New combination therapy

Abstract

The present invention relates to 7-(4,7-diazaspiro[2.5]octan-7-yl)-2-(2,8-dimethylimidazo[1,2-b]pyridazin-6-yl)pyrido[1,2-a]pyrimidin-4-one, also known as risdiplam, for use in the treatment of spinal muscular atrophy (SMA), together with GYM329, pharmaceutical compositions thereof for use in the treatment of SMA, and methods of treating SMA.

Description

[Technical Field]

[0001] The present invention relates to 7-(4,7-diazaspiro[2.5]octan-7-yl)-2-(2,8-dimethylimidazo[1,2-b]pyridazin-6-yl)pyrido[1,2-a]pyrimidin-4-one, also known as risdiplam, for use in the treatment of spinal muscular atrophy (SMA) in conjunction with GYM329, pharmaceutical compositions thereof for use in the treatment of SMA, and methods for the treatment of SMA.

[0002] The present invention relates to the combined administration of risdiplam and the myostatin inhibitor GYM329. In another embodiment, the present invention is risdiplam for use in treating spinal muscular atrophy in combination with GYM329. [Background technology]

[0003] An isolated antibody that binds to latent myostatin and does not bind to mature myostatin, which antibody blocks the non-proteolytic spontaneous release of mature myostatin from latent myostatin and inhibits the activation of myostatin, and which comprises six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO: 6; and an isolated antibody, including risdiplam for use in the treatment of SMA.

[0004] An isolated antibody that binds to latent myostatin and does not bind to mature myostatin, wherein the antibody blocks the non-proteolytic spontaneous release of mature myostatin from latent myostatin and inhibits the activation of myostatin, and the antibody comprises a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7 and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 8, together with risdiplam for use in treating SMA.

[0005] An isolated antibody that binds to latent myostatin and does not bind to mature myostatin, which antibody blocks the non-proteolytic spontaneous release of mature myostatin from latent myostatin and inhibits the activation of myostatin, and which antibody comprises a heavy chain region comprising the amino acid sequence of SEQ ID NO: 9 and a light chain region comprising the amino acid sequence of SEQ ID NO: 10, together with risdiplam for use in treating SMA.

[0006] Spinal muscular atrophy (SMA), in its broadest sense, refers to a group of inherited and acquired central nervous system (CNS) diseases characterized by progressive motor neuron loss in the spinal cord and brainstem, resulting in muscle weakness and atrophy. The most common form of SMA is caused by mutations in the survival motor neuron (SMN) gene and manifests in a wide range of severity, affecting infants through adults (Crawford and Pardo, Neurobiol. Dis., 1996, 3:97).

[0007] Infantile SMA is the most severe form of this neurodegenerative disorder. Symptoms include muscle weakness, poor muscle tone, weak cry, a tendency to slacken or fall, difficulty sucking or swallowing, accumulation of secretions in the lungs or pharynx, difficulty feeding, and increased susceptibility to respiratory infections. The legs tend to be weaker than the arms, and infants may not achieve developmental milestones such as lifting their head or sitting up. In general, the earlier symptoms appear, the shorter their lifespan. Symptoms appear soon after motor neuron cell deterioration. Severe forms of the disease are fatal, and there is no known cure for all forms. The course of SMA is directly related to the rate of motor neuron cell deterioration and the resulting severity of weakness. Infants with severe forms of SMA may die from respiratory disease due to weakness of the muscles that support breathing. Children with milder forms of SMA live significantly longer but may require extensive medical support, especially those at the more severe end of the spectrum. The clinical spectrum of SMA disorders is divided into five groups: 1) Type 0 SMA (intrauterine SMA) is the most severe form of the disease and begins before birth. The first symptom of type 0 SMA is usually reduced fetal movement, which can first be observed between 30 and 36 weeks of gestation. After birth, these newborns have little movement and difficulty swallowing and breathing. 2) Type 1 SMA (infantile SMA or Werdnig-Hoffmann disease) presents between 0 and 6 months of age. This form of SMA is also very severe. Patients never achieve the ability to sit and usually die within the first two years without mechanical ventilation. 3) Type 2 SMA (intermediate SMA) has an onset age of 7-18 months. Patients achieve the ability to sit unsupported but never stand or walk independently. The prognosis for this group depends largely on the severity of respiratory complications. 4) Type 3 SMA (juvenile SMA or Kugelberg-Welander disease) is typically diagnosed after 18 months. Individuals with type 3 SMA are able to walk independently at some point during the course of the disease, but often become wheelchair-bound during adolescence or adulthood. 5) Type 4 SMA (adult-onset SMA). Weakness usually begins in late adolescence in the tongue, hands, or feet, then progresses to other areas of the body. Adult SMA progresses much more slowly and has little or no effect on life expectancy.

[0008] The SMN gene has been mapped by linkage analysis to a complex region of chromosome 5q. In humans, this region contains an approximately 500,000 base pair (kb) inverted duplication, resulting in two nearly identical copies of the SMN gene. SMA is caused by inactivating mutations or deletion of the telomeric copy of the gene (SMN1) on both chromosomes, resulting in loss of SMN1 gene function. However, all patients retain the centromeric copy of the gene (SMN2), and the copy number of the SMN2 gene in SMA patients generally correlates inversely with disease severity. That is, patients with less severe SMA have higher SMN2 copy numbers. Nevertheless, SMN2 cannot fully compensate for the loss of SMN1 function due to alternative splicing of exon 7 caused by a translationally silent C-to-T mutation in exon 7. As a result, the majority of transcripts produced from SMN2 lack exon 7 (Δ7SMN2), encoding a truncated SMN protein that is dysfunctional and rapidly degraded.

[0009] The SMN protein is thought to play a role in RNA processing and metabolism, and its function in mediating the assembly of a specific class of RNA-protein complexes called snRNPs is well characterized. Although SMN may have other functions in motor neurons, its role in preventing selective degeneration of motor neurons is not well established.

[0010] In most cases, SMA is diagnosed based on clinical symptoms and the presence of at least one copy of the SMN1 gene. However, in approximately 5% of cases, SMA is caused by mutations in genes other than SMN1 inactivation, some of which are known and others have not yet been defined. In some cases, if SMN1 gene testing is not feasible or does not show abnormalities, other tests such as electromyography (EMG) or muscle biopsy may be indicated.

[0011] Several mouse models of SMA have been developed. In particular, the SMN delta exon 7 (Δ7SMN) model (Le et al., Hum. Mol. Genet., 2005, 14:845) harbors both the SMN2 gene and several copies of the Δ7SMN2 cDNA, recapitulating many of the phenotypic features of type 1 SMA. The Δ7SMN model can be used to study SMN2 expression and assess motor function and survival. The C / C allele mouse model (Jackson Laboratory strain #008714, The Jackson Laboratory, Bar Harbor, ME) provides a less severe SMA disease model with reduced levels of both full-length SMN2 (FL SMN2) mRNA and SMN protein. The C / C allele mouse phenotype harbors the SMN2 gene and the alternatively spliced ​​hybrid mSMN1-SMN2 gene, but does not exhibit overt muscle weakness. The C / C allele mouse model is used for SMN2 expression studies.

[0012] Improved understanding of the genetic basis and pathophysiology of SMA has led to the development of several treatment strategies, including three approved treatments: Nusinersen (Spinraza®), an intrathecally delivered antisense oligonucleotide (ASO) targeting the SMN2 gene; Onasemnogen-Abeparvovec (Zolgensma®), an intravenously administered adeno-associated viral vector-based gene therapy that delivers a copy of the SMN1 gene; and Risdiplam (Evrysdi®), an oral SMN2 splicing modifier. These available treatments differ by their mechanism of action and means of administration. Risdiplam is the only oral treatment available for SMA patients. It is approved in most major markets.

[0013] Myostatin, also known as growth differentiation factor-8 (GDF8), is a secreted protein and a member of the transforming growth factor-beta (TGF-beta) superfamily of proteins. Members of this superfamily have growth regulatory and morphogenetic properties (see, e.g., Non-Patent Document 1, Non-Patent Document 2, and Patent Document 1). Myostatin is primarily expressed in developing and adult skeletal muscle and functions as a negative regulator of muscle growth. Systemic overexpression of myostatin in adult mice results in muscle wasting (see, e.g., Non-Patent Document 3). Conversely, myostatin knockout mice are characterized by skeletal muscle hypertrophy and hyperplasia, resulting in muscle mass two to three times greater than that of their wild-type littermates (see, e.g., Non-Patent Document 4).

[0014] Like other members of the TGF-beta family, myostatin is synthesized as a large precursor protein containing an N-terminal propeptide domain and a C-terminal domain that is thought to be the active molecule (see, for example, Non-Patent Document 5; Patent Document 2). Two molecules of the myostatin precursor are covalently linked via a single disulfide bond present in the C-terminal growth factor domain. Active mature myostatin (a disulfide-linked homodimer consisting of the C-terminal growth factor domain) is released from the myostatin precursor through multiple steps of proteolytic processing. In the first step of the myostatin activation pathway, the peptide bond between the N-terminal propeptide domain and the C-terminal growth factor domain Arg266-Asp267 is cleaved in both chains of the homodimeric precursor by a furin-type proprotein convertase. However, the resulting three peptides (two propeptides and one mature myostatin (i.e., a disulfide-linked homodimer consisting of the growth factor domain)) remain associated and form a noncovalently inactive complex called "latent myostatin." Mature myostatin can then be liberated from latent myostatin by degradation of the propeptide. Members of the bone morphogenetic protein 1 (BMP1) family of metalloproteinases cleave a single peptide bond within the propeptide Arg98-Asp99, concomitantly releasing the mature, active myostatin homodimer (see, e.g., Non-Patent Document 6). Furthermore, latent myostatin can be activated in vitro by dissociating the complex with either acid or heat treatment (see, e.g., Non-Patent Document 7).

[0015] Myostatin exerts its effects through the transmembrane serine / threonine kinase heterotetramer receptor family, activation of which enhances receptor transphosphorylation and stimulates serine / threonine kinase activity. The myostatin pathway involves an active myostatin dimer that binds with high affinity to activin receptor type IIB (ActRIIB), then recruits and activates the transphosphorylation of low-affinity receptors, activin-like kinase 4 (ALK4) or activin-like kinase 5 (ALK5). It has also been shown that the proteins Smad2 and Smad3 are subsequently activated, form a complex with Smad4, and then translocate to the nucleus to activate target gene transcription. It has been demonstrated that ActRIIB can mediate the effects of myostatin in vivo, as expression of a dominant-negative form of ActRIIB in mice mimics myostatin gene knockout (see, for example, Non-Patent Document 8).

[0016] Many diseases or conditions, such as muscular dystrophy (MD; including Duchenne muscular dystrophy), amyotrophic lateral sclerosis (ALS), spinal muscular atrophy (SMA); spinal muscular atrophy type 1 with respiratory distress; stiff-person syndrome; Troyer syndrome; Guillain-Barré syndrome; organ atrophy, frailty, congestive obstructive pulmonary disease (COPD), sarcopenia, and cachexia due to cancer or other disorders, as well as kidney disease, heart failure or cardiac disease, and liver disease, are associated with muscle wasting (i.e., muscle tissue loss or dysfunction). Patients would benefit from increased muscle mass and / or strength. However, available treatments for these disorders are currently limited. Therefore, due to its role as a negative regulator of skeletal muscle growth, myostatin represents a desirable target for therapeutic or preventive intervention for such disorders or conditions or to monitor their progression. In particular, agents that inhibit myostatin activity may be therapeutically beneficial.

