereof, wherein the first warming device is configured to heat the pharmaceutical formulation of 20% (w / v) IgG to at least about 30° C., to maintain the pharmaceutical formulation of 20% (w / v) IgG at a temperature of at least about 30° C., and combinations thereof.

[0171] In an exemplary embodiment, at least one component of the system is configured to heat the pharmaceutical formulation of 20% (w / v) IgG to a temperature of about 30° C. to about 41° C., to maintain the pharmaceutical formulation of 20% (w / v) IgG at a temperature of about 30° C. to about 41° C., and combinations thereof. An exemplary warming device is configured to maintain the pharmaceutical formulation of 20% (w / v) IgG essentially constant throughout the duration of the infusion into the first infusion site. In an exemplary embodiment, the invention provides an infusion system configured to deliver a pharmaceutical formulation at about 30° C. to a first injection site via a first subcutaneous injection needle at a flow rate of about 3 to about 7.5 mL / min with a tissue backpressure of about 47,000 Pa (350 mmHg) or less.

[0172] In various embodiments, the system further includes a means for pumping the 20% (w / v) IgG pharmaceutical formulation from the first container through the first connecting member to the first hypodermic needle, from where the pharmaceutical formulation exits the system via its distal opening. In an exemplary embodiment, the system further includes a pump for pumping the 20% (w / v) IgG pharmaceutical formulation from the first container through the first connecting member to the first hypodermic needle, from where the pharmaceutical formulation exits the system via its distal opening.

[0173] In various embodiments, the system is utilized to infuse a pharmaceutical formulation of 20% (w / v) IgG into a first injection site at a first final flow rate that is at least about 2 mL / min, at least about 3 mL / min, or at least about 5 mL / min.

[0174] In various embodiments, the pharmaceutical formulation of 20% (w / v) IgG in the system is essentially free of small organic molecules specifically incorporated into the formulation to reduce its viscosity.

[0175] In various embodiments, the first container is selected from an infusion bag and a syringe.

[0176] As mentioned above, the pharmaceutical formulation is associated with a system for its administration to an injection site. An exemplary system includes a first container that serves as a reservoir for the pharmaceutical formulation, a means for releasing the formulation from the reservoir, a hypodermic needle in direct or indirect fluid communication with the first container, and a means for heating the pharmaceutical formulation to an injection temperature (about 30°C to about 40°C). The system optionally further includes other components of known injection devices. In one embodiment, the system includes a pump connected to the reservoir and configured to apply a sufficient amount of pressure to the IgG formulation to drive the IgG formulation from the reservoir through components downstream of the reservoir and into the injection site. In an exemplary embodiment, the pump is a peristaltic pump. In an alternative embodiment, the pump is a pressure-driven flow-controlled pump or an infusion pump.

[0177] In various embodiments, the warming device is a heated syringe. The heated syringe can be a standard syringe that is preheated using a syringe warmer. A syringe warmer generally has one or more openings that can each receive a syringe containing a protein formulation, and a means for heating and maintaining the syringe at a specific temperature (usually above ambient temperature) before use. This is referred to herein as a preheated syringe. Suitable heated syringe warmers include those available from Vista Dental Products and Inter-Med. The warmer can accommodate syringes of various sizes and can be heated to any temperature, usually within about 1° C. up to about 130° C. In some embodiments, the syringe is preheated in a heating bath, such as a water bath, that is maintained at a desired temperature.

[0178] The heated syringe can be a self-heating syringe, i.e., the liquid formulation in the syringe can be heated and maintained at a certain temperature. The self-heating syringe can be a standard medical syringe with a heating device attached. Suitable heating devices that can be attached to the syringe include syringe heaters or syringe heater tapes available from Watlow Electric Manufacturing Co., St. Louis, Mo., and syringe heater blocks, stage heaters, and in-line perfusion heaters available from Warner Instruments, Hamden, Conn., such as the SW-61 type syringe warmer. The heater can be controlled through a central controller, such as the TC-324B or TC-344B type heater controller available from Warner Instruments.

[0179] The heated syringe maintains the liquid protein formulation at a specific temperature, between room temperature and up to about 60° C., as long as the IgG formulation is sufficiently stable at that temperature. Heating the IgG formulation to an elevated temperature prior to and / or during injection reduces the viscosity of the liquid formulation, increases the solubility of the IgG in the formulation, or both.

[0180] In various embodiments, the IgG formulation is injected using a set of needles designed for SC injection. Exemplary needles are attached at a 90° angle to a plastic wing or clear plastic disc to facilitate proper insertion of the needle into the subcutaneous fat and to help hold the needle in place during injection. Numerous infusion sets are available with needle sizes from 19 to 27 gauge, as well as 6, 9, 12, 14, 16, and 19 mm long. In an exemplary embodiment, the system of the invention includes a 19G needle.

[0181] In some embodiments, the first container and the hypodermic needle are attached by and in fluid communication through a first connecting member. An exemplary connecting member is a length of tubing or a tubing set. The type of tubing set selected depends on the site of use and the number of infusion pumps. Tube sets are available with single, two-pronged, three-pronged, four-pronged, and five-pronged prongs attached to a single body, which can be connected to a syringe or an infusion pump.

[0182] The IgG formulation is heated to about 30°C to about 40°C prior to and / or during infusion. The product is drawn into one or more syringes, depending on the amount to be infused and the number and type of infusion pumps used. The infusion needle set tubing is connected to the syringe and the tubing is primed before inserting the needle. Some infusion pumps use an IV bag or "cassette", which is filled with the IgG formulation and connected to the pump. A number of different infusion pumps are used to administer IgG formulations. Most of these are syringe pumps that accept 50 mL syringes, and some can be programmed to set different infusion rates. Useful pumps have enough power to infuse into the SC space, where resistance to flow is much higher compared to IV infusion. The pharmaceutical formulation may be heated while in any component of the infusion system.

[0183] In various embodiments, the system includes one or more components of the systems described in WO2016 / 205687 and / or WO2020 / 072230.

[0184] D. Hyaluronidase Preparations and Methods 1. Hyaluronidase Hyaluronidase is included in the formulations, methods, and combinations provided herein. Soluble hyaluronidase includes any that exists in a soluble form upon expression and secretion from cells. Such soluble hyaluronidases include, but are not limited to, non-human soluble hyaluronidases (including those referred to as sHASEPGs), bacterial soluble hyaluronidase, bovine PH20, ovine PH20, and variants thereof. Soluble hyaluronidases include human PH20 polypeptides that are generally modified by C-terminal truncation, which are secreted and soluble upon expression. For example, hyaluronidases that contain a glycophosphatidylinositol (GPI) anchor, such as human PH20, can be made soluble by cleavage and removal of all or part of the GPI anchor. In one example, human hyaluronidase PH20, which is normally membrane-anchored via a GPI anchor, is made soluble by cleaving and removing all or part of the GPI anchor at the C-terminus.

[0185] (a) Soluble human PH20 An example of a soluble hyaluronidase is soluble human PH20. Soluble forms of recombinant human PH20 have been produced and can be used in the compositions, combinations, and methods described herein. Such soluble forms of PH20 are described and prepared, for example, in U.S. Pat. Nos. 7,767,429, 8,202,517, 8,431,380, 8,431,124, 8,450,470, 8,765,685, 8,772,246, 7,871,607, 7,846,431, 7,829,081, 8,105,586, 8,187,855, 8,257,699, 8,580,252, 9,677,061, and 9,677,062, which are incorporated herein by reference.

[0186] Soluble hyaluronidases include neutral active hyaluronidases, such as soluble human PH20 polypeptides. In certain examples, the hyaluronidases for use in the compositions, combinations, and methods herein are soluble neutral active hyaluronidases.

[0187] Exemplary hyaluronidases include soluble forms of PH20 from any species, such as any of SEQ ID NOs: 3 and 32-66 [first set of linked sequences], and soluble PH20 polypeptides, such as those set forth in SEQ ID NOs: 3 and 44-49. Such soluble forms include truncated forms thereof lacking all or part of the C-terminal GPI anchor, so long as the hyaluronidase is soluble (secreted upon expression) and retains hyaluronidase activity. Such forms are also typically mature forms that lack a signal peptide when expressed in a cell. Soluble hyaluronidases also include soluble forms of any variants of PH20 from any species set forth in SEQ ID NOs: 3 and 32-66 that exhibit hyaluronidase activity. Variants include polypeptides having at least 60%, 70%, 80%, 85%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% or more sequence identity to any of SEQ ID NOs: 3 and 32-66. Amino acid variants include conservative and non-conservative mutations. It is understood that residues important or otherwise required for hyaluronidase, such as any activity described above or known to those of skill in the art, are generally invariant and cannot be altered. These include, for example, active site residues. Thus, for example, amino acid residues 111, 113, and 176 of the human PH20 polypeptide (corresponding to residues in the mature PH20 polypeptide set forth in SEQ ID NO: 3), or a soluble form thereof, are generally invariant and unaltered. Other residues that confer glycosylation and formation of disulfide bonds required for proper folding may also be invariant.

[0188] In some cases, soluble hyaluronidase is usually GPI-anchored (e.g., human PH20, etc.) and is soluble by truncation at the C-terminus. Such truncation can remove all of the GPI-anchored signal sequence or only a portion of the GPI-anchored signal sequence. However, the resulting polypeptide is soluble. If the soluble hyaluronidase retains a portion of the GPI-anchored signal sequence, it can retain 1, 2, 3, 4, 5, 6, 7, or more amino acid residues in the GPI-anchored signal sequence, as long as the polypeptide is soluble. A polypeptide that contains one or more amino acids of the GPI anchor is called an extended soluble hyaluronidase. A person skilled in the art can determine whether a polypeptide is GPI-anchored using methods well known in the art. Such methods include, but are not limited to, using known algorithms to predict the presence and location of GPI anchor attachment signal sequences and ω sites, and performing solubility analyses before and after digestion with phosphatidylinositol-specific phospholipase C (PI-PLC) or D (PI-PLD).

[0189] Extended soluble hyaluronidases, such as those set forth in SEQ ID NOs: 61-66, can be generated by C-terminal truncation of any naturally occurring GPI-anchored hyaluronidase such that the resulting polypeptide is soluble and contains one or more amino acid residues from a GPI anchor attachment signal sequence (see, e.g., U.S. Patent No. 8,927,249). These include hyaluronidases that are neutrally active, soluble, contain amino acid substitutions, and have at least 60%, 70%, 80%, 85%, 90%, 91%, 92%, 93%, 94%, 95% or more sequence identity to any of SEQ ID NOs: 61-66.

[0190] Typically, for use in the compositions, combinations, and methods herein, a soluble human hyaluronidase is used, such as a soluble human PH20, such as any of the PH20 polypeptides of SEQ ID NOs: 3 and 45-49, and variants having, for example, at least 98% sequence identity thereto. Hyaluronidase for use in the methods herein can be recombinantly produced or purified or partially purified from natural sources, such as, for example, testis extracts. Methods for producing recombinant proteins, including recombinant hyaluronidase, are well known in the art.

