Methods of using anti-sclerostin antibodies in the treatment of osteogenesis imperfecta - Patents.com

Abstract

Osteogenesis imperfecta (OI) is a rare genetic disorder of connective tissue characterized by bone fragility and reduced bone mass. OI includes a group of inherited disorders that result primarily, but not always, from mutations in genes encoding type I collagen. Approximately 85% of cases are associated with mutations in one of two genes (COL1A1 and COL1A2) that encode type I collagen. Clinically, OI is characterized by bone fragility that fractures easily without trauma. The present invention discloses a method and dosing regimen for treating a patient with osteogenesis imperfecta, comprising administering to the patient a therapeutically effective amount of an anti-sclerostin antibody. The present invention also provides an anti-sclerostin antibody for use in treating osteogenesis imperfecta, comprising administering each month a therapeutically effective amount of the anti-sclerostin antibody according to a particular dosing regimen.

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority to and the benefit of U.S. Provisional Patent Application No. 63 / 250,918, filed September 30, 2021, and U.S. Provisional Patent Application No. 63 / 374,982, filed September 8, 2022, which are incorporated by reference in their entireties.

[0002] Sequence Listing This application contains a Sequence Listing that has been submitted in XML format via EFS-Web. The contents of the XML copy entitled "ULG-5006PC_122626-5006_Sequence Listing" was created on Sep. 22, 2022, is 227,000 bytes in size, and is incorporated herein by reference in its entirety.

[0003] The present invention relates to antibodies and dosing regimens and their use as pharmaceutical compositions, and more particularly to the long-term use of anti-sclerostin antibodies in the treatment of osteogenesis imperfecta. [Background technology]

[0004] Osteogenesis imperfecta (OI) is a rare genetic disorder of connective tissue characterized by bone fragility and reduced bone mass. OI includes a group of inherited disorders that result primarily, but not always, from mutations in genes encoding type I collagen. Approximately 85% of cases are associated with mutations in one of two genes (COL1A1 and COL1A2) that encode type I collagen. Clinically, OI is characterized by bone fragility that fractures easily without trauma.

[0005] Clinical classification systems categorize OI into types I to V. Patients with type I OI usually suffer from mild, non-deformative disease associated with a premature stop codon in COL1A1. This defect reduces the rate of production of type I collagen and reduces the amount of collagen in bone. Patients with type II OI usually die perinatally as a result of respiratory failure due to multiple severe fractures, including the rib cage. Types III and IV OI are often associated with glycine substitutions in COL1A1 and COL1A2, a qualitative defect that prevents the three polypeptide chains of type I collagen from properly intertwining to form the normal triple alpha-helical structure. Type III OI is the most severe form of OI in affected children who survive infancy, whereas type IV patients show mild to moderate bone deformities.

[0006] Therapeutic agents useful for treating bone-related diseases include anti-sclerostin antibodies. High-affinity, neutralizing fully human anti-sclerostin monoclonal antibodies (collectively "human anti-sclerostin monoclonal antibodies") and their strong in vitro and in vivo activities are disclosed, for example, in U.S. Patent Nos. 7,879,322, 8,246,953, and 8,486,661, which are incorporated herein by reference in their entirety. Treatment of OI with anti-sclerostin antibodies is disclosed in WO2018 / 115879A1 and WO2018 / 115880A1, which are incorporated herein by reference in their entirety. Additional anti-sclerostin antibodies include those described, for example, in WO2013 / 019954A1, U.S. Patent Nos. 8,003,108, 7,592,429, and 8,017,120, and U.S. Patent Application Publication No. 20110044978A1, which are incorporated by reference in their entireties. Formulations of such antibodies are disclosed, for example, in WO2021 / 030179A1, which is incorporated by reference in its entirety.

[0007] Additional anti-sclerostin antibodies include, for example, those described in WO2008 / 115732A2, which is incorporated by reference in its entirety.

[0008] Additional anti-sclerostin antibodies include, for example, those described in US Pat. No. 10,449,250, which is incorporated by reference herein in its entirety.

[0009] Additional anti-sclerostin antibodies include, for example, those described in WO2015 / 087187A1, which is incorporated by reference in its entirety.

[0010] There remains a need for further and improved treatment options for OI. Summary of the Invention

[0011] The results of the studies reported in the Examples surprisingly suggest that human OI patients can be successfully treated long-term with anti-sclerostin antibodies. These results showed that the effect of anti-sclerostin antibodies on bone turnover biomarkers peaked after the first month of treatment and then attenuated, whereas the effect on bone mineral density (BMD) showed continued improvement (significantly exceeding the attenuation of biomarker response).

[0012] Thus, in one aspect, the invention provides methods for the long-term or chronic treatment of osteogenesis imperfecta (OI) with anti-sclerostin antibodies.

[0013] In some embodiments, the disclosure provides a method of treating osteogenesis imperfecta (OI) in a human patient, comprising administering to the human patient a therapeutically effective amount of an anti-sclerostin antibody each month for at least 13 consecutive months.

[0014] In some embodiments, the anti-sclerostin antibody comprises (a) a VH polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 70, and / or (b) a VL polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 81. In one embodiment, the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 70, and a VL polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 81.

[0015] In some embodiments, the anti-sclerostin antibody comprises (a) a VH polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 198, and / or (b) a VL polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 199. In one embodiment, the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 198, and a VL polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 199.

[0016] In some embodiments, the anti-sclerostin antibody comprises (a) a VH polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 202, and / or (b) a VL polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 203. In one embodiment, the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 202, and a VL polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 203.

[0017] In some embodiments, the anti-sclerostin antibody comprises (a) a heavy chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 4, (b) a heavy chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 15, (c) a heavy chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 26, (d) a light chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 37, (e) a light chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 48, and (f) a light chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 59.

[0018] In some embodiments, the anti-sclerostin antibody comprises (a) a heavy chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 178, (b) a heavy chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 179, (c) a heavy chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 26, (d) a light chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 37, (e) a light chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 180, and (f) a light chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 181.

[0019] In some embodiments, the anti-sclerostin antibody comprises (a) a heavy chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 4, (b) a heavy chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 179, (c) a heavy chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 26, (d) a light chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 37, (e) a light chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 180, and (f) a light chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 181.

[0020] In some embodiments, the anti-sclerostin antibody is an antibody described in U.S. Pat. Nos. 7,879,322, 8,246,953, 8,486,661, 8,003,108, 7,592,429, 8,017,120, or 10,449,250, WO2018 / 115879A1, WO2018 / 115880A1, WO2013 / 019954A1, WO2008 / 115732A2, or WO2015 / 087187A1, or U.S. Patent Application Publication No. 20110044978A1, which are incorporated by reference in their entireties.

[0021] In some embodiments, the anti-sclerostin antibody is selected from setrusumab, romosozumab, and brosozumab.

[0022] In some embodiments, a therapeutically effective amount of anti-sclerostin antibody is administered to the patient each month, i.e., every month, for at least 13 consecutive months. In one embodiment, a therapeutically effective amount of anti-sclerostin antibody is administered to the patient each month, i.e., every month, for at least 18 consecutive months. In another embodiment, a therapeutically effective amount of anti-sclerostin antibody is administered to the patient each month, i.e., every month, for at least 24 consecutive months. In yet another embodiment, a therapeutically effective amount of anti-sclerostin antibody is administered to the patient each month, i.e., every month, for at least 30 consecutive months. In yet another embodiment, the anti-sclerostin antibody is administered monthly for at least 36 consecutive months. In yet another embodiment, the anti-sclerostin antibody is administered monthly for up to 18 years.

[0023] In some embodiments, administration of a therapeutically effective amount of an anti-sclerostin antibody increases trabecular bone mineral density (BMD) after 12 months of treatment in human patients. In a related embodiment, administration of a therapeutically effective amount of an anti-sclerostin antibody increases lumbar spine BMD by 5% or more after 12 months of treatment in human patients. BMD may be measured by dual energy x-ray absorptiometry (DXA). In some embodiments, administration of a therapeutically effective amount of an anti-sclerostin antibody increases lumbar spine BMD by 5% or more after 12 months of treatment in human patients.

[0024] In some embodiments, the chronic or long-term dosing regimens disclosed herein are effective in treating any genetic disease of bone that results in fracture or weakness that would benefit from chronic administration, such as an OI. In some embodiments, the OI is type I OI, type III OI, or type IV OI. In some embodiments, the human patient has one or more mutations in the COL1A1 and / or COL1A2 genes.

[0025] In some embodiments, the human patient is a pediatric patient. In some embodiments, the human patient is an adult patient. In some embodiments, the human patient is a child between 0 and 17 years of age, and the anti-sclerostin antibody is administered at a dose of 20-50 mg / kg.

[0026] In some embodiments, the anti-sclerostin antibody is administered monthly at a dose of 10-50 mg / kg. In one embodiment, the anti-sclerostin antibody is administered monthly at a dose selected from 10 mg / kg, 15 mg / kg, 20 mg / kg, 25 mg / kg, 30 mg / kg, 35 mg / kg, 40 mg / kg, 45 mg / kg, and 50 mg / kg. In another embodiment, the anti-sclerostin antibody is administered monthly at a dose of 10 mg / kg. In yet another embodiment, the anti-sclerostin antibody is administered monthly at a dose of 20 mg / kg. In yet another embodiment, the anti-sclerostin antibody is administered monthly at a dose of 40 mg / kg.

[0027] In some embodiments, the anti-sclerostin antibody is administered intravenously or subcutaneously. In one embodiment, the anti-sclerostin antibody is administered intravenously. [Brief description of the drawings]

[0028] [Figure 1] The clinical trial design is shown. [Diagram 2] Graphs showing the mean change from baseline in serum levels of: A, P1NP (intact N-terminal propeptide of procollagen 1), a bone formation biomarker; B, CTX-1 (C-terminal telopeptide), a bone resorption biomarker. [Diagram 3] 1 shows a graph depicting the mean change from baseline in lumbar spine BMD data (measured by DXA) comparing monthly administration of setrusumab 8 mg / kg or 20 mg / kg over a 12-month period. [Figure 4] Graphs showing the effect of setrusumab discontinuation on BMD after 12 months with or without zoledronic acid therapy. A shows lumbar spine BMD after discontinuation. B shows hip BMD after discontinuation. C shows radius total regional volumetric BMD after discontinuation. D shows tibia total regional volumetric BMD after discontinuation. [Diagram 5] Graphs showing the effect of discontinuing setrusumab on bone turnover biomarkers after 12 months in the presence or absence of zoledronic acid therapy. A shows serum P1NP levels after discontinuing setrusumab. B shows serum CTX-1 (i.e., "CTx") levels after discontinuing setrusumab. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0029] The present invention is based on the unexpected and surprising discovery that in human patients with bone-related disease (osteogenesis imperfecta; OI), biomarkers routinely used to measure bone turnover attenuate BMD immediately after the initiation of setrusumab therapy, but setrusumab provides a continuous increase that is not attenuated by the biomarker. Human OI patients treated with monthly doses of setrusumab for one year showed a continuous increase in BMD throughout the treatment period, with the increase in the first six months being similar to that in the next six months (Example 1). In contrast, bone turnover biomarker responses peaked after one month, then declined, returning to levels that were not statistically significantly different from baseline after six months of treatment. Although it has been shown that anti-sclerostin antibody-based treatments for other bone diseases lose efficacy over time and must be discontinued after one year, the present findings indicate that long-term treatment with anti-sclerostin antibodies can provide continued efficacy for the treatment of OI after 12 months of treatment.

[0030] By way of background, sclerostin is a naturally occurring protein that in humans is encoded by the SOST gene. Sclerostin is a secreted glycoprotein with a C-terminal cysteine ​​knot-like (CTCK) domain and sequence similarity to the DAN (Differential Screening Selected Genetic Abnormalities in Neuroblastoma) family of bone morphogenetic protein (BMP) antagonists.

[0031] Anti-sclerostin antibodies have been shown to increase bone formation and density, providing therapeutic benefit in the treatment of bone-related disorders in humans, including osteoporosis and OI. One anti-sclerostin antibody (romosozumab, marketed as EVENITY™) has been approved by the FDA for the treatment of osteoporosis in postmenopausal women at high risk for fracture. However, the anabolic effect of EVENITY™ diminishes after 12 months of monthly treatment (see EVENITY™ Prescribing Information - Indications and Use section, April 2020 Update). Thus, the duration of use of EVENITY™ is limited to 12 months of monthly dosing, after which continued treatment with antiresorptive agents is recommended if osteoporosis treatment is required.