[0017] Inhibition of myostatin expression results in both muscle hypertrophy and hyperplasia (Non-Patent Document 9). Myostatin negatively regulates muscle regeneration after injury, and the lack of myostatin in myostatin-null mice promotes muscle regeneration (see, e.g., Non-Patent Document 10). For example, anti-myostatin (GDF8) antibodies described in Patent Documents 3, 4, 5, 6, and 7, as well as Patent Documents 8, 9, and 10, have been shown to bind to myostatin and inhibit myostatin activity in vitro and in vivo, including myostatin activity related to the negative regulation of skeletal muscle mass. Myostatin-neutralizing antibodies increase body weight, skeletal muscle mass, and skeletal muscle size and strength in wild-type mice (see, e.g., Non-Patent Document 11) and mdx mice, a model of muscular dystrophy (see, e.g., Non-Patent Document 12; Non-Patent Document 13). However, all of these prior art antibodies are specific for mature myostatin, but not for latent myostatin, and the strategies described for inhibiting myostatin activity utilize antibodies that can bind to and neutralize mature myostatin.

[0018] Antibodies have attracted attention as pharmaceuticals due to their high stability in blood and minimal side effects (see, for example, Non-Patent Document 14 and Non-Patent Document 15). Almost all therapeutic antibodies currently on the market are human IgG1 subclass antibodies. One of the known functions of IgG class antibodies is antibody-dependent cell-mediated cytotoxicity (hereinafter referred to as ADCC activity) (see, for example, Non-Patent Document 16). For an antibody to exhibit ADCC activity, the antibody Fc region must bind to an Fc gamma receptor (hereinafter referred to as Fc gamma R), an antibody-binding receptor present on the surface of effector cells such as killer cells, natural killer cells, and activated macrophages. Summary of the Invention

[0019] Quick Overview [Brief explanation of the drawings]

[0020] [Figure 1] Study Design This figure shows the groups examined in this study, including Δ7 mice treated with GYM329 or vehicle alone or in combination with increased expression of SMN, and WT littermates. [Figure 2] Growth curve WT: n = 11, SMA vehicle: n = 10, SMA GYM329: n = 11. WT: wild-type littermates; SMA vehicle: Delta7 mice + low-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-dose SMN-C1 + GYM329. [Figure 3] Body and muscle weights at PND52: A. Body weight. B. Gastrocnemius weight. C. Soleus weight. D. TA weight. E. EDL weight. F. Masseter weight. WT: n=11, SMA Vehicle: n=10, SMA GYM329: n=11. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-dose SMN-C1 + GYM329. [Figure 4] Plantar flexor function at PND52. Maximum torque. WT: n=11, SMA Vehicle: n=10, SMA GYM329: n=11. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-dose SMN-C1 + GYM329. [Figure 5] Masseter muscle function at PND52. Maximum force. WT: n=11, SMA Vehicle: n=10, SMA GYM329: n=11. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-dose SMN-C1 + GYM329. [Figure 6] Plantar flexor muscle fibers and cross-sectional area (CSA). A. Muscle fiber type. B. Average fiber CSA. Type CI fiber CSA. D. Type IIA fiber CSA. E. Type IIB fiber CSA. F. Type IIX fiber CSA. WT: n=11, SMA Vehicle: n=10, SMA GYM329: n=11. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-dose SMN-C1 + GYM329. [Figure 7] Cortical bone parameters: Tibia. A. Section thickness. B. Mean total cross-sectional tissue area. C. Mean total cross-sectional tissue perimeter. D. Mean total cross-sectional bone area. E. Mean total cross-sectional bone perimeter. F. Cortical porosity. WT: n=10, SMA Vehicle: n=8, SMA GYM329: n=10. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-dose SMN-C1 + GYM329. [Figure 8] Trabecular parameters: Tibia. A. Bone volume. B. Trabecular thickness. C. Trabecular number. D. Trabecular separation. WT: n=11, SMA Vehicle: n=8, SMA GYM329: n=10. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-dose SMN-C1 + GYM329. [Figure 9] Growth curve. WT: n=11, SMA vehicle: n=10, SMA GYM329: n=10. WT: wild-type littermates; SMA vehicle: Delta7 mice + low-high dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-high dose SMN-C1 + GYM329. [Figure 10] Body and muscle weights at PND52. A. Body weight. B. Gastrocnemius weight. C. Soleus weight. D. TA weight. E. EDL weight. F. Masseter weight. WT: n=11, SMA Vehicle: n=10, SMA GYM329: n=10. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-high dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-high dose SMN-C1 + GYM329. [Figure 11] Plantar flexor function at PND52. Maximum torque. WT: n=11, SMA Vehicle: n=10, SMA GYM329: n=10. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-high dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-high dose SMN-C1 + GYM329. [Figure 12]Masseter muscle function at PND52. Maximum force. WT: n=11, SMA Vehicle: n=10, SMA GYM329: n=10. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-high dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-high dose SMN-C1 + GYM329. [Figure 13] Plantar flexor muscle fibers and cross-sectional area (CSA). A. Muscle fiber type. B. Average fiber CSA. Type CI fiber CSA. D. Type IIA fiber CSA. E. Type IIB fiber CSA. F. Type IIX fiber CSA. WT: n=11, SMA Vehicle: n=10, SMA GYM329: n=10. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-high dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-high dose SMN-C1 + GYM329. [Figure 14] Cortical bone parameters: Tibia. A. Section thickness. B. Mean total cross-sectional tissue area. C. Mean total cross-sectional tissue perimeter. D. Mean total cross-sectional bone area. E. Mean total cross-sectional bone perimeter. F. Cortical porosity. WT: n=10, SMA Vehicle: n=9, SMA GYM329: n=9. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-high dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-high dose SMN-C1 + GYM329. *p<0.05 vs. SMA vehicle. [Figure 15] Trabecular bone parameters: Tibia. A. Bone mass. B. Trabecular thickness. C. Trabecular number. D. Trabecular separation. WT: n=11, SMA Vehicle: n=9, SMA GYM329: n=9. WT: wild-type littermates; SMA Vehicle: Delta7 mice + low-high dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + low-high dose SMN-C1 + GYM329. [Figure 16] Growth curve. WT: n=11, SMA Vehicle: n=15, SMA GYM329: n=14. WT: wild-type littermates; SMA Vehicle: Delta7 mice + high-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + high-dose SMN-C1 + GYM329. [Figure 17]Body and muscle weights at PND52. A. Body weight. B. Gastrocnemius weight. C. Soleus weight. D. TA weight. E. EDL weight. F. Masseter weight. WT: n=11, SMA Vehicle: n=15, SMA GYM329: n=14. WT: wild-type littermates; SMA Vehicle: Delta7 mice + high-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + high-dose SMN-C1 + GYM329. *p<0.05 vs. SMA Vehicle. [Figure 18] Plantar flexor function at PND52. Maximum torque. WT: n=11, SMA Vehicle: n=15, SMA GYM329: n=14. WT: wild-type littermates; SMA Vehicle: Delta7 mice + high-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + high-dose SMN-C1 + GYM329. [Figure 19] Masseter muscle function at PND52. Maximum force. WT: n=11, SMA Vehicle: n=15, SMA GYM329: n=14. WT: wild-type littermates; SMA Vehicle: Delta7 mice + high-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + high-dose SMN-C1 + GYM329. *p<0.05 SMA GYM329 vs. SMA Vehicle. [Figure 20] Plantar flexor muscle fibers and cross-sectional area (CSA). A. Muscle fiber type. B. Average fiber CSA. Type CI fiber CSA. D. Type IIA fiber CSA. E. Type IIB fiber CSA. F. Type IIX fiber CSA. WT: n=11, SMA Vehicle: n=15, SMA GYM329: n=14. WT: wild-type littermates; SMA Vehicle: Delta7 mice + high-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + high-dose SMN-C1 + GYM329. *p<0.05 vs. SMA vehicle. [Figure 21]Cortical bone parameters: Tibia. A. Mean total cross-sectional tissue circumference. B. Mean total cross-sectional tissue area. C. Mean cross-sectional tissue bone circumference. D. Mean total cross-sectional bone area. E. Section thickness. F. Cortical porosity. WT: n=10, SMA Vehicle: n=10, SMA GYM329: n=13. WT: wild-type littermates; SMA Vehicle: Delta7 mice + high-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + high-dose SMN-C1 + GYM329. *p<0.05 vs. SMA vehicle. [Figure 22] Trabecular bone parameters: Tibia. A. Bone volume fraction. B. Trabecular thickness. C. Trabecular number. D. Trabecular separation. WT: n=11, SMA Vehicle: n=14, SMA GYM329: n=14. WT: wild-type littermates; SMA Vehicle: Delta7 mice + high-dose SMN-C1 + vehicle; SMA GYM329: Delta7 mice + high-dose SMN-C1 + GYM329. *p<0.05 vs. SMA vehicle. [Figure 23] Clinical trial scheme for Part 1. OLE = open-label extension; a Risdiplam-naive participants will be treated with risdiplam for at least 8 weeks in the run-in period before randomization for the 24-week double-blind period. Participants treated with risdiplam for at least 8 consecutive weeks immediately prior to entering the study can be immediately randomized to combination therapy or participate in the run-in period and continue receiving risdiplam monotherapy until randomization. b Age at screening. c Blinded GYM329 or GYM329-matched placebo. d If participants reach the end of the 24-week double-blind treatment period and the pivotal dose has not yet been determined, they will receive GYM329 at the dose of their respective treatment cohort until the pivotal dose is determined. Once the pivotal dose is selected, participants will be switched to this pivotal dose. [Figure 24] Clinical trial scheme for Part 2, OLE = open-label extension. a Age at screening; b GYM329 at the dose selected in Part 1 (pivotal dose); c Blinded GYM329 or GYM329-matched placebo. DETAILED DESCRIPTION OF THE INVENTION

[0021] Detailed Description All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety.

[0022] The nomenclature used in this application is based on the IPUAC systematic nomenclature unless otherwise indicated.

[0023] Unless otherwise defined, technical and scientific terms used herein have the same meaning as commonly understood by those skilled in the art to which this invention belongs. Singleton et al., Dictionary of Microbiology and Molecular Biology, 2nd Edition, J. Wiley & Sons (New York, NY 1994), and March, Advanced Organic Chemistry Reactions, Mechanisms and Structure, 4th Edition, John Wiley & Sons (New York, NY 1992) provide those skilled in the art with a general guide to many of the terms used in this application. All references cited herein, including patent applications and publications, are incorporated by reference in their entirety.

[0024] For purposes of interpreting this specification, the following definitions will apply, and whenever appropriate, terms used in the singular will also include the plural and vice versa. It is to be understood that the terminology used herein is for the purpose of describing particular embodiments only and is not intended to be limiting. Unless otherwise stated, the following terms used in the specification and claims have the meanings indicated below.

[0025] An "individual" or "subject," used interchangeably, is a mammal. Mammals include, but are not limited to, livestock animals (e.g., cows, sheep, cats, dogs, and horses), primates (e.g., humans and non-human primates, such as monkeys), rabbits, and rodents (e.g., mice and rats). In certain embodiments, the individual or subject is a human. In certain embodiments of the present invention, the subject is a human with spinal muscular atrophy (SMA). In another specific embodiment, the subject is a human with SMA, which is caused by inactivating mutations or deletions of the SMN1 gene on both chromosomes, resulting in loss of SMN1 gene function.

[0026] The term "spinal muscular atrophy" (or SMA) refers to a disease caused by inactivating mutations or deletions of the SMN1 gene on both chromosomes, resulting in loss of SMN1 gene function. Depending on the type of SMA, symptoms of SMA include muscle weakness, poor muscle tone, weak cry, weak cough, limping or tendency to fall, difficulty aspirating or swallowing, difficulty breathing, accumulation of secretions in the lungs or throat, clenched fists with sweaty hands, flickering / shaking tongue, frequent tilting of the head to one side when lying down, legs that tend to be weaker than the arms, frequent "frog-legged" position of the legs, difficulty feeding, increased susceptibility to respiratory tract infections, bowel / bladder weakness, lower than normal weight, inability to sit unsupported, inability to walk or crawl, and hypotonia, loss of appetite, as well as multiple congenital contractures (arthrogryposis) associated with loss of anterior horn cells.