[0191] Recombinant soluble forms of human PH20 have been generated and can be used in the compositions, combinations, and methods provided herein. For example, as set forth in SEQ ID NO:1, the soluble form, as set forth in the sequence of full-length precursor PH20 including the signal sequence (residues 1-35), is represented by the C-terminal amino acid residues 467, 468, 469, 470, 471, 472, 473, 474, 475, 476, 477, 478, 479, 480, 481, 482, 483, 484, 485, 486, 487, 488, 489, 490, 491, 492, 493, 494, 495, 496, 497, 498, 49 ...500, 501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522, 523, 524, 525, 526, 527, 528, 529, 530, 531, 532, 533, 534, 535, 536, 537, 538, 539, 540 PH20 polypeptides include, but are not limited to, C-terminal truncated polypeptides of human PH20 set forth in SEQ ID NO: 1 having amino acids 36-464 of SEQ ID NO: 1, 495, 496, 497, 498, 499, or 500, or polypeptides exhibiting at least 85%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% or more sequence identity thereto, that are active at neutral pH and soluble (secreted into the medium when expressed in mammalian cells). Soluble forms of human PH20 generally include those that contain amino acids 36-464 of SEQ ID NO: 1. For example, when expressed in mammalian cells, the 35 amino acid N-terminal signal sequence is cleaved during processing and the mature form of the protein is secreted. Thus, mature soluble polypeptides include polypeptides containing amino acids 36-467, 468, 469, 470, 471, 472, 473, 474, 475, 476, 477, 478, 479, 480, 481, 482, and 483 of SEQ ID NO:1. Examples of soluble hyaluronidases are soluble human PH20 polypeptides that are 442, 443, 444, 445, 446, or 447 amino acids in length, as set forth in any of SEQ ID NOs: 3 and 44-49, as well as variants that have at least 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% sequence identity to the sequence of amino acids set forth in any of SEQ ID NOs: 3 and 44-49, and that retain hyaluronidase activity.The production of such soluble forms of recombinant human PH20 is described, for example, in U.S. Patent Nos. 7,767,429, 8,202,517, 8,431,380, 8,431,124, 8,450,470, 8,765,685, 8,772,246, 7,871,607, 7,846,431, 7,829,081, 8,105,586, 8,187,855, 8,257,699, 8,580,252, 9,677,061, and 9,677,062.

[0192] Because glycosylation is important for the catalytic activity and stability of hyaluronidase, soluble forms of PH20 are generally produced using protein expression systems that promote correct N-glycosylation to ensure that the polypeptide retains activity. Such cells include, for example, Chinese hamster ovary (CHO) cells (e.g., DG44 CHO cells).

[0193] (b) rHuPH20 rHuPH20 refers to a composition produced upon expression in cells, such as CHO cells, of a nucleic acid encoding residues 36-482 of SEQ ID NO:1, generally linked to a native or heterologous signal sequence (residues 1-35 of SEQ ID NO:1). rHuPH20 is produced by expression of a nucleic acid molecule encoding amino acids 1-482 (set forth in SEQ ID NO:1). Post-translational processing removes the 35 residue amino acid signal sequence, leaving a polypeptide or mixture of polypeptides including those set forth in SEQ ID NOs:3 and 44-49. When produced in culture, there is heterogeneity at the C-terminus such that the product referred to as rHuPH20 contains a mixture of species that may contain any one or more of SEQ ID NOs:3 and 44-49 in varying abundance. Typically, rHuPH20 is produced in cells that promote correct N-glycosylation to retain activity, such as CHO cells (e.g., DG44 CHO cells). Generally, the most abundant species is a 446 amino acid polypeptide corresponding to residues 36-481 of SEQ ID NO:1.

[0194] (c) Glycosylation of hyaluronidase Glycosylation, including N- and O-linked glycosylation, of some hyaluronidases, including soluble PH20 hyaluronidase, can be important for their catalytic activity and stability. For some hyaluronidases, removal of N-linked glycosylation almost completely inactivates the hyaluronidase activity. Thus, for such hyaluronidases, the presence of N-linked glycans can be important for generating active enzymes.

[0195] N-linked oligosaccharides are classified into several major types (oligomannose, complex, hybrid, sulfated), all of which have a (Man)3-GlcNAc-GlcNAc-core linked through the amide nitrogen of an Asn residue within the -Asn-Xaa-Thr / Ser- sequence (where Xaa is not Pro). Glycosylation at -Asn-Xaa-Cys- sites has been reported in coagulation protein C. In some cases, hyaluronidases, such as PH20 hyaluronidase, may contain N-glycosidic and O-glycosidic linkages. For example, PH20 has O-linked and N-linked oligosaccharides. There are six potential N-linked glycosylation sites at N82, N166, N235, N254, N368, and N393 of human PH20, as exemplified in SEQ ID NO:1.

[0196] (d) Variants Variants of soluble PH20 polypeptides have been created with altered properties, such as increased stability and / or activity. U.S. Patent Nos. 9,447,401 and 10,865,400, and allowed application 16 / 824,572, which are incorporated by reference, describe and provide structure / function maps of human PH20 detailing the effect of amino acid substitutions at all residues in the catalytic domain of PH20. These patents provide approximately 7000 examples, in which the effect of replacing each amino acid with 15 other amino acids on activity and stability was identified and described. Through these publications and previous publications / patents, virtually all soluble PH20 polypeptide variants, including those with amino acid substitutions, deletions, and insertions, are known in the art. Those skilled in the art can easily prepare soluble hyaluronidase and its variants and learn the properties of the resulting hyaluronidase.

[0197] Other variants are known to those of skill in the art. See International PCT Application Nos. WO2020 / 022791 and WO2020197230A, which are incorporated by reference and describe modified PH20 polypeptides. These polypeptides are variants of the PH20 polypeptides of SEQ ID NOs: 1, 3, and 32-66, and include substitutions, insertions, and deletions, including one or more amino acid residues S343E, M345T, K349E, L353A, L354I, N356E, and I361T. Variants including such and other modifications are described in SEQ ID NOs: 60-115 of International PCT Application No. WO2021 / 150079. Also provided in International PCT Application No. WO2021 / 150079 are variant PH20 polypeptides described as having increased stability.

[0198] 2. Administration of IG and hyaluronidase In various embodiments, any of the above formulations or methods are enhanced by injecting a dose of hyaluronidase into the site of IgG administration prior to or in conjunction with administration of the IgG formulations of the invention to the site of administration. The hyaluronidase is administered at the same or a different temperature as the IgG.

[0199] Diffusion and convective transport of IgG can be enhanced by opening interstitial channels to increase fluid flow. The size of IgG and the presence of interstitial components such as glycosaminoglycans substantially impairs drug diffusion and / or convection. Several consequences may occur that may limit the usefulness of IgG. For example, the pharmacokinetics of IgG may be effectively impaired by slowing absorption and thus distribution of IgG. Furthermore, trapping of some of the IgG at or near the site of administration may limit its bioavailability and potentially cause toxicity as a result of sustained and high local doses. Regarding the latter, for many large biomolecules administered by subcutaneous injection, local toxicity, which may be accompanied by pain or other side effects, is problematic. As a result, the pharmacokinetic (PK) and / or pharmacodynamic (PD) properties of IgG may be enhanced by co-forming the IgG with a sHASEGP (or other glycosaminoglycanase) and / or co-administering the IgG with a sHASEGP (or other glycosaminoglycanase), which may be provided before, simultaneously with, or after the IgG and may be administered at the same or a different site, and this parameter would be subject to optimization in standard models (e.g., animal models commonly used to evaluate the pharmacokinetics and pharmacodynamics of IgG).

[0200] As a further example, but not limited to a particular type of application, a volume (V) of liquid (L) containing sHASEGP or other glycosaminoglycanase (GAG enzyme) can be introduced to a patient administration site. By means described and illustrated herein, an IgG formulation can be delivered to and to some extent through the administration site. Without being limited to a particular mechanism of action, the IgG formulation can be effectively carried to tissue adjacent to the administration site by convective transport through a volume of liquid (L). Convective transport can be driven in part by hydrostatic pressure associated with L, which can provide the driving pressure. In this manner, a fluid-driven pressure differential can be generated.

[0201] As will be appreciated by those of skill in the art, V can range from a volume of less than about 0.1 mL to a volume of more than about 100 mL, and in many applications can range from about 0.5 mL to about 20 mL, and in many applications can range from about 1 mL to about 10 mL, and often from about 2 to about 5 mL, but can vary in particular situations as provided herein. V can also be specifically optimized within such ranges for a particular application, if desired, for example, by comparing standard pharmacokinetic and / or pharmacodynamic properties across a range of test volumes.

[0202] Subcutaneous injection of recombinant human hyaluronidase has been shown to enhance dispersion of IgG-infused SC, allowing patients to inject larger amounts of IG into a single site on a monthly basis. Knight et al.,(2010),63(9):846-7. Clinical trials have demonstrated the safety and efficacy of recombinant human hyaluronidase injection followed by infusion of a 10% IgG product, using doses and rates equivalent to monthly IVIG treatment. Using a single SC site, injection of IgG 10% every 3-4 weeks at doses comparable to monthly IVIG (320 mg / kg / month to 1000 mg / kg / month) and infused at rates up to 300 mL / hour is well tolerated. Schiff et al.,Clin Exp Immunol(2008),154(Suppl 1):121. The rate of local reactions was slightly higher than conventional SCIG, and the rate of systemic reactions was comparable to SCIG but significantly lower than that seen with IVIG. Stein et al., J Allergy Clin Immunol (2012), AB14. Furthermore, the pharmacokinetics of IgG infused with hyaluronidase SC were comparable to IVIG, with therapeutic IgG trough levels and good bioavailability, and the annualized infection rates of patients in the study were lower than those seen in patients with SCIG or IVIG. Stein, supra.

[0203] The present invention provides a pharmaceutical formulation of hyaluronidase in combination with a pharmaceutical formulation of IgG. The hyaluronidase formulation can be used to enhance subcutaneous delivery of IgG. In an exemplary embodiment, the IgG formulation (at least about 20% wt / wt) is administered to the administration site at a temperature of about 22°C to about 40°C. In an exemplary embodiment, the formulation is administered at about room temperature, e.g., about 22°C to about 26°C. In various embodiments, the formulation is administered at a temperature approximating the subject's body temperature, e.g., about 30°C to about 40°C.

[0204] Many molecules injected percutaneously (e.g., by using a needle or other device used to pierce the skin and deposit the molecule in the subdermal layer) reach the circulation slowly or with very low efficiency. Several factors modulate the pharmacokinetics and pharmacodynamics of molecules injected subcutaneously (SC) or intramuscularly (IM). In general, larger molecules reach the circulation slower and less efficiently without active transport into the circulation. Subcutaneous bioavailability is determined by calculating the ratio of the area under the curve for SC administration versus intravenous administration (AUC SC / AUC 静脈内 ). The second factor is the charge and affinity for the matrix molecules, which may play a role in the subcutaneous sequestration of the molecule. If these materials are locally degraded, they may never reach their desired target and therefore may show a decrease in overall systemic bioavailability to the target organs.

