Method for inducing hemodynamic changes by administering anti-NPR1 antibody

Abstract

The present disclosure relates to a method of lowering blood pressure or causing hemodynamic changes in a subject, the method comprising administering to the subject a pharmaceutical composition comprising an agonist of natriuretic peptide receptor 1 (NPR1) (e.g., an agonist anti-NPR1 antibody).

Description

[Technical field]

[0001] The present disclosure relates to methods for treating diseases associated with degenerative hemodynamics, methods for lowering blood pressure, and methods for inducing hemodynamic changes in a subject, each of which comprises administering to the subject a pharmaceutical composition comprising a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to NPR1.

[0002] CROSS-REFERENCE TO RELATED APPLICATIONS This application was filed on October 11, 2022 as a PCT international patent application claiming priority to and benefit of U.S. Provisional Patent Application No. 63 / 254,447, filed on October 11, 2021, the entire contents of which are incorporated herein by reference.

[0003] Reference to sequence table XML This application contains a Sequence Listing in XML format. The XML file is incorporated herein by reference. The XML table, created on October 7, 2022, is named 40848_0111WOU1_SL.xml and is 9,933 bytes in size. [Background technology]

[0004] Natriuretic peptide receptor 1 is a membrane-bound guanylate cyclase that mediates the intracellular conversion of guanosine triphosphate to cyclic guanosine monophosphate (cGMP) (Non-Patent Document 1). NPR1 is widely expressed in the kidney, vasculature, adrenal gland, and brain, including these (Non-Patent Document 2). NPR1 agonism leads to changes in systemic blood pressure (BP) through cGMP-mediated effects on intravascular volume, vasorelaxation, natriuresis, and diuresis.

[0005] NPR1 is activated by the cardiac hormones atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), which are synthesized as propeptides (proANP and proBNP) and stored by the heart in secretory granules present in the atrial and / or ventricular muscles (Non-Patent Document 1). Upon release in response to increased pressure or stretch induced by neurohormonal stimulation, proANP and proBNP are enzymatically cleaved into biologically active ANP and BNP. Clearance of these peptides from the circulation proceeds primarily through degradation by matrix metalloproteinases, including neprilysin, and via the natriuretic peptide clearance receptor, NPR3 (Non-Patent Document 1). Natriuretic peptides have an important role in regulating diuresis and natriuresis, together with inhibition of the renin-angiotensin-aldosterone system, where the effects of the peptides result in modulation of local and systemic hemodynamics. Inhibition of neprilysin, a metalloprotease that degrades natriuretic peptides, reduces their clearance and has been studied in patients with heart failure. Inhibition of neprilysin leads to an increase in endogenous ANP and BNP, which in turn stimulates NPR1 activity.

[0006] Monoclonal antibodies against NPR1 were first described by Kitano et al. in 1995 (Non-Patent Document 3). Activating or agonistic anti-NPR1 antibodies are disclosed, for example, in Patent Documents 1, 2, and 3. Fully human antibodies that specifically bind to and activate the NPR1 protein with high affinity may be important, for example, in the prevention and treatment of hypertension, obesity, and heart failure. [Prior art documents] [Patent documents]

[0007] [Patent Document 1] U.S. Patent No. 9,090,695 [Patent Document 2] U.S. Patent Publication No. 20160168251 [Patent Document 3] WO2010065293 [Non-patent literature]

[0008] [Non-Patent Document 1] Martinez-Rumayor, et al. 2008 Am J Cardiol 101(3a): pp. 3-8 [Non-Patent Document 2] Yancy et al., 2017 Circulation 136(6):e137~e161 [Non-Patent Document 3] Immunol.Lett.47:215-22 Summary of the Invention [Problem to be solved by the invention]

[0009] REGN5381 is a human immunoglobulin G4-based monoclonal antibody (mAb) that binds and activates NPR1 in both the presence and absence of endogenous ligands ANP and BNP. Signaling through NPR1 can recapitulate many physiological responses seen with other natriuretic pathway therapies. REGN5381 is a direct agonist of NPR1, which has a long duration of effect and can provide sustained hemodynamic control and cardiac unloading compared to current therapies such as neprilysin inhibitors, the combination of sacubitril and valsartan, or the recombinant BNP peptide nesiritide. As shown herein, REGN5381 induced a predictable and sustained reduction in systemic BP in telemetered normotensive male cynomolgus monkeys (non-human primates (NHPs)). Thus, REGN5381 is contemplated herein for the treatment of diseases associated with altered hemodynamics, including heart failure, hypertension, and chronic kidney disease.

[0010] Importantly, administration of REGN5381 results in a reduction in blood pressure that is more sustained than other known agents, without the potential adverse effects normally associated with hypotension. As a result, the antibody or antigen-binding fragment thereof of the present invention can be administered less frequently. [Means for solving the problem]

[0011] In one aspect, the present disclosure provides a method of treating a disease associated with altered hemodynamics in a subject, comprising: (i) selecting a subject with a systolic blood pressure (SBP) between 100 mmHg and 140 mmHg or between 135 mmHg and 160 mmHg; (ii) administering to the subject a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1); In a further embodiment, the disease is selected from the group consisting of heart failure, hypertension and chronic kidney disease.

[0012] In another aspect, the present disclosure provides a method of reducing blood pressure in a subject, comprising: (i) selecting a subject with a systolic blood pressure (SBP) between 100 mmHg and 140 mmHg or between 135 mmHg and 160 mmHg; (ii) administering to the subject a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1); In a further embodiment, the blood pressure is selected from the group consisting of systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pulse pressure.

[0013] In yet another aspect, the present disclosure provides a method of inducing a hemodynamic change in a subject, the method comprising: (i) selecting a subject with a systolic blood pressure (SBP) between 100 mmHg and 140 mmHg or between 135 mmHg and 160 mmHg; (ii) administering to the subject a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1); In a further embodiment, the hemodynamic change is a decrease in venous pressure, left ventricular end diastolic pressure (LVEDP), and / or arterial pulse pressure (PP). In yet another embodiment, the decrease in venous pressure is a decrease in central venous pressure (CVP).

[0014] In certain embodiments of the methods according to the present disclosure, urinary volume and systemic organ perfusion are unaffected by administration.

[0015] In certain embodiments of methods according to the present disclosure, the subject's heart rate (HR) is increased.

[0016] In certain embodiments of the methods according to the present disclosure, the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining regions (CDRs) (HCDR1, HCDR2 and HCDR3) contained within a heavy chain variable region (HCVR) comprising the amino acid sequence of SEQ ID NO:1; and three light chain CDRs (LCDR1, LCDR2 and LCDR3) contained within a light chain variable region (LCVR) comprising the amino acid sequence of SEQ ID NO:2.

[0017] In certain embodiments of the methods according to the present disclosure, the antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining regions (CDRs) (HCDR1, HCDR2 and HCDR3) and three light chain CDRs (LCDR1, LCDR2 and LCDR3), where HCDR1 has the amino acid sequence of SEQ ID NO: 3, HCDR2 has the amino acid sequence of SEQ ID NO: 4, HCDR3 has the amino acid sequence of SEQ ID NO: 5, LCDR1 has the amino acid sequence of SEQ ID NO: 6, LCDR2 has the amino acid sequence of VAS, and LCDR3 has the amino acid sequence of SEQ ID NO: 8.

[0018] In certain embodiments of the methods according to the present disclosure, the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) comprising the amino acid sequence of SEQ ID NO:1 and a light chain variable region (LCVR) comprising the amino acid sequence of SEQ ID NO:2.

[0019] In certain embodiments of the methods according to the present disclosure, the antibody comprises a heavy chain and a light chain, wherein the heavy chain comprises the amino acid sequence of SEQ ID NO:9.

[0020] In certain embodiments of the methods according to the present disclosure, the antibody comprises a heavy chain and a light chain, wherein the light chain comprises the amino acid sequence of SEQ ID NO:10.

[0021] In certain embodiments of the methods according to the present disclosure, the antibody comprises a heavy chain and a light chain, wherein the heavy chain comprises the amino acid sequence of SEQ ID NO:9 and the light chain comprises the amino acid sequence of SEQ ID NO:10.

[0022] In certain embodiments, the antibody or antigen-binding fragment thereof is administered at a low dose.

[0023] In certain embodiments of the methods according to the present disclosure, the antibody or antigen-binding fragment thereof is administered at a dose of about 0.031 to about 25 mg / kg of subject body weight.

[0024] In certain embodiments of the methods according to the present disclosure, the antibody or antigen-binding fragment thereof is administered at a dose of about 1 mg to about 200 mg.

[0025] In certain embodiments of the methods according to the present disclosure, the antibody or antigen-binding fragment thereof is administered to the subject intravenously, subcutaneously, intradermally, intraperitoneally, or intramuscularly.

[0026] In certain embodiments of the methods according to the present disclosure, the antibody or antigen-binding fragment thereof is administered to the subject as a single dose.

[0027] In certain embodiments, the method according to the present disclosure further comprises administering to the subject an additional / second therapeutic agent.In certain embodiments, the additional therapeutic agent can be selected from the group consisting of aldosterone antagonists, alpha-adrenergic blockers, angiotensin-converting enzyme (ACE) inhibitors, arteriolar dilators, autonomic ganglionic vasodilators, beta-adrenergic blockers, catecholamine-depleting sympatholytic agents, central alpha-2 adrenergic agonists, calcium channel blockers, diuretics, renin inhibitors, anticoagulants, antiplatelet agents, cholesterol-lowering agents, vasodilators, digitalis, surgery, implantable devices, antitumor therapy, insulin, GLP1 agonists, metformin, dialysis, bone marrow stimulants, hemofiltration, lifestyle modification, dietary supplements, and any other drug or therapy known in the art. In certain embodiments, the additional therapeutic agent can be an agent that helps to counteract or reduce any possible side effects associated with the antibody or antigen-binding fragment thereof that specifically binds to NPR1, if such side effects occur.In certain embodiments, the additional therapeutic agent is administered simultaneously with the composition or separately from the composition.In certain embodiments, the second therapeutic agent is administered simultaneously with the antibody or antigen-binding fragment thereof or separately from the antibody or antigen-binding fragment thereof.

[0028] In certain embodiments of the methods according to the present disclosure, the subject has hypertension. In one embodiment, the subject has mild hypertension. In one embodiment, the subject is a human.

[0029] In one aspect, the disclosure provides a pharmaceutical composition for use in treating a disease associated with altered hemodynamics in a subject, the pharmaceutical composition comprising a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1) and a pharma- ceutical acceptable carrier or diluent.

[0030] In another aspect, the disclosure provides a pharmaceutical composition for use in lowering blood pressure in a subject, the pharmaceutical composition comprising a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to NPR1 and a pharma- ceutical acceptable carrier or diluent.

[0031] In yet another aspect, the disclosure provides a pharmaceutical composition for use in inducing a hemodynamic change in a subject, the pharmaceutical composition comprising a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1) and a pharma- ceutical acceptable carrier or diluent.

[0032] In a further aspect, the present disclosure provides use of an anti-NPR1 antibody or antigen-binding fragment thereof of the present disclosure in the manufacture of a medicament for treating a disease associated with degenerative hemodynamics in a subject, for lowering blood pressure in a subject, and / or for causing changes in hemodynamics in a subject.

[0033] Other embodiments will become apparent from consideration of the detailed description that follows. [Brief description of the drawings]