[0027] The term "treating spinal muscular atrophy (SMA)" or "treatment of spinal muscular atrophy (SMA)" includes one or more of the following effects: (i) reducing or ameliorating the severity of SMA; (ii) delaying the onset of SMA; (iii) inhibiting the progression of SMA; (iv) reducing the hospitalization of a subject; (v) reducing the length of hospitalization of a subject; (vi) increasing the survival rate of a subject; (vii) improving the quality of life of a subject; (viii) reducing the number of symptoms associated with SMA; (ix) reducing or ameliorating the severity of one or more symptoms associated with SMA; (x) reducing the duration of symptoms associated with SMA; (xi) preventing the recurrence of symptoms associated with SMA; (xii) inhibiting the onset or onset of SMA; (xiii) inhibiting the progression of symptoms associated with SMA; and / or (xiv) stabilizing the number of symptoms associated with SMA. More specifically, "treating SMA" means one or more of the following beneficial effects: (i) a reduction in muscle weakness; (ii) an increase in muscle strength; (iii) a reduction in muscle atrophy; (iv) a reduction in loss of motor function; (v) an increase in motor neurons; (vii) a reduction in loss of motor neurons; (viii) protection of SMN-deficient motor neurons from degeneration; (ix) an increase in motor function; (x) an increase in pulmonary function; and / or (xi) a reduction in loss of pulmonary function; and / or (xii) a stabilization of motor function.

[0028] Specifically, "treating SMA" results in or helps to preserve the functional ability of a human infant or toddler to sit unaided, or a human infant, toddler, child, or adult to stand unaided, walk unaided, run unaided, breathe unaided, turn in sleep unaided, or swallow unaided.

[0029] The term "mg / kg" refers to the milligram dose of 7-(4,7-diazaspiro[2.5]octan-7-yl)-2-(2,8-dimethylimidazo[1,2-b]pyridazin-6-yl)pyrido[1,2-a]pyrimidin-4-one used per kg of body weight of the subject to be treated. For example, 0.25mg / kg means that 0.25 milligrams of 7-(4,7-diazaspiro[2.5]octan-7-yl)-2-(2,8-dimethylimidazo[1,2-b]pyridazin-6-yl)pyrido[1,2-a]pyrimidin-4-one is administered per kg of the patient's body weight to be treated.

[0030] The term "patient" refers to a human (such as a male or female human) who has been diagnosed with SMA.

[0031] The term "active pharmaceutical ingredient" (or "API") refers to a compound or molecule in a pharmaceutical composition that has a specific biological activity.

[0032] The terms "pharmaceutically acceptable excipient," "pharmaceutically acceptable carrier," and "therapeutically inactive excipient" are used interchangeably and refer to any pharmaceutically acceptable ingredient in a pharmaceutical composition used in the formulation of a medicament, such as a disintegrant, binder, filler, solvent, buffer, tonicity agent, stabilizer, antioxidant, surfactant, carrier, diluent, or lubricant, that has no therapeutic activity and is non-toxic to a subject to which it is administered.

[0033] The term "pharmaceutical composition" refers to a preparation in a form suitable for potentiating the biological activity of the active ingredient contained therein, and which does not contain additional ingredients that are unacceptably toxic to the subject to which the composition is administered. The term "pharmaceutical composition" refers to a preparation in a form suitable for potentiating the biological activity of the active ingredient contained therein, and which does not contain additional ingredients that are unacceptably toxic to the subject to which the composition is administered.

[0034] According to the present invention, "risdiplam" or "7-(4,7-diazaspiro[2.5]octan-7-yl)-2-(2,8-dimethylimidazo[1,2-b]pyridazin-6-yl)pyrido[1,2-a]pyrimidin-4-one", used interchangeably, is a compound of formula (I): [ka] It refers to the compound of formula (I), also known as Evrysdi®, RG7916, RO7034067, and CAS number 1825352-65-5. Risdiplam according to the present invention may be referred to by its chemical name, chemical structure, or any alternative reference mentioned herein. In particular, risdiplam may be used interchangeably with its chemical name, 7-(4,7-diazaspiro[2.5]octan-7-yl)-2-(2,8-dimethylimidazo[1,2-b]pyridazin-6-yl)pyrido[1,2-a]pyrimidin-4-one. Methods for making and using the compound are described in EP 3143025. Methods for making and using pharmaceutical compositions are described in WO 2017080967 and WO 202079203.

[0035] "C max The term " (expressed in ng / mL) refers to the maximum plasma concentration observed.

[0036] "T max ” (in units of time, or T of the study population) max The term (expressed as the median time to C max means the observation time until T is reached; if it occurs at multiple time points, T max is defined as the first time point with this value.

[0037] "AUC T0-24h The term ” (expressed in units of ng·h / mL) refers to the area under the plasma concentration-time curve (AUC).

[0038] The term "buffer" or "buffer system" refers to a pharmaceutically acceptable excipient or mixture of excipients that stabilizes the pH of a pharmaceutical preparation. Suitable buffers are well known in the art and can be found in the literature. Specific pharmaceutically acceptable buffers include citrate, malate, maleate, or tartrate buffers, most specifically tartrate buffers. Particular buffer systems of the present invention include combinations of an organic acid and its selected salt, such as tribasic sodium citrate and citric acid, malic acid and sodium malate, sodium potassium tartrate and tartaric acid, or disodium tartrate and tartaric acid, particularly sodium potassium tartrate and tartaric acid. Alternatively, an organic acid (particularly tartaric acid) may be used alone as an "acidifying agent" instead of a combination of the acid and its corresponding salt. Regardless of the buffer used, the pH may be adjusted with acids or bases known in the art, such as hydrochloric acid, acetic acid, phosphoric acid, sulfuric acid, and citric acid, sodium hydroxide, and potassium hydroxide. A particular acidifying agent is tartaric acid.

[0039] The term "antioxidant" refers to a pharmaceutically acceptable excipient that prevents oxidation of an active pharmaceutical ingredient. Antioxidants include ascorbic acid, glutathione, cysteine, methionine, vitamin ETPGS, and EDTA.

[0040] As used herein, the term "therapeutically effective amount" refers to an amount of a compound sufficient to treat, ameliorate, or prevent a specified disease or condition, or to exhibit a detectable therapeutic, preventative, or inhibitory effect. The effect may be detected, for example, by an improvement in clinical status or a reduction in symptoms. The precise effective amount for a subject will depend on the subject's weight, size, and health; the nature and extent of the condition; and the therapeutic agent or combination of therapeutic agents selected for administration. If the drug is approved by the U.S. Food and Drug Administration (FDA), "therapeutically effective amount" refers to the dosage approved by the FDA or an equivalent foreign agency for the treatment of the specified disease or condition.

[0041] As used herein, a patient "in need of risdiplam therapy" is a patient who would benefit from the administration of risdiplam. The patient may be suffering from any disease or condition for which risdiplam therapy may be useful in improving symptoms. Risdiplam is being developed for the treatment of spinal muscular atrophy.

[0042] As used herein, a patient "in need of GYM329 therapy" (or "in need of anti-myostatin antibody therapy") is a patient who would benefit from administration of GYM329. The patient may be suffering from any disease or condition for which risdiplam therapy may be useful in improving symptoms. GYM329 is being developed in combination with risdiplam to treat spinal muscular atrophy.

[0043] "GYM329," also known as RO7204239 according to the present invention, refers to an "anti-myostatin antibody," which comprises six complementarity-determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2, and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO: 6. GYM329 may also be defined by a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 7 and a light chain variable region comprising the amino acid sequence of SEQ ID NO: 8. Methods for making and using GYM329 may be prepared according to WO2016098357 and WO2017 / 104783. GYM329 is known to have an engineered Fc that allows for antigen removal from plasma.

[0044] The terms "host cell," "host cell line," and "host cell culture" are used interchangeably and refer to cells into which exogenous nucleic acid has been introduced and their progeny. Host cells include "transformants" and "transformed cells," which include the primary transformed cell and its progeny without regard to the number of passages. The progeny may not be exactly identical in nucleic acid content to the parent cell and may contain mutations. As used herein, included are mutant progeny that have the same function or biological activity as screened or selected for in the originally transformed cell.

[0045] The terms "anti-myostatin antibody" and "antibody that binds to myostatin" refer to an antibody that can bind to myostatin with sufficient affinity so as to be useful as a diagnostic and / or therapeutic agent in targeting myostatin. In one embodiment, the extent of binding of an anti-myostatin antibody to an unrelated, non-myostatin protein is less than about 10% of the binding of the antibody to myostatin, as measured, for example, by radioimmunoassay (RIA). In certain embodiments, an antibody that binds to myostatin has a dissociation constant (Kd) of 1 μM or less, 100 nM or less, 10 nM or less, 1 nM or less, 0.1 nM or less, 0.01 nM or less, or 0.001 nM or less (e.g., 10 M or less, e.g., 10 M to 10 M, e.g., 10 M to 10 M). In certain embodiments, the anti-myostatin antibody binds to an epitope of myostatin that is conserved among myostatin from various species.

[0046] The term "antibody" is used herein in the broadest sense and encompasses a variety of antibody structures, including, but not limited to, monoclonal antibodies, polyclonal antibodies, multispecific antibodies (e.g., bispecific antibodies), and antibody fragments, so long as they exhibit the desired antigen-binding activity.

[0047] "Antibody fragment" refers to a molecule other than an intact antibody that contains a portion of an intact antibody that binds to the antigen to which the intact antibody binds. Examples of antibody fragments include, but are not limited to, Fv, Fab, Fab', Fab'-SH, F(ab')2; diabodies; linear antibodies; single-chain antibody molecules (e.g., scFv); and multispecific antibodies formed from antibody fragments.

[0048] An "antibody that binds to the same epitope" as a reference antibody refers to an antibody that blocks binding of the reference antibody to its antigen in a competition assay, and / or conversely, an antibody that blocks binding of the antibody to its antigen in a competition assay. Exemplary competition assays are provided herein.

[0049] A "human antibody" is an antibody having an amino acid sequence that corresponds to that of an antibody produced by a human or human cell, or to that of an antibody derived from a human antibody repertoire or other non-human source that utilizes human antibody coding sequences. This definition of a human antibody specifically excludes humanized antibodies, which contain non-human antigen-binding residues.

[0050] A "humanized" antibody refers to a chimeric antibody comprising amino acid residues from non-human HVRs and human FRs. In certain embodiments, a humanized antibody comprises substantially all of at least one, and typically two, variable domains, in which all or substantially all of the HVRs (e.g., CDRs) correspond to those of a non-human antibody and all or substantially all of the FRs correspond to those of a human antibody. A humanized antibody may optionally comprise at least a portion of an antibody constant region derived from a human antibody. A "humanized form" of an antibody, e.g., a non-human antibody, refers to an antibody that has undergone humanization.

[0051] As used herein, the term "monoclonal antibody" refers to an antibody obtained from a substantially homogeneous population of antibodies, i.e., the individual antibodies comprising the population are identical and / or bind to the same epitope, with the exception of possible variant antibodies that contain, for example, naturally occurring mutations or that arise during production of the monoclonal antibody preparation, and such variants are generally present in minor amounts. Each monoclonal antibody of a monoclonal antibody preparation is directed against a single determinant on the antigen, in contrast to polyclonal antibody preparations, which typically contain different antibodies against different determinants (epitopes). Thus, the modifier "monoclonal" indicates the character of the antibody as being obtained from a substantially homogeneous population of antibodies and should not be construed as requiring production of the antibody by any particular method. For example, monoclonal antibodies used in accordance with the present invention can be produced by a variety of techniques, including, but not limited to, hybridoma methods, recombinant DNA methods, phage display methods, and methods utilizing transgenic animals containing all or part of the human immunoglobulin loci; such methods and other exemplary methods for producing monoclonal antibodies are described herein.

[0052] The term "chimeric" antibody refers to an antibody in which a portion of the heavy and / or light chain is derived from a particular source or species, while the remainder of the heavy and / or light chain is derived from a different source or species.

[0053] The "class" of an antibody refers to the type of constant domain or constant region carried by its heavy chain. There are five major classes of antibodies: IgA, IgD, IgE, IgG, and IgM, some of which can be further divided into subclasses (isotypes), e.g., IgG1, IgG2, IgG3, IgG4, IgA1, and IgA2. The heavy chain constant domains corresponding to the different classes of immunoglobulins are called alpha, delta, epsilon, gamma, and mu, respectively.