[0205] A further advantage of the present invention is the ability to deliver equivalent or greater volumes of solution ID, SC, or IM without the pain and morbidity associated with the pressure and volume of solution at the injection site.

[0206] Of particular interest is the use of soluble neutral active hyaluronidases or sHASEGPs of mammalian origin, including human origin.Those skilled in the art recognize that, in general, single amino acid substitutions in non-essential regions of a polypeptide do not substantially alter biological activity (see, e.g., Watson et al., (1987) Molecular Biology of the Gene, 4th Edition, The Benjamin / Cummings Pub.co., p.224).

[0207] Parenteral administration of sHASEGP or its soluble human hyaluronidase domain is also contemplated herein, generally characterized by injection, either subcutaneously (infusion), intramuscularly, or intravenously. Injectables can be prepared in conventional forms, either as liquid solutions or suspensions, with solid forms suitable for solution or suspension in liquid prior to injection, or as emulsions. Suitable excipients are, for example, water, saline, dextrose, glycerol, or ethanol. In addition, if desired, the pharmaceutical composition to be administered may also contain small amounts of non-toxic auxiliary substances, such as wetting or emulsifying agents, pH buffers, stabilizers, solubility enhancers, and other such agents, such as sodium acetate, sorbitan monolaurate, triethanolamine oleate, and cyclodextrins. Implantation of a sustained-release or sustained-release system, such that a constant level of dosage is maintained, is also contemplated herein (see, for example, U.S. Pat. No. 3,710,795). The percentage of sHASEGP or a soluble human hyaluronidase domain thereof contained in such parenteral compositions will depend on its specific properties, as well as the activity of the compound and the needs of the subject.

[0208] Parenteral administration of the composition includes intravenous, subcutaneous, and intramuscular administration. Preparations for parenteral administration include sterile solutions ready for injection, sterile dry soluble products such as freeze-dried powders that can be combined with solvents or sterile solutions immediately before use, including subcutaneous tablets, sterile suspensions ready for injection, sterile dry insoluble products that can be combined with vehicles immediately before use, and sterile emulsions. Solutions can be either aqueous or non-aqueous.

[0209] If administered intravenously, suitable carriers include saline or phosphate buffered saline (PBS), as well as solutions containing thickening and solubilizing agents, such as glucose, polyethylene glycol, and polypropylene glycol, and mixtures thereof.

[0210] Pharmaceutically acceptable carriers used in parenteral preparations include aqueous vehicles, non-aqueous vehicles, antibacterial agents, isotonic agents, buffers, antioxidants, local anesthetic agents, suspending and dispersing agents, emulsifying agents, sequestering or chelating agents, and other pharma- ceutically acceptable substances.

[0211] Examples of aqueous vehicles include sodium chloride injection, Ringer's injection, isotonic dextrose injection, sterile water injection, dextrose, and lactated Ringer's injection. Non-aqueous parenteral vehicles include fixed oils of vegetable origin, cottonseed oil, corn oil, sesame oil, and peanut oil. Bacteriostatic or fungistatic concentrations of antibacterial agents must be added to parenteral preparations packaged in multi-dose containers, including phenol or cresol, mercurials, benzyl alcohol, chlorobutanol, methyl and propyl p-hydroxybenzoic acid esters, thiomersal, benzalkonium chloride, and benzethonium chloride. Isotonic agents include sodium chloride and dextrose. Buffers include phosphates and citrates. Antioxidants include sodium bisulfate. Local anesthetics include procaine hydrochloride. Suspending and dispersing agents include sodium carboxymethylcellulose, hydroxypropyl methylcellulose, and polyvinylpyrrolidone. Emulsifying agents include Polysorbate 80 (TWEEN™ 80). Sequestering or chelating agents of metal ions include EDTA. Pharmaceutical carriers also include ethyl alcohol, polyethylene glycol, and propylene glycol for water miscible vehicles, and sodium hydroxide, hydrochloric acid, citric acid, or lactic acid for pH adjustment.

[0212] The concentration of the pharma- ceutical active compound is adjusted so that injection provides an effective amount to produce the desired pharmacological effect. The exact dose depends on the age, weight, and condition of the patient or animal, as is known in the art.

[0213] Unit dose parenteral preparations are packaged in an ampoule, vial, or syringe with a needle. All preparations for parenteral administration must be sterile, as known and practiced in the art.

[0214] Injectables are designed for local administration. Typically, therapeutically effective doses are formulated to contain a concentration of at least about 0.1% w / w to up to about 90% w / w or more, preferably greater than 1% w / w, of the active compound relative to the tissue(s) being treated. The active ingredient, such as sHASEGP or its soluble human hyaluronidase domain, can be administered once or divided into multiple smaller doses spaced apart in time. It is understood that the exact dose and duration of treatment is a function of the tissue being treated and can be determined empirically using known testing protocols or by extrapolation from in vivo or in vitro test data. It is noted that concentration and dosage values ​​may also vary depending on the age of the individual being treated. It is further understood that for any particular subject, the specific dosing regimen should be adjusted over time according to the individual's needs and the professional judgment of the person administering or supervising the administration of the formulation, and that the concentration ranges set forth herein are exemplary only and are not intended to limit the scope or practice of the claimed formulations.

[0215] The compounds provided herein can be formulated for parenteral administration by injection, e.g., bolus injection or continuous infusion. Formulations for injection can be presented in unit dosage form, e.g., in ampoules or multi-dose containers, with additional preservatives. The compositions can be suspensions, solutions, or emulsions in oily or aqueous vehicles and can contain formulating agents such as suspending, stabilizing, and / or dispersing agents. Alternatively, the active ingredient can be in the form of a powder for reconstitution with a suitable vehicle, e.g., pyrogen-free sterile water or other solvent, before use. For example, provided herein is a parenteral formulation containing an effective amount of sHASEGP or a soluble human hyaluronidase domain thereof, e.g., 500 to 500,000 units, in a stabilized solution or lyophilized form.

[0216] The compound may be suspended in micronized or other suitable form, or may be derivatized to produce a more soluble active product or prodrug. The form of the resulting mixture depends on several factors, including the intended mode of administration and the solubility of the compound in the selected carrier or vehicle. The effective concentration is sufficient to alleviate the symptoms of the condition, and may be empirically determined.

[0217] A composition containing a sHASEGP polypeptide or a soluble human hyaluronidase domain thereof, or any of the foregoing agents, can be packaged as an article of manufacture comprising packaging material and, within the packaging material, a compound provided herein, or a suitable derivative thereof, effective for treating a disease or disorder contemplated herein, and a label indicating that the compound, or a suitable derivative thereof, is for treating a disease or disorder contemplated herein. The label can optionally include the disorder for which treatment is warranted.

[0218] The products provided herein include packaging materials. Packaging materials for use in packaging pharmaceutical products are well known to those skilled in the art (see, for example, U.S. Patent Nos. 5,323,907, 5,052,558, and 5,033,352). Examples of pharmaceutical packaging materials include, but are not limited to, blister packs, bottles, tubes, inhalers, pumps, bags, vials, containers, syringes, bottles, and any packaging materials suitable for the selected formulation and intended mode of administration and treatment. A wide range of formulations of the compounds and compositions provided herein are contemplated, as are various treatments for any disorder in which HCV infection is involved as a mediator or contributing factor to symptoms or causes.

[0219] Also provided herein are kits that include the compositions and / or combinations, as well as instructions for administering them. The kits may further include a needle or syringe, typically packaged in sterile form, for injecting the composition, and / or a packaged alcohol pad. Optionally, instructions are included for the physician or patient to administer the active agent. For example, kits are provided herein that include a small volume syringe containing an effective amount of sHASEGP or a soluble human hyaluronidase domain thereof, such as 1-5000 units of the soluble glycoprotein, in a volume of 5-50 μL, and optionally a second syringe having viscoelastic properties. Also provided herein are kits that include a small volume syringe containing an effective amount of sHASEGP or a soluble human hyaluronidase domain thereof, such as 1-500 units of the soluble glycoprotein, and a therapeutic amount of a second active ingredient, such as a drug, small molecule, protein, or nucleic acid.

[0220] E. Exemplary Embodiments In various embodiments, the present invention provides a kit comprising: (a) a first container containing a pharmaceutical formulation of recombinant human hyaluronidase in a pharma- ceutically acceptable carrier; (b) a second container containing a pharmaceutical formulation of 20% (w / v) IgG in a pharma- ceutically acceptable carrier; and (c)(i) a first aliquot of a predetermined volume of the pharmaceutical formulation of recombinant human hyaluronidase, and (ii)(i), followed by a first aliquot of a predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG, sequentially subcutaneously at a first injection site.

[0221] In various embodiments, the invention provides the kit described in the above paragraph, wherein the pharmaceutical formulation of recombinant human hyaluronidase contains 160 U / mL of recombinant human hyaluronidase.

[0222] In various embodiments, the invention provides a kit as described in any of the above paragraphs, wherein the recombinant human hyaluronidase is rHuPH20.

[0223] In various embodiments, the invention provides a kit as described in any of the above paragraphs, further comprising (i) a pharmaceutical formulation of recombinant human hyaluronidase, and (ii) an infusion device for sequentially or simultaneously subcutaneously injecting, following (i), a pharmaceutical formulation of 20% (w / v) IgG.

[0224] In various embodiments, the invention provides a kit according to any of the above paragraphs, further comprising a hypodermic needle set.

[0225] In various embodiments, the invention provides a kit as described in any of the above paragraphs, wherein the instructions are a component of the Dosage and Administration section of the Complete Prescribing Information.

[0226] In various embodiments, the invention provides a kit as described in any of the above paragraphs, wherein the instructions provide guidance for subcutaneously injecting the pharmaceutical formulation of rHuPH20 into the first injection site.

[0227] In various embodiments, the invention provides a kit as described in any of the above paragraphs, wherein the instructions provide guidance for subcutaneously injecting about 50 U / g to about 100 U of rHuPH20 per gram of IgG into the first injection site.

[0228] In various embodiments, the invention provides a kit according to any of the above paragraphs, wherein the instructions provide guidance for subcutaneously injecting up to at least about 100 mL, up to at least about 150 mL, up to at least about 200 mL, up to at least about 250 mL, or up to at least about 300 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site.

[0229] In various embodiments, the invention provides a kit according to any of the above paragraphs, wherein the instructions provide guidance for subcutaneously infusing the first predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site at a rate of at least about 120 mL / hour, at least about 150 mL / hour, at least about 200 mL / hour, at least about 250 mL / hour, or at least about 300 mL / hour.