[0034] [Figure 1A] FIG. 1 shows the effect of REGN5381 on blood pressure and heart rate in normotensive NPR1 hu / hu mice, in this case (FIG. 1A) effect on systolic blood pressure, (FIG. 1B) effect on diastolic blood pressure, (FIG. 1C) effect on pulse pressure, (FIG. 1D) effect on heart rate, and (FIG. 1E) effect on mean arterial pressure. Telemetered normotensive NPR1 hu / hu mice were randomized into 5 groups of equal weight and given a single subcutaneous injection of REGN5381 at the doses listed in Table 3. Phosphate-buffered saline (PBS) was used as a control. All values ​​are mean ± SEM, n=3–6 per group. [Figure 1B]FIG. 1 shows the effect of REGN5381 on blood pressure and heart rate in normotensive NPR1 hu / hu mice, in this case (FIG. 1A) effect on systolic blood pressure, (FIG. 1B) effect on diastolic blood pressure, (FIG. 1C) effect on pulse pressure, (FIG. 1D) effect on heart rate, and (FIG. 1E) effect on mean arterial pressure. Telemetered normotensive NPR1 hu / hu mice were randomized into 5 groups of equal weight and given a single subcutaneous injection of REGN5381 at the doses listed in Table 3. Phosphate-buffered saline (PBS) was used as a control. All values ​​are mean ± SEM, n=3–6 per group. [Figure 1C] FIG. 1 shows the effect of REGN5381 on blood pressure and heart rate in normotensive NPR1 hu / hu mice, in this case (FIG. 1A) effect on systolic blood pressure, (FIG. 1B) effect on diastolic blood pressure, (FIG. 1C) effect on pulse pressure, (FIG. 1D) effect on heart rate, and (FIG. 1E) effect on mean arterial pressure. Telemetered normotensive NPR1 hu / hu mice were randomized into 5 groups of equal weight and given a single subcutaneous injection of REGN5381 at the doses listed in Table 3. Phosphate-buffered saline (PBS) was used as a control. All values ​​are mean ± SEM, n=3–6 per group. [Figure 1D] FIG. 1 shows the effect of REGN5381 on blood pressure and heart rate in normotensive NPR1 hu / hu mice, in this case (FIG. 1A) effect on systolic blood pressure, (FIG. 1B) effect on diastolic blood pressure, (FIG. 1C) effect on pulse pressure, (FIG. 1D) effect on heart rate, and (FIG. 1E) effect on mean arterial pressure. Telemetered normotensive NPR1 hu / hu mice were randomized into 5 groups of equal weight and given a single subcutaneous injection of REGN5381 at the doses listed in Table 3. Phosphate-buffered saline (PBS) was used as a control. All values ​​are mean ± SEM, n=3–6 per group. [Figure 1E]FIG. 1 shows the effect of REGN5381 on blood pressure and heart rate in normotensive NPR1 hu / hu mice, in this case (FIG. 1A) effect on systolic blood pressure, (FIG. 1B) effect on diastolic blood pressure, (FIG. 1C) effect on pulse pressure, (FIG. 1D) effect on heart rate, and (FIG. 1E) effect on mean arterial pressure. Telemetered normotensive NPR1 hu / hu mice were randomized into 5 groups of equal weight and given a single subcutaneous injection of REGN5381 at the doses listed in Table 3. Phosphate-buffered saline (PBS) was used as a control. All values ​​are mean ± SEM, n=3–6 per group. [Diagram 2] Figure 13. REGN5381 serum concentrations on day 7. Telemetered normotensive NPR1 hu / hu mice were randomized into 5 groups of equal weight and received a single subcutaneous injection of REGN5381 at the doses listed in Table 1. Phosphate buffered saline was used as a control. Blood was collected on study day 7 to assess REGN5381 concentrations. All values ​​are mean ± SEM, n=5-6 per group. [Figure 3A] Figure 3A shows the effect of low doses of REGN5381 on blood pressure and heart rate in telemetered normotensive cynomolgus monkeys: (Figure 3A) Systolic blood pressure - change from baseline; (Figure 3B) Diastolic blood pressure - change from baseline; (Figure 3C) Heart rate - change from baseline; (Figure 3D) Mean arterial blood pressure - change from baseline. Telemetered normotensive cynomolgus monkeys were randomized into 4 groups of equal weight and given a single intravenous injection of REGN5381 at the doses listed in Table 4. Systolic pressure, diastolic pressure, heart rate, and mean arterial pressure are illustrated graphically from 43 hours pre-dosing to 48 hours post-dosing. Telemetry data are displayed as 1-hour bins, where the grey area represents the 12-hour dark cycle. All values ​​are mean ± SEM, n=4-7 per group. [Figure 3B]Figure 3A shows the effect of low doses of REGN5381 on blood pressure and heart rate in telemetered normotensive cynomolgus monkeys: (Figure 3A) Systolic blood pressure - change from baseline; (Figure 3B) Diastolic blood pressure - change from baseline; (Figure 3C) Heart rate - change from baseline; (Figure 3D) Mean arterial blood pressure - change from baseline. Telemetered normotensive cynomolgus monkeys were randomized into 4 groups of equal weight and given a single intravenous injection of REGN5381 at the doses listed in Table 4. Systolic pressure, diastolic pressure, heart rate, and mean arterial pressure are illustrated graphically from 43 hours pre-dosing to 48 hours post-dosing. Telemetry data are displayed as 1-hour bins, where the grey area represents the 12-hour dark cycle. All values ​​are mean ± SEM, n=4-7 per group. [Figure 3C] Figure 3A shows the effect of low doses of REGN5381 on blood pressure and heart rate in telemetered normotensive cynomolgus monkeys: (Figure 3A) Systolic blood pressure - change from baseline; (Figure 3B) Diastolic blood pressure - change from baseline; (Figure 3C) Heart rate - change from baseline; (Figure 3D) Mean arterial blood pressure - change from baseline. Telemetered normotensive cynomolgus monkeys were randomized into 4 groups of equal weight and given a single intravenous injection of REGN5381 at the doses listed in Table 4. Systolic pressure, diastolic pressure, heart rate, and mean arterial pressure are illustrated graphically from 43 hours pre-dosing to 48 hours post-dosing. Telemetry data are displayed as 1-hour bins, where the grey area represents the 12-hour dark cycle. All values ​​are mean ± SEM, n=4-7 per group. [Figure 3D]Figure 3A shows the effect of low doses of REGN5381 on blood pressure and heart rate in telemetered normotensive cynomolgus monkeys: (Figure 3A) Systolic blood pressure - change from baseline; (Figure 3B) Diastolic blood pressure - change from baseline; (Figure 3C) Heart rate - change from baseline; (Figure 3D) Mean arterial blood pressure - change from baseline. Telemetered normotensive cynomolgus monkeys were randomized into 4 groups of equal weight and given a single intravenous injection of REGN5381 at the doses listed in Table 4. Systolic pressure, diastolic pressure, heart rate, and mean arterial pressure are illustrated graphically from 43 hours pre-dosing to 48 hours post-dosing. Telemetry data are displayed as 1-hour bins, where the grey area represents the 12-hour dark cycle. All values ​​are mean ± SEM, n=4-7 per group. [Figure 4A] REGN5381-associated acute reduction in central venous pressure correlates with reflex tachycardia response. Figure 4A shows the individual change from baseline central venous pressure; Figure 4B shows the correlation between change in central venous pressure and change in heart rate. Male beagle dogs aged 11-13 months were anesthetized and instrumented for cardiovascular hemodynamic data and urine collection. Each animal received a single IV bolus of saline (n=6), valsartan 10 mg / kg (n=4), or REGN5381 25 mg / kg (n=6). Left ventricular and systemic pressure waveforms were collected for each animal pre-dose (for baseline measurements) and over the course of a 4-hour post-dose monitoring period. (Figure 4A) Shows the change from baseline central venous pressure (CVP) for each individual animal over the first hour post-dose; each line represents one individual animal. (FIG. 4B) The correlation between change from baseline CVP and change from baseline heart rate (HR) is illustrated for each animal at 15 min post-dose; each symbol represents one individual animal. [Figure 4B]REGN5381-associated acute reduction in central venous pressure correlates with reflex tachycardia response. Figure 4A shows the individual change from baseline central venous pressure; Figure 4B shows the correlation between change in central venous pressure and change in heart rate. Male beagle dogs aged 11-13 months were anesthetized and instrumented for cardiovascular hemodynamic data and urine collection. Each animal received a single IV bolus of saline (n=6), valsartan 10 mg / kg (n=4), or REGN5381 25 mg / kg (n=6). Left ventricular and systemic pressure waveforms were collected for each animal pre-dose (for baseline measurements) and over the course of a 4-hour post-dose monitoring period. (Figure 4A) Shows the change from baseline central venous pressure (CVP) for each individual animal over the first hour post-dose; each line represents one individual animal. (FIG. 4B) The correlation between change from baseline CVP and change from baseline heart rate (HR) is illustrated for each animal at 15 min post-dose; each symbol represents one individual animal. [Diagram 5] FIG. 1 shows that REGN5381 induces an acute reduction in left ventricular end-diastolic pressure. Eleven to thirteen month old male beagle dogs were anesthetized and instrumented for cardiovascular hemodynamic data and urine collection. Each animal received a single IV bolus of saline (n=6), valsartan 10 mg / kg (n=4), or REGN5381 25 mg / kg (n=6). Left ventricular and systemic pressure waveforms were collected for each animal pre-dose (for baseline measurements) and over the course of a four hour post-dose monitoring period. The mean change from baseline left ventricular end-diastolic pressure (LVEDP) for each treatment group over the first hour post-dose is shown. Data are expressed as group mean ± standard error of the mean. [Figure 6]Figures 6A and 6B show that REGN5381 does not induce changes in arterial pressure. Figure 6A shows the mean change from baseline mean arterial pressure; Figure 6B shows the mean change from baseline arterial pulse pressure. Eleven- to thirteen-month-old male beagle dogs were anesthetized and instrumented for cardiovascular hemodynamic data and urine collection. Each animal received a single IV bolus of saline (n=6), valsartan 10 mg / kg (n=4), or REGN5381 25 mg / kg (n=6). Left ventricular and systemic pressure waveforms were collected for each animal pre-dose (for baseline measurements) and over the course of a four-hour post-dose monitoring period. (Figure 6A) The mean change from baseline mean arterial pressure (MAP) for each treatment group over the first hour post-dose is shown. (Figure 6B) The mean change from baseline arterial pulse pressure (PP) for each treatment group over the first hour post-dose is shown. Data are expressed as group mean ± standard error of the mean. [Figure 7] FIG. 1 shows a study flow diagram for Parts A and B of the study described in Example 5. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0035] Before describing the methods of the present invention, it is to be understood that this disclosure is not limited to the particular methods and experimental conditions described, as such methods and conditions can vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, since the scope of the disclosure will be limited only by the appended claims.

[0036] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by those skilled in the art to which this disclosure belongs. Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of this disclosure, the preferred methods and materials are described herein. All publications mentioned herein are incorporated herein by reference in their entirety.

[0037] Methods for inducing hemodynamic changes Provided herein is a method of treating a disease associated with altered hemodynamics in a subject, comprising: (i) selecting a subject with a systolic blood pressure (SBP) between 100 mmHg and 140 mmHg or between 135 mmHg and 160 mmHg; (ii) administering to the subject a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1); A method is disclosed that includes:

[0038] As used herein, the terms "treat", "treating" or "treatment" refer to the reduction or amelioration of the severity of at least one symptom or sign of a disease or disorder associated with altered hemodynamics in a subject by administration of a therapeutic agent, such as an antibody described herein, to a subject in need thereof. The term includes the inhibition of progression of the disease or worsening of the symptoms / signs. The term also includes a favorable prognosis for the disease, i.e., the subject may be free of the disease or have remission of the disease by administration of a therapeutic agent, such as an antibody of the present disclosure. In one embodiment, the symptom or sign refers to the blood pressure of the subject. The therapeutic agent may be administered to the subject in a therapeutic dose, as discussed further below.

[0039] Diseases associated with degenerative hemodynamics include, for example, cardiovascular disease, atherosclerotic carotid artery stenosis, heart failure, stroke, hypertension, and chronic kidney disease.

[0040] As used herein, the phrase "altered hemodynamics" refers to changes in blood flow. The changes in blood flow may include changes in one or more of heart rate, stroke volume, cardiac output, systemic vascular resistance, and blood pressure. In certain embodiments, the altered hemodynamics is in the form of a decrease in venous pressure, left ventricular end-diastolic pressure (LVEDP), and / or arterial pulse pressure (PP). The decrease in venous pressure may be a decrease in central venous pressure (CVP).

[0041] Also provided herein is a method of reducing blood pressure in a subject, comprising: (i) selecting a subject with a systolic blood pressure (SBP) between 100 mmHg and 140 mmHg or between 135 mmHg and 160 mmHg; (ii) administering to the subject a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1); Also disclosed is a method comprising:

[0042] As used herein, the phrase "blood pressure" can refer to any one of systolic blood pressure, diastolic blood pressure, mean arterial pressure (area under the arterial pressure / time curve divided by cardiac cycle duration) and pulse pressure (difference between systolic and diastolic pressure). Methods for measuring blood pressure are known in the art. Blood pressure is measured in millimeters of mercury (mmHg) and is usually expressed as systolic (blood) pressure compared to diastolic (blood) pressure. Measurement methods include auscultatory, oscillometric, ultrasound, and finger cuff methods. It can generally be measured using, for example, a digital blood pressure monitor or a sphygmomanometer.

[0043] Provided herein is a method of inducing a hemodynamic change in a subject, comprising: (i) selecting a subject with a systolic blood pressure (SBP) between 100 mmHg and 140 mmHg or between 135 mmHg and 160 mmHg; (ii) administering to the subject a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1); Also disclosed is a method comprising:

[0044] As used herein, the phrase "hemodynamic changes" refers to changes in blood flow. Changes in blood flow may include changes in one or more of heart rate, stroke volume, cardiac output, systemic vascular resistance, and blood pressure. In certain embodiments, the hemodynamic changes are decreases in venous pressure, left ventricular end-diastolic pressure (LVEDP), and / or arterial pulse pressure (PP). The decrease in venous pressure may be a decrease in central venous pressure (CVP).

[0045] As used herein, the term "subject" refers to an animal, preferably a mammal, more preferably a human, in need of amelioration, prevention, and / or treatment of an NPR1-related disease or disorder, such as hypertension. The term includes human subjects having or at risk of having such a disease or disorder. In some embodiments, the subject is normotensive. In some embodiments, the subject is mildly hypertensive but otherwise healthy. In some embodiments, the subject is hypertensive but otherwise healthy. In some embodiments, the subject is hypertensive or mildly hypertensive.

[0046] Hypertension exists over a range, and in some embodiments is defined as systolic blood pressure (SBP) ≧100mmHg and ≦140mmHg, and diastolic blood pressure (DBP) ≧60mmHg and ≦90mmHg, and in some embodiments is defined as systolic blood pressure (SBP) ≧130mmHg and ≦165mmHg, and diastolic blood pressure (DBP) ≧60mmHg and ≦100mmHg. Subjects who are normotensive versus subjects who are mildly hypertensive versus subjects who are hypertensive can be distinguished by those skilled in the art.

[0047] In certain embodiments, the method herein comprises administering a low dose of an anti-NPR1 antibody or antigen-binding fragment thereof. As used herein, "low dose" refers to an antibody dose that is ≦5 mg / kg of subject's body weight. In certain embodiments, the term refers to an antibody dose that is between 1 mg and 200 mg. In certain embodiments, administration of such a low dose results in a reduction in blood pressure that lasts from 24 hours to up to 56 days in a subject in need thereof.

[0048] Anti-NPR1 antibodies and antigen-binding fragments thereof The method disclosed herein includes administering an antibody or antigen-binding fragment thereof that specifically binds to NPR1. Terms such as "specifically bind" mean that the antibody or antigen-binding fragment thereof forms a complex with the antigen that is relatively stable under physiological conditions. Methods for determining whether an antibody specifically binds to an antigen are well known in the art and include, for example, equilibrium dialysis, surface plasmon resonance, and the like. For example, as used in the context of the present disclosure, an antibody that "specifically binds" to NPR1 has a K d The antibodies that bind to NPR1 or a portion thereof include those with a specific binding affinity of less than about 500nM, less than about 300nM, less than about 200nM, less than about 100nM, less than about 90nM, less than about 80nM, less than about 70nM, less than about 60nM, less than about 50nM, less than about 40nM, less than about 30nM, less than about 20nM, less than about 10nM, less than about 5nM, less than about 4nM, less than about 3nM, less than about 2nM, less than about 1nM or less than about 0.5nM. However, an isolated antibody that specifically binds to human NPR1 may have cross-reactivity with other antigens, such as NPR1 molecules from other (non-human) species. As disclosed herein, an antibody that binds to human NPR1 also cross-reacts with monkey and dog NPR1.

[0049] An antibody or antigen-binding fragment thereof that specifically binds to NPR1 is an agonist of natriuretic peptide receptor 1 (NPR1) as described herein (e.g., an agonist anti-NPR1 antibody). An "activating antibody" or "agonist antibody," as used herein (or an "antibody that enhances or enhances NPR1 activity" or an "antibody that stabilizes the activated conformation"), is intended to refer to an antibody whose binding to NPR1 results in activation of at least one biological activity of NPR1. For example, the methods herein include administering an agonist antibody that specifically binds to NPR1, which, when administered to a subject in need thereof, can reduce systemic blood pressure.

[0050] The term "antibody," as used herein, is intended to refer to an immunoglobulin molecule (i.e., an "intact antibody molecule") that is composed of four polypeptide chains, two heavy (H) chains and two light (L) chains inter-connected by disulfide bonds, as well as multimers thereof (e.g., IgM) or antigen-binding fragments thereof. Each heavy chain contains a heavy chain variable region ("HCVR" or "V H ") and the heavy chain constant region (domain C H 1. C H 2 and C H Each light chain is composed of a light chain variable region ("LCVR" or "V L ") and the light chain constant region ("C L "). V H Area and V L The regions can be further subdivided into regions of hypervariability, called complementarity determining regions (CDRs), interspersed with regions of more conserved nature, called framework regions (FRs). H and V L Each is composed of three CDRs and four FRs, arranged from amino terminus to carboxy terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. In certain embodiments of the present disclosure, the FRs of the antibody (or antigen-binding fragment thereof) may be identical to human germline sequences or may be naturally or artificially modified. An amino acid consensus sequence may be defined based on the aligned analysis of two or more CDRs.

[0051] Substitution of one or more CDR residues or omission of one or more CDRs are also possible. Antibodies that may lack one or two CDRs for binding have been described in the scientific literature. Padlan et al. (1995 FASEB J.9:133-139) analyzed the contact areas between an antibody and its antigen based on published crystal structures and concluded that only about one-fifth to one-third of the CDR residues actually contact the antigen. Padlan also found many antibodies in which one or two CDRs do not have amino acids that contact the antigen (see also Vajdos et al., 2002 J Mol Biol 320:415-428).

[0052] CDR residues that do not contact the antigen can be identified by molecular modeling and / or empirically from regions of the Kabat CDRs outside the Chothia CDRs based on previous studies (e.g., residues H60-H65 of CDRH2 are often not required). If a CDR or its residues are omitted, they are typically replaced with amino acids occupying the corresponding positions in other human antibody sequences or consensus portions of such sequences. Substitution positions within the CDRs and the amino acids to be substituted can also be selected empirically. Empirical substitutions can be conservative or non-conservative.

[0053] The fully human anti-NPR1 monoclonal antibodies described herein may contain one or more amino acid substitutions, insertions and / or deletions in the framework and / or CDR regions of the heavy and light chain variable domains compared to the corresponding germline sequences. Such mutations can be easily ascertained by comparing the amino acid sequences disclosed herein to germline sequences available, for example, from public antibody sequence databases. The present disclosure includes antibodies and antigen-binding fragments thereof derived from any of the amino acid sequences disclosed herein, in which one or more amino acids in one or more framework and / or CDR regions are mutated to the corresponding residue in the germline sequence from which the antibody was derived, or to the corresponding residue in another human germline sequence, or to a conservative amino acid substitution of the corresponding germline residue (such sequence changes are collectively referred to herein as "germline mutations"). Starting from the heavy and light chain variable region sequences disclosed herein, one skilled in the art can easily generate a large number of antibodies and antigen-binding fragments containing one or more individual germline mutations or combinations thereof. In certain embodiments, V H Domain and / or V LAll of the framework and / or CDR residues in the domain are backmutated to the residues found in the original germline sequence from which the antibody was derived. In other embodiments, only certain residues are backmutated to the original germline sequence, for example, only mutated residues found within the first 8 amino acids of FR1 or the last 8 amino acids of FR4, or only mutated residues found within CDR1, CDR2 or CDR3. In other embodiments, one or more of the framework and / or CDR residues are mutated to the corresponding residues in a different germline sequence (i.e., a germline different from the germline sequence from which the antibody was originally derived). Furthermore, the antibodies used in the present disclosure can contain any combination of two or more germline mutations within the framework and / or CDR regions, for example, where certain individual residues are mutated to the corresponding residues in a particular germline sequence, while certain other residues that differ from the original germline sequence are maintained or mutated to the corresponding residues in a different germline sequence. Once obtained, antibodies and antigen-binding fragments containing one or more germline mutations can be readily tested for one or more desired properties, such as improved binding specificity, increased binding affinity, improved or enhanced antagonistic biological properties, reduced immunogenicity, etc. Antibodies and antigen-binding fragments obtained in this general manner are encompassed within the present disclosure.