[0054] The term "cytotoxic agent" as used herein refers to a substance that inhibits or prevents cell function and / or causes cell death or destruction.Cytotoxic agents include but are not limited to radioisotopes (for example, At211, I131, I125, Y90, Re186, Re188, Sm153, Bi212, P32, Pb212 and radioisotopes of Lu); chemotherapeutic agents or drugs (for example, methotrexate, adriamycin, vinca alkaloids (vincristine, vinblastine, etoposide), doxorubicin, melphalan, mitomycin C, chlorambucil, daunorubicin or other intercalating agents); growth inhibitors; enzymes and their fragments, for example, nucleases; antibiotics; toxins (including fragments and / or variants thereof), such as small molecule toxins or enzymatically active toxins derived from bacteria, fungi, plants or animals; and various antitumor or anticancer agents as disclosed below.

[0055] The term "epitope" includes any determinant that can be bound by an antibody. An epitope is a region of an antigen that is bound by an antibody that targets that antigen and includes specific amino acids that make direct contact with the antibody. Epitope determinants may include chemically active surface groups of molecules such as amino acids, sugar side chains, phosphoryl or sulfonyl groups, and may have specific three-dimensional structural characteristics and / or specific charge characteristics. Generally, antibodies specific for a particular target antigen will preferentially recognize epitopes on the target antigen in a complex mixture of proteins and / or macromolecules.

[0056] The term "Fc region" is used herein to define the C-terminal region of an immunoglobulin heavy chain containing at least a portion of the constant region. This term includes native-sequence Fc regions and variant Fc regions. In one embodiment, a human IgG heavy chain Fc region extends from Cys226, or from Pro230, to the carboxyl terminus of the heavy chain. However, the C-terminal lysine (Lys447) of the Fc region may or may not be present. Unless otherwise specified herein, the numbering of amino acid residues in the Fc region or constant region is according to the EU numbering system, also referred to as the EU index, as described in Kabat et al., Sequences of Proteins of Immunological Interest, 5th Ed. Public Health Service, National Institutes of Health, Bethesda, MD, 1991.

[0057] The term "Fc region-containing antibody" refers to an antibody that comprises an Fc region. The C-terminal lysine (residue 447 according to the EU numbering system) of the Fc region can be removed, for example, during purification of the antibody or by recombinant engineering of the nucleic acid encoding the antibody. Thus, a composition comprising an antibody with an Fc region according to the present invention can contain antibodies with K447, antibodies with all K447s removed, or a mixture of antibodies with and without the K447 residue.

[0058] "Framework" or "FR" refers to variable domain residues other than hypervariable region (HVR) residues. The FR of a variable domain typically consists of four FR domains: FR1, FR2, FR3, and FR4. Thus, the HVR and FR sequences typically appear in VH (or VL) in the following order: FR1-H1(L1)-FR2-H2(L2)-FR3-H3(L3)-FR4.

[0059] The terms "full length antibody," "intact antibody," and "whole antibody" are used interchangeably herein and refer to an antibody having a structure substantially similar to a native antibody structure, or an antibody having a heavy chain that includes an Fc region as defined herein.

[0060] A "functional Fc region" possesses an "effector function" of a native sequence Fc region. Exemplary "effector functions" include C1q binding; CDC; Fc receptor binding; ADCC; phagocytosis; down-regulation of a cell surface receptor (e.g., a B cell receptor; BCR); and the like. Such effector functions generally require association of the Fc region with a binding domain (e.g., an antibody variable domain) and may be assessed using various assays, e.g., as disclosed in the definitions herein.

[0061] "Percent (%) amino acid sequence identity" with respect to a reference polypeptide sequence is defined as the percentage of amino acid residues in a candidate sequence that are identical to those in the reference polypeptide sequence after sequence alignment and, if necessary, the introduction of gaps to achieve the maximum percent sequence identity, without considering any conservative substitutions as part of the sequence identity. Alignment for purposes of determining percent amino acid sequence identity can be achieved in a variety of ways within the skill of the art, for example, using publicly available computer software such as BLAST, BLAST-2, ALIGN, or Megalign (DNASTAR) software. Those skilled in the art can determine appropriate parameters for sequence alignment, including any algorithms necessary to achieve maximum alignment over the entire length of the sequences being compared. However, for purposes herein, percent amino acid sequence identity values ​​are generated using the sequence comparison computer program ALIGN-2. The ALIGN-2 sequence comparison computer program was written by Genentech, Inc., and the source code has been filed with the U.S. Copyright Office, Washington, D.C. 20559, registered under U.S. Copyright Registration No. TXU510087, along with user documentation. The ALIGN-2 program is publicly available from Genentech, Inc. (South San Francisco, California) or can be compiled from its source code. The ALIGN-2 program should be compiled for use on UNIX operating systems, including Digital UNIX V4.0D. All sequence comparison parameters are set by the ALIGN-2 program and do not vary.

[0062] As used herein, the term "myostatin" can refer to any native myostatin from any vertebrate source, including mammals such as primates (e.g., humans) and rodents (e.g., mice and rats). Unless otherwise indicated, the term "myostatin" refers to a human myostatin protein having the amino acid sequence set forth in SEQ ID NO: 11 and containing the terminal propeptide domain of human myostatin as set forth in SEQ ID NO: 12 or 13. The term encompasses "full-length," unprocessed myostatin, as well as any form of myostatin resulting from processing in cells. The term also encompasses naturally occurring variants of myostatin, such as splice variants or allelic variants. The amino acid sequence of an exemplary human myostatin (promyostatin) is set forth in SEQ ID NO: 11. The amino acid sequence of an exemplary N-terminal propeptide domain of human myostatin is set forth in SEQ ID NO: 12 or 13. Active mature myostatin is a disulfide-linked homodimer consisting of two C-terminal growth factor domains. Inactive, latent myostatin is a non-covalently associated complex of two propeptides and mature myostatin. As disclosed herein, the antibodies of the present invention bind to inactive, latent myostatin but do not bind to the mature, active myostatin homodimer. In some embodiments, the antibodies of the present invention bind to an epitope within a fragment consisting of amino acids 21-100 of the myostatin propeptide (SEQ ID NO: 13) but do not bind to the mature, active myostatin homodimer.

[0063] The term "variable region" or "variable domain" refers to the domain of an antibody heavy or light chain that is involved in binding the antibody to an antigen. The variable domains of the heavy and light chains (VH and VL, respectively) of natural antibodies generally have similar structures, with each domain containing four conserved framework regions (FR) and three hypervariable regions (HVR). (See, for example, Kindt et al., Kuby Immunology, 6th ed., W.H. Freeman and Co., page 91 (2007)). A single VH or VL domain may be sufficient to confer antigen-binding specificity. Furthermore, antibodies that bind to a specific antigen can be isolated using the VH or VL domain of an antibody that binds to that antigen, and a library of complementary VL or VH domains, respectively, can be screened. See, e.g., Portolano et al. J. Immunol. 150:880-887, 1993; Clarkson et al. Nature 352:624-628, 1991.

[0064] A "variant Fc region" comprises an amino acid sequence that differs from that of a native-sequence Fc region by virtue of at least one amino acid modification (alteration), preferably one or more amino acid substitutions. Preferably, the variant Fc region comprises at least one amino acid substitution compared to a native-sequence Fc region or the Fc region of a parent polypeptide, e.g., about one to about ten amino acid substitutions, preferably about one to about five amino acid substitutions, in the native-sequence Fc region or the Fc region of a parent polypeptide. The variant Fc region herein will preferably share at least about 80% homology with the native-sequence Fc region and / or the Fc region of the parent polypeptide, most preferably at least about 90% homology, and more preferably at least about 95% homology thereto.

[0065] As used herein, the term "vector" refers to a nucleic acid molecule capable of propagating another nucleic acid to which it is linked. The term includes vectors as autonomously replicating nucleic acid structures and vectors that integrate into the genome of a host cell into which they are introduced. Certain vectors are capable of directing the expression of nucleic acids to which they are operatively linked. Such vectors are referred to herein as "expression vectors."

[0066] As used herein, the term "hypervariable region" or "HVR" refers to each of the regions of an antibody variable domain that are hypervariable in sequence ("complementarity determining regions" or "CDRs") and / or form structurally defined loops ("hypervariable loops") and / or contain residues that contact the antigen ("antigen contacts"). Generally, antibodies contain six HVRs, three in the VH (H1, H2, H3) and three in the VL (L1, L2, L3). Exemplary HVRs herein include: (a) hypervariable loops occurring at amino acid residues 26-32 (L1), 50-52 (L2), 91-96 (L3), 26-32 (H1), 53-55 (H2), and 96-101 (H3) (Chothia and Lesk, J. Mol. Biol. 196:901-917 (1987)); (b) CDRs occurring at amino acid residues 24-34 (L1), 50-56 (L2), 89-97 (L3), 31-35b (H1), 50-65 (H2), and 95-102 (H3) (Kabat et al., Sequences of Proteins of Immunological Interest, 5th ed. Public Health Service, NIH, Bethesda, MD (1991); (c) antigenic contacts occurring at amino acid residues 27c-36 (L1), 46-55 (L2), 89-96 (L3), 30-35b (H1), 47-58 (H2), and 93-101 (H3) (MacCallum et al., J. Mol. Biol. 262:732-745 (1996)); (d) combinations of (a), (b), and / or (c) including HVR amino acid residues 46-56 (L2), 47-56 (L2), 48-56 (L2), 49-56 (L2), 26-35 (H1), 26-35b (H1), 49-65 (H2), 93-102 (H3), and 94-102 (H3). Unless otherwise indicated, HVR residues and other residues in the variable domain (e.g., FR residues) are numbered herein according to Kabat et al. (supra).

[0067] The term "Revised Hammersmith Scale," also known by the acronym RHS, is a psychometrically and clinically robust functional outcome measure specifically designed to assess physical performance in patients with SMA type 3 who are highly ambulatory, and those with SMA type 2 who are less ambulatory. This scale was developed based on the Expanded Hammersmith Functional Motor Scale (HFMSE). It is widely used in clinical practice, clinical trials, and internationally to document the natural history and disease trajectory of SMA. One of the key strengths of the RHS is its robust development process, which used a well-developed and established scale as its foundation and involved an expert panel throughout to ensure the clinical relevance of the modifications. Psychometric analysis, facilitated by several international pilots, resulted in the construction of a robust SMA-specific clinical outcome assessment tool (Ramsey et al., PLoS One 2017;12:e0172346). The RHS consists of 36 items. To avoid the ceiling effect seen in other functional scales, the RHS includes a revised version of the North Star Ambulatory Assessment (NSAA), which includes two timed tests: RHS item 19 [Walk Time / Run 10m] and item 25 [Floor Stand Time]. The addition of these items expands the scale's range for assessing ambulatory patients with SMA, such as this study's population, and the ordinal scoring used in both items has been shown to further differentiate between clinically distinct abilities (p<0.05; Ramsey et al. PLoS One 2017;12:e0172346). The RHS has published evidence of content validity, construct validity, and inter-rater reliability in SMA (Ramsey et al. Neuromuscular Disord 2015;25:S195; PLoS One 2017;12:e0172346).

[0068] The term "Motor Function Measure-32" (MFM32) refers to a valid, reliable, clinician-reported assessment of motor function performance in neuromuscular disorders. The assessment has been validated in individuals aged 2 years and older with neuromuscular disorders, including SMA (Berard et al. Neuromuscul Disord 2005;15:463-70; Trundell et al. Neurol Ther 2020;9:575-584), and patients have confirmed its relevance to activities of daily living (Duong et al. BMC Neurol 2021;21:143). The MFM32 includes 32 items assessed across three domains of motor function: Domain 1 (D1) (standing and locomotion), Domain 2 (D2) (axial and proximal motor function), and Domain 3 (D3) (distal motor function). When considered independently, each domain has different capabilities for detecting change depending on the patient's abilities. Vuillerot et al. (Arch Phys Med Rehabil 2013;94:1555-61) reported that D2 showed good response in patients with SMA type 2, and D1 showed good response in patients with SMA type 3. In an ambulatory population such as that included in this study, it is hypothesized that these participants would have a greater ability to improve D1 and D2, which include items assessing the ability to stand and walk as well as axial and proximal function. Conversely, because distal motor function remains relatively preserved until the later stages of the disease, D3 would be less sensitive to change in these ambulatory patients.