[0230] In various embodiments, the invention provides a kit according to any of the above paragraphs, wherein the instructions provide guidance for subcutaneously infusing at least about 120 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site at a rate of at least about 120 mL / hour, at least about 150 mL / hour, at least about 200 mL / hour, at least about 250 mL / hour, or at least about 300 mL / hour.

[0231] In various embodiments, the invention provides a kit as described in any of the above paragraphs, wherein the instructions provide guidance for (b) subcutaneously injecting at least about 300 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site.

[0232] In various embodiments, the invention provides a kit as described in any of the above paragraphs, wherein the instructions provide guidance to (a) subcutaneously inject at least about 300 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site at a rate of at least about 300 mL / hour.

[0233] In various embodiments, the invention provides a kit according to any of the above paragraphs, wherein the instructions provide guidance for subcutaneously injecting a pharmaceutical formulation of 20% (w / v) IgG warmed to a temperature of about 30° C. to about 41° C., said pharmaceutical formulation being warmed to said temperature prior to injection, during injection, and combinations thereof.

[0234] In various embodiments, the invention provides a kit as described in any of the above paragraphs, wherein the instructions further provide guidance for simultaneously or sequentially (i) subcutaneously injecting a second aliquot of the predetermined dose of the pharmaceutical formulation of recombinant human hyaluronidase at a second injection site, and (ii) following (i), subcutaneously injecting a second aliquot of the predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG at the second injection site.

[0235] In various embodiments, the invention provides a kit as described in any of the above paragraphs, wherein the instructions provide guidance for subcutaneously injecting the pharmaceutical formulation of rHuPH20 into the first injection site, followed by injecting the pharmaceutical formulation of 20% (w / v) IgG into the first injection site using a component selected from the following: (i) a hypodermic needle set; (ii) a pooling bag; (iii) a gravity fill set equipped with a venting spike; (iv) a syringe, (v) pumps, (vi) warming device; (vii) Tubes, and combinations thereof.

[0236] In various embodiments, the present invention provides a method of subcutaneously injecting a pharmaceutical formulation of 20% (w / v) IgG into a subject in need thereof at a first injection site, the method comprising: (a) injecting a first aliquot of a predetermined dose of hyaluronidase into a first injection site by injecting a volume of a pharmaceutical formulation of hyaluronidase into the first injection site; and (b) following (a), injecting a first aliquot of a predetermined dose of IgG into the first injection site by injecting a first predetermined volume of a pharmaceutical formulation of 20% (w / v) IgG into the first injection site.

[0237] In various embodiments, the present invention provides a method according to paragraph

[0235] above, further comprising: (c) injecting a second aliquot of the predetermined dose of hyaluronidase at the second injection site by injecting a second predetermined volume of the pharmaceutical formulation of hyaluronidase at the second injection site; and (d) following (c), injecting a second aliquot of the predetermined dose of IgG into the second injection site by injecting a second predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG into the second injection site.

[0238] In various embodiments, the present invention provides a kit as described in any of paragraphs

[0235] to

[0236] above, in which a first predetermined volume of a pharmaceutical formulation of 20% (w / v) IgG is subcutaneously injected at a first injection site at a first final predetermined rate.

[0239] In various embodiments, the present invention provides a method according to any of paragraphs

[0235] to

[0236] above, wherein the first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is at least about 120 mL, at least about 150 mL, at least about 180 mL, at least about 200 mL, at least about 220 mL, at least about 250 mL, at least about 280 mL, or at least about 300 mL.

[0240] In various embodiments, the present invention provides a method according to any one of paragraphs

[0235] to

[0238] above, wherein the first final predetermined rate is at least about 120 mL / hour, at least about 150 mL / hour, at least about 180 mL / hour, at least about 200 mL / hour, at least about 220 mL / hour, at least about 250 mL / hour, at least about 280 mL / hour, or at least about 300 mL / hour.

[0241] In various embodiments, the present invention provides a method according to any of paragraphs

[0235] to

[0239] above, wherein a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is about 100 mL to about 300 mL, e.g., about 150 mL to about 200 mL, about 200 mL to about 250 mL, or about 250 mL to about 300 mL, which is infused into a first injection site at a first final rate of about 100 mL / hour to about 300 mL / hour, e.g., about 150 mL / hour to about 200 mL / hour, about 200 mL / hour to about 250 mL / hour, or about 250 mL / hour to about 300 mL / hour.

[0242] In various embodiments, the present invention provides a method according to any of paragraphs

[0235] to

[0240] above, wherein a first intermediate infusion rate of less than 300 mL / hour is maintained for a selected time period before achieving a first final rate of 300 mL / hour, and increased to a first final predetermined rate.

[0243] In various embodiments, the present invention provides a method as described in any of paragraphs

[0235] to

[0241] above, wherein a first predetermined volume of a pharmaceutical formulation of 20% (w / v) IgG is infused into a first injection site at a rate of at least about 300 mL / hour without reducing the rate of infusion or ceasing the infusion due to subject discomfort, pain, or a combination thereof.

[0244] In various embodiments, the present invention provides a method according to any of paragraphs

[0235] to

[0242] above, wherein a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is infused into a first injection site at a rate that includes an ascending phase followed by a terminal phase, the rate of the terminal phase being about 200 to about 300 mL / hour, e.g., about 220 mL / hour, about 240 mL / hour, about 260 mL / hour, about 280 mL / hour, the terminal phase ending upon infusion of the last of the first predetermined volume into the first injection site, and the terminal phase proceeding without reducing the rate of infusion or ceasing the infusion due to the subject's discomfort, pain, or a combination thereof.

[0245] In various embodiments, the present invention provides a method according to any of paragraphs

[0235] to

[0243] above, wherein at least about 60% of the first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is infused into the first infusion site during the terminal phase at a first final rate of at least about 200 mL / hour to about 300 mL / hour, e.g., about 220 mL / hour, about 240 mL / hour, about 260 mL / hour, about 280 mL / hour, without reducing the rate of infusion or ceasing the infusion due to the subject's discomfort, pain, or a combination thereof.

[0246] In various embodiments, the present invention provides a method according to any one of paragraphs

[0235] to

[0244] above, wherein the first predetermined volume is about 200 mL to about 300 mL, e.g., about 220 mL, about 240 mL, about 260 mL, or about 280 mL, and the first final rate is about 200 mL / hour to about 300 mL / hour, e.g., about 220 mL / hour, about 240 mL / hour, about 260 mL / hour, or about 280 mL / hour.

[0247] In various embodiments, the present invention provides a method as described in any of paragraphs

[0235] to

[0245] above, wherein the second final predetermined rate is about 300 mL / hour, and the second intermediate infusion rate is maintained for a selected time before achieving the second final predetermined rate, and then increased to the second final predetermined rate.

[0248] In various embodiments, the present invention provides a method as described in any of paragraphs

[0235] to

[0246] above, in which the predetermined dose of the pharmaceutical formulation of hyaluronidase is essentially similar between the method of injecting a pharmaceutical formulation of 20% (w / v) IgG and the method of injecting an otherwise identical pharmaceutical formulation containing 10% (w / v) IgG.

[0249] In various embodiments, the present invention provides a method as described in any of paragraphs

[0235] to

[0247] above, in which a first predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG is injected into a first injection site at a rate that is about 2 to about 3 times faster than the rate at which the pharmaceutical formulation of 20% (w / v) IgG would be injected without injecting the predetermined dose of hyaluronidase into the first injection site prior to injecting the pharmaceutical formulation of 20% (w / v) IgG into the first injection site.

[0250] In various embodiments, the present invention provides a method according to any one of the above paragraphs

[0235] to

[0248] , the method being carried out using a system configured to carry out the method, the system including: (a) a first container containing a pharmaceutical formulation of recombinant human hyaluronidase in a pharma- ceutically acceptable carrier; (b) a second container containing a pharmaceutical formulation of 20% w / v IgG in a pharma- ceutically acceptable carrier; and (c)(i) a means for continuously subcutaneously injecting a first aliquot of a predetermined volume of the pharmaceutical formulation of recombinant human hyaluronidase, and (ii)(i), followed by a first aliquot of a predetermined volume of the pharmaceutical formulation of 20% IgG, at a first injection site.

[0251] In various embodiments, the present invention provides a method for continuously subcutaneously injecting a first injection site, comprising the method described in any of paragraphs

[0235] to

[0249] above, comprising: (i) a hypodermic needle set; (ii) a pooling bag; (iii) a gravity fill set equipped with a venting spike; (iv) a syringe, (v) pumps, (vi) warming device; (vii) Tubes, and combinations thereof.

[0252] The method described in any one of paragraphs

[0235] to

[0250] can be carried out using any combination of the kits described in any one of paragraphs

[0219] to

[0234] . It will be apparent to one skilled in the art that each of the above elements can be combined in any useful combination.

[0253] In various embodiments, the present invention provides a system for subcutaneous injection of a pharmaceutical formulation of 20% (w / v) IgG, the system being configured to subcutaneously inject the pharmaceutical formulation at a first injection site of a subject in need thereof, the pharmaceutical formulation comprising: at least about 20% (w / v) IgG, and a pharma- ceutically acceptable aqueous carrier in which the IgG is dissolved; Systems including: a first container containing a pharmaceutical formulation of 20% (w / v) IgG; a second container containing a pharmaceutical formulation of hyaluronidase; a first hypodermic needle comprising a first end configured to pierce a first injection site of a subject and a distal opening disposed therein through which the pharmaceutical formulation of 20% (w / v) IgG is delivered to the first injection site; an optional first connection member configured to be in fluid communication with the first container and the hypodermic needle; and A first warming device configured for thermal contact with a system component selected from the first container, the first connecting member, and combinations thereof, configured to heat the pharmaceutical formulation of 20% (w / v) IgG to at least about 30° C., to maintain the pharmaceutical formulation of 20% (w / v) IgG at a temperature of at least about 30° C., and combinations thereof.

[0254] In various embodiments, the invention provides a system as described in the above paragraph, wherein at least one component of the system is configured to heat the pharmaceutical formulation of 20% (w / v) IgG to a temperature of about 30° C. to about 41° C., to maintain the pharmaceutical formulation of 20% (w / v) IgG at a temperature of about 30° C. to about 41° C., and combinations thereof.

[0255] In various embodiments, the present invention provides a system described in any of paragraphs

[0252] to

[0253] above, wherein the warming device is configured to maintain the pharmaceutical formulation of 20% (w / v) IgG essentially constant throughout the duration of the infusion into the first infusion site.

[0256] In various embodiments, the present invention provides a system as described in any of paragraphs

[0252] to

[0254] above, wherein the system further includes means for pumping the 20% (w / v) IgG pharmaceutical formulation from the first container through the first connecting member to the first hypodermic needle, from which the pharmaceutical formulation exits the system via its distal opening.

[0257] In various embodiments, the present invention provides a system as described in any of paragraphs

[0252] to

[0255] above, wherein the system further includes a pump for pumping the pharmaceutical formulation of 20% (w / v) IgG from the first container through the first connecting member to the first hypodermic needle, from which the pharmaceutical formulation exits the system via its distal opening.