[0032] This example shows that the effect of anti-sclerostin antibody on BMD does not fade even after 12 months of monthly administration for the treatment of OI. This result is particularly surprising because the bone turnover biomarker response peaked just one month after anti-sclerostin antibody treatment, after which the bone turnover biomarker response rapidly decayed. Even if the biomarker response declined quite early, the fact that BMD continues to increase after 12 months of treatment suggests that anti-sclerostin antibody treatment is particularly suitable for long-term treatment of OI. Thus, monthly anti-sclerostin antibody therapy offers the advantage of prolonged treatment of OI without the need to stop treatment due to the fading of the antibody effect. Thus, the clinical utility of anti-sclerostin antibody therapy unexpectedly includes chronic or long-term treatment of genetic bone diseases that cause fractures or frailty in humans, such as OI.

[0033] Thus, the present invention relates to methods of using anti-sclerostin antibodies in the chronic treatment of inherited bone disorders that lead to fractures or weakness, such as OI, hi one aspect, the invention relates to the treatment of OI by monthly administration of anti-sclerostin antibodies for at least 13 consecutive months.

[0034] The methods and uses of anti-sclerostin antibodies in the present invention were unexpected and surprising, as monthly treatment of OI patients resulted in continued increases in BMD over a 12-month period, despite bone turnover biomarker responses peaking after one month and then declining thereafter.

[0035] definition In order that the present invention may be more readily understood, certain terms are first defined. Further definitions are set forth throughout the detailed description.

[0036] The term "comprising" encompasses "including" and "consisting", e.g., a composition "comprising" X may consist only of X or may include something additional (e.g., X+Y).

[0037] The term "about" in reference to a numerical value x means, for example, x±10%.

[0038] The term "sclerostin" refers to human sclerostin as defined in SEQ ID NO: 155 (MQLPLALCLVCLLVHTAFRVVEGQGWQAFKNDATEIIPELGEYPEPPPELENKTMNRAENGGRPPHHPFETKDVSEYSCRELHFTRYVTDGPCRSAKPVTELVCSGQCGPARLLPNAIGRGKWWRPSGPDFRCIPDRYRAQRVQLLCPGGEAPRARKVRLVASCKCKRLTRFHNQSELKDFGTEAARPQKGRKPRPRARSAKANQAELENAY). Recombinant human sclerostin is available from R&D Systems (Minneapolis, Minn., USA; 2006 Catalog No. 1406-ST-025). Additionally, recombinant mouse sclerostin / SOST is commercially available from R&D Systems (Minneapolis, Minn., USA; 2006 Catalog No. 1589-ST-025). U.S. Patent Nos. 6,395,511 and 6,803,453, and U.S. Patent Publications 20040009535 and 20050106683 refer generally to anti-sclerostin antibodies.

[0039] The term "antibody" as used herein includes whole antibodies and any antigen-binding fragments (i.e., "antigen-binding portions") thereof or single chains. A naturally occurring "antibody" is a glycoprotein comprising at least two heavy (H) chains and two light (L) chains interconnected by disulfide bonds. Each heavy chain comprises a heavy chain variable region (abbreviated herein as VH) and a heavy chain constant region. The heavy chain constant region comprises three domains, CH1, CH2, and CH3. Each light chain comprises a light chain variable region (abbreviated herein as VL) and a light chain constant region. The light chain constant region comprises one domain, CL. The VH and VL regions can be further subdivided into regions of hypervariability, termed complementarity determining regions (CDRs), with more conserved regions in between, termed framework regions (FRs). Each VH and VL consists of three CDRs and four FRs, arranged from the amino terminus to the carboxy terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. The variable regions of the heavy and light chains contain a binding domain that interacts with an antigen. The constant region of the antibody may mediate the binding of the immunoglobulin to host tissues or factors, including various cells of the immune system (e.g., effector cells) and the first component (C1q) of the classical complement system. In one embodiment, reference to an antibody herein includes isolated monoclonal antibodies, human monoclonal antibodies, and humanized monoclonal antibodies.

[0040] As used herein, the term "antigen-binding portion" of an antibody refers to a full-length or one or more fragments of an antibody that retains the ability to specifically bind to an antigen (e.g., sclerostin). It has been shown that the antigen-binding function of an antibody can be performed by a fragment of a full-length antibody. Examples of binding fragments encompassed by the term "antigen-binding portion" of an antibody include Fab fragments, i.e., a monovalent fragment consisting of the VL, VH, CL, and CH1 domains, F(ab)2 fragments, i.e., a bivalent fragment comprising two Fab fragments linked by a disulfide bridge at the hinge region, Fd fragments consisting of the VH and CH1 domains, Fv fragments consisting of the VL and VH domains of a single arm of an antibody, dAb fragments consisting of the VH domain (Ward et al., 1989 Nature 341:544-546), and isolated complementarity determining regions (CDRs).

[0041] Furthermore, although the two domains of the Fv fragment, VL and VH, are encoded by separate genes, they can be joined using recombinant methods with a synthetic linker that allows them to be produced as a single protein chain (known as single-chain Fv (scFv); see, e.g., Bird et al., 1988 Science 242:423-426, and Huston et al., 1988, Proc. Natl. Acad. Sci. 85:5879-5883) in which the VL and VH regions pair to form a monovalent molecule. Such single-chain antibodies are also intended to be encompassed by the term "antigen-binding portion" of an antibody. These antibody fragments are obtained using conventional techniques known to those of skill in the art, and the fragments are screened for utility in the same manner as intact antibodies.

[0042] As used herein, an "isolated antibody" refers to an antibody that is substantially free of other antibodies having different antigenic specificities (e.g., an isolated antibody that specifically binds to sclerostin is substantially free of antibodies that specifically bind to antigens other than sclerostin). However, an isolated antibody that specifically binds to sclerostin may have cross-reactivity to other antigens, such as sclerostin molecules from other species. Additionally, an isolated antibody may be substantially free of other cellular material and / or chemicals. In one embodiment, references herein to an antibody refer to an isolated antibody.

[0043] The terms "monoclonal antibody" or "monoclonal antibody composition" as used herein refer to a preparation of antibody molecules of single molecular composition. A monoclonal antibody composition displays a single binding specificity and affinity for a particular epitope.

[0044] As used herein, the term "human antibody" is intended to include antibodies having variable regions in which both the framework and CDR regions are derived from sequences of human origin. Furthermore, when a human antibody comprises a constant region, the constant region is also derived from such a human sequence, for example, an antibody comprising a consensus framework sequence derived from a human framework sequence described in Knappik et al. (2000.J Mol Biol 296,57-86), either from a human germline sequence or a variant of a human germline sequence.

[0045] Human antibodies may include amino acid residues not encoded by human sequences (e.g., mutations introduced by random or site-specific mutagenesis in vitro or by somatic mutation in vivo). However, as used herein, the term "human antibody" is not intended to include antibodies in which CDR sequences derived from the germline of another mammalian species, such as a mouse, have been grafted onto human framework sequences.

[0046] The term "human monoclonal antibody" refers to antibodies displaying a single binding specificity having variable regions in which both the framework and CDR regions are derived from human sequences. In one embodiment, human monoclonal antibodies are produced by a hybridoma comprising a B cell obtained from a transgenic non-human animal, e.g., a transgenic mouse, whose genome comprises human heavy chain and light chain transgenes, fused to an immortalized cell.

[0047] As used herein, the term "recombinant human antibody" includes all human antibodies prepared, expressed, created, or isolated by recombinant means, such as antibodies isolated from transgenic or transchromosomic animals (e.g., mice) of human immunoglobulin genes or hybridomas prepared therefrom, antibodies isolated from host cells, e.g., transfectomas, transformed to express human antibodies, antibodies isolated from recombinant combinatorial human antibody libraries, and antibodies prepared, expressed, created, or isolated by any other means including splicing all or part of the sequence of a human immunoglobulin gene to other DNA sequences. Such recombinant human antibodies have variable regions in which the framework and CDR regions are derived from human germline immunoglobulin sequences. However, in certain embodiments, such recombinant human antibodies may be subjected to in vitro mutagenesis (or, in the case of animals transgenic for human Ig sequences, in vivo somatic mutagenesis) such that the amino acid sequences of the VH and VL regions of the recombinant antibodies, while derived from and related to human germline VH and VL sequences, are sequences that may not naturally occur within the human antibody germline repertoire in vivo.

[0048] In one embodiment, as used herein, an antibody that binds sclerostin (e.g., an anti-sclerostin antibody) means that it specifically binds to a sclerostin polypeptide. "Specifically binds to a sclerostin polypeptide" refers to an antibody that specifically binds to a sclerostin polypeptide at a concentration of at least 1×10 -8 M or less, 1×10 -9 M or less, or 1×10-10 K below M D As used herein, the term "K" refers to an antibody that binds to a sclerostin polypeptide at D " is intended to refer to the dissociation constant, which is K a K for d The ratio of (i.e., K d / K a ) and expressed as molar concentration (M). D Values ​​can be determined using methods well established in the art. D Methods for determining are by using surface plasmon resonance or by using a biosensor system such as a Biacore® system.

[0049] Standard assays for evaluating the binding ability of antibodies to various species of sclerostin are known in the art, including, for example, ELISA, Western blot, and RIA.Suitable assays are described in detail in WO2009 / 047356.The binding kinetics (e.g., binding affinity) of antibodies can also be evaluated by standard assays known in the art, such as Biacore analysis.The assays for evaluating the effect of antibodies on the functional properties of sclerostin (e.g., receptor binding, prevention or improvement of osteolysis) are described in more detail in WO2009 / 047356.

[0050] As used herein, the percentage of identity between two sequences is a function of the number of identical positions shared by the sequences, taking into account the number of gaps that need to be introduced for optimal alignment of the two sequences and the length of each gap (i.e., % identity = number of identical positions / total number of positions x 100). As described in the non-limiting examples below, the comparison of sequences and determination of the percentage of identity between two sequences can be accomplished using a mathematical algorithm.

[0051] The percentage of identity between two amino acid sequences can be determined using the algorithm of E. Meyers and W. Miller (Comput. Appl. Biosci., 4:11-17, 1988) as incorporated into the ALIGN program (version 2.0) using a PAM120 weighted residue table, a gap length penalty of 12, and a gap penalty of 4. Additionally, the percentage of identity between two amino acid sequences can be determined using the Needleman and Wunsch (J. Mol. Biol. 48:444-453, 1970) algorithm as incorporated into the GAP program of the GCG software package (available at www.gcg.com) using either a Blossom62 matrix or a PAM250 matrix, and gap weights of 16, 14, 12, 10, 8, 6, or 4, and length weights of 1, 2, 3, 4, 5, or 6.

[0052] Additionally or alternatively, the protein sequences of the present invention can further be used as a "query sequence" to perform searches against public databases, for example to identify related sequences. Such searches can be performed using the BLASTX program (version 2.0) of Altschul et al., 1990 J. Mol. Biol. 215:403-10. BLAST protein searches can be performed using the BLASTX program, score=50, wordlength=3, to obtain amino acid sequences homologous to the antibody molecules of the present invention. To obtain gapped alignments for comparison purposes, Gapped BLAST can be utilized as described in Altschul et al., 1997 Nucleic Acids Res. 25(17):3389-3402. When utilizing BLAST and Gapped BLAST programs, the default parameters of the respective programs (e.g., BLASTX and BLASTN) can be used. See www.ncbi.nlm.nih.gov.

[0053] The terms "cross-blocking", "cross-blocked" and "cross-blocking" are used interchangeably herein to refer to the ability of an antibody or other binding agent to interfere with the binding of another antibody or binding agent to sclerostin in a standard competitive binding assay. The ability or extent to which an antibody or other binding agent can interfere with the binding of another antibody or binding molecule to sclerostin, and therefore whether it is said to be cross-blocking according to the present invention, can be determined using a standard competitive binding assay. One suitable assay involves the use of Biacore technology (e.g., by using a Biacore3000 instrument (Biacore, Uppsala, Sweden)), which can measure the degree of interaction using surface plasmon resonance technology. Another assay for measuring cross-blocking uses an ELISA-based approach. Further details regarding both methods are described in WO2009 / 047356, specifically incorporated herein by reference.

[0054] As used herein, "monthly" administration, or "monthly" administration, refers to administration of a dose of anti-sclerostin antibody once a month for a given period of consecutive months.