[0054] The present disclosure also employs fully human anti-NPR1 monoclonal antibodies that include variants of any of the HCVR, LCVR, and / or CDR amino acid sequences disclosed herein, with one or more conservative substitutions. For example, the present disclosure may employ anti-NPR1 antibodies that have HCVR, LCVR, and / or CDR amino acid sequences with, for example, 10 or fewer, 8 or fewer, 6 or fewer, 4 or fewer, etc., conservative amino acid substitutions compared to any of the HCVR, LCVR, and / or CDR amino acid sequences disclosed herein.

[0055] The term "human antibody", or "fully human antibody", as used herein, is intended to include antibodies having variable and constant regions derived from human germline immunoglobulin sequences. Human mAbs described herein can include amino acid residues (e.g., mutations introduced by random or site-specific mutagenesis in vitro or by somatic mutation in vivo), e.g., in the CDRs, particularly in CDR3, that are not encoded by human germline immunoglobulin sequences. However, the term "human antibody" or "fully human antibody", as used herein, is not intended to include mAbs in which CDR sequences derived from the germline of another mammalian species (e.g., mouse) have been grafted onto human FR sequences. The term includes antibodies that are recombinantly produced in or within the cells of a non-human mammal. The term is not intended to include antibodies that are isolated from or generated in a human subject.

[0056] The term "recombinant" as used herein refers to an antibody or antigen-binding fragment thereof disclosed herein that has been created, expressed, isolated, or obtained by techniques or methods known in the art as recombinant DNA technology, including, for example, DNA splicing and transgenic expression. The term refers to an antibody expressed in a non-human mammal (including a transgenic non-human mammal, e.g., a transgenic mouse) or in a cellular (e.g., CHO cell) expression system, or an antibody isolated from a recombinant combinatorial human antibody library.

[0057] The terms "antigen-binding portion" of an antibody, "antigen-binding fragment" of an antibody, and the like, as used herein, include any naturally occurring, enzymatically obtainable, synthetic, or genetically engineered polypeptide or glycoprotein that specifically binds to an antigen to form a complex. The term "antigen-binding fragment" of an antibody or "antibody fragment," as used herein, refers to one or more fragments of an antibody that retain the ability to bind to the NPR1 protein.

[0058] In certain embodiments, the antibodies or antibody fragments described herein can be conjugated to a moiety, such as a ligand or therapeutic moiety (an "immunoconjugate"), a second anti-NPR1 antibody, or any other therapeutic moiety useful for treating an NPR1-related disease or disorder.

[0059] The term "substantial identity" or "substantially identical," when referring to a nucleic acid or a fragment thereof, indicates that when optimally aligned with another nucleic acid (or its complementary strand), with appropriate nucleotide insertions or deletions, there is at least about 90% identity of the nucleotide sequence of the nucleotide bases, more preferably at least about 95%, 96%, 97%, 98% or 99%, as measured by any well-known algorithm of sequence identity, such as FASTA, BLAST or GAP, discussed below. A nucleic acid molecule having substantial identity to a reference nucleic acid molecule can, in certain instances, encode a polypeptide having the same or substantially similar amino acid sequence as the polypeptide encoded by the reference nucleic acid molecule.

[0060] As applied to polypeptides, the term "substantial similarity" or "substantially similar" means that two peptide sequences share at least 90% sequence identity, more preferably at least 95%, 98% or 99% sequence identity, when optimally aligned, for example, by the programs GAP or BESTFIT using default gap weights. Preferably, non-identical residue positions are distinguished by conservative amino acid substitutions. A "conservative amino acid substitution" is one in which an amino acid residue is replaced by another amino acid residue having a side chain (R group) with similar chemical properties (e.g., charge or hydrophobicity). Generally, conservative amino acid substitutions do not substantially alter the functional properties of a protein. When two or more amino acid sequences are distinguished from one another by conservative substitutions, the percent or degree of similarity can be adjusted upwards to correct for the conservative nature of the substitution. Means for making such adjustments are well known to those of skill in the art. See, e.g., Pearson, (1994) Methods Mol. Biol. 24:307-331, which is incorporated herein by reference. Examples of groups of amino acids having side chains with similar chemical properties include: 1) aliphatic side chains: glycine, alanine, valine, leucine, and isoleucine; 2) aliphatic-hydroxyl side chains: serine and threonine; 3) amide-containing side chains: asparagine and glutamine; 4) aromatic side chains: phenylalanine, tyrosine, and tryptophan; 5) basic side chains: lysine, arginine, and histidine; 6) acidic side chains: aspartic acid and glutamic acid; and 7) sulfur-containing side chains: cysteine ​​and methionine. Preferred conservative amino acid substitution groups are: valine-leucine-isoleucine, phenylalanine-tyrosine, lysine-arginine, alanine-valine, glutamic acid-aspartic acid, and asparagine-glutamine. Alternatively, a conservative replacement is any change that has a positive value in the PAM250 log-likelihood matrix disclosed in Gonnetet et al. (1992) Science 256:1443-45, which is incorporated herein by reference.A "reasonably conservative" replacement is any change that has a non-negative value in the PAM250 log-likelihood matrix.

[0061] The sequence similarity of polypeptides is usually measured using sequence analysis software. Protein analysis software uses a measure of similarity assigned to various substitutions, deletions and other modifications, including conservative amino acid substitutions, to match similar sequences. For example, GCG software contains programs such as GAP and BESTFIT, which can be used with default parameters to determine sequence homology or sequence identity between closely related polypeptides, such as homologous polypeptides from various species of organisms, or between a wild-type protein and its mutant protein. See, for example, GCG Version 6.1. Polypeptide sequences can also be compared using FASTA; a program in GCG Version 6.1, with default or recommended parameters. FASTA (e.g., FASTA2 and FASTA3) provides alignment and percent sequence identity of the best overlapping regions between the query sequence and the search sequence (Pearson (2000) supra). Another preferred algorithm for comparing the sequences of the present disclosure to a database containing a large number of sequences from various organisms is the computer program BLAST, particularly BLASTP or TBLASTN, using default parameters. See, e.g., Altschul et al., (1990) J. Mol. Biol. 215:403-410 and (1997) Nucleic Acids Res. 25:3389-3402, each of which is incorporated herein by reference.

[0062] Unless otherwise specifically indicated, the term "antibody" as used herein is understood to encompass an antibody molecule comprising two immunoglobulin heavy chains and two immunoglobulin light chains (i.e., an "intact antibody molecule") as well as antigen-binding fragments thereof. The terms "antigen-binding portion" of an antibody, "antigen-binding fragment" of an antibody, and the like, as used herein, include any naturally occurring, enzymatically obtainable, synthetic, or genetically engineered polypeptide or glycoprotein that specifically binds to an antigen to form a complex. The term "antigen-binding fragment" of an antibody or "antibody fragment" as used herein refers to one or more fragments of an antibody that retain the ability to specifically bind to an NPR1 protein. Antibody fragments include Fab fragments, F(ab') ... 2 The term "antigen-binding fragment" refers to a polypeptide fragment of a multispecific antigen-binding molecule. Antigen-binding fragments of antibodies can be derived from intact antibody molecules using any suitable standard technique, such as, for example, proteolytic digestion or recombinant genetic engineering techniques involving the manipulation and expression of DNA encoding the variable and (optionally) constant domains of the antibody. Such DNA is known and / or readily available, for example, from commercial sources, DNA libraries (including, for example, phage antibody libraries), or can be synthesized. Such DNA can be sequenced and manipulated, for example, by using chemical or molecular biology techniques to place one or more variable and / or constant domains in the appropriate configuration, or to introduce codons, create cysteine ​​residues, modify, add or delete amino acids, etc.

[0063] Non-limiting examples of antigen-binding fragments include: (i) Fab fragments; (ii) F(ab')2 fragments; (iii) Fd fragments; (iv) Fv fragments; (v) single chain Fv (scFv) molecules; (vi) dAb fragments; and (vii) minimal recognition units consisting of amino acid residues mimicking the hypervariable regions (e.g., isolated complementarity determining regions (CDRs), such as CDR3 peptides) of an antibody or limited FR3-CDR3-FR4 peptides. Domain-specific antibodies, single domain antibodies, domain deleted antibodies, chimeric antibodies, CDR-grafted antibodies, diabodies, triabodies, tetrabodies, minibodies, nanobodies (e.g., monovalent nanobodies, bivalent nanobodies, etc.), small modular immunopharmaceuticals (SMIPs), and other engineered molecules such as shark variable IgNAR domains are also encompassed within the term "antigen-binding fragment" as used herein.

[0064] Antigen-binding fragments of antibodies usually contain at least one variable domain. A variable domain can be of any size or amino acid composition and generally contains at least one CDR, which is adjacent or in frame with one or more framework sequences. L A V associated with the domain H In the case of an antigen-binding fragment having a domain, H Domain and above V L The domains can be positioned relative to each other in any suitable configuration. For example, the variable region can be a dimer, with the V H -V H , V H -V L or V L -V L Alternatively, the antigen-binding fragment of an antibody may contain a dimer of monomeric V H domain, and the monomer V L It may contain domains.

[0065] In certain embodiments, an antigen-binding fragment of an antibody can contain at least one variable domain covalently linked to at least one constant domain. Non-limiting exemplary configurations of variable and constant domains that can be found in an antigen-binding fragment of an antibody of the present disclosure include: (i) a V H -C H 1;(ii)V H -CH 2 (iii) V H -C H 3;(iv)V H -C H 1-C H 2;(v)V H -C H 1-C H 2-C H 3;(vi)V H -C H 2-C H 3;(vii)V H -C L ;(viii)V L -C H 1;(ix)V L -C H 2;(x)V L -C H 3;(xi)V L -C H 1-C H 2;(xii)V L -C H 1-C H 2-C H 3;(xiii)V L -C H 2-C H 3; and (xiv) V L -C LIn any configuration of variable and constant domains, including any of the exemplary configurations listed above, the variable and constant domains may be directly linked to each other or may be linked by a complete or partial hinge or linker region. The hinge region may consist of at least two (e.g., 5, 10, 15, 20, 40, 60 or more) amino acids, resulting in a flexible or semi-flexible linkage between adjacent variable and / or constant domains within a single polypeptide molecule. Furthermore, antigen-binding fragments of antibodies of the present disclosure may be homodimers or heterodimers (or other multimers) of any of the variable and constant domain configurations listed above, linked together and / or with one or more monomeric Vs. H Domain or V L It may be included in a non-covalent association with the domain (eg, by one or more disulfide bonds).

[0066] As with intact antibody molecules, antigen-binding fragments may be monospecific or multispecific (e.g., bispecific). Multispecific antigen-binding fragments of antibodies typically contain at least two different variable domains, where each variable domain can specifically bind to a separate antigen or to a different epitope on the same antigen. Any multispecific antibody format, including the exemplary bispecific antibody formats disclosed herein, can be adapted for use in the context of the antigen-binding fragments of antibodies of the present disclosure using routine techniques available in the art.

[0067] According to certain exemplary embodiments, an anti-NPR1 antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR), a light chain variable region (LCVR), and / or a complementarity determining region comprising the amino acid sequence of any of the anti-NPR1 antibodies described in U.S. Patent Application Publication No. 20200123263, the entirety of which is incorporated herein by reference. In certain exemplary embodiments, an anti-NPR1 antibody or antigen-binding fragment thereof that can be used in the context of the present disclosure comprises a heavy chain complementarity determining region (HCDR) of the heavy chain variable region (HCVR) comprising the amino acid sequence of SEQ ID NO:1 and a light chain complementarity determining region (LCDR) of the light chain variable region (LCVR) comprising the amino acid sequence of SEQ ID NO:2. According to certain embodiments, the anti-NPR1 antibody or antigen-binding fragment thereof comprises three HCDRs (HCDR1, HCDR2 and HCDR3) and three LCDRs (LCDR1, LCDR2 and LCDR3), where HCDR1 comprises the amino acid sequence of SEQ ID NO:3; HCDR2 comprises the amino acid sequence of SEQ ID NO:4; HCDR3 comprises the amino acid sequence of SEQ ID NO:5; LCDR1 comprises the amino acid sequence of SEQ ID NO:6; LCDR2 comprises the amino acid sequence of VAS; LCDR3 comprises the amino acid sequence of SEQ ID NO:8. In yet other embodiments, the anti-NPR1 antibody or antigen-binding fragment thereof comprises a HCVR comprising SEQ ID NO:1 and a LCVR comprising SEQ ID NO:2. In certain embodiments, the method of the disclosure comprises the use of an anti-NPR1 antibody, where the antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO:9. In some embodiments, the anti-NPR1 antibody comprises a light chain comprising the amino acid sequence of SEQ ID NO:10. An exemplary antibody comprising a heavy chain variable region comprising the amino acid sequence of SEQ ID NO:1 and a light chain variable region comprising the amino acid sequence of SEQ ID NO:2 is the fully human anti-NPR1 antibody known as REGN5381.

[0068] According to certain exemplary embodiments, the method of the present disclosure includes the use of REGN5381 or its biological equivalent. As used herein, the term "biological equivalent" refers to an anti-NPR1 antibody or NPR1 binding protein or fragment thereof that is a pharmaceutical equivalent or pharmaceutical substitute, whose rate and / or extent of absorption does not significantly differ from that of a reference antibody (e.g., REGN5381) when administered at the same molar dose, either in a single dose or multiple doses, under similar experimental conditions. In the context of the present disclosure, the term "biological equivalent" includes an antigen binding protein that binds to NPR1 but does not have clinically meaningful differences from REGN5381 in terms of safety, purity and / or potency.

[0069] According to certain embodiments of the present disclosure, the anti-human NPR1 or antigen-binding fragment thereof comprises a HCVR having 90%, 95%, 97% or 98% sequence identity to SEQ ID NO:1.

[0070] According to certain embodiments of the present disclosure, the anti-human NPR1 or antigen-binding fragment thereof comprises an LCVR having 90%, 95%, 97% or 98% sequence identity to SEQ ID NO:2.

[0071] According to certain embodiments of the present disclosure, the anti-human NPR1 or antigen-binding fragment thereof comprises a HCVR comprising the amino acid sequence of SEQ ID NO: 1 with no more than five amino acid substitutions. According to certain embodiments of the present disclosure, the anti-human NPR1 or antigen-binding fragment thereof comprises a LCVR comprising the amino acid sequence of SEQ ID NO: 2 with no more than two amino acid substitutions.

[0072] Sequence identity can be measured by methods known in the art (eg, GAP, BESTFIT, and BLAST).

[0073] The present disclosure also includes the use of an anti-NPR1 antibody or antigen-binding fragment thereof in a method of lowering blood pressure or causing hemodynamic changes, wherein the anti-NPR1 antibody or antigen-binding fragment thereof comprises a variant of any of the HCVR, LCVR and / or CDR amino acid sequences disclosed herein having one or more conservative amino acid substitutions. For example, the present disclosure includes the use of an anti-NPR1 antibody or antigen-binding fragment thereof having an HCVR, LCVR and / or CDR amino acid sequence with, for example, 10 or less, 8 or less, 6 or less, 4 or less, etc., conservative amino acid substitutions compared to any of the HCVR, LCVR and / or CDR amino acid sequences disclosed herein.

[0074] Other anti-NPR1 antibodies or antigen-binding fragments thereof that can be used in the context of the methods of the present disclosure include, for example, any of the anti-NPR1 antibodies described in US2012 / 0114659A1. The entire portions of the aforementioned publications identifying anti-NPR1 antibodies are incorporated herein by reference.