[0258] In various embodiments, the present invention provides a kit described in any of paragraphs

[0252] to

[0197] above, in which a pharmaceutical formulation of 20% (w / v) IgG is infused into a first injection site at a first final flow rate that is at least about 2 mL / min, at least about 3 mL / min, at least about 4 mL / min, or at least about 5 mL / min.

[0259] In various embodiments, the present invention provides a system described in any of paragraphs

[0252] to

[0257] above, wherein the pharmaceutical formulation of 20% (w / v) IgG is essentially free of small organic molecules specifically incorporated into the formulation to reduce its viscosity.

[0260] In various embodiments, the present invention provides a system described in any of paragraphs

[0252] to

[0258] above, wherein the first container is selected from an infusion bag and a syringe.

[0261] The system described in any one of paragraphs

[0252] to

[0259] can be implemented using the method described in any one of paragraphs

[0235] to

[0250] and / or can be implemented using any combination of the kit described in any one of paragraphs

[0219] to

[0234] . As will be apparent to one of skill in the art, any of the above elements can be utilized in any combination.

[0262] In various embodiments described in any of the preceding paragraphs, the IgG pharmaceutical formulation comprises about 15% to about 30% (w / v) IgG, e.g., about 15% to about 20%, or about 20% to about 30%, e.g., about 22%, about 24%, about 26%, or about 28% (w / v) IgG. Exemplary formulations include about 25% (w / v) IgG. In various embodiments, the dose of hyaluronidase required to facilitate IgG administration by rapid infusion, as that term is defined herein, is about the same for these IgG formulations as the dose for a 10% (w / v) IgG formulation, or a 20% (w / v) IgG formulation exemplified herein. EXAMPLES

[0263] The following examples are provided to illustrate exemplary embodiments of the invention, but do not define or limit its scope. Working Example Example 1 [Table 2] [Table 3] [Table 4]

[0264] 1. Introduction and Background The Accelerated 20% IGSC project investigated the potential combination of PH20 and Cuvitru, which would provide significant patient benefit by reducing injection volume and injection time compared to Immunoglobulin Infusion 10% (Human) with Recombinant Human Hyaluronidase (HyQvia®). The main clinical aspect in this regard is the flow rate achievable during injection. Initial preclinical studies have shown that the viscosity of the 20% IGG product was so high that a flow of only 2.0 mL / min was considered achievable without creating unacceptably high backpressure. This low flow rate would ultimately offset the effect of the reduced injection volume. Therefore, methods to reduce the viscosity of the IgG solution were investigated. One possible approach is to increase the temperature of the injectate, since it has been shown that at higher temperatures the viscosity of 20% IgG decreases.

[0265] As shown in Figure 2, the tubing between the pooling bag and the scale consists of a tubing set with a spike (gray) connected with a 3.5 m long tubing (red, thin) and a tubing-24G-needle set (red, thick), the latter of which is covered with a flow tube device to maintain the temperature of the IGG solution after it has passed through the infusion warmer.

[0266] After assembling the infusion warmer setup, the experiments summarized in Table 5 were carried out. To prepare the required amount of 20% IGG solution for each of these experiments, four 50 mL vials of 20% IGG containers + 10 mL of a fifth container were transferred from the glass vials to the pooling bag using a 60 mL plastic syringe. For this, a vent needle was first inserted into the 50 mL container, then the required amount (50 mL and 10 mL) was drawn from the vial using the 60 mL plastic syringe and finally injected into the septum port of the pooling bag. After pooling was completed, the bag was gently shaken briefly to homogenize. Then, a 10 mL starting sample was taken directly through the septum port using a plastic syringe. The necessary adjustments of the peristaltic pump and the infusion warmer were set and the experiment was started by the pump. When approximately 200 mL of IGG solution had passed through the injection warmer system and been collected in an appropriate container, the run was stopped and 10 mL of this material was withdrawn and aliquoted according to the analytical section Table 6 and immediately analyzed for MFI, DLS, appearance, and turbidity, and an aliquot for SEC was frozen at ≦−60° C. [Table 5] [Table 6]

[0267] The results for the experimental 20% IgG samples in Table 5 tested according to Table 6 were within expected ranges with no increase in turbidity or subvisible particles observed.

[0268] Example 2 Example 2 describes experiments measuring the viscosity of IgGSC (20%) formulations under various conditions.

[0269] Approximately 1 mL of 20% IGG solution was transferred by syringe into a rolling ball viscometer Lovis 2000 using a measuring capillary with a diameter of 1.59 mm. A 1.5 mm steel ball was added to the capillary and the instrument was adjusted to the required temperature. Then the measurement was started. Figures 1A and 1B and Table 7. [Table 7]

[0270] Example 3 A study was conducted in pigs to evaluate the feasibility and local tolerability of SC injection of warmed accelerated IGSC, 20%. The specific objectives were to compare in-line pressure, bleb size, and local reactions at the injection site following SC injection of accelerated warmed IGSC, 20% with conventional IGSC, 20%.

[0271] For experimental conditions requiring heating, the IG solution was connected to a three-way stopcock using tubing passing through a heating device (Biegler GmbH, model BW685). The set point of the heating device was 41°C, targeting the physiological temperature of the needle. On one side of the three-way stopcock, a syringe containing rHuPH20 or buffer was connected. On the other side of the three-way stopcock, a pressure transducer was placed before the needle set to record the in-line pressure. For conditions with heating, a temperature sensor was placed between the pressure transducer and the needle.

[0272] As this was the first administration, rHuPH20 / buffer was allowed to fill the system up to the needle through the open side three-way stopcock before puncturing the animal. For the 10% IGI condition, rHuPH20 was diluted 1:1 with buffer to maintain a constant volume and the appropriate enzyme to IG ratio (80U rHuPH20 / g IG). After administration of rHuPH20 / buffer was completed, the three-way stopcock was opened on the other side and IG solution was administered. The setup for this study is shown in Figure 3.

[0273] Three animals per group were injected subcutaneously at two simultaneous sites in the abdominal region at flow rates of 3, 4, or 5 mL / min. For each individual pig, 5 mL of rHuPH20 was delivered sequentially to one side, followed by 50 mL of warmed IGSC, 20% (maximum temperature 32 °C-36 °C, measured immediately before needle insertion), and 5 mL of buffer was delivered to the contralateral side, followed by 50 mL of unwarmed IGSC, 20%.

[0274] The different treatment approaches are outlined in Table 8. [Table 8]

[0275] In-line pressure was assessed throughout the entire infusion period, and in-line pressure curves were developed from PowerLab charts. For each treatment, the mean in-line pressure curves during infusion were plotted using GraphPad Prism, Version 8.02. The mean and maximum in-line pressures during IG infusion (from the start of IG infusion to the end of infusion) were determined and compared between treatments using unpaired T-tests.

[0276] The temperature of the IGSC, 20% component in the heated accelerated IGSC, 20% was also measured in-line.

[0277] SC administration of 50 mL of IGSC, 20% at flow rates of 3, 4, or 5 mL / min showed a clear reduction in in-line pressure with warmed accelerated IGSC, 20% compared to conventional IGSC, 20%. Figure 10 shows the results of in-line pressure during infusion. A summary of the data and descriptive statistics are shown in Tables 9, 10, and 11, and statistical comparisons are shown in Table 12. [Table 9] [Table 10] [Table 11] [Table 12]

[0278] Statistical analysis shows that these differences are significant for a flow rate of 5 mL / min. In general, a flow-rate-dependent increase in mean and maximum in-line pressure was observed with the conventional IGSC, 20%, whereas with the heated accelerated IGSC, 20%, in-line pressure remained at a lower level up to the highest flow rates tested.

[0279] Further experiments were performed comparing conventional IGSC,20% with warmed IGSC,20% without facilitation using the setup as described above. Three animals per group were subcutaneously infused simultaneously at two sites in the abdominal region at flow rates of 3 or 5 mL / min. For each individual pig, 5 mL of buffer was delivered sequentially on one side followed by 50 mL of warmed IGSC,20% (maximum temperature 32°C-36°C, measured immediately before needle insertion) and 5 mL of buffer followed by 50 mL of non-warmed IGSC,20% on the other side. In-line pressure during infusion was comparable at 3 ml / min but was reduced with warming compared to non-warming at 5 ml / min.

[0280] Example 4 A PK study was performed in sows to compare the PK properties of human IG following three different single subcutaneous injection approaches of IGSC,20%. Each group of pigs (n=3 / group) received IGSC,20% as follows: 1) Group 1: In-line heated IGSC, 20%, stimulated with rHuPH20 2) Group 2: IGSC, 20%, no rHuPH20 (IGSC, 20%) 3) Group 3: In-line heated IGSC, 20%, without rHuPH20 (heated IGSC, 20%)

[0281] Pigs received 400 mg / kg IGSC,20% by a single subcutaneous injection of in-line warmed (infusion rate: 5 mL / min) (Groups 1, 3) or room temperature (infusion rate: 1 mL / min) (Group 2) IGSC,20% after SC administration of rHuPH20 (Group 1: 79.5 U rHuPH20 / gram IG; infusion rate: 2 mL / min) or buffer instead of rHuPH20 (Groups 2, 3).

[0282] Whole blood samples from all animals were collected at 0.5, 1, 3, 6, 12, 24, 48, 72, 96, 120, 168, 216, 288, 336, 408, 480, 576, and 672 hours post-injection over a 28-day period. Serum was prepared from the whole blood samples for analysis of human IgG using an ELISA for total human IgG concentration. Pharmacokinetic parameters were determined based on individual pharmacokinetic profiles using a noncompartmental model using WinNonlin® (Certara, Princeton, NJ).

[0283] Subcutaneous injection of IGSC, 20% solution without in-line heating and without rHuPH20 pretreatment (group 2) resulted in a mean ± standard deviation of 3.8 ± 0.7 mg / mL. max The injection resulted in a mean t of 192.3 ± 5.6 hours, which was achieved after 40 ± 13.9 hours. 1 / 2 , and the mean area under the concentration-time curve (AUC ) of 775.1 ± 266.5 h·mg / mL from time 0 to the last quantifiable concentration. 0-t After SC administration of TAK-881 (group 1) and without rHuPH20 (warmed IGSC, 20%, group 3), the mean C max was 4.9 ± 1.5 mg / mL in group 1 and 3.6 ± 1.5 mg / mL in group 3, achieved after 48 ± 24 and 40 ± 13.9 hours, respectively. With the in-line heated IGSC, 20% approach (group 3), the apparent t 1 / 2 , and AUC of 759.7 ± 239.0 h·mg / mL 0-t whereas in the presence of rHuPH20, the t 1 / 2 , and AUC of 813.8 ± 109.1 h·mg / mL 0-t was obtained (Table 13).

[0284] Pooled PK characteristics are shown in Table 13, and warmed accelerated IGSC, 20% reduced C max There is a tendency for the number of cases to increase. [Table 13]

[0285] Example 5 Designed, conducted, and evaluated a Phase I human clinical trial.