[0055] Various aspects of the invention are described in further detail in the following subsections.

[0056] osteogenesis imperfecta The results of the Examples surprisingly show that anti-sclerostin therapy continues to increase BMD in OI patients for a long period of time after the effects on bone turnover biomarkers have worn off or attenuated. Thus, anti-sclerostin antibody therapy is surprisingly suitable for the long-term or chronic treatment of bone-related genetic disorders such as OI that result in weakened bones or increased fracture incidence.

[0057] In one aspect, the present invention relates to a method of treating a patient having a bone-related genetic disease, such as OI. As used herein, the term "patient" means a human patient.

[0058] In one aspect, the invention provides the use of an anti-sclerostin antibody for the manufacture of a medicament for the treatment of osteogenesis imperfecta. All other aspects / embodiments described herein apply equally to this particular aspect of the invention.

[0059] In another aspect, the invention provides an anti-sclerostin antibody for use in treating osteogenesis imperfecta. All other aspects / embodiments described herein apply equally to this particular aspect of the invention.

[0060] The Examples report trials of anti-sclerostin antibody therapy in OI patients, showing that OI patients respond to monthly anti-sclerostin antibody therapy. Thus, in one embodiment, the methods and uses described herein are for treating osteogenesis imperfecta (OI) using the anti-sclerostin antibodies described herein.

[0061] OI is classified according to genetics and disease severity and can be classified as type I OI, type II OI, type III OI, type IV OI, or type V OI according to the classification of Van Dijk and Sillence (2014, Am J Med Genet Part A 164A:1470-1481 and Van Dijk and Sillence, 2014, Am J Med Genet Part A 167A:1178; which are incorporated herein by reference in their entirety). The classification relies on a combination of clinical evaluation / diagnosis, biochemical analysis, and molecular genetic testing and is routine for those skilled in the art. The nomenclature / classification of OI used herein is that proposed by Van Dijk and Sillence, as referenced in the publications mentioned above. Study participants suffered from type I, type III, or type IV OI, and all OI types responded to setrusumab therapy. Thus, in certain embodiments, the bone-related disease is type I OI, type III OI, or type IV OI.

[0062] In 80%-90% of people affected by OI, OI is caused by mutations in the COL1A1 and COL1A2 genes (17q21.33 and 7q22.3, respectively), which code for the α1 and α2 chains of type I collagen. A comprehensive database of over 1,000 known mutations has been published with genotype-phenotype correlations (oi.gene.le.ac.uk / home.php; accessed 29 September 2021). Mutations in other genes, such as CRTAP, LEPRE1, or PPIB, are also known. Molecular genetic testing for mutations in the COL1A1 and COL1A2 genes is known and routine to those skilled in the art. As an example, Korkko et al. (1998) described PCR amplification of the COL1A1 and COL1A2 genes followed by mutation scanning by conformational sensitive gel electrophoresis (CSGE) (Am. J. Hum. Genet. 62:98-110, 1998). van Dijk et al. (2010) described COL1A1 mutation detection by multiplex ligation-dependent probe amplification (MLPA) (Genet Med 12(11):736-741). More recently, Arvai, K. et al. (2016) described next-generation sequencing (Sci. Rep. 6, 28417). These references are incorporated herein by reference.

[0063] Thus, in one embodiment, the methods and uses described herein are for treating patients exhibiting a deficiency of collagen I, e.g., OI types I to IV. As a result, the normal structure of bone, consisting of collagen fibrils and hydroxyapatite crystals, is altered, resulting in brittleness. In one embodiment, the methods and uses described herein are for treating human OI patients characterized by one or more mutations in COL1A1 and / or COL1A2.

[0064] In one embodiment, the methods and uses described herein are for treating type I, III, and / or IV OI. In one embodiment, type I, III, and IV OI are confirmed by DNA testing, i.e., detection of COL1A1 / COL1A2 mutations. Thus, in one embodiment, the methods and uses described herein are for treating type I, III, and / or IV OI characterized by one or more mutations in COL1A1 and / or COL1A2.

[0065] In some embodiments, the anti-sclerostin antibody methods and uses are for treating mild to moderate forms of OI. In other embodiments of the anti-sclerostin antibody methods and uses, the patient being treated has type I OI, type II OI, type III OI, or type IV OI.

[0066] In certain embodiments, the invention provides a method for treating OI in a human patient, comprising administering to the human patient a therapeutically effective amount of setrusumab at a dose of 300-1500 mg each month for a period of at least 30 consecutive months and up to 18 years.

[0067] Pediatric Use In some embodiments of the anti-sclerostin antibody methods and uses, the OI patient is an adult patient aged 18 years or older. In yet other embodiments of the anti-sclerostin antibody methods and uses, the OI patient is a pediatric patient. Pediatric patients, as defined herein, include children aged 0-17 years, such as 2-17 years, 3-17 years, 4-17 years, or 5-17 years.

[0068] Because the rate of drug clearance relative to body weight or body surface area is higher in children (especially infants) than in adults, pediatric doses, expressed, for example, in mg / kg, generally need to be higher than the equivalent adult dose to ensure that children receive a high enough dose of the drug to be effective. The appropriate pediatric dose can be estimated from the 0.7 power of the ratio of child to adult body weight, as shown in Equation 1 (Pediatric Pharmacology - Therapeutic Principles in Practice, 2013). nd Eds.,Yaffe and Aranda). Formula: Pediatric dose conversion

number

[0069] Applying this formula, a dose of 20 mg / kg in an adult patient (70 kg) is equivalent to a dose of 40 mg / kg in a 7 kg child (approximately 6 months of age). Thus, the smallest patients may require doses of up to 40 mg / kg to achieve similar therapeutic results as adults receiving 20 mg / kg of setrusumab. Thus, if the mg / kg dose in adults is higher, pediatric patients will require even higher doses. Thus, in one embodiment, the patient is 0-17 years old and the anti-sclerostin antibody is administered at a dose of 20-50 mg / kg each month. In a particular embodiment, the patient is 0-17 years old and the anti-sclerostin antibody is administered at a dose of 20-40 mg / kg each month.

[0070] Thus, in certain embodiments, the invention provides a method for treating OI in a human patient aged 0-17 years, comprising administering to the human patient a therapeutically effective amount of an anti-sclerostin antibody at a dose of 20-50 mg / kg each month for a period of at least 13 consecutive months, e.g., at least 18 consecutive months, at least 24 consecutive months, or at least 30 consecutive months, up to 18 years.

[0071] Thus, in certain embodiments, the invention provides a method for treating OI in a human patient aged 0-17 years, comprising administering to the human patient a therapeutically effective amount of an anti-sclerostin antibody at a dose of 20-50 mg / kg each month for a period of at least 13 consecutive months, e.g., at least 18 consecutive months, at least 24 consecutive months, or at least 30 consecutive months, up to 18 years.

[0072] Throughout this specification, numerical ranges are provided for specific amounts, such as doses of anti-sclerostin antibodies. These ranges should be understood to include endpoints and all subranges therein, including each integer within and between the disclosed ranges. Thus, the range "20-50" includes all possible ranges therein (e.g., 21-49, 22-48, 23-47, etc.), as well as individual integers between 20 and 50 (e.g., 20, 21, 22, 23, 24, etc.). When ranges are provided in the form of fractions, percentages, decimals, etc., such ranges similarly include all possible subranges therein, and individual fractions, percentages, decimals, etc., within and between the disclosed ranges. For example, the range "0.1-1.0" includes all possible ranges therein (e.g., 0.2-0.9, etc.), as well as individual tenths of decimals between 0.1 and 1.0 (e.g., 0.1, 0.2, 0.3, 0.4, etc.). Thus, doses of 20 to 50 mg / kg of anti-sclerostin antibody include doses of 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50 mg / kg of anti-sclerostin antibody.

[0073] Dosage regimen The present invention is based on the discovery that anti-sclerostin antibody therapy can be used long-term, even though bone turnover biomarkers decline soon after the start of treatment.Thus, the present invention relates to monthly administration of anti-sclerostin antibody for at least 13 months.The dosage regimen is adjusted to provide the optimal desired response (e.g., therapeutic response).For example, the dosage may be increased or decreased depending on the exigencies of the treatment situation.

[0074] For administration of anti-sclerostin antibodies, dosages range from about 8 milligrams of the antibody per kilogram of patient body weight (referred to throughout this application as "mg / kg") to 50 mg / kg, more typically about 20-40 mg / kg. For example, dosages can be about 20 mg / kg body weight, about 30 mg / kg body weight, about 40 mg / kg body weight, or about 50 mg / kg body weight. In another embodiment, the monthly dosage is about 20-30 mg / kg.

[0075] In one embodiment, the anti-sclerostin antibody is administered at a dose of 20 mg per kg of patient body weight, or 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40 mg / kg.

[0076] Table 2 reports that the weights of the patients in this example study ranged from 19.9 to 120.7 kg. Thus, in a related embodiment, the anti-sclerostin antibody is administered at a dose of 150 to 3000 mg, for example 150 to 2500 mg. In one embodiment, the anti-sclerostin antibody is administered at a dose of 200 to 2500 mg, 400 to 2500 mg, 150 to 2000 mg, 200 to 2000 mg, 400 to 2000 mg, 150 to 1500 mg, 200 to 1500 mg, 400 to 1500 mg. In one embodiment, the anti-sclerostin antibody is administered at a dose of 200 to 2500 mg. In one embodiment, the anti-sclerostin antibody is administered at a dose of 400 to 2500 mg. In one embodiment, the anti-sclerostin antibody is administered at a dose of 150 to 2000 mg. In one embodiment, the anti-sclerostin antibody is administered at a dose of 200-2000 mg. In one embodiment, the anti-sclerostin antibody is administered at a dose of 400-2000 mg. In one embodiment, the anti-sclerostin antibody is administered at a dose of 150-1500 mg. In one embodiment, the anti-sclerostin antibody is administered at a dose of 200-1500 mg. In one embodiment, the anti-sclerostin antibody is administered at a dose of 400-1500 mg.

[0077] In one embodiment, the anti-sclerostin antibody is administered at a dose of 200 mg, or 250, 300, 350, 400, 450, 500, 550, 600, 650, 700, 750, 800, 850, 900, 950, 1000, 1050, 1100, 1150, 1200, 1250, 1300, 1350, 1400, 1450, 1500, 1550, 1600, 1650, 1700, 1750, 1800, 1850, 1900, 1950, 2000, 2050, 2100, 2150, 2200, 2250, 2300, 2350, 2400, or 2450 mg.

[0078] The present invention relates to the surprising suitability of anti-sclerostin antibodies for long-term treatment. Thus, according to the methods of the present invention, the anti-sclerostin antibody is administered monthly for at least 13 consecutive months. In some embodiments, the anti-sclerostin antibody is administered monthly for a period of at least 18 consecutive months. In some embodiments, the anti-sclerostin antibody is administered monthly for a period of at least 24 consecutive months. In some embodiments, the anti-sclerostin antibody is administered monthly for a period of at least 30 consecutive months. In some embodiments, the anti-sclerostin antibody is administered monthly for a period of at least 36 consecutive months.

[0079] In some embodiments, the anti-sclerostin antibody is administered monthly for a period of up to 18 years, meaning that the period during which the anti-sclerostin antibody is administered each month does not last more than 18 years. Thus, in one embodiment, the anti-sclerostin antibody is administered monthly for a period of at least 13 consecutive months and up to 18 years. In a related embodiment, the anti-sclerostin antibody is administered monthly for a period of at least 18 consecutive months and up to 18 years. In a related embodiment, the anti-sclerostin antibody is administered monthly for a period of at least 24 consecutive months and up to 18 years. In a related embodiment, the anti-sclerostin antibody is administered monthly for a period of at least 30 consecutive months and up to 18 years. In a related embodiment, the anti-sclerostin antibody is administered monthly for a period of at least 36 consecutive months and up to 18 years.

[0080] An exemplary treatment regime involves administration of multiple doses (which may be the same dose) ranging from about 150-3000 mg on a monthly dosing schedule for a period of at least 13 consecutive months and up to 18 years. In some embodiments, treatment involves monthly dosing for at least 18 consecutive months. In some embodiments, treatment involves monthly dosing for at least 24 consecutive months. In some embodiments, treatment involves monthly dosing for at least 30 consecutive months. In some embodiments, treatment involves monthly dosing for at least 36 consecutive months.

[0081] In certain embodiments, the anti-sclerostin antibody is administered at a dose of 150-2500 mg monthly for a period of at least 30 consecutive months and up to 18 years.