[0069] The Phase II / III study will evaluate the safety, tolerability, pharmacokinetics, pharmacodynamics, and efficacy of GYM239, a humanized monoclonal antibody described herein that binds to human latent myostatin, in combination with risdiplam (Evrysdi®) in ambulatory pediatric patients (ages 2-10) with spinal muscular atrophy (SMA). Despite three treatments already available for SMA patients, unmet medical need remains, as patients treated with existing disease-modifying therapies may remain with significant motor dysfunction related to the skeletal musculature.

[0070] A therapeutic approach to improving motor function in patients is to directly target skeletal muscle to reduce muscle atrophy and, consequently, improve muscle strength in subjects with muscle conditions such as SMA. Inhibition of myostatin (also known as growth and differentiation factor 8, or GDF-8) offers a promising approach to increasing muscle mass and function in patients with muscle conditions, such as SMA. Myostatin is a member of the TGF superfamily and is a key negative regulator of muscle growth. Genetic loss of myostatin results in a significant increase in muscle mass, resulting from both myocyte hypertrophy and hyperplasia (ACM McPherron et al. Nature 387, 83-90, 1997). Similar to loss-of-function mutations in myostatin, pharmacological inhibition of myostatin also increases muscle mass, mediated through muscle hypertrophy but not hyperplasia (SJ Lee et al. Proc Natl Acad Sci USA 98, 9306-9311, 2001).

[0071] The present invention has demonstrated the surprising effect of combining treatment with a splicing regulator such as risdiplam and GYM329 on the treatment of SMA. Surprisingly, without effective pretreatment with a splicing regulator such as risdiplam, GYM329 was found to have little effect on SMA.

[0072] The present invention relates to risdiplam for use in treating, preventing, delaying progression and / or ameliorating SMA when used in combination with an antibody comprising a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO:7 and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO:8.

[0073] In a specific embodiment, the present invention relates to risdiplam for use in treating, preventing, delaying progression and / or ameliorating SMA when used in combination with an antibody comprising a VH having sequence identity to the amino acid sequence of SEQ ID NO:7 and a VL having sequence identity to the amino acid sequence of SEQ ID NO:8.

[0074] In a further embodiment, the invention relates to risdiplam for use in the treatment of SMA when used in combination with an antibody comprising a VH having sequence identity to the amino acid sequence of SEQ ID NO:7, and a VL having sequence identity to the amino acid sequence of SEQ ID NO:8.

[0075] In certain embodiments, the antibody used in combination with risdiplam is an anti-myostatin antibody. More specifically, the antibody according to the present invention comprises one or more CDR sequences, variable heavy and light chain sequences, or heavy and light chain sequences selected from those set forth in Table 1, Table 2. [Table 1] [Table 2]

[0076] In some embodiments, the isolated anti-myostatin antibody of the present invention is a monoclonal antibody. In some embodiments, the isolated anti-myostatin antibody of the present invention is a human antibody, a humanized antibody, or a chimeric antibody. In some embodiments, the isolated anti-myostatin antibody of the present invention is an antibody fragment that binds to myostatin. In some embodiments, the isolated anti-myostatin antibody of the present invention is an antibody fragment that binds to latent myostatin. In some embodiments, the isolated anti-myostatin antibody of the present invention is a full-length IgG antibody.

[0077] Antibodies or polypeptides comprising variant Fc regions of the present invention (and optionally any additional therapeutic agents) can be administered by any suitable means, including parenteral, intrapulmonary, and intranasal, and, if desired for localized treatment, intralesional administration. Parenteral infusions include intramuscular, intravenous, intraarterial, intraperitoneal, or subcutaneous administration. Administration can be by any suitable route, for example, injection, such as intravenous or subcutaneous injection, depending in part on whether the administration is short-term or long-term. Various dosing schedules are contemplated herein, including, but not limited to, a single dose or multiple doses over various time periods, bolus administration, and pulse infusion.

[0078] Antibodies or polypeptides comprising the variant Fc regions of the present invention may be formulated, administered, and administered in a manner consistent with good medical practice. Factors to consider in this regard include the particular disorder being treated, the particular mammal being treated, the clinical condition of the individual patient, the cause of the disorder, the site of drug delivery, the method of administration, the administration schedule, and other factors known to medical practitioners. The antibody is optionally, but need not be, formulated with one or more agents currently used to prevent or treat the disorder in question. Effective amounts of such other agents will depend on the amount of antibody present in the formulation, the type of disorder or treatment, and other factors discussed above. These will generally be used in dosages similar to those described herein, or about 1-99% of the dosages described herein, or at any dosage and route of administration determined empirically / clinically appropriate.

[0079] For disease prevention or treatment, the appropriate dosage of an antibody of the present invention will depend on the course of the disease, whether the antibody is administered for prophylactic or therapeutic purposes, and previous treatment. Antibodies or polypeptides comprising the variant Fc regions of the present invention are appropriately administered to patients at one time or over a series of treatments. Depending on the type and severity of the disease, an initial candidate dosage for administration to a patient may be approximately 1 μg / kg to 15 mg / kg (e.g., 0.1 mg / kg to 10 mg / kg), whether by one or more separate administrations or by continuous infusion. In particular, anti-myostatin antibodies may be administered intermittently, weekly, every three weeks, or more specifically, every four weeks, more specifically every four weeks. An initial higher loading dose may be administered, followed by one or more lower doses. The progress of this therapy is easily monitored by conventional techniques and assays.

[0080] According to the present invention, the anti-myostatin can be formulated into a pharmaceutical formulation comprising the antibody and a pharmaceutically acceptable carrier.

[0081] Exemplary lyophilized antibody formulations are described in U.S. Patent No. 6,267,958. Aqueous antibody formulations include those described in U.S. Patent No. 6,171,586 and WO 2006 / 044908, the latter formulations containing a histidine acetate buffer.

[0082] In a further aspect, the invention provides pharmaceutical formulations comprising the anti-myostatin antibodies provided herein, e.g., for use in SMA in combination with risdiplam. In one embodiment, the pharmaceutical formulation comprises the anti-myostatin antibodies provided herein and a pharmaceutically acceptable carrier.

[0083] In a further aspect, the anti-myostatin pharmaceutical formulations described herein are for treating SMA. The anti-myostatin antibodies of the present invention may exhibit pH-dependent binding properties. In a further embodiment, the pharmaceutical formulations are for enhancing the clearance of myostatin from plasma. In one embodiment, the pharmaceutical formulations are administered to an individual with SMA.

[0084] Antibodies or polypeptides comprising the variant Fc region of the present invention can be administered by any suitable means, including parenteral, intrapulmonary, and intranasal administration, and, if desired for localized treatment, intralesional administration. Parenteral infusions include intramuscular, intravenous, intraarterial, intraperitoneal, or subcutaneous administration. Administration can be by any suitable route, for example, injection, such as intravenous or subcutaneous injection, depending in part on whether the administration is short-term or long-term. Various dosing schedules are contemplated herein, including, but not limited to, a single administration or multiple administrations over various time periods, bolus administration, and pulse infusion. More specifically, the administration of anti-myostatin antibodies according to the present invention will be administered every four weeks, more specifically by subcutaneous injection.

[0085] In a further aspect, the present invention provides a method for preparing a medicament or pharmaceutical formulation, the method comprising mixing an anti-myostatin antibody provided herein with a pharmaceutically acceptable carrier for use, for example, in the treatment of SMA.

[0086] Polypeptides comprising the variant Fc regions provided herein can be used in therapeutic methods. In a further aspect, the present invention provides pharmaceutical formulations comprising a polypeptide comprising any of the polypeptides comprising a variant Fc region provided herein, for use, for example, in the treatment of SMA. In one embodiment, the pharmaceutical formulation comprises a polypeptide comprising any of the polypeptides comprising a variant Fc region provided herein and a pharmaceutically acceptable carrier.

[0087] Muscle atrophy is a key clinical feature of disease progression in SMA. In patients with more severe disease, such progression results in a loss of functional muscle in the upper and lower limbs (Chabanon et al., PLoS One 2018;13:e0201004). Data from patients with neuromuscular disease indicate that blood levels of myostatin decline with disease progression (Burch et al., J Neurol 2017;264:541-553). Given that myostatin is the target of GYM329, the ambulatory SMA subpopulation was considered to have the greatest potential for demonstrating the benefit of anti-myostatin treatment in SMA in a clinical research setting due to greater functional muscle preservation as a result of less advanced disease.

[0088] To avoid confounding results with the physical changes that occur during puberty, patients over the age of 10 were not included in this particular clinical trial. This does not necessarily mean that the combined treatment is limited to patients under the age of 10. Treatment should be available for older SMA patients.

[0089] According to the present invention, an effective amount of a myostatin inhibitor for treating a muscle condition is an amount that achieves both clinical efficacy and safety. In some embodiments, the effective amount is an amount that enhances muscle function, such as force production and motor function. In some embodiments, the effective amount is an amount that enhances motor function requiring fast-twitch muscle fibers (e.g., type II fibers). In some embodiments, motor function includes eccentric muscle contraction. In some embodiments, an effective amount of myostatin treatment is sufficient to slow or alleviate the progression of a disease (e.g., muscle atrophy); maintain the disease state (e.g., as measured / monitored by appropriate motor function tests, plasma protein markers, metabolic markers, etc.); delay loss of motor neurons; prevent or delay the expression of immature muscle markers; prevent, alleviate, or delay intramuscular fat deposition (e.g., fatty replacement of muscle tissue); prevent metabolic dysregulation; prevent or reduce bone loss or fracture frequency; increase the Expanded Hammersmith Functional Motor Scale score by more than 1 point compared to a control not administered a myostatin inhibitor; slow the rate of deterioration; delay regression (e.g., gradual decline) of the Expanded Hammersmith Functional Motor Scale over a 12-month, 24-month, or 36-month period; and / or increase the CHOP INTEND score by more than 1 point compared to a control not receiving a myostatin inhibitor; and / or increase the MFM-32 score by more than 1 point compared to a control not receiving a myostatin inhibitor.

[0090] In some embodiments, the muscle condition treated with a myostatin inhibitor is associated with a neuromuscular disease, including, but not limited to, amyotrophic lateral sclerosis (ALS); congenital myasthenic syndromes; congenital myopathies; spastic fasciculations syndrome; Duchenne muscular dystrophy (DMD); type II glycogen storage disorder; hereditary spastic paraplegia; inclusion body myositis (IBM); Isaac syndrome; Kearns-Sayre syndrome; Lambert-Eaton myasthenic syndrome; mitochondrial myopathy; muscular dystrophies; myasthenia gravis; myotonic dystrophy; peripheral neuropathy; spinal and spinal-bulbar muscular atrophies; spinal muscular atrophy (SMA); spinal muscular atrophy type 1 with respiratory distress; stiff-person syndrome; Troyer syndrome; Guillain-Barré syndrome.

[0091] In accordance with the invention described herein, more detailed embodiments of the invention are described below.

[0092] Embodiment 1. Risdiplam for use in treating, preventing, delaying progression and / or ameliorating SMA, particularly in a patient, when used in combination with an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5 and CDRL3 comprises the sequence set forth in SEQ ID NO: 6.

[0093] Embodiment 2. Risdiplam for use in the treatment of SMA in combination with an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO: 6.

[0094] Embodiment 3. Risdiplam for use in the treatment of SMA according to embodiment 1 or 2, wherein the anti-myostatin antibody inhibits activation of myostatin.

[0095] Embodiment 4. Risdiplam for use in the treatment of SMA according to any one of embodiments 1 to 3, wherein the anti-myostatin antibody blocks the proteolytic release of mature myostatin.