[0075] Therapeutic Administration and Formulations The methods described herein include administering an anti-NPR1 antibody or antigen-binding fragment thereof to a subject in need thereof. The anti-NPR1 antibody or antigen-binding fragment thereof can be included in a pharmaceutical composition. The pharmaceutical (or "therapeutic") composition according to the present disclosure is administered with suitable carriers, excipients, and other agents that are incorporated into the formulation to improve entry, delivery, tolerability, etc. A large number of suitable formulations can be found in a formulary known to any pharmaceutical chemist: Remington's Pharmaceutical Sciences, Mack Publishing Company, Easton, PA. These formulations include, for example, powders, pastes, ointments, jellies, waxes, oils, lipids, lipid (cationic or anionic)-containing vesicles (such as LIPOFECTIN™), DNA conjugates, anhydrous absorption pastes, oil-in-water and water-in-oil emulsions, emulsion carbowax (polyethylene glycol of various molecular weights), semi-solid gels, and semi-solid mixtures containing carbowax. See also Powell et al., "Compendium of excipients for parenteral formulations," PDA (1998) J Pharm Sci Technol 52:238-311.

[0076] The dose of the antibody can vary depending on the age and size of the subject to be administered, the target disease, the condition, the route of administration, etc. Depending on the severity of the condition, the frequency and duration of treatment can be adjusted. In certain embodiments, the antibody or antigen-binding fragment thereof can be administered as a single dose. In other embodiments, the antibody or antigen-binding fragment thereof can be administered as an initial dose, followed by a second dose or multiple subsequent doses of the antibody or antigen-binding fragment thereof in an amount that may be about the same as the amount of the initial dose or less, where the subsequent doses are separated by at least 1-3 days; at least 1 week; at least 2 weeks; at least 3 weeks; at least 4 weeks; at least 5 weeks; at least 6 weeks; at least 7 weeks; at least 8 weeks; at least 9 weeks; at least 10 weeks; at least 12 weeks; or at least 14 weeks. In certain embodiments, the subsequent doses are administered at least 2 weeks, at least 3 weeks, or at least 4 weeks after the initial dose. In a further embodiment, the reduction in blood pressure resulting from administration of the anti-NPR1 antibody or antigen-binding fragment thereof is sustained between administration of the first dose and administration of subsequent doses.

[0077] Various delivery systems are known and can be used to administer the pharmaceutical compositions of the present disclosure, for example, encapsulation in liposomes, microparticles, microcapsules, recombinant cells capable of expressing mutant viruses, receptor-mediated endocytosis (see, for example, Wu et al. (1987) J.Biol.Chem.262:4429-4432). Methods of introduction include, but are not limited to, intradermal, transdermal, intramuscular, intraperitoneal, intravenous, subcutaneous, intranasal, epidural and oral routes. The compositions can be administered by any convenient route, for example, by infusion or bolus injection, by absorption through epithelial or mucocutaneous linings (e.g., oral mucosa, rectal and intestinal mucosa, etc.), and can be administered together with other biologically active agents. Administration can be systemic or local. The pharmaceutical compositions can also be delivered in vesicles, particularly liposomes (see, for example, Langer (1990) Science 249:1527-1533).

[0078] The use of nanoparticles to deliver the antibodies described herein is also contemplated herein. Antibody-conjugated nanoparticles can be used for both therapeutic and diagnostic applications. Antibody-conjugated nanoparticles and methods of preparation and use are described in detail in Arruebo, M. et al., 2009 ("Antibody-conjugated nanoparticles for biomedical applications" in J.Nanomat., Vol. 2009, Article ID 439389, p. 24, doi:10.1155 / 2009 / 439389), which is incorporated herein by reference. Nanoparticles can be developed and conjugated to antibodies contained in pharmaceutical compositions against target cells to target cells. Nanoparticles for drug delivery are also described, for example, in US8257740 or US8246995, each of which is incorporated herein in its entirety.

[0079] In certain circumstances, the pharmaceutical composition can be delivered in a controlled release system. In one embodiment, a pump can be used. In another embodiment, a polymeric material can be used. In yet another embodiment, the controlled release system can be placed in close proximity to the target of the composition, such that only a fraction of the systemic dose is required.

[0080] The injectable preparations include dosage forms for intravenous, subcutaneous, intracranial, intraperitoneal and intramuscular injections, drip infusions, etc. Such injectable preparations can be manufactured by known methods.

[0081] The pharmaceutical composition of the present disclosure can be delivered subcutaneously or intravenously using a standard needle and syringe. In addition, in relation to subcutaneous delivery, a pen delivery device is easy to apply when delivering the pharmaceutical composition of the present disclosure. Such a pen delivery device may be reusable or disposable. A reusable pen delivery device generally utilizes a replaceable cartridge containing the pharmaceutical composition. Once all the pharmaceutical composition in the cartridge has been administered and the cartridge is empty, the empty cartridge can be easily discarded and replaced with a new cartridge containing the pharmaceutical composition. The pen delivery device may then be reused. In a disposable pen delivery device, there is no replaceable cartridge. Rather, the disposable pen delivery device is pre-filled with the pharmaceutical composition held in a reservoir within the device. Once the reservoir is empty of the pharmaceutical composition, the entire device is discarded.

[0082] Advantageously, the above-mentioned pharmaceutical composition for oral or parenteral use is prepared into a dosage form of a unit dose suitable for the dosage of the active ingredient. Such dosage forms of a unit dose include, for example, tablets, pills, capsules, injections (ampoules), suppositories, etc. The amount of the antibody contained, particularly in the form of an injection, is generally about 5 to about 500 mg or about 1 mg to about 200 mg per dosage form of a unit dose.

[0083] Combination therapy The disclosed methods include administering an anti-NPR1 antibody or antigen-binding fragment thereof in combination with an additional therapeutic agent or therapy. The combination therapy can include the antibodies or biologically active fragments of antibodies described herein and any additional therapeutic agents that can be advantageously combined therewith.

[0084] Depending on the disease, disorder, or condition, the antibodies described herein can be used in combination with one or more additional therapeutic agents, including, but not limited to, aldosterone antagonists (e.g., eplerenone, spironolactone), alpha-adrenergic blockers (e.g., doxazosin, phenoxybenzamine, phentolamine, prazosin, terazosin), angiotensin-converting enzyme (ACE) inhibitors (e.g., benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, , perindopril, quinapril, ramipril, trandolapril), arterial vasodilators (e.g., hydrazine, minoxidil), autonomic ganglionic vasodilators (e.g., mecamylamine), beta-adrenergic blocking agents (acebutolol, atenolol, betaxolol, bisoprolol, carvedilol, carteolol, esmolol, labetrol, metoprolol, nadolol, penbuterol, pindolol, propranolol, timolol), catecholamine-depleting sympatholytic agents (e.g., deserpinidine, reserpine), central alpha-2 antagonists (e.g., cebulol, atenolol, betaxolol, bisoprolol, carvedilol, carteolol, esmolol, labetrol, metoprolol, nadolol, penbuterol, pindolol, propranolol, timolol), Adrenergic agonists (e.g., clonidine, guanabenzyl, guanfacine, methyldopa), calcium channel blockers (diltiazem, verapamil, amlodipine, felodipine, isradipine, nicadipine, nifedipine, nisoldipine), diuretics (e.g., bumetanide, ethaclinic acid, furosemide, torsemide, chlorothiazide, hydrochlorothiazide, hydroflumethiazide, methyclothiazide, polythiazide, chlorthalidone, indapamide, metolazone), renin inhibitors (e.g., aliskiren), anticoagulants (e.g., coumadan, dabigatran ... gadolinium, apixaban), antiplatelet agents (e.g., aspirin, clopidogrel), cholesterol lowering agents (e.g., statins, PCSK9 inhibitors such as alirocumab), vasodilators (e.g., minoxidil, hydralazine, nitrates), digitalis, surgery (e.g., angioplasty, coronary artery bypass surgery, heart transplant), implantable devices (e.g., valve replacement, defibrillator, left ventricular assist device, pacemaker), anti-tumor therapy (e.g., chemotherapy, surgery, radiation, PD-1 inhibitors), insulin, GLP1 agonists (e.g., exenatide, liraglutide,Lixisenatide, albiglutide, dulaglutide, semaglutide), metformin, blood pressure medications, dialysis, bone marrow stimulants, hemofiltration, lifestyle modifications, and dietary supplements.

[0085] As used herein, the term "in combination with" means that the additional therapeutic active ingredient may be administered prior to, simultaneously with, or after administration of the anti-NPR1 antibody or antigen-binding fragment thereof. The term "in combination with" also includes sequential or simultaneous administration of the anti-NPR1 antibody and a second therapeutic agent.

[0086] The additional therapeutic active ingredient can be administered to the subject prior to administration of the anti-NPR1 antibody or antigen-binding fragment thereof. For example, if the first component is administered 1 week, 72 hours, 60 hours, 48 ​​hours, 36 hours, 24 hours, 12 hours, 6 hours, 5 hours, 4 hours, 3 hours, 2 hours, 1 hour, 30 minutes, or less than 30 minutes before administration of the second component, the first component can be considered to be administered "before" the second component. In other embodiments, the additional therapeutic active ingredient can be administered to the subject after administration of the anti-NPR1 antibody of the present disclosure. For example, if the first component is administered 30 minutes, 1 hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 12 hours, 24 hours, 36 hours, 48 ​​hours, 60 hours, 72 hours, or more after administration of the second component, the first component can be considered to be administered "after" the second component. In yet other embodiments, the additional therapeutic active ingredient may be administered to the subject simultaneously with administration of the anti-NPR1 antibody or antigen-binding fragment thereof. "Concurrent" administration, for purposes of this disclosure, includes, for example, administration of the anti-NPR1 antibody and the additional therapeutic active ingredient in a single dosage form to the subject, or in separate dosage forms administered to the subject within about 30 minutes or less of each other. When administered in separate dosage forms, each dosage form may be administered via the same route (e.g., both the anti-NPR1 antibody and the additional therapeutic active ingredient may be administered intravenously, etc.); alternatively, each dosage form may be administered via a different route (e.g., the anti-NPR1 antibody may be administered intravenously and the additional therapeutic active ingredient may be administered orally). In any case, administration of the ingredients in a single dosage form, in separate dosage forms by the same route, or in separate dosage forms by different routes, are all considered to be "concurrent administration" for purposes of this disclosure. For purposes of this disclosure, administration of an anti-NPR1 antibody "before," "concurrently with," or "after" administration of an additional therapeutically active ingredient (as these terms are defined herein above) is considered administration of an anti-NPR1 antibody "in combination with" the additional therapeutically active ingredient.

[0087] Dosage The amount of anti-NPR1 antibody or antigen-binding fragment thereof administered to a subject according to the methods disclosed herein is generally a therapeutically effective amount. The phrase "therapeutically effective amount" as used herein refers to an amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1) and produces a desired effect, for which a therapeutically effective amount is administered. In certain embodiments, the desired effect is to lower blood pressure in a subject. In further embodiments, the desired effect is to lower blood pressure in a subject without causing adverse effects associated with low blood pressure (including but not limited to nausea, lightheadedness, vomiting, lack of oxygen, heart problems, kidney damage, fainting and related injuries), changes in locomotion and even death.

[0088] In certain embodiments, dosage may be expressed as a flat dose or as a weight-based dose.

[0089] In certain embodiments, a therapeutically effective amount of an anti-NPR1 antibody or antigen-binding fragment thereof, such as REGN5381 or a biological equivalent thereof, can be from about 0.01 mg to about 500 mg, from about 0.1 mg to about 400 mg, from about 1 mg to about 300 mg, from about 5 mg to about 250 mg, from about 10 mg to about 200 mg, or from about 5 mg to about 150 mg of antibody. For example, in various embodiments, the amount of antibody is as follows: about 0.01 mg, about 0.05 mg, about 0.1 mg, about 0.2 mg, about 0.3 mg, about 0.4 mg, about 0.5 mg, about 1 mg, about 2 mg, about 3 mg, about 4 mg, about 5 mg, about 6 mg, about 7 mg, about 8 mg, about 9 mg, about 10 mg, about 11 mg, about 12 mg, about 13 mg, about 14 mg, about 15 mg, about 16 mg, about 17mg, about 18mg, about 19mg, about 20mg, about 21mg, about 22mg, about 23mg, about 24mg, about 25mg, about 26mg, about 27mg, about 28mg, about 29mg, about 30mg, about 31mg, about 32mg, about 33mg, about 34mg, about 35mg, about 36mg, about 37mg, about 38mg, about 39mg, about 40mg, about 41mg, about 42mg, about 43mg, about 44mg, about 45mg, about 46mg, about 47mg, about 48mg, about 49mg, about 50mg, about 55mg, about 60mg, about 65mg, about 70mg, about 75mg, about 80mg, about 85mg, about 90mg, about 95mg, about 100mg, about 105mg, about 110mg, about 115mg, about 120mg, about 125mg, about 130mg, about 135mg, about 140mg, about 145mg, about 150mg, about 1 55 mg, about 160 mg, about 165 mg, about 170 mg, about 175 mg, about 180 mg, about 185 mg, about 190 mg, about 195 mg, about 200 mg, about 210 mg, about 220 mg, about 230 mg, about 240 mg, about 250 mg, about 260 mg, about 270 mg, about 280 mg, about 290 mg, about 300 mg, about 350 mg, about 400 mg, about 450 mg, or about 500 mg. In certain embodiments, the antibody or antigen-binding fragment thereof is administered at a low dose of about 1 mg to about 200 mg.

[0090] The amount of antibody contained within an individual dose can be expressed in milligrams of antibody per kilogram of subject body weight (i.e., mg / kg). In certain embodiments, the antibodies used in the methods disclosed herein can be administered to a subject at a dose of about 0.0001 to about 50 mg / kg of subject body weight. In certain embodiments, the anti-NPR1 antibodies can be administered at a dose of about 0.1 mg / kg of subject body weight to about 25 mg / kg of subject body weight. In certain embodiments, the methods of the disclosure include administration of the antibody at a dose of about 0.1 mg / kg of subject body weight to 5 mg / kg of subject body weight, 1 mg / kg of subject body weight to 3 mg / kg of subject body weight, 1 mg / kg of subject body weight to 5 mg / kg of subject body weight, 1 mg / kg of subject body weight to 10 mg / kg of subject body weight, 1 mg / kg of subject body weight, 3 mg / kg of subject body weight, 5 mg / kg of subject body weight, or 10 mg / kg of subject body weight. In certain embodiments, the antibody or antigen-binding fragment thereof is administered at a dose of about 0.031 to about 5 mg / kg of subject body weight or at a dose of about 5 mg / kg of subject body weight to about 25 mg / kg of subject body weight. In further embodiments, a low dose of the antibody or antigen-binding fragment is administered to the subject. In one embodiment, the low dose is ≦about 5 mg / kg. EXAMPLES

[0091] The following examples are provided to provide those skilled in the art with a complete disclosure and description of how to make and use the disclosed methods and compositions, and are not intended to limit the scope of what the inventors regard as their disclosure. Efforts have been made to ensure accuracy with respect to numbers used (e.g., amounts, temperature, etc.), but some experimental error and deviation should be allowed for. Unless otherwise indicated, parts are parts by weight, molecular weight is average molecular weight, temperature is in degrees Celsius, room temperature is about 25°C, and pressure is at or near atmospheric pressure.

[0092] An exemplary antibody used in the following examples is REGN5381, a fully human agonistic antibody that specifically binds NPR1 and comprises HCVR / LCVR of SEQ ID NO:1 / 2, HCDR1-HCDR2-HCDR3-LCDR1-LCDR2-LCDR3 of SEQ ID NO:3-SEQ ID NO:4-SEQ ID NO:5-SEQ ID NO:6-VAS-SEQ ID NO:8. See also US20200123263. EXAMPLES

[0093] Normotensive NPR1 hu / hu Effects of a single dose of NPR1 agonist mAb (R5381) on systemic blood pressure in mice Experimental procedure Telemetry normotensive NPR1 hu / hu To assess the dose response of low doses of the NPR1 agonist antibody REGN5381 on systemic blood pressure in mice, we used 11-week-old male NPR1 mice. hu / hu Mice (n=30) were implanted with PA-C10 telemeters (DSI, St. Paul, MN) and allowed to recover for at least 7 days before being assigned to groups (Groups 1-5) (Table 1). Animals were housed individually under standard conditions (temperature 64°F-84°F (18°C-29°C), relative humidity 30%-70%) and maintained on a 12-h light / 12-h dark cycle. Food (Research Diets standard pelleted chow) and water were provided ad libitum.