[0082] Another exemplary treatment regime involves administration of multiple doses (which may be the same dose) ranging from about 150-3000 mg under a monthly dosing schedule for at least 13 consecutive months until a treatment goal is achieved or reached in the patient. The treatment goal is achieved or reached after a certain number of doses. The treatment goal is complete normalization of bone mineral density, partial normalization of bone mineral density, or reduced incidence of fractures. Thus, in one embodiment, monthly administration of an anti-sclerostin antibody increases bone mineral density (BMD) at the lumbar spine by 5% or more after 12 consecutive months of treatment.

[0083] In another embodiment, the invention provides an anti-sclerostin antibody for use in treating OI, wherein the anti-sclerostin antibody reduces the fracture rate in a patient / patient population compared to a control patient / patient population. Preferably, the anti-sclerostin antibody reduces the fracture rate by at least 10, 20, 30, 35, 40, 50, 60, 70, 80, or 90 percent. In one embodiment, the anti-sclerostin antibody reduces the fracture rate by at least 30 percent. In one embodiment, the fracture is defined as a peripheral or vertebral fracture (including all major fractures, minor fractures, and clinical fractures of the spine, but excluding fractures detected only by examination without clinical symptoms) confirmed by radiological examination(s). In one embodiment, the fracture rate belongs to a patient population. The patient population and the control patient population are preferably of a size that allows for a statistically significant comparison.

[0084] The anti-sclerostin antibody is administered intravenously. In certain embodiments, administration is performed intravenously by infusion.

[0085] Measurement of targets is known in the art. For example, bone mineral density (BMD) may be measured by dual energy x-ray absorptiometry (DXA), single energy x-ray absorptiometry (SXA), quantitative computed tomography (CT), ultrasound, and high resolution peripheral quantitative computed tomography (HR-pQCT). DXA is an x-ray technique that has become the standard in the art for measuring bone density. It can be used to measure any skeletal site, but clinical decisions are usually made at the lumbar spine and hips. Portable DXA machines have been developed to measure the heel (calcaneus), forearm (radius and ulna), or finger (phalanges), and DXA can also be used to measure body composition. As a result, it has become standard practice to relate results to "normal" values ​​using T-scores, which compare an individual's results to those of a race- and sex-matched younger population. Alternatively, Z-scores compare an individual's results to those of an age-matched, race- and sex-matched population. Thus, for example, a 60-year-old woman with a Z score of −1 (1 SD below the mean for her age) could have a T score of −2.5 (2.5 SD below the mean for a younger control group).

[0086] Radial bone strength may be measured by micro-finite element analysis (microFEA).

[0087] In some embodiments, the actual dosage level of the anti-sclerostin antibody may be varied to provide an amount of anti-sclerostin antibody effective to achieve the desired therapeutic response for a particular patient, composition, and mode of administration without being toxic to the patient. The selected dosage level will depend on a variety of pharmacokinetic factors, including the particular composition used, the route of administration, the time of administration, the excretion rate of the particular anti-sclerostin antibody being used, the duration of treatment, other drugs, compounds, and / or substances used in combination with the particular composition used, the age, sex, weight, condition, general health and medical history of the patient being treated, and similar factors well known in the medical arts.

[0088] A "therapeutically effective amount" of an anti-sclerostin antibody may result in a decrease in the severity of disease symptoms, an increase in the frequency and duration of disease symptom-free periods, or prevention of functional impairment or disability due to disease affliction. Thus, in one embodiment, monthly administration of an anti-sclerostin antibody results in an increase in bone mineral density (BMD) of the lumbar spine of 5% or more after 12 months of treatment.

[0089] Specific Dosing Regimens In another aspect, the invention provides a method of treating osteogenesis imperfecta (OI) in a human patient comprising administering to the human patient in need of treatment a therapeutically effective amount of an anti-sclerostin antibody, which involves administering a first dose during an initial administration period, followed by maintenance doses. In some embodiments, the anti-sclerostin antibody is administered monthly for an initial administration period of 12 months or more, followed by periodic maintenance doses.

[0090] In some embodiments, the maintenance dose immediately follows the initial dosing period, without a drug holiday between the initial dosing period and the maintenance dosing period. In some embodiments, the maintenance dose comprises a different dosing regimen than the dosing regimen administered during the initial dosing period, i.e., the maintenance dose comprises administration of the anti-sclerostin antibody at a different frequency and / or dose than that administered during the initial dosing period.

[0091] In some embodiments, the anti-sclerostin antibody is administered at a dose of 20-50 mg / kg, 20-40 mg / kg, or 20 mg / kg during the initial administration period. In certain embodiments, the anti-sclerostin antibody is administered at a dose of 20 mg / kg monthly during the initial administration period.

[0092] A maintenance dose can be a dose of anti-sclerostin antibody administered monthly, about every 2 months, about every 3 months, about every 4 months, about every 6 months, or about every 12 months. The maintenance dose can be the same amount administered during the initial administration period (e.g., about 20 mg / kg) or can be a lower amount administered during the initial administration period (e.g., less than 20 mg / kg).

[0093] In some embodiments, the maintenance dose is administered periodically for a period of at least 2, at least 4, at least 6, at least 8, at least 10, or at least 12 consecutive months after the initial administration period. In some embodiments, the maintenance dose is administered for a period of at least 18 consecutive months after the initial administration period. In some embodiments, the maintenance dose is administered for a period of at least 24 consecutive months after the initial administration period. In some embodiments, the maintenance dose is administered for a period of at least 30 consecutive months after the initial administration period. In some embodiments, the maintenance dose is administered for a period of at least 36 consecutive months after the initial administration period. In some embodiments, the maintenance dose is administered for a period of up to 18 years after the initial administration period.

[0094] Thus, in one embodiment, the anti-sclerostin antibody is administered monthly for a period of 12 months or more, followed by bimonthly administration for up to 18 years, for example. In certain embodiments, the anti-sclerostin antibody is administered monthly at a dose of 20 mg / kg during an initial administration period, followed by a maintenance dose of 20 mg / kg every other month, every 3 months, every 4 months, every 6 months, or every 12 months. In certain embodiments, the anti-sclerostin antibody is administered monthly at a dose of 20 mg / kg during an initial administration period, followed by a maintenance dose of 20 mg / kg every other month. In another embodiment, the anti-sclerostin antibody is administered monthly at a dose of about 20 mg / kg for 12 months or more, followed by a monthly dose of less than 20 mg / kg for up to 18 years, for example. In certain embodiments, the anti-sclerostin antibody is administered monthly at a dose of 20 mg / kg during an initial administration period, followed by a maintenance dose of less than 20 mg / kg every month. Maintenance doses of anti-sclerostin antibodies below 20 mg / kg are: 2-20 mg / kg, 5-20 mg / kg, 8-20 mg / kg, 10-20 mg / kg, 15-20 mg / kg, 2-19 mg / kg, 5-19 mg / kg, 8-19 mg / kg, 10-19 mg / kg, 15-19 mg / kg, 2-15 mg / kg, 5-15 mg / kg, 8-15 mg / kg, 10-15 mg / kg, 2-10 mg / kg, 5-10 mg / kg, 8-10 mg / kg, less than 19 mg / kg or about 19 mg / kg, less than 15 mg / kg or about 15 mg / kg, less than 10 mg / kg or about 10 mg / kg, less than 8 mg / kg or about 8 mg / kg, less than 2 mg / kg or about 2 mg / kg, about 2 mg / kg, about 8 mg / kg, about 10 mg / kg, about 11 mg / kg, about 12 mg / kg, about 13 mg / kg, about 14 mg / kg, about 15 mg / kg, about 16 mg / kg, about 17 mg / kg, about 18 mg / kg, about 19 mg / kg of the anti-sclerostin antibody.

[0095] The maintenance dose may be a dose sufficient to maintain BMD and / or stable bone turnover biomarker levels in the patient after the initial administration period. In some embodiments, the maintenance dose is a dose sufficient to maintain an increase (or rate of increase) in BMD in the patient after the initial administration period. The maintenance dose may be lower than the dose administered to the patient during the initial administration period. For example, the maintenance dose may be less than about 50 mg / kg of anti-sclerostin antibody, less than about 40 mg / kg of anti-sclerostin antibody, less than about 30 mg / kg of anti-sclerostin antibody, less than about 20 mg / kg of anti-sclerostin antibody, less than about 10 mg / kg of anti-sclerostin antibody, less than about 8 mg / kg of anti-sclerostin antibody, or less than about 2 mg / kg of anti-sclerostin antibody. In some embodiments, the maintenance dose is about 2 mg / kg of anti-sclerostin antibody, about 8 mg / kg of anti-sclerostin antibody, about 10 mg / kg of anti-sclerostin antibody, about 11 mg / kg of anti-sclerostin antibody, about 12 mg / kg of anti-sclerostin antibody, about 13 mg / kg of anti-sclerostin antibody, about 14 mg / kg of anti-sclerostin antibody, about 15 mg / kg of anti-sclerostin antibody, about 16 mg / kg of anti-sclerostin antibody, about 17 mg / kg of anti-sclerostin antibody, about 18 mg / kg of anti-sclerostin antibody, about 19 mg / kg of anti-sclerostin antibody, or about 20 mg / kg of anti-sclerostin antibody.

[0096] As noted above, ranges as provided herein for doses of anti-sclerostin antibodies should be understood to include endpoints and all subranges therein, including each integer within and between the disclosed ranges. Thus, the range "20-50" includes all possible ranges therein (e.g., 21-49, 22-48, 23-47, etc.), as well as individual integers between 20 and 50 (e.g., 20, 21, 22, 23, 24, etc.). Thus, a dose of 20-50 mg / kg of anti-sclerostin antibody includes doses of 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, and 50 mg / kg of anti-sclerostin antibody. Doses of anti-sclerostin antibody less than 20 mg / kg include doses of anti-sclerostin antibody of 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, 2, and 1 mg / kg.

[0097] Anti-sclerostin antibodies The present invention relates to the treatment of bone-related diseases with anti-sclerostin antibodies. In some embodiments, the anti-sclerostin antibody comprises a VH comprising HCDR1, HCDR2, and HCDR3 of the VH sequence of SEQ ID NO:70, and a VL comprising LCDR1, LCDR2, and LCDR3 of the VL sequence of SEQ ID NO:81.

[0098] In one embodiment, the anti-sclerostin antibody comprises (a) an HCDR1 having the amino acid sequence of SEQ ID NO: 4 (GFTFRSHWLS), (b) an HCDR2 having the amino acid sequence of SEQ ID NO: 15 (WVSNINYDGSSTYYADSVKG), (c) an HCDR3 having the amino acid sequence of SEQ ID NO: 26 (DTYLHFDY), (d) an LCDR1 having the amino acid sequence of SEQ ID NO: 37 (TGTSSDVGDINDVS), (e) an LCDR2 having the amino acid sequence of SEQ ID NO: 48 (LMIYDVNNRPS), and (f) an LCDR3 having the amino acid sequence of SEQ ID NO: 59 (QSYAGSYLSE).

[0099] The CDRs within a VH or VL sequence may be described by a variety of classification and numbering systems. Thus, the CDRs may be referred to by IMGT, Kabat, Chothia, AbM, Contact, a combination of these systems, or another system. For example, Kabat (Kabat, EA, et al., 1991 Sequences of Proteins of Immunological Interest, Fifth Edition, USDepartment of Health and Human Services, NIH Publication No. 91-3242); Chothia (Chothia et al. (1987) J Mol Biol 196:901-17); IMGT (Leffanc et al. (2003) Dev Comp Immunol 27:55-77); AbM (Martin and Thornton J Bmol Biol 263:800-15, 1996); and Contact (MacCallum, RM, Martin, ACR and Thornton, JT "Antibody-antigen interactions: Contact analysis and binding site topography" J. Mol. Biol. 262:732-745). The overlaps and differences between these classification systems have been described (see, e.g., Lefranc et al. (2003) Dev Comp Immunol 27:55-77; Honegger and Pluckthun, J Mol Biol (2001) 309:657-70; International ImMunoGeneTics (IMGT) database; web resource, www.imgt.org). Those skilled in the art can use methods in the art to identify CDRs within VH and VL sequences. For example, CDRs can be described using available programs such as abYsis (www.abysis.org; Swindells et al. J Mol Biol. 2017 Feb 3; 429(3):356-64).