[0096] Embodiment 5. Risdiplam for use in treatment according to any one of embodiments 1 to 4, wherein the anti-myostatin antibody comprises a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7, and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 8.

[0097] Embodiment 6. Risdiplam for use in treatment according to any one of embodiments 1 to 5, wherein the anti-myostatin antibody comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 7 and a light chain variable region comprising the amino acid sequence of SEQ ID NO: 8.

[0098] Embodiment 7. Risdiplam for use in treatment according to any one of embodiments 1 to 6, wherein the anti-myostatin antibody comprises a heavy chain region comprising the amino acid sequence of SEQ ID NO: 9 and a light chain region comprising the amino acid sequence of SEQ ID NO: 10.

[0099] Embodiment 8. Risdiplam for use in a treatment according to any one of embodiments 1 to 7, wherein the anti-myostatin antibody is GM329.

[0100] Embodiment 9. Risdiplam for use in the treatment of a patient (particularly a patient in need thereof) according to any one of embodiments 1 to 8, wherein the patient is a human (such as a male or female human).

[0101] Embodiment 10. Risdiplam for use in treatment according to any one of embodiments 1 to 9, wherein the patient to be treated has initially been treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before the first dose of the antibody is administered to the patient.

[0102] Embodiment 11. Risdiplam for use in treatment according to any one of embodiments 1 to 10, wherein the total daily dose of risdiplam is administered to a patient at a dose of 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

[0103] Embodiment 12. Risdiplam for use in the treatment of any one of embodiments 1 to 11, wherein the dose of the anti-myostatin antibody is administered to the patient at a dose of 7.4 mg or 24 mg for patients older than 2 years and weighing less than 20 kg, and at a dose of 10.6 mg or 36 mg for patients weighing 20 kg or more, and in particular, the dose of the antibody is administered to the patient at a dose of 24 mg for patients older than 2 years and weighing less than 20 kg, and at a dose of 36 mg for patients weighing 20 kg or more every 4 weeks.

[0104] Embodiment 13. Risdiplam for use in a treatment according to any one of embodiments 1 to 12, wherein the anti-myostatin antibody is administered every four weeks.

[0105] Embodiment 14. Risdiplam for use in the treatment of any one of embodiments 1 to 13, wherein the patient has SMA.

[0106] Embodiment 15. Risdiplam for use in the treatment of any one of embodiments 1 to 14, wherein the SMA is SMA Type I, SMA Type II, or SMA Type III.

[0107] Embodiment 16. Risdiplam for use in the treatment of SMA according to any one of embodiments 1 to 15, wherein the patient being treated has been initially treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before the anti-myostatin is first administered.

[0108] Embodiment 17. Risdiplam is 1 to 10% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2 to 15% by weight, in particular 4 to 6% by weight, of a buffer system, in particular a buffer system selected from citrate, malate, maleate, or tartrate, more in particular malate or tartrate, most in particular tartrate; or the corresponding acid of a buffer system as the sole acidifying agent, specifically tartaric acid; 40-90% by weight of a diluent, in particular mannitol or a mixture of mannitol and isomalt, more particularly mannitol; · 0.5-4% by weight of an antioxidant, specifically ascorbic acid; 0.2-2% by weight of a stabilizer, specifically edetate disodium; · 0.5-2% by weight of a lubricant, specifically PEG 6000; 1 to 8% by weight, in particular 1 to 4% by weight, of a preservative selected from potassium sorbate or sodium benzoate; 0 to 3% by weight of a sweetener, particularly sucralose or sodium saccharin, most particularly sucralose; and 0 to 20% by weight of a flavoring, in particular a strawberry flavoring or a vanilla flavoring, 17. Risdiplam for use in treatment according to any one of embodiments 1 to 16, wherein the risdiplam is administered in a pharmaceutical composition, the total amount of components of which does not exceed 100% by weight.

[0109] Embodiment 18. Risdiplam is 1 to 5% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2-8% by weight, in particular 4-6% by weight, of a tartrate buffer system; 60-75% by weight of mannitol as a first diluent and 10-15% by weight of isomalt as a second diluent; 0.5-1.5% by weight of ascorbic acid as an antioxidant; 0.25-0.75% by weight of disodium edetate as a stabilizer; · 0.5-2 wt% PEG6000 as a lubricant; · 1-8% by weight, in particular 1-4% by weight, of sodium benzoate as a preservative; 0.5 to 1% by weight of sucralose as a sweetener; and 5 to 10% by weight of strawberry flavoring, 18. The risdiplam for use in treatment according to any one of embodiments 1 to 17, wherein the risdiplam is administered in a pharmaceutical composition wherein the total amount of ingredients does not exceed 100% by weight.

[0110] A combination of risdiplam and an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5 and CDRL3 comprises the sequence set forth in SEQ ID NO: 6.

[0111] Embodiment 19. The combination described in claim 19 for use in treating, preventing, delaying progression and / or ameliorating SMA, wherein the anti-myostatin antibody comprises a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7 and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 8.

[0112] Embodiment 20. The combination of claim 19 or 20, wherein the anti-myostatin antibody comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 7 and a light chain variable region comprising the amino acid sequence of SEQ ID NO: 8.

[0113] Embodiment 21. A combination described in any one of embodiments 19 to 21, wherein the anti-myostatin antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 9 and a light chain comprising the amino acid sequence of SEQ ID NO: 10.

[0114] Embodiment 22. A combination according to any one of embodiments 19 to 21 in a patient (particularly a patient in need thereof), wherein the patient is a human (such as a male or female human).

[0115] Embodiment 23. The combination of any one of embodiments 19 to 23, wherein the patient to be treated has initially been treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before the first dose of the antibody is administered to the patient.

[0116] Embodiment 24. The combination of any one of embodiments 19 to 24, wherein a total daily dose of risdiplam is administered to a patient at a dose of 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

[0117] Embodiment 25. A combination described in any one of embodiments 19 to 25, wherein the dose of the anti-myostatin antibody is administered to the patient at a dose of 7.4 mg or 24 mg for patients older than 2 years and weighing less than 20 kg, and 10.6 mg or 36 mg for patients weighing 20 kg or more, and in particular, the dose of the antibody is administered to the patient at a dose of 24 mg for patients older than 2 years and weighing less than 20 kg, and 36 mg for patients weighing 20 kg or more every 4 weeks.

[0118] Embodiment 26. A combination according to any one of embodiments 19 to 26, wherein the anti-myostatin antibody is GM329.

[0119] Embodiment 27. A combination according to any one of embodiments 19 to 27, wherein the anti-myostatin antibody is administered every four weeks.

[0120] Embodiment 28. A combination according to any one of embodiments 19 to 28, wherein the patient has SMA.

[0121] Embodiment 29. A combination according to any one of embodiments 19 to 29, wherein the SMA is SMA Type I, SMA Type II or SMA Type III.

[0122] Embodiment 30. Risdiplam is 1 to 10% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2 to 15% by weight, in particular 4 to 6% by weight, of a buffer system, in particular a buffer system selected from citrate, malate, maleate, or tartrate, more in particular malate or tartrate, most in particular tartrate; or the corresponding acid of the buffer system as the sole acidifying agent, in particular tartaric acid; 40-90% by weight of a diluent, in particular mannitol or a mixture of mannitol and isomalt, more particularly mannitol; · 0.5-4% by weight of an antioxidant, specifically ascorbic acid; 0.2-2% by weight of a stabilizer, specifically edetate disodium; · 0.5-2% by weight of a lubricant, specifically PEG 6000; 1 to 8% by weight, in particular 1 to 4% by weight, of a preservative selected from potassium sorbate or sodium benzoate; 0 to 3% by weight of a sweetener, particularly sucralose or sodium saccharin, most particularly sucralose; and 0 to 20% by weight of a flavoring, in particular a strawberry flavoring or a vanilla flavoring, The risdiplam for use in treatment according to any one of embodiments 19-21 or 23-30, wherein the risdiplam is administered in a pharmaceutical composition wherein the total amount of the components does not exceed 100% by weight.

[0123] Embodiment 31. Risdiplam is 1 to 5% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2-8% by weight, in particular 4-6% by weight, of a tartrate buffer system; 60-75% by weight of mannitol as a first diluent and 10-15% by weight of isomalt as a second diluent; 0.5-1.5% by weight of ascorbic acid as an antioxidant; 0.25-0.75% by weight of disodium edetate as a stabilizer; · 0.5-2 wt% PEG6000 as a lubricant; · 1-8% by weight, in particular 1-4% by weight, of sodium benzoate as a preservative; 0.5 to 1% by weight of sucralose as a sweetener; and 5 to 10% by weight of strawberry flavoring, The combination according to any one of embodiments 19 to 21 or 23 to 31, wherein the combination is administered in a pharmaceutical composition, the total amount of the components not exceeding 100% by weight.

[0124] Embodiment 32. A method for treating, preventing, slowing the progression of and / or ameliorating SMA in a subject in need thereof, comprising administering to the patient: a) treated with risdiplam for at least 2 weeks, specifically at least 3 weeks, more specifically at least 4 weeks, even more specifically at least 6 weeks, and most specifically at least 8 weeks, and then b) A method in which the patient is treated with risdiplam and an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO: 6.

[0125] Embodiment 33. A method for treating, preventing, delaying progression and / or ameliorating SMA, comprising administering a combination of risdiplam and an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO: 6.

[0126] Embodiment 34. The method of embodiment 33 or 34, wherein the anti-myostatin antibody comprises a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7 and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 8.

[0127] Embodiment 35. The method of any one of embodiments 33 to 35, wherein the anti-myostatin antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 9 and a light chain comprising the amino acid sequence of SEQ ID NO: 10.

[0128] Embodiment 36. The method of any one of embodiments 33-36, wherein a total daily dose of risdiplam is administered to the patient is 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

[0129] Embodiment 37. The method of any one of embodiments 33-37, wherein the antibody is administered to the patient at a dose of 7.4 mg or 24 mg every four weeks for patients older than 2 years and weighing less than 20 kg, and 10.6 mg or 36 mg for patients weighing 20 kg or more, particularly wherein the antibody is administered to the patient at a dose of 24 mg every four weeks for patients older than 2 years and weighing less than 20 kg, and 36 mg every four weeks for patients weighing 20 kg or more.

[0130] Embodiment 38. The method of any one of embodiments 33 to 38, wherein the patient has SMA Type I; SMA Type II or SMA Type III.

[0131] Embodiment 39. The method according to any one of embodiments 33 to 39 in a patient (particularly a patient in need thereof), wherein the patient is a human (such as a male or female human).

[0132] Embodiment 40. The method of any one of embodiments 34 to 40, wherein the patient to be treated has been initially treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before the first dose of the antibody is administered to the patient.

[0133] Embodiment 41. The method of any one of embodiments 33-41, wherein a total daily dose of risdiplam is administered to the patient is 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years who weigh less than 20 kg, and 5 mg for patients weighing 20 kg or more.

[0134] Embodiment 42. The method of any one of embodiments 33 to 42, wherein the dose of anti-myostatin antibody is administered to the patient at a dose of 7.4 mg or 24 mg for patients older than 2 years and weighing less than 20 kg, and at a dose of 10.6 mg or 36 mg for patients weighing 20 kg or more, and in particular, the dose of antibody is administered to the patient at a dose of 24 mg for patients older than 2 years and weighing less than 20 kg, and at a dose of 36 mg for patients weighing 20 kg or more every 4 weeks.

[0135] Embodiment 43. The method of any one of embodiments 33 to 43, wherein the anti-myostatin antibody is GM329.

[0136] Embodiment 44. The method of any one of embodiments 33 to 44, wherein the anti-myostatin antibody is administered every four weeks.

[0137] Embodiment 45. The method of any one of embodiments 33 to 45, wherein the patient has SMA.

[0138] Embodiment 46. The method of any one of embodiments 33 to 46, wherein the SMA is SMA Type I, SMA Type II, or SMA Type III.