[0094] [Table 1]

[0095] Test proteins were administered to corresponding animals via subcutaneous injection once on day 0. Dose volumes for each animal were based on the most recent body weight measurement. Blood samples were collected on day 7 and termination of the study for serum biomarker assessment, and urine was collected on day 22 for urinary biomarker analysis.

[0096] Systolic pressure, diastolic pressure, mean arterial pressure, pulse pressure, and heart rate were collected for 10 seconds every 10 minutes for the duration of the study. Graphical telemetry data was obtained from animals with a survival signal for the duration of the survival portion of the study.

[0097] result Blood pressure (Figures 1A-1C and 1E) was measured in all normotensive NPR1 mice that received a single dose of REGN5381. hu / hu The magnitude of pressure reduction was significant and sustained in mice. The magnitude of pressure reduction was largely dose-dependent, with the highest dose (25 mg / kg) producing a reduction in pressure of approximately 10-15 mmHg for the duration of the study. Figure 1 shows the changes in (1A) systolic, (1B) diastolic, (1C) pulse pressure, (1D) heart rate, and (1E) mean arterial pressure following administration of a single dose of the NPR1 agonist mAb REGN5381 or PBS. REGN5381 produced significant reductions in systolic blood pressure, diastolic blood pressure, pulse pressure, and mean arterial blood pressure (Figure 1, Table 2). The duration of the pharmacodynamic effect was dose-proportional and was maintained for up to 26 days at the highest dose of REGN5381 (25 mg / kg). A compensatory increase in heart rate was observed at doses of 0.5 mg / kg and above compared to PBS control-dosed animals. Significant and sustained blood pressure effects were detected at single doses of REGN5381 as low as 0.125 mg / kg. The duration of blood pressure reduction was also dose-dependent and consistent with REGN5381 serum concentrations on day 7 in that the highest exposure correlated with the longest test article-related effects on hemodynamic endpoints (Figure 2). Peak acute pressure reduction appeared to be dose-dependent, but in this case the duration of blood pressure effect was approximately 10 days at 0.125 mg / kg and longer than 26 days for 25 mg / kg. No effect on urine volume was observed at day 22, and urinary cGMP concentrations assessed on day 22 (Table 3) were not significantly different from control values ​​for any of the REGN5381 groups.

[0098] [Table 2]

[0099] [Table 3] EXAMPLES

[0100] Investigation of a single intravenous low dose of REGN5381 on systemic blood pressure in telemetered normotensive cynomolgus monkeys Experimental procedure To identify intravenous low doses of the NPR1 agonist antibody REGN5381 that induced a transient but detectable decrease in systemic blood pressure in telemetered normotensive cynomolgus monkeys, male cynomolgus monkeys (n=22) weighing 3-5 kg ​​were pre-implanted with PhysioTel Digital model L11 telemeters (DSI, St. Paul, MN). Animals were allowed to acclimate to laboratory housing for at least 5 weeks before random assignment to dose groups (Groups 1-4) (Table 4). Animals were housed under standard conditions (temperature 64°F-84°F (18°C-29°C); relative humidity 30%-70%) and maintained on a 12-hour light / 12-hour dark cycle. Food (PMI Nutrition International Certified Primate Chow No. 5048) and water were provided ad libitum.

[0101] [Table 4]

[0102] Test proteins or saline control were administered to corresponding animals via intravenous injection once on day 1. Dose volumes for each animal were based on the most recent body weight measurement. Blood samples for drug level assessment were taken at baseline, 72 hours post-dose, and on days 7 and 14 of the study.

[0103] Systolic, diastolic, mean arterial pressure, and heart rate were collected continuously for the duration of the experiment, with data binned into 60-minute averages for the duration of the study period. Telemetry data was obtained from animals with a survival signal for the duration of the survival portion of the study.

[0104] result Blood pressure (Tables 5 and 6; Figures 3A, 3B, and 3D) was reduced in a dose-dependent manner over the first 24 hours. Statistically significant reductions in systolic pressure were observed over the first 24 hours post-dosing in the 31 and 125 μg / kg groups. Systolic pressure was reduced by approximately 3.0 and 5.1 mmHg, respectively. These effects were temporary, with pressure returning to saline control levels over the 24-48 hour post-dosing period. Statistically significant reductions in diastolic pressure were observed over the first 24 hours post-dosing in the 31 and 125 μg / kg groups. Diastolic pressure was reduced by approximately 2.6 and 4.2 mmHg, respectively. These effects were temporary, with pressure returning to saline control levels over the 24-48 hour post-dosing period. Consistent with the effects on systolic and diastolic pressures, statistically significant reductions in mean arterial pressure (MAP) were observed over the first 24 hours post-dosing in the 31 and 125 μg / kg groups. MAP was reduced by approximately 2.7 and 4.8 mmHg, respectively. These effects were temporary, with pressures returning to saline control levels over the 24-48 hour post-dosing period. The lower dose of 8 μg / kg caused a trendy but not statistically significant reduction in systolic, diastolic, and MAP over the first 24 hours, but no differences were observed thereafter. After dosing, heart rate was reduced in all animals. No statistically significant REGN5381-related effects on heart rate were observed at any of the time points evaluated, although a trendy but not statistically significant increase was observed at 125 μg / kg when compared to saline controls.

[0105] [Table 5]

[0106] [Table 6]

[0107] Total REGN5381 serum concentrations were measured using an enzyme-linked immunosorbent assay. Serum samples were obtained pre-dose, then 72 hours and on days 7 and 14 post-dose. REGN5381 concentrations were below the limit of quantification of 0.078 μg / mL at 72 hours post-dose in all samples except the 125 μg / kg group.

[0108] [Table 7]

[0109] FIG. 3A shows the change in systolic pressure following administration of a single dose of the NPR1 agonist mAb REGN5381 NPR1 agonist mAb or saline. FIG. 3B shows the change in diastolic pressure following administration of a single dose of the NPR1 agonist mAb REGN5381 NPR1 agonist mAb or saline. FIG. 3C shows the change in heart rate following administration of a single dose of the NPR1 agonist mAb REGN5381 NPR1 agonist mAb or saline. FIG. 3D shows the change in mean arterial pressure following administration of a single dose of the NPR1 agonist mAb REGN5381 NPR1 agonist mAb or saline. The key finding is that the NPR1 agonist mAb REGN5381 produced a statistically significant, but transient, effect on blood pressure following a single intravenous dose as low as 31 μg / kg. These effects were dose-dependent and lasted for less than 48 hours as evidenced by the lack of statistically significant differences in any of the REGN5381-treated animals versus control animals over the 24-48 hour post-dosing period. These pressure effects occurred independent of any significant effects on heart rate.

[0110] Further data show the effect of REGN5381 on plasma volume (vs. 5% blood drawdown or control). Changes in plasma volume over time were measured in 24 male cynomolgus monkeys that were assigned to one of three groups on day 0 and dosed on day 6 with saline (control, n=8), saline + 5% blood drawdown (n=8), or REGN5381 25 mg / kg (n=8) via the cephalic or saphenous vein. Blood samples of 3-5 ml were taken from all animals on days 0 (baseline), 6 (dosing), and 20 (recovery) for blood volume measurements. Samples were analyzed for total radioactivity. Data are presented as group means ± standard error of the mean. Statistical significance was determined using two-way repeated measures ANOVA followed by Tukey's post-hoc multiple comparison test (α=0.05).

[0111] [Table 8]

[0112] REGN5381 significantly reduced mean plasma volume and was effective in reducing plasma volume such that there was a 5% blood drawdown. EXAMPLES

[0113] Acute Hemodynamic Evaluation of REGN5381 in Anesthetized Beagle Dogs Experimental procedure The purpose of this study was to evaluate the acute hemodynamic profile of REGN5381 when administered via a single IV bolus injection to anesthetized male beagle dogs. To evaluate the acute hemodynamic profile of REGN5381 when administered via a single IV bolus injection to anesthetized male beagle dogs, each animal was anesthetized and instrumented for cardiovascular hemodynamic data acquisition and urine collection prior to dose administration. Each animal received a single IV bolus dose of saline (n=6), valsartan 10 mg / kg (n=4), or REGN5381 25 mg / kg (n=6). Following dose administration, animals were monitored for 4 hours to evaluate hemodynamic changes. Left ventricular and systemic pressure waveforms were collected for each animal pre-dose and over the course of a 4-hour post-dose monitoring period; the pre-dose measurements were used as the baseline for each animal. End-systolic and end-diastolic volumes were assessed pre-dose and hourly after dosing using transthoracic echocardiograms. Urine was collected from the bladder and its volume was measured pre-dose and hourly after dosing. Renal cortical and medullary perfusion, measured using neutron-activated microspheres, was determined pre-dose and 2 and 4 hours after dosing for some animals receiving REGN5381 (n=4) and saline (n=4). Pre-dose measurements were used as baseline for each animal.

[0114] result REGN5381 produced an acute, transient mean decrease from baseline central venous pressure (CVP) over the course of the first hour after dosing, which was accompanied by an acute, transient mean increase from baseline HR. The observed changes in mean CVP and HR were attributed to readings from three of six animals that received REGN5381, where the degree of change in CVP correlated with the degree of change in HR (Figures 4A and 4B). In addition, a mean decrease from baseline left ventricular end-diastolic pressure (LVEDP) was observed over the course of the first hour after dosing, which was attributed to the same three animals, consistent with REGN5381-induced preload reduction, which was consistent with the observed effect on CVP in these three animals (Figure 5).

[0115] In the other three animals that received REGN5381, post-dose CVP and heart rate over the course of the first hour post-dose were similar to baseline levels. Exposure assessments indicated that all animals had comparable REGN5381 serum concentrations (data not shown). Consistent with the arterial systolic pressure data, no changes in MAP or systemic vascular resistance (SVR) were observed. A transient mean decrease from baseline in arterial pulse pressure (PP) was observed (Figures 6A and 6B). The lack of change in arterial pressure and the transient nature of the hemodynamic effects were not consistent with those observed in conscious telemetry dogs (data not shown), non-human primates (data not shown), and mice (data not reported), likely due to the experimental conditions associated with this surgical procedure, including, but not limited to, anesthesia (both induction and maintenance), lateral positioning, and mechanical ventilation during the data acquisition process.

[0116] In animals receiving valsartan, no mean changes in CVP or HR were observed over the course of the first hour post-dose; in animals receiving valsartan, an early, transient mean decrease from baseline LVEDP was observed over the course of the first hour post-dose; however, this was attributed to readings from one animal (probably due to poor catheter placement). In animals receiving valsartan, mean decreases from baseline MAP and PP were observed over the course of the first hour post-dose, as well as mean decreases in SVR over the 4-hour monitoring period, consistent with valsartan's mechanism of action as an angiotensin II receptor blocker.

[0117] No mean changes in CVP, HR, LVEDP, PP, or SVR were observed in animals receiving saline. A slight increase in MAP was observed in animals receiving saline; however, this effect was likely due to the surgical preparation (i.e., temperature and / or depth of the anesthetic plane).

[0118] Overall, in dogs responding to REGN5381, these results show that REGN5381 induces robust, transient effects on venous pressure with correlated reflex tachycardial responses when administered to anesthetized, lateral-lying, instrumented normotensive male beagle dogs. The observed hemodynamic changes are independent of any changes in urine volume or systemic organ perfusion. The observed REGN5381-induced hemodynamic effects are different from those induced by the standard of care, valsartan, suggesting a different mechanism of action for the REGN5381-induced hemodynamic effects.

[0119] Finally, REGN5381 did not affect renal perfusion or induce a diuretic effect. In animals receiving REGN5381, no changes from baseline perfusion of the renal cortex or medulla were observed at 2 and 4 hours post-dose. In addition, no changes from baseline urine volume were observed among animals receiving REGN5381 at the time points assessed. A significant increase in urine volume was observed at 1 and 2 hours post-dose among animals receiving valsartan when compared with time-matched control animals. No mean changes in urine volume or renal perfusion were observed in animals receiving saline.

[0120] Thus, in a study evaluating the acute hemodynamic effects of a single 25 mg / kg dose of REGN5381 administered IV in anesthetized dogs, REGN5381 acutely reduced venous pressure without any effect on arterial pressure in 3 of 6 animals over the course of the first hour after dosing. REGN5381 induced an acute mean reduction in central venous pressure (CVP) compared to both baseline values ​​and those of time-matched control animals. In conjunction with the observed acute reduction in CVP, animals dosed with REGN5381 experienced an acute, transient increase in heart rate (HR) when compared to both baseline and time-matched control animals over the course of the first hour after dosing. Evaluation of individual animal data showed that hemodynamic and associated HR changes were limited to 3 of 6 animals receiving REGN5381, where the magnitude of the CVP reduction correlated with the extent of HR change. Arterial pressure was not affected by REGN5381 in this anesthesia model, as there were no differences both in change from baseline and in comparison to time-matched control mean arterial pressure (MAP). Organ perfusion was not affected by REGN5381-induced hemodynamic changes, as no changes from baseline or compared to time-matched controls were observed in renal cortical or medullary perfusion at 2 and 4 hours post-dosing. In addition, no REGN5381-related effects were observed on urine volume when assessed hourly after dosing. The observed variability in response to REGN5381 may be related to individual differences in NPR1 expression and / or function, which may be attributed to the anesthetic preparation and anesthesia plane of each animal, as well as the mechanical ventilation and lateral positioning of the dogs. The observed magnitude of the decrease in venous pressure correlated with the concomitant degree of increase in heart rate over the course of the first hour post-dosing. This effect appears to be a compensatory reflex tachycardiac response to maintain cardiac output in REGN5381-responsive animals. EXAMPLES

[0121] A single subcutaneous and intravenous injection pharmacokinetic and pharmacodynamic study evaluating REGN5381 in telemetered male cynomolgus monkeys The objective of this study was to determine the magnitude and duration of effect of a single intravenous (IV) bolus or subcutaneous (SC) injection of REGN5381 on systemic blood pressure in telemetered male cynomolgus monkeys. In addition, the pharmacokinetics (PK) of REGN5381 were evaluated.

[0122] Thirty male cynomolgus monkeys were assigned to one of six groups (5 animals / group) (Table 9). Animals received a single SC injection of control or REGN5381 at 1, 5 or 25 mg / kg, or a single IV bolus injection of REGN5381 at 5 or 25 mg / kg.

[0123] [Table 9]

[0124] Note: CL / F was calculated for the SC group and CL was calculated for the IV group.

[0125] Bioavailability was calculated using the AUClast from the SC group and compared with the IV dose group at the same dose level.

[0126] Blood samples for determination of serum total REGN5381 concentrations were collected from all animals pre-dose through day 56.

[0127] Blood samples, processed to plasma or serum, were collected from all animals pre-dose and at selected time points for biomarker analysis, including cyclic guanosine monophosphate (cGMP) and / or N-terminal pro-atrial natriuretic peptide (NTproANP). Urine testing for cGMP was also performed at these time points.

[0128] Electrocardiograms (ECGs) and blood pressure were recorded over a 24-h period during the pretreatment course (week -1) and for 4 weeks after dosing (from 3 h before dosing until day 28), then weekly over 24 h from days 29 to 56.

[0129] result The concentration-time profile of total REGN5381 following administration of REGN5381 at dose levels ranging from 1 to 25 mg / kg is characterized by an initial short distribution phase (IV) or absorption phase (SC), followed by a linear beta elimination phase at higher concentrations, consistent with saturation of the target-mediated clearance (TMC) pathway, and a non-linear elimination phase at lower concentrations reflecting TMC. The linear beta phase is primarily observed at dose levels of 5 mg / kg and 25 mg / kg.

[0130] Approximately equivalent dose-normalized C after IV doses of REGN5381 at 5 and 25 mg / kg max As shown by the value, C max increased in a dose-proportional manner.

[0131] Following IV administration, there was a dose-proportional increase in exposure (AUC last ) was observed across the two dose levels, indicating a shift towards non-linear kinetics. Total body clearance (CL) decreased slightly with increasing dose and concomitant increases in concentration from 4.80 mL / day / kg in the 5 mg / kg group to 3.95 mL / day / kg in the 25 mg / kg group.