[0286] 1. Background TAK-881, immunoglobulin subcutaneous (human), 20% solution (IGSC, 20%), in combination with recombinant human hyaluronidase (rHuPH20) is an accelerated subcutaneous immunoglobulin (IG).

[0287] HyQvia® is Immunoglobulin Injection 10% (human) in combination with recombinant human hyaluronidase, and CUVITRU® is Immunoglobulin Subcutaneous (human), 20% solution. TAK-881 differs from HyQvia® only in that it uses warmed or unwarmed (room temperature) IGSC, 20% (CUVITRU®, Immunoglobulin Subcutaneous (human), 20% solution) instead of room temperature 10% Immunoglobulin Injection (IGI).

[0288] TAK-881 is administered by sequential subcutaneous (SC) injection of rHuPH20 first followed immediately (within 10 minutes) by warmed or room temperature IGSC, 20%. The ratio of rHuPH20 to IG is the same as that of HyQvia®, Immunoglobulin Infusion 10% (Human) with Recombinant Human Hyaluronidase, 80 U of rHuPH20 per gram of IG.

[0289] Given the doubled IG concentration delivered with TAK-881, the required infusion volume would be reduced by 50% at comparable dose levels compared to HYQVIA, which may translate to improved tolerability due to fewer local site reactions and better patient outcomes.

[0290] However, similar to CUVITRU® [Immunoglobulin Subcutaneous (Human), 20% Solution], higher IG concentrations are associated with higher viscosity and increased in-line pressure, which allows for only slower infusion rates with conventional subcutaneous 20% IgG therapy.

[0291] Kinematic viscosity is inversely proportional to temperature: in a liquid, viscous forces arise from the mutual attraction of molecules, and as temperature increases, viscosity decreases because the particles gain more thermal energy and are able to overcome the attractive forces holding them together.

[0292] Therefore, to reduce viscosity, a commercially available in-line warming device was used for TAK-881 (in this study, only treatment groups 1 and 2) to warm the infusion tubing used to inject the IGSC, 20% component. In treatment group 3, an in-line warming device was not used for TAK-881, and the IGSC, 20% component was administered at room temperature.

[0293] By using either warmed reduced viscosity IGSC, 20% and hyaluronidase or standard viscosity IGSC, 20% at room temperature with hyaluronidase, TAK-881 may allow for faster infusion times compared to CUVITRU® [Immunoglobulin Subcutaneous (Human), 20% Solution] (currently up to 1 mL / min) and lower subcutaneous injection volumes and associated shorter infusion times compared to HYQVIA.

[0294] The IGSC, 20% component of TAK-881 is a liquid immunoglobulin G (IgG) product purified from human plasma commercially available as CUVITRU® [Immunoglobulin Subcutaneous (Human), 20% Solution]. The IgG subclass distribution of the final product is within the normal range for human serum and contains antibodies against certain bacterial and viral pathogens. The preparation retains all Fab and Fc mediated functions of the IgG molecule.

[0295] The rHuPH20 component of TAK-881 is a highly purified recombinant human hyaluronidase that depolymerizes gel-like hyaluronan in the local subcutaneous tissue where it is injected. This local effect results in a transient increase in permeability, dispersing the IGI and allowing it to more easily reach the systemic circulation than without rHuPH20.

[0296] Extensive safety data are available for the individual components of TAK-881, rHuPH20, and IGSC, 20%, based on the safety profile of the approved products HyQvia®, i.e., Immunoglobulin Injection Solution 10% (Human) and CUVITRU® [Immunoglobulin Subcutaneous (Human), 20% Solution] in combination with recombinant human hyaluronidase. Furthermore, through analytical and preclinical studies, it was shown that warming of IGSC, 20% does not affect important quality parameters and local tolerability, and that warming and acceleration of IGSC, 20% allows for higher flow rates than those currently used for CUVITRU® [Immunoglobulin Subcutaneous (Human), 20% Solution]. Finally, the combination of rHuPH20 and warmed IGSC, 20% was well tolerated in preclinical studies, thereby supporting the proof of concept for clinical trials.

[0297] 2. Protocol Overview Protocol number: TAK-881-1001.

[0298] Drug: TAK-881 - Immunoglobulin Subcutaneous (Human), 20% solution (abbreviated as IGSC, 20%) in combination with recombinant human hyaluronidase (abbreviated as rHuPH20).

[0299] Study Title: A Phase I, Single-Dose, Single-Center, Open-Label, Three-Arm Study to Evaluate the Safety Tolerability of Immunoglobulin Subcutaneous (Human), 20% Solution (TAK-881) in Combination with Recombinant Human Hyaluronidase at Various Infusion Rates in Healthy Adult Subjects.

[0300] Number of Subjects (total and for each treatment group): The total sample size for this study was 24 subjects, with 8 subjects enrolled / treated in each of the 3 treatment groups.

[0301] Facility(s) and Region(s): Single facility, United States.

[0302] Study population: aged 19-50 years (inclusive) at the time of consent and with a body mass index (BMI) of 18.0-30.0 kg / m2 at screening. 2 Healthy male and female subjects with BMI below 18.0 kg / m2 (including borderline values) were enrolled in the study. Eight subjects were enrolled in each of three treatment groups, with two BMI groups in each treatment group: 18.0 to <25.0 kg / m2. 2 , ≧25.0~30.0kg / m 2 ) a minimum of three subjects were enrolled in each study.

[0303] Inclusion Criteria: Patients must be considered "healthy". Health will be determined by the investigator based on screening assessments. Healthy status is defined by the absence of evidence of any active or chronic disease after a complete physical examination including detailed medical and surgical history, vital signs, 12-lead ECG, hematology, blood chemistry, and urinalysis. BMI 18.0-30.0 kg / m 2 is inclusive of the boundary values.

[0304] the purpose: 1) Primary: To evaluate the tolerability of TAK-881 at various subcutaneous (SC) infusion rates in healthy adult subjects. 2) Secondary: To evaluate the safety of TAK-881 at various subcutaneous infusion rates and the immunogenicity of TAK-881 in healthy adult subjects. 3) Exploratory: To evaluate serum total immunoglobulin G (IgG) levels.

[0305] Rationale: TAK-881 (IGSC, 20% solution with rHuPH20) is an accelerated immunoglobulin subcutaneous (IGSC) infusion solution evolved from HyQvia®, immunoglobulin infusion 10% (human) in combination with recombinant human hyaluronidase, and CUVITRU® [immunoglobulin subcutaneous (human), 20% solution]. Both HyQvia®, immunoglobulin infusion 10% (human) in combination with recombinant human hyaluronidase, and CUVITRU® [immunoglobulin subcutaneous (human), 20% solution] have very well established efficacy and safety data. Compared to HyQvia®, immunoglobulin infusion 10% (human) in combination with recombinant human hyaluronidase, the higher concentration of TAK-881 (IGSC 20%) has the potential to reduce the infusion volume by 50%, reduce the infusion time, and improve tolerability. This Phase I study was conducted to evaluate the tolerability, safety, and immunogenicity of TAK-881 at various subcutaneous infusion rates in healthy adult subjects, with a focus on evaluating key dosing and administration parameters to support further clinical development.

[0306] 3. Study Evaluation Items Primary Endpoint: The primary endpoint for this study, which addressed the primary objective, was the occurrence of infusion-related tolerance of TAK-881 per infusion site. A tolerable event was considered to have occurred if the infusion was tolerated. An infusion was considered to be tolerable if any treatment-emergent adverse event (TEAE) related to TAK-881 did not result in a reduction in the infusion rate or in interruption or cessation of the infusion.

[0307] Secondary endpoints: 1) Safety and immunogenicity endpoints (i.e., occurrence of TEAEs, including but not limited to TAK-881-related and unrelated TEAEs; clinical laboratory parameters; vital signs; immunogenicity, e.g., occurrence of binding and neutralizing antibodies to rHuPH20). 2) Subcutaneous administration endpoints (i.e., supportive tolerability and safety measures: maximum tolerated infusion rate achieved per infusion site, total infusion volume per infusion site, time to deliver total infusion volume per infusion site).

[0308] Exploratory endpoints: Serum total IgG levels pre- and post-dose of subcutaneous TAK-881.

[0309] 4. Study Design 4.1 Study Design This was a Phase I, single-dose, single-center, open-label, three-arm study to evaluate the tolerability, safety, and immunogenicity of TAK-881 at various infusion rates in healthy adult subjects.

[0310] The overall study design is shown in FIG.

[0311] The study included three treatment arms. 1) Treatment Group 1 - Subjects received a single dose of TAK-881 containing 0.4 g / kg (in-line heated) IGSC, 20%, at an escalating infusion rate, and rHuPH20 at a dose of 80 U / g IgG on Day 1 of the study treatment period. 2) Treatment Group 2 - Subjects received a single dose of TAK-881 containing 1.0 g / kg (in-line heated) IGSC, 20%, at an escalating infusion rate, and rHuPH20 at a dose of 80 U / g IgG on Day 1 of the study treatment period. 3) Treatment Group 3 - Subjects received a single dose of TAK-881 containing 1.0 g / kg (unheated) IGSC, 20%, at an escalating infusion rate, and rHuPH20 at a dose of 80 U / g IgG on Day 1 of the study treatment period.

[0312] The dosing and infusion rates set forth in Section 5.1.4 were followed in this study.

[0313] A total of 24 subjects were enrolled / treated in each of the three treatment arms.

[0314] 4.2 Test period The study consisted of three periods: 1) Screening period: up to 21 days prior to administration. 2) Study treatment period: 4 days. 3) Follow-up period: up to 12 (± 1) weeks after TAK-881 injection.

[0315] For all three treatment arms, the tolerability and safety, including immunogenicity, of TAK-881 were evaluated during the treatment and follow-up periods.

[0316] All subjects were monitored for anti-rHuPH20 antibody binding (anti-drug antibody [ADA] binding) formation pre-dose (baseline), post-dose (day 30 ± 3 days), and end of study [EOS] (week 12 ± 1 week). Post-dose samples with antibody titers ≥ 1:160 (ADA positive) were analyzed for the presence of neutralizing antibodies. No subjects in this clinical trial had post-dose samples with antibody titers ≥ 1:160 (ADA positive).

[0317] After the EOS visit is completed, no further visits will be scheduled unless deemed necessary by the investigator. Positive binding antibody titers associated with serious or severe AEs would have required further follow-up evaluation, but none occurred in this study.

[0318] 4.3 Test Schedule Study Treatment Dosing: Dose levels were 0.4 g / kg (in-line warming), 1.0 g / kg (in-line warming), and 1.0 g / kg (unwarmed) of rHuPH20 80 U / g IgG for treatment arms 1, 2, and 3, respectively. Subjects received a single dose intraperitoneally at escalating infusion rates according to the schedule set forth in Section 5.3.2.