[0139] Embodiment 47. Risdiplam is 1 to 10% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2 to 15% by weight, in particular 4 to 6% by weight, of a buffer system, in particular a buffer system selected from citrate, malate, maleate, or tartrate, more in particular malate or tartrate, most in particular tartrate; or the corresponding acid of the buffer system as the sole acidifying agent, in particular tartaric acid; 40-90% by weight of a diluent, in particular mannitol or a mixture of mannitol and isomalt, more particularly mannitol; · 0.5-4% by weight of an antioxidant, specifically ascorbic acid; 0.2-2% by weight of a stabilizer, specifically edetate disodium; · 0.5-2% by weight of a lubricant, specifically PEG 6000; 1 to 8% by weight, in particular 1 to 4% by weight, of a preservative selected from potassium sorbate or sodium benzoate; 0 to 3% by weight of a sweetener, particularly sucralose or sodium saccharin, most particularly sucralose; and 0 to 20% by weight of a flavoring, in particular a strawberry flavoring or a vanilla flavoring, The method of any one of embodiments 33-47, wherein the composition is administered in a pharmaceutical composition, the total amount of ingredients of which does not exceed 100% by weight.

[0140] Embodiment 48. Risdiplam is 1 to 5% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2-8% by weight, in particular 4-6% by weight, of a tartrate buffer system; 60-75% by weight of mannitol as a first diluent and 10-15% by weight of isomalt as a second diluent; 0.5-1.5% by weight of ascorbic acid as an antioxidant; 0.25-0.75% by weight of disodium edetate as a stabilizer; · 0.5-2 wt% PEG6000 as a lubricant; · 1-8% by weight, in particular 1-4% by weight, of sodium benzoate as a preservative; 0.5 to 1% by weight of sucralose as a sweetener; and 5 to 10% by weight of strawberry flavoring, The method of any one of embodiments 33-48, wherein the composition is administered in a pharmaceutical composition, the total amount of ingredients of which does not exceed 100% by weight.

[0141] Embodiment 49. Use of risdiplam in the manufacture of a medicament for the treatment of SMA, wherein a subject treated with risdiplam is further treated with an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO: 6.

[0142] Embodiment 50. The use described in embodiment 50, wherein the anti-myostatin antibody comprises a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7 and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 8.

[0143] Embodiment 51. The use described in embodiment 50, wherein the anti-myostatin antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 9 and a light chain comprising the amino acid sequence of SEQ ID NO: 10.

[0144] Embodiment 52. Risdiplam and GYM329 for use in the treatment, prevention, delay of progression and / or amelioration of SMA.

[0145] Embodiment 53. Risdiplam and GYM329 for use in treating, preventing, slowing the progression of and / or ameliorating SMA in a patient.

[0146] Embodiment 54. Risdiplam and GYM329 for use according to embodiment 53 or 54, wherein the patient to be treated has already been treated with risdiplam.

[0147] Embodiment 55. Risdiplam and GYM329 for use according to any one of embodiments 53 to 55, wherein the patient to be treated has been initially treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks, before GYM329 is initially administered with risdiplam.

[0148] Embodiment 56. Risdiplam for use in treating, preventing, delaying progression and / or ameliorating SMA in a patient when used in combination with an antibody comprising an antibody comprising six complementarity determining regions: CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5 and CDRL3 comprises the sequence set forth in SEQ ID NO: 6.

[0149] Embodiment 57. Risdiplam for use in treatment according to embodiment 57, comprising a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7, and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 8.

[0150] Embodiment 58. The risdiplam for use in treatment of embodiment 57 or 58, wherein the antibody comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 7, and a light chain variable region comprising the amino acid sequence of SEQ ID NO: 8.

[0151] Embodiment 59. Risdiplam for use in treatment according to any one of embodiments 57 to 59, wherein the anti-myostatin antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 9 and a light chain comprising the amino acid sequence of SEQ ID NO: 10.

[0152] Embodiment 60. Risdiplam for use in the treatment of any one of embodiments 57 to 60, wherein the patient is being treated

[0153] Embodiment 61. Use of risdiplam and GYM329 in the treatment of SMA in a patient.

[0154] Embodiment 62. The use of claim 62, wherein the patient is a human (such as a male or female human).

[0155] Embodiment 63. The use according to claim 62 or 63, wherein the SMA is SMA type I, SMA type II or SMA type III.

[0156] Embodiment 64. The use of any one of embodiments 62 to 64, wherein the total daily dose of risdiplam is administered to the patient is 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

[0157] Embodiment 65. The use of any one of embodiments 62 to 65, wherein the antibody is administered to the patient at a dose of 7.4 mg or 24 mg every 4 weeks for patients older than 2 years and weighing less than 20 kg, and 10.6 mg or 36 mg for patients weighing 20 kg or more, in particular wherein the antibody is administered to the patient at a dose of 24 mg every 4 weeks for patients older than 2 years and weighing less than 20 kg, and 36 mg every 4 weeks for patients weighing 20 kg or more.

[0158] Embodiment 66. A package or kit comprising: (a) risdiplam, optionally in a container, and (b) a package insert, packaging label, instructions, or other labeling for use according to any one of embodiments 62 to 66.

[0159] Embodiment 67. The package or kit of claim 67, further comprising (c) GYM329.

[0160] Embodiment 68. According to any of the embodiments described herein, the patient to be treated begins treatment (particularly risdiplam + anti-myostatin antibody) between the ages of 2 and 10.

[0161] Embodiment 69. An anti-myostatin antibody for use in the treatment, prevention, delay of progression and / or amelioration of SMA, particularly when used in combination with risdiplam in a patient, comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5 and CDRL3 comprises the sequence set forth in SEQ ID NO: 6.

[0162] Embodiment 70. An anti-myostatin antibody for use in the treatment of SMA in combination with risdiplam, comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO: 6.

[0163] Embodiment 71. Use of an anti-myostatin antibody for use in the treatment of SMA according to embodiment 69 or embodiment 70, which inhibits the activation of myostatin.

[0164] Embodiment 72. An anti-myostatin antibody for use in the treatment of SMA described in any one of embodiments 69 to 71, which blocks the proteolytic release of mature myostatin.

[0165] Embodiment 73. An anti-myostatin antibody for use in treatment described in any one of embodiments 69 to 72, comprising a VH having at least 90% sequence identity with the amino acid sequence of SEQ ID NO: 7, and a VL having at least 90% sequence identity with the amino acid sequence of SEQ ID NO: 8.

[0166] Embodiment 74. An anti-myostatin antibody for use in the treatment described in any one of embodiments 69 to 73, comprising a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 7 and a light chain variable region comprising the amino acid sequence of SEQ ID NO: 8.

[0167] Embodiment 75. An anti-myostatin antibody for use in the treatment described in any one of embodiments 69 to 74, comprising a heavy chain region comprising the amino acid sequence of SEQ ID NO: 9 and a light chain region comprising the amino acid sequence of SEQ ID NO: 10.

[0168] Embodiment 76. An anti-myostatin antibody for use in the treatment of any one of embodiments 69 to 75, which is GM329.

[0169] Embodiment 77. An anti-myostatin antibody for use in the treatment of a patient (particularly a patient in need of treatment) described in any one of embodiments 69 to 76, particularly wherein the patient is a human (e.g., a male or female human).

[0170] Embodiment 78. An anti-myostatin antibody for use in a treatment described in any one of embodiments 69 to 77, wherein the patient to be treated has been initially treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before the first dose of the antibody is administered to the patient.

[0171] Embodiment 79. An anti-myostatin antibody for use in treatment according to any one of embodiments 69 to 78, wherein the total daily dose of risdiplam is administered to a patient at a dose of 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

[0172] Embodiment 80. An anti-myostatin antibody for use in treatment described in any one of embodiments 69 to 79, wherein the patient is administered a dose of the anti-myostatin antibody at 7.4 mg or 24 mg for patients over 2 years of age and weighing less than 20 kg, and 10.6 mg or 36 mg for patients weighing 20 kg or more, and in particular, the patient is administered a dose of the antibody at 24 mg for patients over 2 years of age and weighing less than 20 kg, and 36 mg for patients weighing 20 kg or more, every four weeks.

[0173] Embodiment 81. An anti-myostatin antibody for use in a treatment described in any one of embodiments 69 to 80, wherein the anti-myostatin antibody is administered every four weeks.

[0174] Embodiment 82. An anti-myostatin antibody for use in the treatment of any one of embodiments 69 to 81, wherein the patient has SMA.

[0175] Embodiment 83. An anti-myostatin antibody for use in the treatment of any one of embodiments 69 to 82, wherein the SMA is SMA type I, SMA type II, or SMA type III.

[0176] Embodiment 84. Risdiplam is 1 to 10% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2 to 15% by weight, in particular 4 to 6% by weight, of a buffer system, in particular a buffer system selected from citrate, malate, maleate, or tartrate, more in particular malate or tartrate, most in particular tartrate; or the corresponding acid of the buffer system as the sole acidifying agent, in particular tartaric acid; 40-90% by weight of a diluent, in particular mannitol or a mixture of mannitol and isomalt, more particularly mannitol; · 0.5-4% by weight of an antioxidant, specifically ascorbic acid; 0.2-2% by weight of a stabilizer, specifically edetate disodium; · 0.5-2% by weight of a lubricant, specifically PEG 6000; 1 to 8% by weight, in particular 1 to 4% by weight, of a preservative selected from potassium sorbate or sodium benzoate; 0 to 3% by weight of a sweetener, particularly sucralose or sodium saccharin, most particularly sucralose; and 0 to 20% by weight of a flavoring, in particular a strawberry flavoring or a vanilla flavoring, An anti-myostatin antibody for use in treatment described in any one of embodiments 69 to 83, administered in a pharmaceutical composition in which the total amount of components does not exceed 100% by weight.

[0177] Embodiment 85. Risdiplam is 1 to 5% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2-8% by weight, in particular 4-6% by weight, of a tartrate buffer system; 60-75% by weight of mannitol as a first diluent and 10-15% by weight of isomalt as a second diluent; 0.5-1.5% by weight of ascorbic acid as an antioxidant; 0.25-0.75% by weight of disodium edetate as a stabilizer; · 0.5-2 wt% PEG6000 as a lubricant; · 1-8% by weight, in particular 1-4% by weight, of sodium benzoate as a preservative; 0.5 to 1% by weight of sucralose as a sweetener; and 5 to 10% by weight of strawberry flavoring, An anti-myostatin antibody for use in treatment described in any one of embodiments 69 to 84, administered in a pharmaceutical composition in which the total amount of components does not exceed 100% by weight.

[0178] The following examples are intended merely to illustrate the practice of the present invention and are not offered as limitations.