[0132] After SC doses of REGN5381 at 1, 5, and 25 mg / kg, max A dose-proportional increase in mean t max A dose-proportional increase in exposure (AUC last ) was observed. The calculated bioavailability following 5 mg / kg and 25 mg / kg SC was essentially complete.

[0133] Elimination half-life (t 1 / 2 ) were estimated in the terminal phase of the concentration-time profile. Estimates were generally comparable between IV and SC doses at the same dose levels. A linear beta phase was observed throughout the study in the 25 mg / kg group, with an estimated half-life of approximately 9 to 11 days.

[0134] [Table 10]

[0135] There were REGN5381-associated reductions in blood pressure in all dose groups. The overall magnitude of change was similar across the three dose levels; however, a sustained antihypertensive effect was observed for the entire recording session (56 days) with the 25 mg / kg SC and IV dose groups, while mean blood pressure tended to be similar to controls by the end of the recording session (56 days) for the 1 mg / kg and 5 mg / kg dose groups.

[0136] Remarkably, REGN5381 induced significant and sustained reductions in systemic blood pressure in telemetered male cynomolgus monkeys without evidence of adverse hypotension (i.e., syncope, locomotion changes, death). EXAMPLES

[0137] A Randomized, Double-Blind, Placebo-Controlled, Two-Part, Single Ascending Dose Study to Evaluate the Safety, Tolerability, and Pharmacokinetics of REGN5381 in Humans Purpose of the test The primary objective of the study is to evaluate the safety and tolerability of a single intravenous (IV) dose of REGN5381 in healthy normotensive adults and otherwise healthy hypertensive adults.

[0138] Secondary objectives of this study are to evaluate the effect of a single IV dose of REGN5381 on blood pressure (BP) and heart rate (HR) in healthy normotensive adults and otherwise healthy hypertensive adults; to evaluate the effect of a single IV dose of REGN5381 on cardiac output (SV); to evaluate the pharmacokinetics (PK) of a single IV dose of REGN5381; and to evaluate the immunogenicity of a single IV dose of REGN5381.

[0139] The exploratory objectives of this study are to evaluate the effect of a single IV dose of REGN5381 on serum and urinary pharmacodynamic (PD) biomarkers of natriuretic peptide receptor 1 (NPR1) agonism indicative of target capture; to evaluate the effect of a single IV dose of REGN5381 on additional exploratory biomarkers related to myocardial and renal function; to evaluate the effect of a single IV dose of REGN5381 on cardiac contractility, respiratory variation in cardiac function, and systemic vascular resistance (SVR); to evaluate the effect of a single IV dose of REGN5381 on diuresis and natriuresis; to evaluate the effect of a single IV dose of REGN5381 on BP variation; to evaluate the hemodynamic effects of a crystalloid bolus in subjects receiving a single IV dose of REGN5381; and to conduct exploratory studies of safety and efficacy of REGN5381, NPR1 and BP.

[0140] Study Evaluation Items The primary endpoint of the study is the type, incidence, and severity of investigational treatment-emergent adverse events (TEAEs) following administration of a single IV dose of REGN5381 or placebo over time.

[0141] Secondary endpoints of the study include: change from baseline in systolic blood pressure (SEP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP), heart rate (HR), and stroke volume (SV) over time; maximum change from baseline in SBP, DBP, MAP, PP, HR, and SV over the first 24 hours post-dose; change from baseline in 24-hour average SBP, DBP, MAP, PP, and HR measured from 0 to 24 hours, 24 to 48 hours, and 48 to 72 hours post-dose; concentration of REGN5381 over time; and number and percentage of subjects expressing anti-drug antibodies (ADA) and titers over time.

[0142] Exploratory endpoints in this study include: change from baseline in urinary cGMP and plasma cGMP over time; change from baseline in renin, aldosterone, N-terminal (NT)-proBNP, and cardiac troponin T over time after dose administration; change from baseline in derivative of blood pressure (dP / dt); change from baseline in urine volume and sodium clearance over time; change from baseline in BP variability; and change from baseline in SV, stroke volume variation (SVV), SBP, DBP, and MAP over time after a crystalloid bolus.

[0143] Test Variables Study variables included: i) demographic and baseline characteristics (baseline characteristics included standard demographics (e.g., age, race, weight, height, etc.), medical and medication history for each subject); ii) safety variables (safety variables included oscillometric BP and HR (both recumbent and orthostatic), telemetry, other vital signs (temperature and respiratory rate, etc.), physical examination, electrocardiogram (ECG), clinical laboratory assessments (hematology, chemistry, and urinalysis), and adverse events (AEs)); iii) pharmacokinetic variables (PK variables were total REGN5381 concentration and time); iv) immunogenicity variables (immunogenicity variables were ADA status and titer, and scheduled sampling times. and v) pharmacodynamic and other biomarker variables (pharmacodynamic variables are derived from continuous pulse wave analysis (PWA) and include SBP, DBP, MAP, cardiac output, SV, SVV, SVR, and dP / dT; additional biomarker variables evaluated include 24-hour urinary cGMP, plasma cGMP, plasma renin, plasma aldosterone, plasma N-terminal (NT)-proBNP, and plasma high-sensitivity cardiac troponin T (hs-cTnT); biomarker variables are the concentrations of each biomarker in urine (24-hour urinary cGMP) or plasma (cGMP, renin, aldosterone, NT-proBNP, and plasma hs-cTnT) at each time point that a sample is taken.

[0144] Test Plan: This is a two-part, Phase 1, randomized, double-blind, placebo-controlled, first-in-human (FIH) study of REGN5381. The objective of the study is to test the safety, tolerability, PK, and PD of single ascending IV doses of REGN5381, an agonist mAb against NPR1, in healthy normotensive and otherwise healthy hypertensive adults between the ages of 18 and 55. The study is conducted in two sequential parts (Parts A and B). Part A comprises a single ascending dose (SAD) study of REGN5381 in healthy normotensive and otherwise healthy hypertensive adults to evaluate safety and tolerability across a range of doses. Part B consists of an evaluation of the hemodynamic response of selected doses of REGN5381 followed by an IV infusion bolus.

[0145] Both Part A and Part B of the study include a screening period (day -32 to day -3), a conditional antihypertensive washout rescreening period (day -25 to day -3, described below), an inpatient treatment / observation period (day -2 to day 4), a conditional safety inpatient extended monitoring period (day 5 to day 21), and an outpatient follow-up period (day 8 / week 2 to day 78 / week 12). On study day 1, subjects will be randomized to receive REGN5381 (stored on-site at a temperature between 2°C and 8°C) or placebo in a 6:2 ratio. The study drug will be administered as an IV infusion (Figure 7).

[0146] Subjects who attend the first screening with a stable antihypertensive regimen consisting of a single antihypertensive agent may be eligible for the study but must undergo a washout period of at least 1 week or 5 half-lives, whichever is longer, but not to exceed a maximum of 8 weeks. Subjects are not eligible for washout if they are taking more than one antihypertensive agent or have an SPB of more than 140 mmHg during the course of the screening visit. Subjects undergoing antihypertensive washout will be asked to report any new symptoms, including a home BP assessment if possible. Subjects may be asked to resume antihypertensive treatment and will not be considered eligible for the study. These subjects will be required to return for a washout rescreening visit after a suitable washout of antihypertensive agents to confirm their eligibility for the study and will then undergo randomization. Subjects will be off their antihypertensive agents until the end of the inpatient treatment / observation period. Subjects may resume their home antihypertensive agents any time after discharge.

[0147] Study eligibility will be determined using BP and HR measurements at screening: Part A: For the early cohort, systolic blood pressure (SEP) ≥ 100mmHg and ≤ 140mmHg, and diastolic blood pressure (DBP) ≥ 60mmHg and ≤ 90mmHg, with the option to match enrollment to subjects with SBP ≥ 130mmHg and ≤ 165mmHg and DBP ≥ 60mmHg and ≤ 100mmHg (below); Part B: SBP ≥ 130mmHg and ≤ 165mmHg and DBP ≥ 60mmHg and ≤ 100mmHg.

[0148] For matching enrollment, the Part A BP inclusion criteria may be matched (decision will be based on review of aggregate safety data, including BP and HR, from early cohorts according to the following criteria): 3 or more subjects have a decrease in SBP or DBP from Day 1 (pre-dose) of more than 15 mmHg below baseline that is sustained for more than 2 hours; 3 or more subjects have both a HR>110 bpm and an increase in HR of at least 20 bpm above baseline from Day 1 (pre-dose) that is sustained for more than 2 hours; or Two or more subjects require rescue therapy. If the criteria for eligible enrollment are met, the dose level will be reduced or, if already at the lowest dose, the dose level will be repeated.

[0149] Notable exclusion criteria for this study included a history of cardiovascular disease (including stroke / transient ischemic attack [TIA]), diabetes mellitus or other risk factors for cardiovascular disease, hyperlipidemia, a history of severe hypertension (SBP>180 or DBP>110 mmHg), and a history of unexplained syncope, autonomic dysfunction, or neurological disease.

[0150] Eligible subjects who sign informed consent will be admitted to the inpatient treatment / observation unit on study day -2. During the course of their inpatient stay, subjects will be monitored using automated oscillatory BP recording and a combination of continuous PWA and cardiac telemetry. Investigational site preparations to treat expected or unexpected pharmacology-related signs or symptoms will include the following: availability of trained staff, two IV catheters including one ≤ 18 gauge that will be placed prior to drug infusion and left in place for a minimum of 4 hours, and readily available rescue therapy.

[0151] Detailed hemodynamic assessments will be performed over the course of the inpatient treatment / observation period. Subjects will be provided with a fixed sodium diet (approximately 3,000 mg daily) for the length of the inpatient treatment / observation period, and fluid intake and total urine volume will be recorded. Orthostatic BP will be collected on day -1 to ensure optimal fluid status prior to receiving REGN5381. Total oral fluid intake on days -1 and 1 will be maintained within a consistent range for all subjects.

[0152] The length of the inpatient treatment / observation period following study drug administration will be at least 72 hours. Strict discharge and study discontinuation criteria will be in place to ensure adequate recovery of hemodynamic effects prior to discharge. After discharge, subjects will participate in a series of weekly outpatient follow-up evaluations to monitor safety and PK for up to 11 weeks. These evaluations may be terminated during the inpatient extended safety monitoring course if further monitoring is required. There are no dietary restrictions during the inpatient extended safety monitoring or outpatient course.

[0153] For Part B only, a fluid bolus will be administered to otherwise healthy hypertensive adults. Further description of cohorts and dose escalation is provided below. Dose selection for Part B will be based on available PD and safety results through Day 8 from the highest dose cohort in Part A.

[0154] Subjects in cohorts 10 and 11 will receive a 500-1,000 cc crystalloid bolus 2-24 hours after study drug administration to assess hemodynamic response. Determine the exact volume and timing of the crystalloid bolus, which will be the same across cohorts.

[0155] The expected total duration of this FIH trial, including Parts A and B, is approximately 65 weeks.

[0156] Investigational Drug REGN5381 drug product will be supplied as a 12.5 mg lyophilized powder in sterile single-use vials. Part A and Part B subjects will receive either REGN5381 IV or matching placebo IV as a single dose administered via IV infusion at a rate of 20 mL / hour using a syringe pump. Anticipated dose levels in Part A include 0.3 mg IV up to a planned maximum dose of 100 mg IV. Dose levels in Part B will not exceed doses tested in Part A and will be based on a review of Part A data. REGN5381 matching placebo will be supplied as a lyophilized powder in sterile single-use vials.

[0157] Study cohort, part A Up to 72 normotensive or otherwise healthy hypertensive subjects will be enrolled and randomized into up to nine sequential ascending dose cohorts to include doses from 0.3 mg to 100 mg. Cohorts 8 and 9 are optional cohorts in which the dose should not exceed 100 mg. These additional cohorts can be used to better understand the safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) of REGN5381 based on the accumulated PD and safety data from cohorts 1-7.

[0158] Each dose cohort will consist of 8 subjects; 6 will be randomized to receive a single IV dose of REGN5381 and 2 will be randomized to receive placebo. To optimize safety, the first 2 subjects of each cohort (1 active: 1 placebo) will be enrolled as a sentinel group and will be dosed at least 48 hours before the remaining subjects. The remaining subjects will be dosed only after both subjects in the sentinel cohort have safely completed at least 48 hours of safety assessments, safety data has been reviewed, and a decision to continue dosing with the investigational drug has been recorded. Sentinel subjects are not required if dose levels are to be repeated or reduced.

[0159] Plan 3- to 3.3-fold dose escalation between cohorts according to the dose escalation criteria below. Dose escalation may be adjusted based on the PD response observed within each cohort; dose level escalation of less than 3- to 3.3-fold increments may be warranted. Maximum dose should not exceed 100 mg.

[0160] Ongoing review of available PD and safety data will be used throughout the study to inform duration of evaluation and dose escalation for the remaining cohorts. Cohort 5 will repeat the dose ≤10 mg in subjects with mild hypertension. Dose selection for Cohort 8 will occur after review of complete PD and safety data through Day 8 from Cohorts 1 through 7. Data from Cohort 8 through Day 8 will inform dose selection for Cohort 9.

[0161] Dose escalation cohorts will be enrolled as follows: Cohort 1: REGN5381 (or placebo) at 0.3 mg IV, single dose Cohort 2: ≤1 mg IV REGN5381 (or placebo), single dose Cohort 3: ≤3 mg IV REGN5381 (or placebo), single dose Cohort 4: ≤10 mg IV REGN5381 (or placebo), single dose Cohort 5: ≤10 mg IV REGN5381 (or placebo), single dose Cohort 6: ≤30 mg IV REGN5381 (or placebo), single dose Cohort 7: ≤100 mg IV REGN5381 (or placebo), single dose Cohort 8 (optional): ≤100 mg IV REGN5381 (or placebo), single dose Cohort 9 (optional): ≤100 mg IV REGN5381 (or placebo), single dose

[0162] Study cohort, Part B Up to 40 hypertensive but otherwise healthy subjects will be enrolled in up to 11 cohorts (Cohort 11 is optional). In each cohort, 10 subjects will be randomized to receive a single IV dose of REGN5381 and 10 subjects will be randomized to receive placebo. These two cohorts in Part B do not require a sentinel group.

[0163] Dose levels in Part B will not exceed those tested in Part A and will be based on a review of available safety and PD data through Day 8 in the highest dose cohort. Optional cohorts may be used to evaluate additional dose levels from the range previously evaluated in Parts A and B. Inclusion of final optional cohorts in Part B will be based on available data from Parts A and B, including available safety and PD data. Dose cohorts will be enrolled as follows: Cohort 10: REGN5381 ≤ 100 mg IV, single dose (or placebo) + IV fluid bolus Cohort 11 (optional): REGN5381 ≤ 100 mg IV, single dose (or placebo) + IV fluid bolus The objective of Part B is to characterize the hemodynamic response to IV infusion following selected doses of REGN5381.

[0164] Both Part A and Part B of the study included a screening period, a conditional antihypertensive medication washout rescreening period, an inpatient treatment / observation period, a conditional safety inpatient extended monitoring period, and an outpatient follow-up period.

[0165] Dose Escalation, Part A Enrollment will begin in dose cohort 1. A decision to escalate to the next higher dose cohort will be made following review of safety data through Day 8. Aggregate safety data will be reviewed to determine the dose level to be tested in the next cohort, including dose escalation, dose level drop, repeat dose level, adaptation of enrollment to a higher BP range, or potentially discontinuing study drug dosing altogether and progressing to Part B.

[0166] As part of the aggregate safety data review, dose escalation should not occur if 3 or more subjects receiving REGN5381 require extended monitoring for hemodynamic effects for more than 72 hours, according to the individual subject discharge criteria below.

[0167] Discharge Criteria for Individual Subjects, Part A and Part B Seventy-two hours after dosing, subjects will undergo oscillometric BP and HR assessments and must meet all of the following criteria to be eligible for discharge from inpatient monitoring: Median SBP ≥ 90mmHg; and · Median HR ≤ 100 bpm or ≤ 1.2 × (≤ 120%) of baseline from Day 1 (pre-dose), whichever is greater; No unresolved AEs requiring continued inpatient monitoring (Note: if a subject has an unresolved AE at 72 hours post-dose, the subject may be discharged if the first two criteria are met and the AE can be reasonably managed in an outpatient setting).