[0100] Table 1 shows the amino acid sequences of the CDR sequences of setrusumab (an antibody having a VH of SEQ ID NO: 70 and a VL of SEQ ID NO: 81) defined according to the Kabat, Chothia, IMGT, AbM, and Contact systems. [Table 1]

[0101] In one embodiment, the CDRs of setrusumab are as described by Kabat. Thus, in one embodiment, the anti-sclerostin antibody comprises (a) an HCDR1 having the amino acid sequence of SEQ ID NO: 178, (b) an HCDR2 having the amino acid sequence of SEQ ID NO: 179, (c) an HCDR3 having the amino acid sequence of SEQ ID NO: 26, (d) an LCDR1 having the amino acid sequence of SEQ ID NO: 37, (e) an LCDR2 having the amino acid sequence of SEQ ID NO: 180, and (f) an LCDR3 having the amino acid sequence of SEQ ID NO: 181.

[0102] In another embodiment, the CDRs of Setrusumab are described by Chothia. Thus, in one embodiment, an anti-sclerostin antibody comprises (a) an HCDR1 having the amino acid sequence of SEQ ID NO: 182, (b) an HCDR2 having the amino acid sequence of SEQ ID NO: 183, (c) an HCDR3 having the amino acid sequence of SEQ ID NO: 26, (d) an LCDR1 having the amino acid sequence of SEQ ID NO: 37, (e) an LCDR2 having the amino acid sequence of SEQ ID NO: 180, and (f) an LCDR3 having the amino acid sequence of SEQ ID NO: 181.

[0103] In another embodiment, the setrusumab CDRs of the anti-sclerostin antibody are defined to encompass the CDRs defined by both Kabat and Chothia. Thus, each CDR sequence spans the sequence from the most N-terminal residue of the CDR defined by Kabat and Chothia to the most C-terminal residue of the CDR defined by Kabat and Chothia. Thus, in one embodiment, the anti-sclerostin antibody comprises (a) an HCDR1 having the amino acid sequence of SEQ ID NO:4, (b) an HCDR2 having the amino acid sequence of SEQ ID NO:179, (c) an HCDR3 having the amino acid sequence of SEQ ID NO:26, (d) an LCDR1 having the amino acid sequence of SEQ ID NO:37, (e) an LCDR2 having the amino acid sequence of SEQ ID NO:180, and (f) an LCDR3 having the amino acid sequence of SEQ ID NO:181.

[0104] In one embodiment, the CDRs of setrusumab are described by IMGT. Thus, in one embodiment, an anti-sclerostin antibody comprises (a) an HCDR1 having the amino acid sequence of SEQ ID NO: 184, (b) an HCDR2 having the amino acid sequence of SEQ ID NO: 185, (c) an HCDR3 having the amino acid sequence of SEQ ID NO: 186, (d) an LCDR1 having the amino acid sequence of SEQ ID NO: 187, (e) an LCDR2 having the amino acid sequence of SEQ ID NO: 188, and (f) an LCDR3 having the amino acid sequence of SEQ ID NO: 181.

[0105] In one embodiment, the CDRs of setrusumab are described by AbM. Thus, in one embodiment, an anti-sclerostin antibody comprises (a) an HCDR1 having the amino acid sequence of SEQ ID NO:4, (b) an HCDR2 having the amino acid sequence of SEQ ID NO:189, (c) an HCDR3 having the amino acid sequence of SEQ ID NO:26, (d) an LCDR1 having the amino acid sequence of SEQ ID NO:37, (e) an LCDR2 having the amino acid sequence of SEQ ID NO:180, and (f) an LCDR3 having the amino acid sequence of SEQ ID NO:181.

[0106] In one embodiment, the CDRs of setrusumab are described by Contact. Thus, in one embodiment, an anti-sclerostin antibody comprises (a) an HCDR1 having the amino acid sequence of SEQ ID NO: 190, (b) an HCDR2 having the amino acid sequence of SEQ ID NO: 191, (c) an HCDR3 having the amino acid sequence of SEQ ID NO: 192, (d) an LCDR1 having the amino acid sequence of SEQ ID NO: 193, (e) an LCDR2 having the amino acid sequence of SEQ ID NO: 194, and (f) an LCDR3 having the amino acid sequence of SEQ ID NO: 59.

[0107] In certain embodiments, the anti-sclerostin antibody comprises a VH polypeptide amino acid sequence having at least 95 percent identity to the amino acid sequence of SEQ ID NO:70.

[0108] In certain embodiments, the anti-sclerostin antibody comprises a VL polypeptide amino acid sequence having at least 95 percent identity to the amino acid sequence of SEQ ID NO:81.

[0109] In certain embodiments, the anti-sclerostin antibody comprises a VH polypeptide amino acid sequence having at least 95 percent identity to the amino acid sequence of SEQ ID NO:70, and a VL polypeptide amino acid sequence having at least 95 percent identity to the amino acid sequence of SEQ ID NO:81.

[0110] In a specific embodiment, the anti-sclerostin antibody comprises a VH polypeptide amino acid sequence of SEQ ID NO:70, and a VL polypeptide amino acid sequence of SEQ ID NO:81.

[0111] In certain embodiments, the anti-sclerostin antibody is selected from the group consisting of SEQ ID NO: 114 (MAWVWTLPFLMAAAQSVQAQVQLVESGGGLVQPGGSLRLSCAASGFTFRSHWLSWVRQAPGKGLEWVSNINYDGSSTYYADSVKGRFTISRDNSKNTLYLQMNSLRAEDTAVYYCARDTYLHFDYWGQGTLVTVSSASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSNFGTQTYTCNVDHKPSNTKVDKTVERKCCVECPPCPAPPVAGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTFRVVSVLTVVHQDWLNGKEYKCKVSNKGLPAPIEKTISKTKGQPREPQVYTLPP SREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPMLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK), or the heavy chain polypeptide amino acid sequence of SEQ ID NO: 172, and the light chain polypeptide amino acid sequence of SEQ ID NO: 125 (MSVLTQVLALLLLWLTGTRCDIALTQPASVSGSPGQSITISCTGTSSDVGDINDVSWYQQHPGKAPKLMIYDVNNRPSGVSNRFSGSSKSGNTASLTISGLQAEDEADYYCQSYAGSYLSEVFGGGTKLTVLGQPKAAPSVTLFPPSSEELQANKATLVCLISDFYPGAVTVAWKADSSPVKAGVETTTPSKQSNNKYAASSYLSLTPEQWKSHRSYSCQVTHEGSTVEKTVAPTECS), or the light chain polypeptide amino acid sequence of SEQ ID NO: 173.

[0112] In one embodiment, the anti-sclerostin antibody of the invention is a monoclonal anti-sclerostin antibody. In one embodiment, the anti-sclerostin antibody of the invention is a human or humanized monoclonal anti-sclerostin antibody. Alternatively, the antibody can be, for example, a chimeric antibody.

[0113] In a preferred embodiment, the anti-sclerostin antibody is the Setrusumab antibody, which is a human anti-sclerostin monoclonal antibody. The VH and VL sequences of Setrusumab comprise the VH polypeptide amino acid sequence of SEQ ID NO: 70 and the VL polypeptide amino acid sequence of SEQ ID NO: 81. The heavy and light chain sequences of Setrusumab comprise the heavy chain polypeptide amino acid sequence of SEQ ID NO: 172 and the light chain polypeptide amino acid sequence of SEQ ID NO: 173.

[0114] Setrusumab VH sequence (SEQ ID NO:70): QVQLVESGGGLVQPGGSLRLSCAASGFTFRSHWLSWVRQAPGKGLEWVSNINYDGSSTYYADSVKGRFTISRDNSKNTLYLQMNSLRAEDTAVYYCARDTYLHFDYWGQGTLVTVSS

[0115] Setrusumab VL sequence (SEQ ID NO:81): DIALTQPASVGSPGQSITISCTGTSSDVGDINDVSWYQQHPGKAPKLMIYDVNNRPSGVSNRFSGSKSGNTASLTISGLQAEDEADYYCQSYAGSYLSEVFGGGTKLTVL

[0116] Setrusumab H chain sequence (SEQ ID NO: 172): QVQLVESGGGLVQPGGSLRLSCAASGFTFRSHWLSWVRQAPGKGLEWVSNINYDGSSTYYADSVKGRFTISRDNSKNTLYLQMNSLRAEDTAVYYCARDTYLHFDYWGQG TLVTVSSASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSNFGTQTYTCNVDHKPSNTKVDKTVERKCCV ECPPCPAPPVAGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTFRVVSVLTVVHQDWLNGKEYKCKVSNKGLPAPIEKTI SKTKGQPREPQVYTLPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPMLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

[0117] Setrusumab light chain sequence (SEQ ID NO: 173): DIALTQPASVGSPGQSITISCTGTSSDVGDINDVSWYQQHPGKAPKLMIYDVNNRPSGVSNRFSGSKSGNTASLTISGLQAEDEADYYCQSYAGSYLSEVFGGGTKL TVLGQPKAAPSVTLFPPSSEELQANKATLVCLISDFYPGAVTVAWKADSSPVKAGVETTTPSKQSNNKYAASSYLSLTPEQWKSHRSYSCQVTHEGSTVEKTVAPTECS

[0118] In a related embodiment, the anti-sclerostin antibody comprises a VH polypeptide amino acid sequence of SEQ ID NO: 70 and a VL polypeptide amino acid sequence of SEQ ID NO: 195 (DIALTQPASVSGSPGQSITISCTGTSSDVGDINDVSWYQQHPGKAPKLMIYDVNNRPSGVSNRFSGSKSGNTASLTISGLQAEDEADYYCQSYAGSYLSEVFGGGTKLTVLGQ). The VL polypeptide amino acid sequence of SEQ ID NO: 81 is described according to the Kabat system. The VL polypeptide amino acid sequence of 195 is another description of the VL domain, encompassing the sequence according to Kabat, but including two additional amino acids.

[0119] Further characteristics of anti-sclerostin antibodies for use in the present invention, such as setrusumab, are described in WO2009 / 047356, the disclosure, discussion, and data of which are incorporated herein by reference. By way of example only, the antibody may exhibit at least one of the following functional properties: the antibody blocks the inhibitory effect of sclerostin in a cell-based wnt signaling assay, the antibody blocks the inhibitory effect of sclerostin in a cell-based mineralization assay, the antibody blocks the inhibitory effect of sclerostin in a Smad1 phosphorylation assay, the antibody inhibits the binding of sclerostin to LRP-6, and the antibody increases bone formation and bone mass and density. As noted above, these properties are described in detail in WO2009 / 047356.

[0120] In some embodiments, the anti-sclerostin antibody comprises (a) a VH polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 198, and / or (b) a VL polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 199. In one embodiment, the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 198, and a VL polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 199. In some embodiments, the anti-sclerostin antibody comprises a heavy chain (HC) polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 196, and / or a light chain (LC) polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 197. In one embodiment, the anti-sclerostin antibody comprises a HC polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 196, and a LC polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 197.

[0121] In some embodiments, the anti-sclerostin antibody comprises (a) a VH polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 202, and / or (b) a VL polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 203. In one embodiment, the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 202, and a VL polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 203. In some embodiments, the anti-sclerostin antibody comprises a heavy chain (HC) polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 200, and / or a light chain (LC) polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence set forth in SEQ ID NO: 201. In one embodiment, the anti-sclerostin antibody comprises a HC polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 200, and a LC polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO: 201.