[0319] Serum chemistry, hematology, and urinalysis

[0320] Hematology included CBC. Serum chemistry included ALT, AST, ALP, K. + , Na + , Cl - , Ca2+ , Mg 2+ , bilirubin (total and direct), LDH, BUN, creatinine, uric acid, glucose, albumin, and lipid profile. Standard urinalysis and hemolysis panel were also performed.

[0321] Coagulation testing included aPTT and INR assessments performed at screening and on day -1 as clinically indicated.

[0322] No potential safety signals were identified in any of the above studies, and test results were largely within expected ranges.

[0323] Immunogenicity Panel: An immunogenicity panel was collected at baseline (day -1) and at any time deemed necessary during the course of the study. Subjects who had (a) two consecutive anti-rHuPH20 antibody titers ≥ 1:160 that were elevated from the subject's baseline titer, and (b) a moderate or severe AE (≥ grade 2 according to CTCAE v5.0) that could be the result of an immune-mediated response to either immunoglobulin, rHuPH20, or other concomitant medications, were asked to return to the CRC as soon as possible to undergo an additional panel of immunogenicity studies. No subjects in this clinical trial had anti-rHuPH20 antibody titers ≥ 1:160 that were elevated from the subject's baseline titer.

[0324] Serum total IgG levels: Serum total IgG samples were collected on day -1, day 4 (at discharge), day 30 (± 3 days), and week 12 (± 1 week) / EOS or ET.

[0325] 5. Clinical Trial Drugs 5.1 Identity of the Clinical Trial Medicinal Product(s) Immunoglobulin Subcutaneous (Human), 20% Solution (IGSC, 20%) in Combination with Recombinant Human Hyaluronidase (rHuPH20) (also referred to as IGSC, 20% in combination with rHuPH20, or TAK-881). IGSC, 20% (Human) is supplied at 8 g / 40 mL vial and rHuPH20 160 units / mL is supplied separately in a 15 mL vial.

[0326] 5.1.1 Immunoglobulin Subcutaneous 20% (Human) - IGSC, 20% IGSC,20% (Human) is a ready-to-use sterile liquid preparation of highly purified and concentrated IgG antibodies. The distribution of IgG subclasses is similar to that of normal plasma. Fc and Fab functions are maintained in the primary component. Prekallikrein activator activity is undetectable. IGSC,20% (Human) contains 200mg / mL (20%) protein. At least ≥98% of the protein is IgG with trace amounts of IgA (average concentration of 80mcg / mL). IGSC,20% (Human) contains a broad range of IgG antibodies against bacterial and viral agents. Glycine (0.25M) serves as a stabilizer and buffer. No sugar, sodium, or preservatives are added. The pH is 4.6-5.1. The osmolality is 280-292 mOsmol / kg. IGSC,20% (Human) is manufactured from a large pool of human plasma. IgG preparations are purified from plasma pools using a modified Cohn-Oncley cold ethanol fractionation process and cation and anion exchange chromatography.

[0327] To further improve the safety margin, validated viral inactivation / removal steps have been incorporated into the manufacturing and formulation process, namely, solvent / detergent (S / D) treatment, 35 nm nanofiltration, and low pH incubation at elevated temperature (30°C-32°C). The solvent / detergent process involves treatment with an organic mixture of tri-n-butyl phosphate, octoxynol 9, and polysorbate 80 at 18°C-25°C for a minimum of 60 minutes. The solvent / detergent treatment inactivates the investigated lipid-enveloped viruses to below the detection limit within minutes. An ethanol fractionation process provides further viral clearance potential.

[0328] 5.1.2 Recombinant human hyaluronidase - rHuPH20 The rHuPH20 component of TAK-881 is produced from genetically modified Chinese Hamster Ovary cells containing a DNA plasmid encoding a soluble fragment of human hyaluronidase PH20. rHuPH20 is used in HyQvia®, Immunoglobulin Infusion 10% (Human) in combination with recombinant human hyaluronidase. The purified hyaluronidase glycoprotein contains 447 amino acids with a molecular weight of approximately 61,000 daltons. This component is supplied as a sterile, clear, colorless, ready-to-use solution with an approximate pH of 7.4 and an osmolality of 290-350 milliosmoles. Each vial contains 160 U / mL of recombinant human hyaluronidase. No preservatives are included.

[0329] Due to comprehensive viral testing at the master cell bank, working cell bank, and bulk harvest stages, effective viral reduction during the purification process, and the use of pharmaceutical-grade human albumin as an excipient with no other materials of human or animal origin involved in the manufacturing process, rHuPH20 offers a high safety margin with respect to viruses.

[0330] 5.1.3 Medication The study included three treatment arms. 1) Treatment Group 1 - Subjects received a single dose of TAK-881 containing 0.4 g / kg (in-line heated) IGSC, 20%, at an escalating infusion rate, and rHuPH20 at a dose of 80 U / g IgG on Day 1 of the study treatment period. 2) Treatment Group 2 - Subjects received a single dose of TAK-881 containing 1.0 g / kg (in-line heated) IGSC, 20%, at an escalating infusion rate, and rHuPH20 at a dose of 80 U / g IgG on Day 1 of the study treatment period. 3) Treatment Group 3 - Subjects received a single dose of TAK-881 containing 1.0 g / kg (unheated) IGSC, 20%, at an escalating infusion rate, and rHuPH20 at a dose of 80 U / g IgG on Day 1 of the study treatment period.

[0331] The dose of rHuPH20 is 80 U / g IgG. The units of rHuPH20 were calculated as follows: 1) The dose of rHuPH20 is 80 units x planned IGSC 20% dose (in grams) = total units to inject (e.g., 80U x 40g = 3200U). 2) Then, to calculate the volume needed, if each vial has a concentration of 160 U / mL, divide the stated units by 160 (e.g., 3200 U ÷ 160 U / mL = 20 mL).

[0332] Dosing began with a lower dose level first (arm 1, 0.4 g / kg, in-line heating), followed by a higher dose level (arm 2, 1.0 g / kg, in-line heating), followed by a non-warmed group (arm 3, 1.0 g / kg, no heating). To ensure optimal tolerability and safety, subjects in all three arms were dosed according to a sentinel dosing schedule with ongoing safety monitoring by the investigator. Subjects in each arm were divided into four subgroups of 1, 1, 2, and 4 subjects, respectively. Subgroups were dosed in a sequential order to allow for evaluation of safety and tolerability before initiating dosing of subsequent subgroups.

[0333] Subjects were adequately hydrated prior to drug administration.

[0334] 5.1.4 Mode of administration TAK-881-1001 clinical trial drug (IP) was administered via the subcutaneous route using a 22-24 gauge subcutaneous needle set. rHuPH20 solution was administered first, followed by IGSC20% using the same needle set.

[0335] The rHuPH20 solution was administered subcutaneously via a peristaltic infusion pump at a rate of 120 mL / hour / site and a maximum infusion volume of 30 mL / site.

[0336] The injection site(s) were either in the abdomen (mid to upper abdomen) or thigh (left or right).

[0337] Within 10 minutes of completing the subcutaneous infusion of rHuPH20 solution with a peristaltic infusion pump with programmable infusion rate and infusion volume up to 300 mL / site, a subcutaneous infusion of IGSC 20% solution was initiated; one or two infusion sites could be required. If two infusion sites were required, doses would be administered sequentially with the maximum 300 mL infusion administered first. Due to the large priming volume of the two administration systems, a saline flush step was required to ensure the total dose was administered. No saline was infused into the subjects. For each infusion site, the infusion rate escalation schedule was followed as shown in Tables 14, 15, and 16.

[0338] If an infusion site was reduced or discontinued due to a tolerability failure event, the infusion rate remained at the maximally tolerated infusion rate (e.g., if the maximum infusion rate was 300 mL and it was not tolerated, the infusion rate was reduced to the previous infusion rate of 180 mL, which was assumed to be well tolerated). Since no tolerance events occurred in this study, the final infusion rate per infusion site used was recorded as the best tolerated infusion rate for that infusion site (e.g., if the total volume at the second infusion site was 20 ml, the best tolerated infusion rate recorded for that site would be 120 ml / hour).

[0339] The study followed the following stepwise infusion rate titration regimen based on tolerability of each infusion rate (Tables 14, 15, and 16). [Table 14] [Table 15] [Table 16]

[0340] 6. Clinical Trial Results The results of the Phase I clinical trial are shown in Tables 17, 18, 19, 20, and 21. [Table 17] [Table 18] [Table 19] [Table 20] [Table 21] TIFF2024535021000022.tif171165TIFF2024535021000023.tif178165

[0341] The present invention has been described with reference to various exemplary embodiments and examples. As will be apparent to those skilled in the art, other embodiments and variations of the present invention may be devised by those skilled in the art without departing from the true spirit and scope of the present invention. It is intended that the appended claims be construed to include all such embodiments and equivalent variations.

[0342] The disclosures of any and all patents, patent applications, and publications cited herein are hereby incorporated by reference in their entireties. [Prior art documents] [Non-patent literature]

[0343] [Non-Patent Document 1] Perez,et al.,J Allergy Clin Immunol.(2017),139:S1-S46 [Non-Patent Document 2] Kobrynski L,Biologics(2012),6:277-287 [Non-Patent Document 3] Anderson et al.,J.Clin.Immunol.(2021)41:458-469

Claims

1. (a) a first container containing a pharmaceutical formulation of recombinant human hyaluronidase in a pharmaceutically acceptable carrier; (b) a second container containing a pharmaceutical formulation of 20% (w / v) IgG in a pharmaceutically acceptable carrier; and (c) instructions providing guidance for sequentially subcutaneously injecting (i) a first aliquot of a predetermined dose of the pharmaceutical formulation of recombinant human hyaluronidase, and (ii) (i), followed by a first aliquot of a predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG, at a first injection site; Includes a kit.

2. 2. The kit of claim 1, wherein the pharmaceutical preparation of recombinant human hyaluronidase contains 20% (w / v) recombinant human hyaluronidase.

3. 2. The kit of claim 1, wherein the recombinant human hyaluronidase is rHuPH20.

4. 10. The kit of claim 1, further comprising an injection device for sequentially or simultaneously subcutaneously injecting (i) the pharmaceutical formulation of recombinant human hyaluronidase, and (ii) (i) followed by the pharmaceutical formulation of 20% (w / v) IgG.

5. The kit of claim 1 further comprising a hypodermic needle set.

6. 10. The kit of claim 1, wherein the instructions are a component of the Dosage and Administration section of the Complete Prescribing Information.

7. 10. The kit of claim 1, wherein the instructions provide guidance for subcutaneously injecting the pharmaceutical formulation of rHuPH20 into the first injection site.

8. 10. The kit of claim 1, wherein the instructions provide guidance for subcutaneously injecting about 50 U / g to about 100 U rHuPH20 per gram of IgG into the first injection site.