[0168] If 3 or more subjects receiving REGN5381 require extended monitoring, one may choose to repeat the dose cohort, reduce the dose level, and / or match enrollment to the remainder of Part A. Alternatively, dose escalation in Part A may be terminated and the study may proceed to Part B. A 3- to 3.3-fold dose escalation interval between cohorts is planned, although this interval may be shortened. If a decision is made to match enrollment to a subject with mild hypertension, either lower the dose level or, if already at the lowest dose, repeat the dose level using the matching enrollment criteria.

[0169] Subjects who do not meet the individual subject discharge criteria at 72 hours post-dose will remain for safety inpatient extended monitoring. Subjects will be evaluated every additional day until they are able to meet the discharge criteria. Modifications to the currently outlined dose, dosing regimen, and / or clinical or laboratory procedures (including timing of PK and biomarker sampling) may be necessary to achieve the scientific goals of the study objectives and / or to ensure adequate safety monitoring of study participants. Thus, some variation from the currently outlined dose and / or dosing regimen may be acceptable based on newly available data, but the maximum dose should not exceed that currently outlined in the protocol. Permitted modifications within protocol parameters include dose escalation, dose level reduction, repeat dose level, adaptation of enrollment to a higher BP range (as above), or possible discontinuation of study drug dosing altogether and progression to Part B. Entire cohorts may be omitted, and inter-cohort pauses may be required for review of available PK, PD, and safety data, if necessary.

[0170] Some subjects may not meet discharge criteria at 72 hours due to BP decline secondary to inactivity or low sodium diet during the inpatient treatment / observation course; therefore, decisions regarding dose escalation will be based on subjects receiving REGN5381 and completing safety assessments on Day 8. The flexibility to repeat dose levels or reduce to lower doses allows for further characterization of the magnitude and duration of hemodynamic effects as well as other safety parameters.

[0171] End of study (EOS) is defined as the date on which the last subject completes the last study visit, discontinues the study, or is lost to follow-up (i.e., the study subject is no longer contactable).

[0172] Subject of the test Up to 112 adults will be enrolled, randomized, and dosed in the study (up to 72 in Part A and 40 in Part B). Given that the dose-escalation discontinuation criteria in Part A are based on response to REGN5381 (safety data including, but not limited to, BP and HR) and optional cohorts in Parts A and B, fewer subjects may be required to meet the study objectives. Eligible subjects include healthy men and women aged 18-55 years (inclusive) with normal or mildly elevated BP.

[0173] Inclusion criteria: Male or female subjects aged 18–55 years (inclusive) at the time of first screening; · SBP and DBP within 20 mmHg between measurements in both arms at the first screening visit; For Part A, SBP between 100 and 140 mmHg (inclusive) and DBP between 60 and 90 mmHg (inclusive) at initial screening, repeatable once during the screening period (Note: BP inclusion criteria for Part A may be adapted based on review of aggregated safety data for SBP between 130 and 165 mmHg (inclusive) and DBP between 60 and 100 mmHg (inclusive) at initial screening, repeatable once during the screening period); For Part B, SBP between 130 and 165 mmHg (inclusive) and DBP between 60 and 100 mmHg (inclusive) at initial screening, repeatable once during the screening period; SBP at least 100mmHg before study drug administration and on study day 1; Resting HR between 45 and 100 bpm (inclusive) at initial screening, repeatable once during the screening period; Body mass index 18 to 33 kg / m at initial screening 2 Between (inclusive); Subjects are deemed to be in good health based on medical history, physical examination, vital sign measurements, and ECGs performed at screening and / or prior to administration of study drug; Subjects are in good health based on clinical safety tests obtained during the screening period (Note: abnormal laboratory results that are not clinically significant (e.g., creatine phosphokinase within 3x upper limit of normal; due to suspected causes attributable to strenuous physical activity) may be repeated once during the screening period; if repeat tests are within normal limits or outside normal limits and not clinically significant, subjects may be enrolled); A negative pregnancy test prior to study drug administration; · Willing and able to comply with clinic visit and study-related procedures; and · Study subjects provided signed informed consent.

[0174] Exclusion criteria Active hypertension requiring treatment with two or more antihypertensive drugs; history of severe hypertension (SBP>180, or DBP>110mmHg); a) subjects taking a single drug therapy for hypertension may be enrolled after a washout period of at least 1 week (or at least 5 half-lives, whichever is longer); subjects will be excluded from the washout period if they are on treatment with two or more antihypertensive drugs, are taking high-dose beta-blocker therapy, or have an SBP of >140mmHg during the screening visit. b) subjects may wash out of single-agent low-dose beta-blocker therapy, defined as a total daily dose of metoprolol ≤ 100 mg, a total daily dose of carvedilol ≤ 25 mg, a total daily dose of atenolol ≤ 50 mg, a total daily dose of propranolol ≤ 80 mg, a total daily dose of bisoprolol ≤ 5 mg, or an equivalent dose of another beta-blocker; c) the washout period may not extend beyond 8 weeks prior to dose administration; subjects may resume antihypertensive therapy upon discharge; · History of Raynaud's disease, previous finger injury that would preclude wearing of a noninvasive PWA device, or insufficient arterial pulses in both fingers as determined by the PWA signal; · History of unexplained syncope or autonomic dysfunction; History of clinically significant cardiovascular (including stroke / TIA), respiratory, hepatic, renal, gastrointestinal, endocrine, hematological, psychiatric or neurological disease that may confound the results of the study or that may pose additional risks to the subject from participation in the study; Any physical examination findings and / or any medical history that may confound the study results or that may pose additional risks to the subject through study participation; · Hospitalization for any reason (>24 hours) within 30 days of the screening visit; · Current or former nicotine use (combustible cigarettes or electronic nicotine delivery systems, including e-cigarettes) who have quit smoking within 3 months prior to screening, or current users of nicotine replacement therapy; negative cotinine test at screening and before administration of study drug; · History of drug or alcohol abuse within 1 year prior to the screening visit; negative drug and alcohol tests at screening and before administration of study drug; Presence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV) seropositivity at screening or within 3 months prior to study drug administration, excluding false-positive screening tests documented by polymerase chain reaction or Western blot; HCV-seropositive subjects with documentation of sustained virologic response for 12 months will continue to be allowed to enroll; · Malignancy within the past 5 years, with no evidence of metastatic disease within 3 years, except excised basal or squamous cell carcinoma of the skin or intraepithelial carcinoma of the cervix or anus; Estimated glomerular filtration rate (using the Modification of Diet in Renal Disease Trial formula or the Chronic Kidney Disease Epidemiology Collaboration formula) <60 mL / min / 1.73 m at screening 2 , may be repeated once during the screening period; · History of acute hypersensitivity and / or anaphylaxis to protein therapeutics, components of the formulation or allergies that may pose a substantial risk to the subject; Participation in a clinical trial evaluating another investigational drug or therapy; within 90 days or at least 5 half-lives (whichever is longer) prior to the screening visit for the current trial for an investigational biologic drug, or within at least 30 days for another investigational product, or within 6 months for an immunotherapy; Males of reproductive potential who are unwilling to use the following medically acceptable methods of contraception during the course of study drug treatment through the EOS visit: vasectomy with medical evaluation of surgical success, or consistent use of condoms; sperm donation is prohibited through the EOS visit; · Pregnant or breastfeeding women; Women of childbearing potential (women who are fertile from menarche until menopause (absence of menstruation for 12 months unless for another medical reason) unless permanently infertile due to permanent sterilization methods including WOCBP, hysterectomy, bilateral salpingectomy and bilateral oophorectomy) who are unwilling to practice highly effective contraception before the first dose / initiation of first treatment, throughout the course of the study, and throughout the EOS visit; highly effective contraception methods include: i) stable use of combined (estrogen and progestogen-containing) hormonal contraceptives (oral, vaginal, transdermal) or progestogen-only hormonal contraceptives (oral, injectable, implantable) associated with inhibition of ovulation, initiated for at least two menstrual cycles prior to screening; ii) intrauterine devices; intrauterine hormone-releasing systems; iii) bilateral tubal ligation; iv) vasectomized partner (provided that the male vasectomized partner is the WOCBP study participant's only sexual partner and that the vasectomized partner has received a medical evaluation of the procedure for surgical success); and / or v) sexual abstinence (considered highly effective only if identified as abstaining from heterosexual intercourse for the entire course of risk associated with the study drug; the reliability of sexual abstinence must be evaluated in relation to the duration of the study and the subject's desired and usual lifestyle; cyclical abstinence (calendar, symptomatic temperature, postovulatory), pull-out ejaculation (abortion intercourse), spermicide alone, and lactational amenorrhea are not acceptable methods of contraception; female and male condoms should not be used simultaneously).

[0175] Study treatment REGN5381 or placebo will be dosed as single fixed ascending IV doses as follows: · REGN5381 drug product is supplied as a 12.5 mg lyophilized powder in sterile single-use vials. Matching placebo to REGN5381 will be supplied as a lyophilized powder in sterile, single-use vials.

[0176] Subjects in Part A will receive either REGN5381 IV or matching placebo IV as a single dose administered via IV infusion at a rate of 20 mL / hour using a syringe pump. For Part A, anticipated dose levels include 0.3 mg IV up to a maximum dose of 10 mg IV.

[0177] Part B subjects will receive either REGN5381 IV or matching placebo IV as a single dose at dose levels administered via IV infusion at a rate of 20 mL / hour using a syringe pump. Dose levels in Part B will not exceed those studied in Part A and will be based on a review of the Part A data. Part B will use a commercially available crystalloid bolus of 500-1,000 cc.

[0178] Safety and tolerability data and PK / PD data from the initial cohorts will be reviewed during the conduct of the study. Doses in subsequent cohorts may be adjusted based on emerging data from previous cohorts. Subjects should not receive doses higher than those specified in the protocol, but may receive lower doses or doses previously administered in other cohorts to confirm safety and tolerability and / or further evaluate PD effects.

[0179] Test procedure Blood pressure will be measured throughout the inpatient monitoring period and the outpatient follow-up period. Blood pressure will be assessed using two separate methods: an automated oscillometric upper arm cuff and a non-invasive finger cuff. Automated oscillometric BP measurements will be used to assess BP at each visit for inclusion / exclusion and as a safety measure throughout the study. The finger cuff system will collect BP data using a combination of photoplethysmography and volume clamp techniques, thus capturing pulse wave data continuously for non-invasive hemodynamic monitoring during the course of the inpatient treatment / observation period. Continuous BP measurements will allow accurate PD assessment for the first 72 hours after dose administration. All oscillometric BP and HR measurements referred to in this study should be taken as 4 consecutive measurements taken approximately 1 minute or more apart. The median BP and HR measurements of the last 3 measurements should be used as the value at that time point. The subject's arm (left vs. right) used for each assessment should be recorded.

[0180] Two-lead HR telemetry will be assessed throughout inpatient treatment / observation and safety hospital extended monitoring.

[0181] Food and Water Intake: Subjects will be kept on a fixed sodium diet for the length of the inpatient monitoring period. Subjects will be allowed approximately 3000 mg of sodium daily across all meals and snacks. Subjects will be kept on a fixed fluid intake on days -1 and 1. Oral fluid intake and urine output volume will be recorded at 6 hour intervals. Prior to commencing urine collection on day -1, subjects will be asked to empty their bladders. The start of urine collection and fluid restriction should coincide with the start of medication on day 1 (± 2 hours). For each interval, start / stop times will be recorded and fluid inflow and outflow will be recorded. The volume of fluid intake will be fixed at approximately 2.5 L on days -1 and 1, respectively.

[0182] Part B Fluid Bolus Challenge: A single bolus of 500-1,000 cc of crystalloid fluid (via IV infusion over approximately 15 minutes) will be administered between 2 and 48 hours after study drug administration and will be determined based on Part A PK / PD.

[0183] Laboratory Tests: Collected samples will be tested for blood chemistry (sodium, potassium, chloride, bicarbonate, calcium, glucose, albumin, total protein (serum), creatinine, blood urea nitrogen (BUN) / urea, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase, lactate dehydrogenase (LDH), total bilirubin, triglycerides, uric acid, creatine phosphokinase (CPK), magnesium), hematology (hemoglobin, hematocrit, red blood cells (RBC), white blood cells (WBC), red blood cell indices, platelet count, differential (neutrophils, lymphocytes, monocytes, basophils, eosinophils)), and urinalysis (dipstick (bilirubin, pH, specific gravity, ketones, protein), urinobilogen, nitrite, RBC heme, glucose, microscopy (RBC count, WBC count, urinary formed elements)). Other laboratory tests include alcohol / drug, pregnancy, HIV, HBV, HCV, TSH, lipid panel, HbA1c, FSH, PD assessment, drug concentrations, immunogenicity, and exploratory biomarkers.

[0184] Pharmacodynamic and descriptive biomarker procedures: Studies will be evaluated to explore how REGN5381 alters NPR1 signaling in healthy adults and in hypertensive but otherwise healthy adults. In particular, the role of NPR1 agonism and the effects of REGN5381 on cGMP, natriuresis / diuresis, and cardiac function will be explored.

[0185] Further physiological measures include 24-hour urine collection to assess diuresis and natriuresis. Natriuretic peptides and NPR1 agonists (e.g., nesiritide) have important effects on sodium and blood volume homeostasis. Nonclinical studies have not demonstrated the effect of REGN5381 on sodium or water balance; however, it is important to test the effect in humans. For this reason, subjects are placed on a fixed sodium diet during the inpatient monitoring process, with fixed water intake on days -1 and 1 of the study, and total intake and output are recorded for each 24-hour period. These data provide further data regarding the mechanism of action of REGN5381 in healthy volunteers. Biomarker samples are collected at designated time points (before and after drug administration) during the inpatient monitoring period and outpatient follow-up period.

[0186] Pharmacodynamic / biomarker measurements will be performed to determine effects on biomarkers of NPR1 activity, cardiac and renal function, or related physiological and pathogenic processes. Biomarkers tested will be relevant to the pathophysiology of the indication, evidence of target capture, mechanism of action of REGN5381, and / or possible early signs of toxicity. Biomarker measurements will provide further information regarding the safety and efficacy of REGN5381. This will include, but is not limited to, biomarkers of cardiac damage (cardiac troponins). · Plasma cardiac troponin (high-sensitivity cardiac troponin-T (hs-cTnT) is a sensitive biomarker of cardiac ischemia in response to cardiac activity); · cGMP (plasma and urinary cGMP are highly proximate measures of NPR1 activity in response to capture by NPR1 agonists); Sodium (urinary sodium is a measure of sodium excretion by the kidney; increased natriuresis (or urinary sodium excretion) has been observed with NPR1 trapping; modulation of urinary sodium over time by REGN5381 is an exploratory measure in this study; results from these analyses will be reported in CSR); · Renin (plasma renin measurement will allow testing of the effects of REGN5381 on other endogenous natriuretic hormones); · Aldosterone (measurement of aldosterone at baseline and modulation of aldosterone over time are exploratory measures in the study; results from these analyses will be reported in the CSR); · NT-proBNP (plasma NT-proBNP is a biomarker that allows testing of the effect of REGN5381 agonism of NPR1 on one of its measurable endogenous agonists); Pulse wave analysis (pulse wave analysis allows advanced hemodynamic parameters and continuous non-invasive BP from a finger cuff; continuous advanced hemodynamic parameters include: SBP, DBP, MAP, cardiac output, SV, SVV, dP / dt, and SVR; in certain clinical settings, an increase in SVV occurs with a decrease in venous pressure; the derivative of BP over time of the pulse waveform can be used to estimate cardiac contractility under certain circumstances; systemic vascular resistance is calculated based on SBP and SV; these data provide information on the hemodynamic response to REGN5381 in healthy volunteers as well as in hypertensive volunteers); and Pharmacogenomic analysis (whole blood samples may be collected for DNA extraction to identify genomic associations with clinical or biomarker response to REGN5381, other heart failure, hypertension, and / or chronic kidney disease related clinical outcome measures and possible AEs).