[0122] The polypeptide sequences of various anti-sclerostin antibodies are set forth below:

[0123] HC Polypeptide Sequence: EVQLVQSGAEVKKPGASVKVSCKASGYTFTDYNMHWVRQAPGQGLEWMGEINPNSGGAGYNQKFKGRVTMTTDTSTSTAYMELRSLRSDDTAVYYCARLGYDDIYDDWYFDVWGQGTTVTVSSASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSNFGTQTYTCNVDHKPSNTKVDKTVER KCCVECPPCPAPPVAGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTFRVVSVLTVVHQDWLNGKEYKCKVSNKGLPAPIEKTISKTKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPMLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK (SEQ ID NO: 196)

[0124] LC polypeptide sequence: DIQMTQSPSSLSASVGDRVTITCRASQDISNYLNWYQQKPGKAPKLLIYYTSRLLSGVPSRFSGSGSGTDFTLTISSLQPEDFATYYCQQGDTLPYTFGGGTKVEIKRTVAAPSVFIFPPSDEQLKSGTASVVCLLNNFYPREAKVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTLTLSKADYEKHKVYACEVTHQGLSSPVTKSFNRGEC (SEQ ID NO: 197)

[0125] VH polypeptide sequence: EVQLVQSGAEVKKPGASVKVSCKASGYTFTDYNMHWVRQAPGQGLEWMGEINPNSGGAGYNQKFKGRVTMTTDTSTSTAYMELRSLRSDDTAVYYCARLGYDDIYDDWYFDVWGQGTTVTVSS (SEQ ID NO: 198)

[0126] VL polypeptide sequence: DIQMTQSPSSLSASVGDRVTITCRASQDISNYLNWYQQKPGKAPKLLIYYTSRLLSGVPSRFSGSGSGTDFTLTISSLQPEDFATYYCQQGDTLPYTFGGGTKVEIKRTV (SEQ ID NO: 199)

[0127] HC polypeptide sequence: QVQLVQSGAEVKKPGASVKVSCKVSGFPIKDTFQHWVRQAPGKGLEWMGWSDPEIGDTEYASKFQGRVTMTEDTSTDTAYMELSSLRSEDTAVYYCATGDTTYKFDFWGQGTTVTVSSASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSSLGTKTYTCNVDHKPSNTKVDKRVESKYG PPCPPCPAPEFLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKGLPSSIEKTISKAKGQPREPQVYTLPPSQEEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGNVFSCSVMHEALHNHYTQKSLSLSLG (sequence number 200)

[0128] LC polypeptide sequence: DIQMTQSPSSLSASVGDRVTITCKASQDVHTAVAWYQQKPGKAPKLLIYWASTRWTGVPSRFSGSGSGTDFTLTISSLQPEDFATYYCQQYSDYPWTFGGGTKVEIKRTVAAPSVFIFPPSDEQLKSGTASVVCLLNNFYPREAKVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTLTLSKADYEKHKVYACEVTHQGLSSPVTKSFNRGEC (SEQ ID NO: 201)

[0129] VH polypeptide sequence: QVQLVQSGAEVKKPGASVKVSCKVSGFPIKDTFQHWVRQAPGKGLEWMGWSDPEIGDTEYASKFQGRVTMTEDTSTDTAYMELSSLRSEDTAVYYCATGDTTYKFDFWGQGTTVTVSS (SEQ ID NO: 202)

[0130] VL polypeptide sequence: DIQMTQSPSSLSASVGDRVTITCKASQDVHTAVAWYQQKPGKAPKLLIYWASTRWTGVPSRFSGSGSGTDFTLTISSLQPEDFATYYCQQYSDYPWTFGGGTKVEIKRTV (SEQ ID NO: 203)

[0131] In some embodiments, the anti-sclerostin antibody comprises (a) a heavy chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 4, (b) a heavy chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 15, (c) a heavy chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 26, (d) a light chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 37, (e) a light chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 48, and (f) a light chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 59.

[0132] In some embodiments, the anti-sclerostin antibody comprises (a) a heavy chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 178, (b) a heavy chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 179, (c) a heavy chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 26, (d) a light chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 37, (e) a light chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 180, and (f) a light chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 181.

[0133] In some embodiments, the anti-sclerostin antibody comprises (a) a heavy chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 4, (b) a heavy chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 179, (c) a heavy chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 26, (d) a light chain variable region CDR1 comprising the amino acid sequence set forth in SEQ ID NO: 37, (e) a light chain variable region CDR2 comprising the amino acid sequence set forth in SEQ ID NO: 180, and (f) a light chain variable region CDR3 comprising the amino acid sequence set forth in SEQ ID NO: 181.

[0134] In some embodiments, the anti-sclerostin antibody is an antibody described in U.S. Pat. Nos. 7,879,322, 8,246,953, 8,486,661, 8,003,108, 7,592,429, 8,017,120, or 10,449,250, International Patent Application Nos. WO2018 / 115879A1, WO2018 / 115880A1, WO2013 / 019954A1, WO2008 / 115732A2, or WO2015 / 087187A1, or U.S. Patent Application Publication No. 20110044978A1, which are incorporated by reference in their entireties.

[0135] In some embodiments, the anti-sclerostin antibody is selected from setrusumab, romosozumab, and brosozumab.

[0136] With respect to an antibody that "blocks the inhibitory effect of sclerostin in a cell-based wnt signaling assay," this is intended to refer to an antibody that restores wnt-induced signaling in the presence of sclerostin in a cell-based supertop flash (STF) assay with an IC50 of less than 1 mM, less than 100 nM, less than 20 nM, less than 10 nM, or less. WO2009 / 047356 describes said wnt STF assay.

[0137] With respect to an antibody that "blocks the inhibitory effect of sclerostin in a cell-based calcification assay," this is intended to refer to an antibody that restores BMP2-induced calcification in the presence of sclerostin in a cell-based assay with an IC50 of less than 1 mM, less than 500 nM, less than 100 nM, less than 10 nM, less than 1 nM, or less.

[0138] With respect to an antibody that "blocks the inhibitory effect of sclerostin in a Smad1 phosphorylation assay," this is intended to refer to an antibody that restores BMP6-induced Smad1 phosphorylation in the presence of sclerostin in a cell-based assay with an IC50 of less than 1 mM, less than 500 nM, less than 100 nM, less than 10 nM, less than 1 nM, or less.

[0139] With respect to an antibody that "inhibits sclerostin binding to LRP-6," this is intended to refer to an antibody that inhibits sclerostin binding to LRP-6 with an IC50 of less than 1 mM, less than 500 nM, less than 100 nM, less than 10 nM, less than 5 nM, less than 3 nM, less than 1 nM, or less.

[0140] With respect to an antibody that "increases bone formation, mass and density," this is intended to refer to an antibody that can reach the levels of bone formation, mass and density with daily intermittent treatment with high anabolic doses of PTH, e.g., daily intermittent treatment with 100 μg / kg hPTH.

[0141] In one embodiment, the anti-sclerostin antibodies of the invention increase bone formation and / or decrease bone resorption.

[0142] In one aspect, the invention provides a method for treating a bone-related disease in a human patient, comprising administering to the human patient each month for at least 13 consecutive months a therapeutically effective amount of an anti-sclerostin antibody, which cross-blocks an anti-sclerostin antibody comprising a VH comprising the HCDR1, HCDR2, and HCDR3 domains of the VH sequence of SEQ ID NO: 70, and a VL comprising the LCDR1, LCDR2, and LCDR3 domains of the VL sequence of SEQ ID NO: 81.

[0143] In another aspect, the invention provides an anti-sclerostin antibody for use in treating a bone-related disease, wherein a therapeutically effective amount of an anti-sclerostin antibody is administered each month for at least 13 consecutive months, which antibody cross-blocks an anti-sclerostin antibody comprising a VH comprising the HCDR1, HCDR2, and HCDR3 domains of the VH sequence of SEQ ID NO: 70, and a VL comprising the LCDR1, LCDR2, and LCDR3 domains of the VL sequence of SEQ ID NO: 81.

[0144] In another aspect, the invention provides use of an anti-sclerostin antibody for the manufacture of a medicament for treating a bone-related disease, wherein the treatment comprises administering a therapeutically effective amount of an anti-sclerostin antibody each month for at least 13 consecutive months, which antibody cross-blocks an anti-sclerostin antibody comprising a VH comprising the HCDR1, HCDR2, and HCDR3 domains of the VH sequence of SEQ ID NO: 70, and a VL comprising the LCDR1, LCDR2, and LCDR3 domains of the VL sequence of SEQ ID NO: 81.

[0145] In one embodiment, the anti-sclerostin antibody used in accordance with the present invention is -11It binds to sclerostin with an affinity of less than or equal to M (as measured by Biacore) and cross-blocks an anti-sclerostin antibody comprising a VH comprising the HCDR1, HCDR2, and HCDR3 domains of the VH sequence of SEQ ID NO: 70, and a VL comprising the LCDR1, LCDR2, and LCDR3 domains of the VL sequence of SEQ ID NO: 81.

[0146] According to the invention, a cross-blocking antibody or other binding agent according to the invention binds to sclerostin in a Biacore cross-blocking assay as described below such that the recorded binding of the antibody or binding agent combination (mixture) is between 80% and 0.1% (e.g. between 80% and 4%) of the theoretical maximum binding (as defined above) of the combination of the two antibodies or binding agents, in particular between 75% and 0.1% (e.g. between 75% and 4%) of the theoretical maximum binding, more particularly between 70% and 0.1% (e.g. between 70% and 4%), more particularly between 65% and 0.1% (e.g. between 65% and 4%) of the theoretical maximum binding.

[0147] Below is outlined a suitable Biacore assay for determining whether an antibody or other binding agent cross-blocks, or is capable of cross-blocking, an antibody according to the invention. It will be understood that this assay can be used with any of the sclerostin-binding antibodies described herein.

[0148] The Biacore machine (eg, Biacore3000) is operated according to the manufacturer's recommendations.

[0149] Sclerostin may be coupled to, for example, a CM5 Biacore chip by routine amine coupling chemistry, such as EDC-NHS amine coupling, to create a sclerostin-coated surface. To obtain a measurable level of binding, typically 200-800 resonance units of sclerostin may be coupled to the chip (this amount is readily saturable by the concentration of test reagent used while still providing a measurable level of binding).

[0150] Another method of attaching sclerostin to the Biacore chip is to use a "tagged" version of sclerostin, such as N- or C-terminal His-tagged sclerostin. In this format, an anti-His antibody is coupled to the Biacore chip and then the His-tagged sclerostin is passed over the chip surface and captured by the anti-His antibody.

[0151] The two antibodies that are evaluated for their ability to cross-block each other are mixed in a suitable buffer with stoichiometric amounts of binding sites, for example, a 1:1 molar ratio, to produce a test mixture.The buffer used is generally the buffer normally used in protein chemistry, for example, PBS (136 mM NaCl, 2.7 mM KCl, 10 mM Na2HPO4, 1.76 mM KH2PO4, pH 7.4).When calculating concentration based on binding sites, the molecular weight of the antibody is assumed to be the total molecular weight of the antibody divided by the number of target (i.e., sclerostin) binding sites on the antibody.

[0152] The concentration of each antibody in the test mixture should be high enough to ensure saturation of the binding sites for that antibody on the sclerostin molecules bound to the Biacore chip. The antibodies in the mixture will be at the same molar concentration (on a binding basis), and their concentrations will typically be between 1.0 mM and 1.5 mM (on a binding site basis).

[0153] Separate solutions are also prepared containing the separate antibodies themselves. The buffers used for these separate solutions should be the same buffers and at the same concentrations as those used for the test mixture.

[0154] The test mixture is passed over the sclerostin-coated Biacore chip and binding is recorded. The bound antibody is then removed by treating the chip with acid, for example, 30 mM HCl, for about 1 minute. It is important that the sclerostin molecules bound to the chip are not damaged. A solution of only the first antibody is then passed over the sclerostin-coated surface and binding is recorded. The chip is then treated, for example, with the acid treatment described above, to remove all the bound antibody without damaging the sclerostin bound to the chip. A solution of only the second antibody is then passed over the sclerostin-coated surface and the amount of binding is recorded.

[0155] The theoretical maximum binding can be defined as the sum of the binding of each antibody to sclerostin separately.This is then compared with the actual binding of the antibody mixture measured.If the actual binding is lower than the theoretical binding, the two antibodies cross-block each other.

[0156] An antibody is defined as cross-blocking in an ELISA assay, as described below, if the solution-phase anti-sclerostin antibody can produce a 60%-100%, specifically 70%-100%, more specifically 80%-100% reduction in the sclerostin detection signal (i.e., the amount of sclerostin bound by the coated antibody) compared to the sclerostin detection signal obtained in the absence of solution-phase anti-sclerostin antibody (i.e., positive control wells).

[0157] Cross-blocking of anti-sclerostin antibodies or other sclerostin binding agents may also be detected using ELISA assays.The general principle of ELISA assays involves coating anti-sclerostin antibodies onto the wells of an ELISA plate.An excess amount of a second potentially cross-blocking anti-sclerostin antibody is then added in solution (i.e., not bound to the ELISA plate).A limited amount of sclerostin is then added to the wells.

[0158] The antibody coated on the well and the antibody in solution compete for binding to a limited number of sclerostin molecules.The plate is then washed to remove sclerostin that did not bind to the coated antibody, and also removes the second liquid phase antibody and the complex formed between the second liquid phase antibody and sclerostin.The amount of bound sclerostin is then measured using a suitable sclerostin detection reagent.An antibody in solution that can cross-block the coated antibody can reduce the number of sclerostin molecules that the coated antibody can bind compared to the number of sclerostin molecules that the coated antibody can bind in the absence of the second liquid phase antibody.