9. 10. The kit of claim 1, wherein the instructions provide guidance for subcutaneously injecting up to at least about 100 mL, up to at least about 150 mL, up to at least about 200 mL, up to at least about 250 mL, or up to at least about 300 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site.

10. 10. The kit of claim 1, wherein the instructions provide guidance for subcutaneously infusing a first predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site at a rate of at least about 120 mL / hour, at least about 150 mL / hour, at least about 200 mL / hour, at least about 250 mL / hour, or at least about 300 mL / hour.

11. 10. The kit of claim 1, wherein the instructions provide guidance for subcutaneously infusing at least about 120 mL of the pharmaceutical formulation of 20% (w / v) IgG into a first injection site at a rate of at least about 120 mL / hour, at least about 150 mL / hour, at least about 200 mL / hour, at least about 250 mL / hour, or at least about 300 mL / hour.

12. 10. The kit of claim 1, wherein the instructions provide guidance for subcutaneously injecting at least about 300 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site.

13. 10. The kit of claim 1, wherein the instructions provide guidance for subcutaneously injecting at least about 300 mL of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site at a rate of at least about 300 mL / hour.

14. The instructions, subcutaneously injecting the pharmaceutical formulation of 20% (w / v) IgG warmed to a temperature of about 30°C to about 41°C, wherein the pharmaceutical formulation is warmed to said temperature before, during, and combinations thereof. The kit of claim 1 , wherein the kit provides guidance for:

15. The instructions, Simultaneously or sequentially, at a second injection site, (i) a second aliquot of the predetermined dose of the pharmaceutical formulation of recombinant human hyaluronidase is subcutaneously injected, and (ii) following (i), a second aliquot of the predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG is subcutaneously injected at the second injection site. The kit of claim 1, further providing guidance on how to administer the kit.

16. The instructions, The pharmaceutical formulation of rHuPH20 is subcutaneously injected into the first injection site, followed by (i) a hypodermic needle set; (ii) a pooling bag; (iii) a gravity fill set with vent spikes; (iv) a syringe; (v) a pump; (vi) warming device; (vii) Tubes, and combinations thereof injecting the pharmaceutical formulation of 20% (w / v) IgG into the first injection site using a member selected from 10. The kit of claim 1, wherein the kit provides guidance for the use of the kit.

17. 1. A pharmaceutical formulation comprising 20% ​​(w / v) IgG for use in a method of subcutaneous injection of the pharmaceutical formulation of 20% (w / v) IgG at a first injection site in a subject in need thereof, said method comprising: (a) injecting a first aliquot of a predetermined dose of hyaluronidase into the first injection site by injecting a predetermined volume of a pharmaceutical formulation of hyaluronidase into the first injection site; and (b) following (a), injecting a first aliquot of a predetermined dose of IgG into the first injection site by injecting a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG into the first injection site.

10. A pharmaceutical formulation comprising:

18. The method comprising: (c) injecting a second aliquot of the predetermined dose of hyaluronidase into a second injection site by injecting a second predetermined volume of the pharmaceutical formulation of hyaluronidase into the second injection site; and (d) following (c), injecting a second aliquot of the predetermined dose of IgG into the second injection site by injecting a second predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG into the second injection site.

18. The pharmaceutical formulation of claim 17, further comprising:

19. 18. The pharmaceutical formulation of claim 17, wherein a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is subcutaneously injected at a first final predetermined rate into the first injection site.

20. 18. The pharmaceutical formulation of claim 17, wherein the first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is at least about 120 mL, at least about 150 mL, at least about 180 mL, at least about 200 mL, at least about 220 mL, at least about 250 mL, at least about 280 mL, or at least about 300 mL.

21. 18. The pharmaceutical formulation of claim 17, wherein the first final predetermined rate is at least about 120 mL / hr, at least about 150 mL / hr, at least about 180 mL / hr, at least about 200 mL / hr, at least about 220 mL / hr, at least about 250 mL / hr, at least about 280 mL / hr, or at least about 300 mL / hr.

22. 18. The pharmaceutical formulation of claim 17, wherein a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is about 100 mL to about 300 mL, e.g., about 150 mL to about 200 mL, about 200 mL to about 250 mL, or about 250 mL to about 300 mL, and is infused into the first infusion site at a first final rate of about 100 mL / hour to about 300 mL / hour, e.g., about 150 mL / hour to about 200 mL / hour, about 200 mL / hour to about 250 mL / hour, or about 250 mL / hour to about 300 mL / hour.

23. 18. The pharmaceutical formulation of claim 17, wherein a first intermediate infusion rate of less than 300 mL / hour is maintained for a selected time period before achieving a first final predetermined rate of 300 mL / hour and then increased to said first final predetermined rate.

24. 18. The pharmaceutical formulation of claim 17, wherein a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is infused into the first infusion site at a rate of at least about 300 mL / hour without reducing the rate of infusion or stopping the infusion due to the subject's discomfort, pain, or a combination thereof.

25. 18. The pharmaceutical formulation of claim 17, wherein a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is infused into the first infusion site at a rate comprising an ascending phase followed by a terminal phase, the rate of the terminal phase being about 200 to about 300 mL / hour, e.g., about 220 mL / hour, about 240 mL / hour, about 260 mL / hour, about 280 mL / hour, the terminal phase ending upon infusion of the last of the first predetermined volume into the first infusion site, and the terminal phase proceeding without the subject reducing the rate of infusion or stopping the infusion due to discomfort, pain, or a combination thereof.

26. 26. The pharmaceutical formulation of claim 25, wherein at least about 60% of a first predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is infused into the first infusion site during the terminal phase at a first final rate of at least about 200 mL / hr to about 300 mL / hr, e.g., about 220 mL / hr, about 240 mL / hr, about 260 mL / hr, or about 280 mL / hr, without reducing the rate or ceasing the infusion due to the subject's discomfort, pain, or a combination thereof.

27. 18. The pharmaceutical formulation of claim 17, wherein the first predetermined volume is about 200 mL to about 300 mL, e.g., about 220 mL, about 240 mL, about 260 mL, or about 280 mL, and the first final predetermined rate is about 200 mL / hour to about 300 mL / hour, e.g., about 220 mL / hour, about 240 mL / hour, about 260 mL / hour, or about 280 mL / hour.

28. The pharmaceutical formulation of claim 18, wherein a second predetermined volume of the pharmaceutical formulation of 20% (w / v) IgG is subcutaneously injected into the second injection site at a second final predetermined rate, the second final predetermined rate being approximately 300 mL / hour, and a second intermediate injection rate is maintained for a selected time before achieving the second final predetermined rate and then increased to the second final predetermined rate.

29. 18. The pharmaceutical preparation of claim 17, wherein the predetermined dose of the pharmaceutical preparation of hyaluronidase is essentially the same between the method of injecting the pharmaceutical preparation of 20% (w / v) IgG and the method of injecting an identical pharmaceutical preparation except that it contains 10% (w / v) IgG.

30. 18. The pharmaceutical formulation of claim 17, wherein a first predetermined dose of the pharmaceutical formulation of 20% (w / v) IgG is injected into the first injection site at a rate that is about two to about three times faster than the rate at which the pharmaceutical formulation of 20% (w / v) IgG would be injected without injecting a predetermined dose of hyaluronidase into the first injection site prior to injecting the pharmaceutical formulation of 20% (w / v) IgG into the first injection site.

31. The method is performed using a system configured to perform the method, the system comprising: (a) a first container containing a pharmaceutical formulation of recombinant human hyaluronidase in a pharmaceutically acceptable carrier; (b) a second container containing a pharmaceutical formulation of 20% w / v IgG in a pharmaceutically acceptable carrier; and (c) means for sequentially subcutaneously injecting (i) a first aliquot of a predetermined dose of said pharmaceutical formulation of recombinant human hyaluronidase, and (ii) following (i), a first aliquot of a predetermined dose of said pharmaceutical formulation of 20% IgG at a first injection site.

18. The pharmaceutical formulation of claim 17, comprising:

32. said means for continuously infusing subcutaneously at a first infusion site comprising: (i) a hypodermic needle set; (ii) a pooling bag; (iii) a gravity fill set with vent spikes; (iv) a syringe; (v) a pump; (vi) warming device; (vii) Tubes, and combinations thereof 32. The pharmaceutical formulation of claim 31 , comprising:

33. 1. A system for subcutaneously injecting a pharmaceutical formulation of 20% (w / v) IgG, the system being configured to subcutaneously inject the pharmaceutical formulation into a first injection site of a subject in need thereof, the pharmaceutical formulation comprising: At least about 20% (w / v) IgG and a pharmaceutically acceptable aqueous carrier in which the IgG is dissolved. wherein the system comprises: a. a first container containing a pharmaceutical formulation of 20% (w / v) IgG; b. a second container containing a pharmaceutical formulation of hyaluronidase; c. a first hypodermic needle comprising a first end configured to pierce a first injection site in the subject and a distal opening disposed therein through which the pharmaceutical formulation of 20% (w / v) IgG is delivered to the first injection site; d. an optional first connecting member configured to fluidly connect the first container and the hypodermic needle; and e. a first warming device configured for thermal contact with a system component selected from the first container, the first connecting member, and combinations thereof, configured to heat the 20% (w / v) IgG pharmaceutical formulation to at least about 30° C., maintain the 20% (w / v) IgG pharmaceutical formulation at a temperature of at least about 30° C., and combinations thereof. The system comprising:

34. 34. The system of claim 33, wherein at least one component of the system is configured to heat the 20% (w / v) IgG pharmaceutical formulation to a temperature of about 30°C to about 41°C, to maintain the 20% (w / v) IgG pharmaceutical formulation at a temperature of about 30°C to about 41°C, and combinations thereof.

35. 34. The system of claim 33, wherein the warming device is configured to maintain the pharmaceutical formulation of 20% (w / v) IgG essentially constant throughout the duration of the infusion into the first infusion site.

36. 34. The system of claim 33, further comprising means for pumping the 20% (w / v) IgG pharmaceutical formulation from the first container through the first connecting member and into the first hypodermic needle, from which the pharmaceutical formulation exits the system through its distal opening.

37. 34. The system of claim 33, wherein the system further comprises a pump for pumping the 20% (w / v) IgG pharmaceutical formulation from the first container through the first connecting member and into the first hypodermic needle, from which the pharmaceutical formulation exits the system through its distal opening.

38. 34. The system of claim 33, wherein the pharmaceutical formulation of 20% (w / v) IgG is infused into the first infusion site at a first final flow rate that is at least about 2 mL / min, at least about 3 mL / min, or at least about 5 mL / min.

39. 34. The system of claim 33, wherein the pharmaceutical formulation of 20% (w / v) IgG is essentially free of small organic molecules specifically incorporated into the formulation to reduce its viscosity.

40. 34. The system of claim 33, wherein the first container is selected from an infusion bag and a syringe.

41. Use of a pharmaceutical formulation according to any one of claims 17 to 32 or a kit according to any one of claims 1 to 16 for the manufacture of a medicament for improving or facilitating subcutaneous delivery.

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