[0187] Statistical Planning The statistical analysis sets included: i) efficacy analysis set; ii) safety analysis set (SAF, includes all randomized subjects who received any investigational drug; SAF is based on treatment received (as treated); treatment compliance / administration and all clinical safety variables will be analyzed using the SAF); iii) pharmacokinetic analysis set (PK analysis population includes all subjects who received any investigational drug and had at least one non-missing outcome after the first dose of investigational drug); and iv) immunogenicity analysis set (ADA analysis set, includes all subjects who received investigational drug and had at least one non-missing ADA outcome after the first test dose).

[0188] Statistical Methods: There is no formal primary efficacy analysis in this study. For continuous variables, descriptive statistics include the following information: number of subjects (n), mean, SD, Q1, median, Q3, minimum and maximum reflected in the calculation. Plots of values ​​over time are provided, as well as the change over time or percent change over time. For categorical or ordinal data, frequencies and percentages are presented for each category. Subjects receiving placebo are pooled across cohorts within Part A and Part B, respectively, unless otherwise stated.

[0189] Pharmacokinetics Analysis of Drug Concentration Data: Concentrations of total REGN5381 over time are measured. Pharmacokinetic parameters include, but are not limited to, the following (and dose-normalized versions thereof, if applicable): AUC last (area under the curve (AUC) calculated from time zero to the time of the last positive concentration), AUC inf (AUC extrapolated from time zero to infinity), C max (peak concentration), T max (time to peak concentration), T last(time of last positive (quantifiable) concentration), and CL (clearance). Total REGN5381 concentrations over time and selected PK parameters are summarized by descriptive statistics for each cohort to estimate exposure in these groups. The descriptive statistical evaluation includes geometric means and, where appropriate, may include geometric mean ratios for selected PK parameters.

[0190] Analysis of immunogenicity data: Immunogenicity is characterized by observed ADA responses: i) pre-existing immune reactivity (defined as a positive ADA assay response at baseline with all post-dose ADA results negative or a positive assay response at baseline with all post-dose ADA assay responses not >9-fold compared to baseline titer levels); ii) treatment-emergent ADA response (defined as a post-dose positive ADA assay response when baseline results are negative); iii) treatment-emergent boosted ADA response (defined as a post-dose positive ADA assay response that is 9-fold compared to baseline titer levels when baseline is ADA assay positive); iv) maximum ADA titer (low (titer <1,000) / medium (1,000 <= titer <10,000) / high (titer >10,000)). A list of pre-existing, treatment-emergent boosted, and treatment-emergent ADA responses, ADA titers, time points, and dose cohorts / groups presented by subjects is provided. The incidence of treatment-emergent ADA is assessed as absolute incidence (N) and percent of subjects (%) grouped by study cohort and ADA titer level. Drug concentration plots are examined to assess the impact of ADA on individual PK profiles. An assessment of the impact of ADA on safety and efficacy can be provided.

[0191] Pharmacodynamic and Exploratory Biomarker Data Analysis: The PD biomarker population consists of all subjects in the PK analysis set with at least one evaluable biomarker measurement at baseline and at least one post-baseline time point. For biomarkers including plasma and urinary cGMP, plasma renin levels, plasma aldosterone levels, plasma NT-proBNP, and hs-cTnT, the following descriptive data will be generated: raw data at baseline, by treatment group and overall. Biomarkers measured after treatment will be summarized over time, and the change and / or percent change from baseline to each scheduled assessment time will be summarized by treatment using descriptive statistics. Additionally, mean concentrations and mean percent change from baseline will be generated at each visit.

[0192] With regard to the evaluation of the effect of a single IV dose of REGN5381 on BP and HR in normotensive and otherwise healthy hypertensive adults, as well as the evaluation of the effect of REGN5381 on cardiac SV, each scheduled assessment and their change from baseline in SBP, DBP, MAP, PP and HR over time will be summarized by dose cohort and treatment group using descriptive statistics with two-sided 90% confidence intervals. Concurrent maximum changes from baseline in SBP, DBP, MAP, PP and cardiac SV over the first 24 hours after dosing will be reported by dose cohort and treatment group using local regression or moving averages. Mean and / or percent changes from baseline in SBP, DBP and MAP will be plotted over time by dose cohort and treatment group. The dose response of reductions from baseline in SBP, DBP, SV and PP will be quantitatively assessed using valid statistical models.

[0193] Other exploratory endpoints will also be analyzed.

[0194] Status and Preliminary Results In cohorts 1-4 of Part A, 32 subjects (25 men, 7 women, age 20-51 years) were randomized as planned (6:2 ratio to REGN5381 vs placebo), with no subjects discontinuing the study. As part of dose escalation, a blinded review of safety data was conducted after the EOS visit for Cohort 4, when all subjects had completed 21 days of follow-up after a single dose of study drug (REGN5381 or placebo). Treatment with study drug was generally well tolerated when administered via the IV route at single doses up to 10 mg. There were no treatment interruptions or discontinuations. No serious study drug-emergent adverse events (TEAEs), serious TEAEs, or deaths were reported. Mild TEAEs were reported by 13 subjects (41%), and moderate TEAEs were reported by one subject (3%). The most frequent TEAEs were hematuria and pyuria on routine urinalysis. These TEAEs occurred in five asymptomatic individuals, each with a single abnormal laboratory result, with no apparent correlation between dose cohorts. One subject with a moderate TEAE experienced nausea and vomiting during infusion on Day 1. Symptomatic hypotension and tachycardia were not observed. There were no clinically meaningful or dose-related treatment-emergent changes in hematology and chemistry parameters in all four cohorts. There were no clinically meaningful abnormalities or dose-related shifts from baseline in vital signs or in any ECG parameters (i.e., ventricular rate, PR, QRS, QT, and RR intervals). All subjects across all four cohorts met discharge criteria at 72 hours.

[0195] They have begun enrolling patients with mild hypertension, and results to date are consistent with those observed in healthy volunteers. EXAMPLES

[0196] REGN5381 induces sustained and well-tolerated modulation of systemic hemodynamics in healthy patients background Natriuretic peptide receptor 1 (NPR1) is a membrane-bound guanylate cyclase; NPR1 agonism alters blood pressure (BP) through cGMP-mediated effects on intravascular volume, vasorelaxation, natriuresis, and diuresis. NPR1 is activated by natriuretic peptides (NPs); NPR1 and NP are therapeutic targets in patients with heart failure (HF) due to their role in fluid homeostasis and sodium balance. We report in this study the generation, preclinical characterization, and first-in-human (FIH) evaluation of REGN5381, an agonistic antibody against NPR1.

[0197] method REGN5381 was isolated using the VelocImmune® technology platform. In vivo preclinical pharmacology experiments were performed in mice and cynomolgus monkeys. In an ongoing Phase 1, double-blind, placebo-controlled, two-part, single ascending dose study (Example 5; NCT04506645) designed to evaluate the safety, tolerability, and pharmacokinetics / pharmacodynamics of REGN5381, 32 healthy adults were randomized 6:2 to single-dose IV REGN5381 (0.3, 1, 3, or 10 mg) or IV placebo.

[0198] result A sustained, dose-dependent reduction in systolic BP (SBP) (approximately 12 mmHg) was observed in normotensive NPR1-humanized mice following REGN5381 dosing, with additive effects when combined with SOC oral therapy. REGN5381 25 mg / kg induced a sustained reduction in SBP (approximately 30 mmHg) in hypertensive NPR1-humanized mice. In normotensive cynomolgus monkeys, REGN5381 reduced SBP (10-15 mmHg) with modest effects at higher doses (25 mg / kg SC and IV) that persisted for the duration of the study (56 days). In an ongoing FIH study, REGN5381 reduced SBP by 6-9 mmHg 12-24 hours after dosing, with no changes in urine volume across all dose cohorts. The reduction in SBP was associated with an increase in plasma cGMP. No serious adverse events were reported, and the most common treatment-related treatment-emergent adverse event (TEAE) was postural induced dizziness, reported in three subjects across three different dose cohorts. Other treatment-related TEAEs included palpitations and headache, each reported in two subjects.

[0199] conclusion Preclinical and first-in-human results demonstrate that the NPR1 agonist REGN5381 produces sustained hemodynamic benefits without evidence of adverse hypotension in normotensive healthy volunteers. EXAMPLES

[0200] Evaluation of REGN5381 in Humans A Phase 1, double-blind, placebo-controlled, two-part, single ascending dose study was designed to evaluate the safety, tolerability, and pharmacodynamics / pharmacokinetics of REGN5381 in healthy adults (ages 18-55 years).

[0201] Participants were randomized 6:2 to receive a single dose of intravenous REGN5381 (0.3, 1, 3, 10, 30, or 100 mg) or intravenous placebo. After study drug administration on Day 1, participants remained in the clinic until Day 4 with close hemodynamic monitoring. On Day 4, participants were assessed for safety before discharge. Study duration was based on predicted blood levels of serum REGN5381 concentrations across all dose cohorts; end of study visit occurred 21 days or more after administration of study drug. The primary endpoint of the study was the type, incidence, and severity of TEAEs over time following administration of a single intravenous dose of REGN5381 or placebo.

[0202] Data regarding the mean change from baseline in pulse pressure assessed via pulse wave analysis according to intravenous treatment group (pooled placebo, REGN5381 10 mg, REGN5381 30 mg, or REGN5381 100 mg) are shown below in Table 11. The mean change from baseline in pulse pressure is presented as an average over a 24-hour period.

[0203] [Table 11]

[0204] REGN 100 mg IV demonstrated a large and significant reduction in pulse pressure compared with placebo after a single dose over a 3-day course of monitoring.

[0205] The present disclosure is not to be limited in scope by the specific embodiments described herein. Indeed, various modifications of the present disclosure in addition to those described herein will become apparent to those skilled in the art from the foregoing description and accompanying drawings. Such modifications are intended to be included within the scope of the appended claims.

Claims

1. 1. Use of a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1) in the manufacture of a medicament, pharmaceutical composition, or product for treating a disease associated with altered hemodynamics in a subject, comprising: The use, wherein the subject has a systolic blood pressure (SBP) between 100 mmHg and 140 mmHg or between 135 mmHg and 160 mmHg.

2. 2. The use according to claim 1, wherein the disease is selected from the group consisting of heart failure, hypertension and chronic kidney disease.

3. 1. Use of a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1) in the manufacture of a medicament, pharmaceutical composition, or product for lowering blood pressure in a subject, comprising: The use, wherein the subject has a systolic blood pressure (SBP) between 100 mmHg and 140 mmHg or between 135 mmHg and 160 mmHg.

4. 4. The use of claim 3, wherein the blood pressure is selected from the group consisting of systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pulse pressure.

5. 1. Use of a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1) in the manufacture of a medicament, pharmaceutical composition, or product for inducing a hemodynamic change in a subject, comprising: The use wherein the subject has a systolic blood pressure (SBP) between 100 mmHg and 140 mmHg or between 135 mmHg and 160 mmHg.

6. The use according to claim 5, wherein the hemodynamic change is a decrease in venous pressure, left ventricular end-diastolic pressure (LVEDP), and / or arterial pulse pressure (PP).

7. 7. The use according to claim 6, wherein the reduction in venous pressure is a reduction in central venous pressure (CVP).

8. The use according to any one of claims 5 to 7, wherein urine output and systemic organ perfusion are not affected by the administration.

9. 6. The use according to any one of claims 1, 3 and 5, wherein the subject's heart rate (HR) is increased.

10. The antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining regions (CDRs) (HCDR1, HCDR2, and HCDR3) contained within a heavy chain variable region (HCVR) comprising the amino acids of SEQ ID NO: 1; and Three light chain CDRs (LCDR1, LCDR2, and LCDR3) contained within a light chain variable region (LCVR) comprising the amino acid sequence of SEQ ID NO:2 6. The use according to any one of claims 1, 3 and 5, comprising:

11. The antibody or antigen-binding fragment thereof comprises three heavy chain complementarity determining regions (CDRs) (HCDR1, HCDR2, and HCDR3) and three light chain CDRs (LCDR1, LCDR2, and LCDR3); wherein HCDR1 has the amino acid sequence of SEQ ID NO: 3, HCDR2 has the amino acid sequence of SEQ ID NO: 4, HCDR3 has the amino acid sequence of SEQ ID NO: 5, LCDR1 has the amino acid sequence of SEQ ID NO: 6, LCDR2 has the amino acid sequence of VAS, and LCDR3 has the amino acid sequence of SEQ ID NO:

8.

6. Use according to any one of claims 1, 3 and 5.

12. The use of any one of claims 1, 3 and 5, wherein the antibody or antigen-binding fragment thereof comprises a heavy chain variable region (HCVR) comprising the amino acid sequence of SEQ ID NO: 1 and a light chain variable region (LCVR) comprising the amino acid sequence of SEQ ID NO:

2.

13. The antibody comprises a heavy chain and a light chain, wherein the heavy chain comprises the amino acid sequence of SEQ ID NO:

9.

6. Use according to any one of claims 1, 3 and 5.

14. The antibody comprises a heavy chain and a light chain, wherein the light chain comprises the amino acid sequence of SEQ ID NO:

10.

6. Use according to any one of claims 1, 3 and 5.

15. The antibody comprises a heavy chain and a light chain, wherein the heavy chain comprises the amino acid sequence of SEQ ID NO: 9 and the light chain comprises the amino acid sequence of SEQ ID NO: 10; 6. Use according to any one of claims 1, 3 and 5.

16. The use of any one of claims 1, 3 and 5, wherein the antibody or antigen-binding fragment thereof is included in the medicament, pharmaceutical composition or product at a dose of about 0.031 to about 25 mg / kg of subject body weight.

17. The use of any one of claims 1, 3 and 5, wherein the antibody or antigen-binding fragment thereof is included in the medicament, pharmaceutical composition or product at a dose of about 1 mg to about 200 mg.

18. The use of any one of claims 1, 3 and 5, wherein the antibody or antigen-binding fragment thereof is useful for administration to a subject intravenously, subcutaneously, intradermally, intraperitoneally, or intramuscularly.

19. The use of any one of claims 1, 3 and 5, wherein the antibody or antigen-binding fragment thereof is useful for administration to a subject as a single dose.

20. The use of any one of claims 1, 3, and 5, wherein the antibody or antigen-binding fragment thereof is used in combination with an additional therapeutic agent in a subject selected from the group consisting of aldosterone antagonists, alpha-adrenergic blockers, angiotensin-converting enzyme (ACE) inhibitors, arteriolar dilating agents, autonomic ganglionic vasodilators, beta-adrenergic blockers, catecholamine-depleting sympatholytic agents, central alpha-2 adrenergic agonists, calcium channel blockers, diuretics, renin inhibitors, anticoagulants, antiplatelet agents, cholesterol-lowering agents, vasodilators, digitalis, implantable devices, anti-tumor therapies, insulin, GLP1 agonists, metformin, dialysis, bone marrow stimulating agents, hemofiltration, lifestyle modifications, dietary supplements, and agents that serve to counteract or reduce any possible side effects associated with an antibody or antigen-binding fragment thereof that specifically binds to NPR1.

21. The use of claim 20, wherein the second therapeutic agent is usefully administered simultaneously with or separately from the antibody or antigen-binding fragment thereof.

22. 6. The use according to any one of claims 1, 3 and 5, wherein the subject has high blood pressure.

23. 23. The use of claim 22, wherein the subject has mild hypertension.

24. The use according to any one of claims 1, 3 and 5, wherein the subject is a human.

25. 1. A pharmaceutical composition for use in treating a disease associated with altered hemodynamics in a subject, comprising: A pharmaceutical composition comprising a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1) and a pharmaceutically acceptable carrier or diluent.

26. 1. A pharmaceutical composition for use in lowering blood pressure in a subject, comprising: A pharmaceutical composition comprising a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to NPR1 and a pharmaceutically acceptable carrier or diluent.

27. 1. A pharmaceutical composition for use in inducing a hemodynamic change in a subject, comprising: A pharmaceutical composition comprising a therapeutically effective amount of an antibody or antigen-binding fragment thereof that specifically binds to natriuretic peptide receptor 1 (NPR1) and a pharmaceutically acceptable carrier or diluent.

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