[0159] The assay is described in more detail below for two antibodies, designated Ab-X and Ab-Y. If Ab-X is selected as the immobilized antibody, it is coated onto the wells of an ELISA plate, and the plate is then blocked with a suitable blocking solution to minimize non-specific binding of the subsequently added reagent. An excess of Ab-Y is then added to the ELISA plate such that the number of moles of Ab-Y sclerostin binding sites per well is at least 10-fold higher than the number of moles of Ab-X sclerostin binding sites per well used during coating of the ELISA plate. Sclerostin is then added such that the number of moles of sclerostin added per well is at least 25-fold lower than the number of moles of Ab-X sclerostin binding sites used to coat each well. After a suitable incubation period, the ELISA plate is washed and a sclerostin detection reagent is added to measure the amount of sclerostin specifically bound by the coated anti-sclerostin antibody (in this case Ab-X). The background signal of the assay is defined as the signal obtained in wells containing the coated antibody (in this case Ab-X), the second liquid phase antibody (in this case Ab-Y), sclerostin buffer only (i.e., no sclerostin), and the sclerostin detection reagent. The positive control signal of the assay is defined as the signal obtained in wells containing the coated antibody (in this case Ab-X), the second liquid phase antibody buffer only (i.e., no second liquid phase antibody), sclerostin, and the sclerostin detection reagent. The ELISA assay should be performed in such a way that the positive control signal is at least 6-fold greater than the background signal.

[0160] To avoid artifacts resulting from the choice of which antibody to use as the coating antibody and which antibody to use as the second (competing) antibody (e.g., significantly different affinities of Ab-X and Ab-Y for sclerostin), cross-blocking assays should be performed in two formats: 1) in format 1, Ab-X is the antibody to be coated on the ELISA plate and Ab-Y is the competing antibody in solution; and 2) in format 2, Ab-Y is the antibody to be coated on the ELISA plate and Ab-X is the competing antibody in solution.

[0161] In another aspect, the invention provides a method for treating a bone-related disease in a human patient, comprising administering to the human patient each month for at least 13 consecutive months a therapeutically effective amount of an anti-sclerostin antibody which binds to the same epitope as an anti-sclerostin antibody comprising a VH comprising the HCDR1, HCDR2, and HCDR3 domains of the VH sequence of SEQ ID NO: 70, and a VL comprising the LCDR1, LCDR2, and LCDR3 domains of the VL sequence of SEQ ID NO: 81.

[0162] In another aspect, the invention provides an anti-sclerostin antibody for use in treating a bone-related disease, wherein a therapeutically effective amount of an anti-sclerostin antibody is administered each month for at least 13 consecutive months, which antibody binds to the same epitope as an anti-sclerostin antibody comprising a VH comprising the HCDR1, HCDR2, and HCDR3 domains of the VH sequence of SEQ ID NO: 70, and a VL comprising the LCDR1, LCDR2, and LCDR3 domains of the VL sequence of SEQ ID NO: 81.

[0163] In another aspect, the invention provides use of an anti-sclerostin antibody for the manufacture of a medicament for treating a bone-related disease, wherein the treatment comprises administering a therapeutically effective amount of an anti-sclerostin antibody each month for at least 13 consecutive months, which antibody binds to the same epitope as an anti-sclerostin antibody comprising a VH comprising the HCDR1, HCDR2, and HCDR3 domains of the VH sequence of SEQ ID NO: 70, and a VL comprising the LCDR1, LCDR2, and LCDR3 domains of the VL sequence of SEQ ID NO: 81.

[0164] In one embodiment, the anti-sclerostin antibody used in accordance with the present invention is -11 It binds to sclerostin with an affinity of less than or equal to M (as measured by Biacore) and binds to the same epitope as an anti-sclerostin antibody comprising a VH comprising the HCDR1, HCDR2, and HCDR3 domains of the VH sequence of SEQ ID NO: 70, and a VL comprising the LCDR1, LCDR2, and LCDR3 domains of the VL sequence of SEQ ID NO: 81.

[0165] Standard assays for determining the epitope of an antibody are known in the art and include, for example, X-ray crystallography, nuclear magnetic resonance (NMR), hydrogen-deuterium exchange coupled with mass spectrometry, peptide-based approaches, or mutagenesis-based approaches (all discussed in Abbott et al. "Current approaches to fine mapping of antigen-antibody interactions." Immunology vol. 142, 4 (2014): 526-35, and references therein).

[0166] Pharmaceutical Compositions In one embodiment, the anti-sclerostin antibody is provided as a pharmaceutical composition. The pharmaceutical composition may be formulated with a pharma- ceutical acceptable carrier. Thus, in one aspect, the invention provides a pharmaceutical composition comprising an anti-sclerostin antibody as defined herein and a pharma- ceutical acceptable carrier for use in treating bone-related disease, wherein a therapeutically effective amount of the anti-sclerostin antibody is administered each month for at least 13 consecutive months. In some embodiments of the pharmaceutical composition, the antibody comprises a VH comprising the HCDR1, HCDR2, and HCDR3 domains of the VH sequence of SEQ ID NO: 70, and a VL comprising the LCDR1, LCDR2, and LCDR3 domains of the VL sequence of SEQ ID NO: 81. Pharmaceutically acceptable carriers include sterile aqueous solutions.

[0167] Specific Embodiments In one embodiment, the invention provides a method for treating OI in a human patient, comprising administering to the human patient a therapeutically effective amount of 150-2500 mg of an anti-sclerostin antibody each month for a period of at least 13 consecutive months and up to 18 years.

[0168] In a related embodiment, the invention provides a method for treating OI in a human patient, comprising administering to the human patient a therapeutically effective amount of 150-2500 mg of an anti-sclerostin antibody each month for a period of at least 30 consecutive months and up to 18 years.

[0169] In another embodiment, the invention provides a method for treating OI in a human patient between 0 and 17 years of age, comprising administering to the human patient a therapeutically effective amount of 20-40 mg / kg of an anti-sclerostin antibody each month for a period of at least 13 consecutive months and up to 18 years.

[0170] In a related embodiment, the invention provides a method for treating OI in a human patient aged 0-17 years, comprising administering to the human patient a therapeutically effective amount of 20-40 mg / kg of an anti-sclerostin antibody each month for a period of at least 30 consecutive months and up to 18 years.

[0171] In one embodiment, the invention provides a method for treating OI in a human patient, comprising administering to the human patient a therapeutically effective amount of 150 to 2500 mg of an anti-sclerostin antibody each month for a period of at least 13 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence having the amino acid sequence of SEQ ID NO:70 and a VL polypeptide sequence having the amino acid sequence of SEQ ID NO:81.

[0172] In a related embodiment, the invention provides a method for treating OI in a human patient, comprising administering to the human patient a therapeutically effective amount of 150 to 2500 mg of an anti-sclerostin antibody each month for a period of at least 30 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence having the amino acid sequence of SEQ ID NO:70 and a VL polypeptide sequence having the amino acid sequence of SEQ ID NO:81.

[0173] In another embodiment, the invention provides a method for treating OI in a human patient age 0-17 years, comprising administering to the human patient a therapeutically effective amount of 20-40 mg / kg of an anti-sclerostin antibody each month for a period of at least 13 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence having the amino acid sequence of SEQ ID NO:70 and a VL polypeptide sequence having the amino acid sequence of SEQ ID NO:81.

[0174] In a related embodiment, the invention provides a method for treating OI in a human patient aged 0-17 years, comprising administering to the human patient a therapeutically effective amount of 20-40 mg / kg of an anti-sclerostin antibody each month for a period of at least 30 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence having the amino acid sequence of SEQ ID NO:70 and a VL polypeptide sequence having the amino acid sequence of SEQ ID NO:81.

[0175] In one embodiment, the invention provides a method for treating OI in a human patient, comprising administering to the human patient a therapeutically effective amount of 150 to 2500 mg of an anti-sclerostin antibody each month for a period of at least 13 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO:198 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:199.

[0176] In a related embodiment, the invention provides a method for treating OI in a human patient, comprising administering to the human patient a therapeutically effective amount of 150 to 2500 mg of an anti-sclerostin antibody each month for a period of at least 30 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO:198 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:199.

[0177] In another embodiment, the invention provides a method for treating OI in a human patient between 0 and 17 years of age, comprising administering to the human patient a therapeutically effective amount of 20-40 mg / kg of an anti-sclerostin antibody each month for a period of at least 13 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO:198 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:199.

[0178] In a related embodiment, the invention provides a method for treating OI in a human patient between 0 and 17 years of age, comprising administering to the human patient a therapeutically effective amount of 20-40 mg / kg of an anti-sclerostin antibody each month for a period of at least 30 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO:198 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:199.

[0179] In one embodiment, the invention provides a method for treating OI in a human patient, comprising administering to the human patient a therapeutically effective amount of 150 to 2500 mg of an anti-sclerostin antibody each month for a period of at least 13 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO:202 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:203.

[0180] In a related embodiment, the invention provides a method for treating OI in a human patient, comprising administering to the human patient a therapeutically effective amount of 150 to 2500 mg of an anti-sclerostin antibody each month for a period of at least 30 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO:202 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:203.

[0181] In another embodiment, the invention provides a method for treating OI in a human patient between 0 and 17 years of age, comprising administering to the human patient a therapeutically effective amount of 20-40 mg / kg of an anti-sclerostin antibody each month for a period of at least 13 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO:202 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:203.

[0182] In a related embodiment, the invention provides a method for treating OI in a human patient between 0 and 17 years of age, comprising administering to the human patient a therapeutically effective amount of 20-40 mg / kg of an anti-sclerostin antibody each month for a period of at least 30 consecutive months and up to 18 years, where the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO:202 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:203. EXAMPLES

[0183] Example 1 This example describes a 12-month randomized, double-blind, phase 2b clinical trial in 60 adults diagnosed with osteogenesis imperfecta (OI) type I, III, or IV, with confirmed COL1A1 / COL1A2 mutations, and a fracture in the past 5 years. Patients received setrusumab at a dose of 8 mg / kg or 20 mg / kg monthly for 12 months. Setrusumab was administered intravenously by infusion. The study measured percent change from baseline in areal bone mineral density (BMD) of the lumbar spine measured by DXA at ​​6 and 12 months. Additionally, N-terminal propeptide of procollagen I (PINP), a biomarker of bone formation, and C-terminal telopeptide (CTX-1), a biomarker of bone resorption, were measured at 1, 3, 6, 9, and 12 months.

[0184] Of the 60 patients randomized to the setrusumab treatment group, 29 were treated with 8 mg / kg monthly and 31 with 20 mg / kg monthly. Baseline patient characteristics (Table 2) and medical histories (Table 3) of these patients were comparable between treatment groups. [Table 2] [Table 3]

[0185] result Assay results for bone turnover biomarkers in the study are shown in Figures 2A and 2B. The results show that setrusumab therapy improved serum biomarkers of bone turnover from baseline in a dose-dependent manner. Remarkably, both biomarkers showed a peak response in the first month, after which the response attenuated, with biomarker levels returning to levels not significantly different from baseline levels within 6–9 months of treatment initiation.

[0186] Levels of a bone formation biomarker (P1NP) were statistically significantly above baseline levels during the first 6 months of setrusumab therapy at 20 mg / kg monthly and during the first month of treatment at 8 mg / kg monthly (Figure 2A). Statistical significance was tested using an ANCOVA model with baseline values, treatment group, and OI type as covariates ( ** p < 0.01; *** With both doses of setrusumab, P1NP levels peaked during the first month and then declined over the 11-month treatment period.

[0187] Levels of a bone resorption marker (CTX-1) were significantly below baseline levels during the first 3 months of setrusumab therapy at 20 mg / kg monthly and during the first month of treatment at 8 mg / kg monthly (Figure 2B). Statistical significance was tested using an ANCOVA model with baseline values, treatment group, and OI type as covariates ( ** p < 0.01; *** With both doses of setrusumab, CTX-1 levels reached a nadir during the first month and then increased again over the following 11 months of treatment.

[0188] In contrast, Figure 3 shows that improvements in lumbar spine BMD over baseline were sustained with setrusumab therapy. Patients receiving 20 mg / kg setrusumab monthly increased lumbar spine BMD (measured by DXA) by approximately 4% at 6 months and 8.5% at 12 months. Similarly, patients receiving 8 mg / kg setrusumab monthly increased lumbar spine BMD (measured by DXA) by approximately 4.7% at 6 months and 6.8% at 12 months. These increases were statistically significant compared to baseline based on ANCOVA models with baseline values, treatment group, and OI type as covariates ( *** Thus, despite the decline in biomarkers early in treatment, similar increases in BMD were observed during the first and second 6 months of monthly setrusumab therapy.

[0189] Furthermore, the study demonstrated that the anti-sclerostin antibody was safe and well tolerated in adult patients with OI. Few treatment-emergent serious adverse events (TEAEs) were observed across groups during the treatment period. There were only two discontinuations due to adverse events (AEs): neutropenia and headache. There were no clinically significant abnormalities in hematology, clinical chemistry, urinalysis, ECG, or vital sign data that would compromise patient safety.

[0190] According to the results of clinical trials, setrusumab continuously increases BMD in patients with OI, even though biomarkers indicate that the effect of setrusumab fades with long-term use. Surprisingly, these results show that the response analyzed by biomarkers was separate from the effect on BMD. The observed improvement in BMD was continuous, with comparable improvements achieved in the first and second 6 months of treatment. In contrast, transient changes were observed in the biomarkers, with the biomarker response peaking in the first month of setrusumab treatment and then rapidly decaying despite continued treatment. Thus, these results indicate that setrusumab continues to have a clinically relevant effect with long-term use, i.e., an increase in BMD, even if the response observed in the levels of bone turnover biomarkers fades early in treatment. These surprising results led to the conclusion that setrusumab can be used for long-term (or chronic) treatment and that no drug holiday is required for setrusumab therapy.

[0191] Example 2 After 12 months of setrusumab therapy, setrusumab was discontinued and BMD was monitored through month 24. A subset of patients received zoledronic acid therapy at months 12 and / or 18 ("any ZOL"), and another subset did not receive zoledronic acid therapy after discontinuation of setrusumab ("no ZOL"). Over this 1-year period, lumbar spine BMD (Figure 4A), hip BMD (Figure 4B), radial total area volumetric BMD (Figure 4C), and tibial total area volumetric BMD (Figure 4D) were assessed. The initial BMD gains attributable to setrusumab therapy diminished over the 1-year period following discontinuation of setrusumab therapy. Large BMD losses were observed in the peripheral skeleton, while moderate BMD losses were observed in the spine and hip. Administration of zoledronic acid (ZOL) prevented BMD loss in the spine and hip, but not in the distal radius and tibia.

[0192] The bone turnover markers P1NP and CTx were evaluated in the serum of patients during the 12-month treatment with setrusumab (20 mg / kg) and up to 18 months after treatment (a total of 6 months after setrusumab treatment). Patients were given or not given zoledronic acid according to physician recommendations. Serum P1NP (an indicator of bone formation) decreased in patients regardless of treatment with zoledronic acid (ZOL) (Figure 5A). Meanwhile, serum CTx (indicating bone resorption) increased in patients not receiving zoledronic acid.

[0193] During follow-up after the initial 12-month treatment period, patients were also evaluated for adverse events. Safety findings during follow-up were consistent with expected outcomes, with fracture rates fluctuating but not significantly exceeding those during the initial 12-month treatment period. No major adverse cardiovascular events occurred throughout the 2-year study.

[0194] These results show that not only does the BMD gain resulting from setrusumab therapy continue well after the decline suggested by bone turnover biomarkers (Example 1), but also that antiresorptive therapy such as zoledronic acid alone is insufficient to maintain the initial gains with setrusumab. Furthermore, the initial peaks and valleys observed in bone turnover biomarkers with setrusumab therapy gradually level out during the treatment period with setrusumab, but when setrusumab is discontinued, stable maintenance levels switch to rapid changes from baseline. In the case of P1NP (bone formation), discontinuing setrusumab results in a decline regardless of zoledronic acid treatment. In the case of CTx (bone resorption), discontinuing setrusumab results in a rapid increase. Thus, the decline in BMD and changes in bone turnover biomarkers after discontinuing setrusumab therapy support the need for continued treatment after 12 months.

[0195] The teachings of all patents, published applications, and references cited herein are incorporated by reference in their entirety for all purposes. The patents and publications cited herein are illustrative of the general technology of the art. In the event of any inconsistency between the cited documents and the present specification, the present specification shall control. In describing the embodiments of this application, specific terms are used for clarity. However, the present invention is not intended to be limited to the specific terms so selected. Nothing herein should be considered as limiting the scope of the present invention. All examples presented are representative and non-limiting. The above embodiments may be modified or altered as understood by those skilled in the art in light of the above teachings without departing from the present invention. It is therefore to be understood that within the scope of the claims and their equivalents, the present invention may be practiced otherwise than as specifically described.

Claims

1. 1. A pharmaceutical composition for treating osteogenesis imperfecta (OI) in a human patient, comprising a therapeutically effective amount of an anti-sclerostin antibody, A pharmaceutical composition administered to a human patient each month for at least 13 consecutive months.

2. the anti-sclerostin antibody (a) a heavy chain variable region (VH) polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence of SEQ ID NO: 70, and / or (b) a light chain variable region (VL) polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence of SEQ ID NO:

81.

2. The pharmaceutical composition of claim 1, comprising:

3. 3. The pharmaceutical composition of claim 2, wherein the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO:70 and a VL polypeptide sequence comprising the amino acid sequence set forth in SEQ ID NO:

81.

4. the anti-sclerostin antibody (a) an HCDR1 having the amino acid sequence of SEQ ID NO: 4; (b) an HCDR2 having the amino acid sequence of SEQ ID NO: 15; (c) an HCDR3 having the amino acid sequence of SEQ ID NO: 26; (d) an LCDR1 having the amino acid sequence of SEQ ID NO: 37; (e) an LCDR2 having the amino acid sequence of SEQ ID NO: 48, and (f) an LCDR3 having the amino acid sequence of SEQ ID NO:

59.

2. The pharmaceutical composition of claim 1, comprising:

5. the anti-sclerostin antibody (a) an HCDR1 having the amino acid sequence of SEQ ID NO: 178; (b) an HCDR2 having the amino acid sequence of SEQ ID NO: 179; (c) an HCDR3 having the amino acid sequence of SEQ ID NO: 26; (d) an LCDR1 having the amino acid sequence of SEQ ID NO: 37; (e) an LCDR2 having the amino acid sequence of SEQ ID NO: 180; and (f) an LCDR3 having the amino acid sequence of SEQ ID NO:

181.

2. The pharmaceutical composition of claim 1, comprising:

6. the anti-sclerostin antibody (a) an HCDR1 having the amino acid sequence of SEQ ID NO: 4; (b) an HCDR2 having the amino acid sequence of SEQ ID NO: 179; (c) an HCDR3 having the amino acid sequence of SEQ ID NO: 26; (d) an LCDR1 having the amino acid sequence of SEQ ID NO: 37; (e) an LCDR2 having the amino acid sequence of SEQ ID NO: 180; and (f) an LCDR3 having the amino acid sequence of SEQ ID NO:

181.

2. The pharmaceutical composition of claim 1, comprising:

7. the anti-sclerostin antibody (a) a VH polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence of SEQ ID NO: 198, and / or (b) a VL polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence of SEQ ID NO:

199.

2. The pharmaceutical composition of claim 1, comprising:

8. 8. The pharmaceutical composition of claim 7, wherein the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO: 198 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:

199.

9. the anti-sclerostin antibody (a) a VH polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence of SEQ ID NO: 202, and / or (b) a VL polypeptide sequence having at least 90 percent sequence identity to the amino acid sequence of SEQ ID NO:

203.

2. The pharmaceutical composition of claim 1, comprising:

10. 10. The pharmaceutical composition of claim 9, wherein the anti-sclerostin antibody comprises a VH polypeptide sequence comprising the amino acid sequence of SEQ ID NO:202 and a VL polypeptide sequence comprising the amino acid sequence of SEQ ID NO:

203.

11. 2. The pharmaceutical composition of claim 1, wherein the anti-sclerostin antibody is setrusumab.

12. The pharmaceutical composition of claim 1 , wherein the anti-sclerostin antibody is romosozumab.

13. The pharmaceutical composition of claim 1 , wherein the anti-sclerostin antibody is burozumab.

14. 10. The pharmaceutical composition of claim 1, administered monthly for a period of at least 18 consecutive months.

15. 10. The pharmaceutical composition of claim 1, administered monthly for a period of at least 24 consecutive months.

16. 10. The pharmaceutical composition of claim 1, administered monthly for a period of at least 30 consecutive months.

17. 10. The pharmaceutical composition of claim 1, administered monthly for a period of at least 36 consecutive months.

18. 10. The pharmaceutical composition of claim 1, administered monthly for up to 18 years.

19. 2. The pharmaceutical composition of claim 1, wherein administration of the therapeutically effective amount of the anti-sclerostin antibody increases trabecular bone mineral density (BMD) in the human patient after 12 months of treatment.

20. 2. The pharmaceutical composition of claim 1, wherein administration of the therapeutically effective amount of the anti-sclerostin antibody results in a 5% or greater increase in lumbar bone mineral density (BMD) in the human patient after 12 months of treatment.

21. The pharmaceutical composition of claim 1 , wherein the OI is type I OI, type III OI, or type IV OI.

22. The pharmaceutical composition of claim 1 , wherein the human patient has one or more mutations in the COL1A1 gene and / or the COL1A2 gene.

23. 2. The pharmaceutical composition of claim 1, wherein the human patient is aged 0-17 years.

24. 10. The pharmaceutical composition of claim 1, wherein the human patient is a child between 0 and 17 years of age and the anti-sclerostin antibody is administered monthly at a dose of 20 to 50 mg / kg.

25. An anti-sclerostin antibody as defined in any one of claims 1 to 13, an antibody that cross-blocks the anti-sclerostin antibody as defined in any one of claims 1 to 13, or an antibody that binds to the same epitope as the anti-sclerostin antibody as defined in any one of claims 1 to 13, for use in a method for treating osteogenesis imperfecta (OI) in a human patient.

26. 14. A pharmaceutical composition for treating osteogenesis imperfecta (OI) in a human patient, comprising a therapeutically effective amount of an antibody that cross-blocks the anti-sclerostin antibody defined in any one of claims 1 to 13 or that binds to the same epitope as the anti-sclerostin antibody defined in any one of claims 1 to 13, A pharmaceutical composition administered to a human patient each month for at least 13 consecutive months.

27. 1. A pharmaceutical composition for treating osteogenesis imperfecta (OI) in a human patient, comprising a therapeutically effective amount of an anti-sclerostin antibody, A pharmaceutical composition in which a human patient is administered a first dose monthly for an initial administration period of 12 months or more, followed by periodic maintenance doses.

28. 28. The pharmaceutical composition of claim 27, wherein the first dose comprises 20-50 mg / kg of the anti-sclerostin antibody administered monthly.

29. 28. The pharmaceutical composition of claim 27, wherein the first dose comprises 20-40 mg / kg of the anti-sclerostin antibody administered monthly.

30. 28. The pharmaceutical composition of claim 27, wherein the first dose comprises 20 mg / kg of the anti-sclerostin antibody administered monthly.

31. 28. The pharmaceutical composition of claim 27, wherein the maintenance dose comprises administration of the anti-sclerostin antibody monthly, every two months, every three months, every four months, every six months, or every twelve months.

32. 28. The pharmaceutical composition of claim 27, wherein the maintenance dose comprises administering an amount of the anti-sclerostin antibody that is equal to or lower than the amount administered during the initial administration period.

33. 28. The pharmaceutical composition of claim 27, wherein the maintenance dose comprises no more than 20 mg / kg of the anti-sclerostin antibody.

34. 28. The pharmaceutical composition of claim 27, wherein the initial administration period is administered at 20 mg / kg monthly for a period of 12 months or more, followed by a maintenance dose of 20 mg / kg or less every two months.

35. 28. The pharmaceutical composition of claim 27, wherein the initial administration period is administered at 20 mg / kg monthly for a period of 12 months or more, followed by a maintenance dose of 20 mg / kg every two months.

36. 28. The pharmaceutical composition of claim 27, wherein the initial administration period is administered at 20 mg / kg monthly for a period of 12 months, followed by a maintenance dose of less than 20 mg / kg each month thereafter.

37. 28. The pharmaceutical composition of claim 27, wherein the maintenance dose is administered for a period of up to 18 years.

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