[0179] The following abbreviations and definitions are used: ADA (anti-drug antibody), ASO (antisense oligonucleotide), AUC (area under the concentration-time curve), BW (body weight), CaGI-C (caregiver's global impression of change), cohort (CH), Cmax (maximum concentration), CPK-MB (creatine phosphokinase kinase myocardial band), CRF (case report form), CRS (cytokine release syndrome), CSA (cross-sectional area), cTnI (cardiac troponin I), cTnT (cardiac troponin T), D1 (domain 1), D 2 (Domain 2), D3 (Domain 3), DXA (Dual-Energy X-ray Absorptiometry), EC (Ethics Committee), eCOA (Electronic Clinical Outcome Assessment), eCRF (Electronic Case Report Form), EDC (Electronic Data Capture), EIH (Introducing In Humans), EQ-5D-5L (EuroQoL 5 Dimensions-5 Level), GDF-8 (Growth Differentiation Factor-8), HDAC (Histone Deacetylase), HFMSE (Extended Hammersmith Functional Rating Scale), ICH (International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use), iDCC (Independent Data Coordinating Center), iDMC (Independent Data Monitoring Committee), IMC (Internal Monitoring Committee), IMP (Investigational Medicine), IRB (Institutional Review Board), ITT (Intention to Treat), IxRS (Interactive Voice or Web-Based Response System), mAb (Monoclonal Antibody), MAR (Missing at Random), MATE (Multidrug and Toxin Excretion), MFM32 (Motor Function Measure-32 Items), MMRM (Mixed Model Repeated Measures), MRI (Magnetic Resonance Imaging), NCICTCAE (National Cancer Institute Common Terminology Criteria for Adverse Events), NIMP (Non-Investigational Drug Product), NONMEM (Non-Linear Mixed-Effects Modeling (Software)), NSAA (North Star Ambulatory Assessment), ObsRO (Observer-Reported Outcome), OLE (Open Label Extension), OTC (Over-the-Counter), PD (Pharmacodynamics), PROMIS (Patient-Reported Outcomes Measurement Information System), PK (Pharmacokinetics), QTcB (QT interval corrected using the Budget formula), QTcF (QT interval corrected using the Fridericia formula), RHS (Revised Ha Smith Scale), SAD (Single Ascending Dose), SAP (Statistical Analysis Plan), SMA (Spinal Muscular Atrophy), SMAIS (SMA Independence Scale), SMN (Survival of Motor Neuron), SMN1 (Survival of Motor Neuron 1), SMN2 (Survival of Motor Neuron 2), SMNΔ7 (SMN2 mRNA without exon 7), SPA (Statistical Programming and Analysis), TGF-β (Transforming Growth Factor β), ULN (Upper Limit of Normal), VAS (Visual Analog Scale) [Example]

[0180] Example 1: Mouse model of SMA (type II / III) The SMA mouse model (pharmacological model) used in the preclinical studies herein is Delta7 mice treated with submaximal doses of the SMN upregulatory compound SMN-C1, as described in Naryshkin et al., Science 345, 688-693, 2014. As a result of this treatment, the mice survived to adulthood, developed reduced SMN levels, and exhibited an SMA-like neuromuscular phenotype (Z. Feng et al., Hum Mol Genet 25, 964-975, 2016). The advantage of this model is that, while it has a more severe phenotype than existing milder models, it survives to adulthood, allowing for testing of SMA treatments after disease onset.

[0181] This study demonstrated that GYM329, in combination with SMN-C1, resulted in increases in muscle mass and function using three different pharmacological models: (1) monotherapy, (2) combination therapy with an SMN-increasing compound administered at disease onset, and (3) a mild model of SMA. Myostatin inhibitor administration began on PND 24 and continued for 28 days until PND 52. In all of these models, GYM329 was administered weekly at 3 mg / kg (four subcutaneous injections). A cohort of vehicle-treated wild-type (WT) littermates served as a reference group. At study conclusion, in vivo muscle force frequency, muscle weight, muscle histopathology, bone morphometry, and spontaneous running were assessed.

[0182] method Experimental design The cohorts investigated in this study are shown in Figure 1. Study vehicles and treatments are shown in Table 3. [Table 3]

[0183] Animal models A pharmacological model was created by treating Delta7 mice (FVB.Cg-Tg(SMN2*Delta7)4299Ahmb Tg(SMN2)89Ahmb, homozygous knockout mice completely lacking Smn1) with a dose of the SMN expression-increasing compound, SMN-C1. For CH1 and CH2, mice received a suboptimal dose of SMN-C1 (0.1 mg / kg / day) for the duration of the study. For CH3 and CH4, mice received a suboptimal dose of SMN-C1 (0.1 mg / kg daily) from PND 1-23 and switched to a higher dose (3 mg / kg daily) from PND 24-52. For CH5 and CH6, mice were treated with a high dose of SMN-C1 (3 mg / kg daily) for the duration of the study. Wild-type (WT) mice [FVB.Cg-Tg(SMN2*delta7)4299AhmbTg(SMN2)89Ahmb, homozygous for the mouse Smn1 gene] were used as a reference.

[0184] Drug treatment Details regarding upregulation of SMN and treatment with anti-myostatin therapy are shown in Table 4. [Table 4]

[0185] In vivo muscle function Hindlimb muscle strength performance was measured in vivo using a 305C muscle lever system (Aurora Scientific Inc., Aurora, Canada). Mice were anesthetized by inhalation (approximately 4-5% isoflurane, or depending on efficacy), and anesthesia was maintained by nose cone (approximately 2% isoflurane, or depending on efficacy) on a temperature-controlled table. Hair was removed from the lower leg by applying depilatory cream for 3 minutes, followed by thorough rinsing with physiological buffer. The leg was then wiped with 5% povidone-iodine solution, followed by 70% isopropyl alcohol. The knee was isolated using a pin piercing the tibial head, and the foot was firmly fixed to the footplate on the motor shaft. Contraction was induced in the gastrocnemius muscle by percutaneous electrical stimulation of the sciatic nerve.

[0186] To assess masseter muscle function, mice were anesthetized by inhalation (approximately 4-5% isoflurane, or depending on efficacy) and placed on a thermostatically controlled table where anesthesia was maintained with a nose cone (approximately 2% isoflurane, or depending on efficacy). The mice were placed in a supine position with a specially designed restraint to ensure access to the jaw for testing. The lever arm of a 305C muscle lever system (Aurora Scientific Inc., Aurora, Canada) was placed in the diastolic position of the mandible, and a suture was passed under the central incisors of the mouse and attached to the lever arm. The masseter muscle was contracted by electrical stimulation using surface electrodes.

[0187] Force-frequency responses were performed on both muscles. Briefly, trains were performed at increasing stimulation frequencies (0.2 ms pulses, 500 ms train duration): 1, 10, 20, 40, 60, 80, 100, and 150 Hz, followed by a final stimulation at 1 Hz.

[0188] Self-propelled wheel performance Starting on PND45, mice were housed in survival chambers equipped with running wheels for 7 days. Each cage was designed for a single mouse and measured 8.4 inches long, 14.25 inches wide, and 5.6 inches high. It contained a 5-inch diameter running wheel that rotated with less than 3 grams of force, allowing the mouse to run easily and comfortably. The wheel was equipped with an electronic counter connected to a computer interface for continuous activity monitoring. The animals were allowed to run for 1 week before euthanasia and the endpoint of in vivo muscle function assessment.

[0189] Histology and muscle fiber typing Frozen plantar flexor muscle samples (gastrocnemius, plantaris, and soleus) for histological examination were embedded in cryomatrix on a soft cork surface to allow for easy sectioning. Briefly, the frozen and embedded tissue was mounted on a cryotome and serially sectioned (10 µm thick) perpendicular to the fiber axis. Multiple slices (5–10) were taken from different parts of the muscle. The slices were then fixed in ice-cold paraformaldehyde and stored at -80 °C until further use.

[0190] To determine cross-sectional area, fixed sections from the mid-belly of the muscle were stained with wheat germ agglutinin (WGA) conjugated to a fluorophore to visualize cell membranes. Sections were digitized using a fluorescence microscope, and cell boundaries were tracked using predictive software to determine cross-sectional area through unbiased automated measurements. For muscle fiber type determination, histological sections were collected from the mid-belly of the soleus and gastrocnemius muscles. Fixed tissue sections were then blocked with SuperBlock PBS blocking buffer (Thermo Fisher) for 1 hour at room temperature. Slides were then washed with PBS and covered with primary antibodies against either MyHC-I, MyHC-IIa, or MyHC-IIb (1:20 dilution; Developmental Studies Hybridoma Database) and incubated overnight at 4°C. The slides were then washed with PBS, and the appropriate secondary antibodies were added for 1 hour at room temperature. The slides were washed again with PBS, covered with mounting solution, and coverslips were used to seal the tissue sections for fluorescence microscopy. Fluorescently labeled tissue sections were digitized using a fluorescence microscope (Nikon), and images were then analyzed for cell number using standard counting software.

[0191] Data and statistical analysis Muscle function data were analyzed using the Aurora Scientific 615A Dynamic Muscle Analysis Software Suite in high-throughput mode. The software automatically determined the baseline, maximum, and minimum values. The baseline was then subtracted from the maximum to obtain the maximum force. Each data file was manually inspected to ensure that cursors and fits were properly assigned and corrected as necessary. Data were then grouped, and the mean and standard error of the mean (SEM) were calculated. For the plantar flexors, the assay measures the force generated by the gastrocnemius muscle rotating around the ankle, so results were presented as torque, expressed in mN·m. Force was measured directly with a mass scale and expressed in grams.

[0192] Statistical analysis was performed using SigmaPlot v11. Muscle performance data were analyzed using a two-way repeated measures ANOVA. Post-hoc analysis for pairwise comparisons was performed using the Holm-Sidak test. Body weight, muscle weight, muscle fiber type classification data, and cortical and trabecular bone data were analyzed using a one-way ANOVA, with post-hoc analysis performed with the Holm-Sidak test. Data are presented as mean ± SEM.

[0193] result: a) SMA Monotherapy: Low-Dose SMN-C1 PND1-52, Cohort 1 and Cohort 2 Body weight was measured daily for SMA mice and weekly for WT mice. Growth curves are shown in Figure 2. Body weight did not increase significantly in mice treated with GYM329. Treatment with GYM329 did not significantly affect muscle weight. However, there was a trend toward increased gastrocnemius muscle weight in mice treated with GYM329 (p = 0.061; Figure 3).

[0194] Plantar flexor function Plantar flexor function was assessed at PND52. There was a trend toward improvement with GMY329 treatment (main effect: p=0.078) compared to SMA vehicle (Figure 4).

[0195] Masseter muscle function The masseter muscle is a vulnerable muscle in SMA, and its performance was measured at PND 52. GYM329 did not affect masseter muscle function compared to SMA vehicle mice (Figure 5).

[0196] Muscle cross-sectional area and fiber type classification Histology was performed to assess muscle fiber type and cross-sectional area (CSA). There were no differences between treatments in muscle fiber type percentage or muscle fiber cross-sectional area (Figure 6).

[0197] Bone microCT: tibia. Bone micro-CT scans were performed on tibiae collected on PND 52. There was no effect of treatment on cortical or trabecular parameters (Figures 7 and 8).

[0198] b) SMA combination therapy: low-dose SMN-C1 PND1-23, high-dose SMN-C1 PND24-52, Cohort 3 and Cohort 4 Visual observation: body weight and muscle weight Body weight was measured daily for SMA mice and weekly for WT mice. Growth curves of the mice are shown in Figure 9. Muscle weight was not affected by treatment (Figure 10).

[0199] Plantar flexor function Plantar flexor function was assessed on PND 52. There was no effect of treatment on plantar flexor function (Figure 11).

[0200] Masseter muscle function Masseter muscle function was assessed at PND 52. There was no effect of treatment on masseter muscle function in these mice (Figure 12).

[0201] Muscle cross-sectional area and fiber type classification Histology was performed on mounted plantar flexor slices to assess muscle fiber type and CSA. Muscle fiber type composition and muscle fiber cross-sectional area were unaffected by treatment (Figure 13).

[0202] Bone microCT: tibia. Bone micro-CT scans of the tibia showed that GYM329 improved cortical bone cross-sectional thickness and mean total cross-sectional bone area (Figure 14). There was no effect of treatment on trabecular parameters (Figure 15).

[0203] c) SMA Combination Therapy (Mild Model): High-Dose SMN-C1 PND1-52 Cohort 5 and Cohort 6 Visual observation: body weight and muscle weight Body weight was measured daily for SMA mice and weekly for WT mice, and their growth curves are shown in Figure 16. At the time of study, body weight, gastrocnemius muscle weight, soleus muscle weight, and TA weight were significantly increased with GYM329 treatment (Figure 17).

[0204] Plantar flexor function At PND52, plantar flexor function was assessed and was not significantly affected by GYM329 treatment (Figure 18).

[0205] Masseter muscle function GYM329 treatment improved masseter muscle function (main effect: p=0.048 vs. SMA vehicle). Pairwise comparisons using the Holm-Sidak method showed that GYM329 treatment increased maximum force compared to SMA vehicle at 80, 100, and 150 Hz (Figure 19).

[0206] Muscle cross-sectional area and fiber type classification Histological examination was performed on plantar flexor muscle sections to evaluate muscle fiber type and cross-sectional area. There were no significant differences in muscle fiber types between treatments. However, GYM329 treatment increased mean fiber and type IIB fiber cross-sectional area compared to SMA vehicle mice (Figure 20).

[0207] Bone microCT: tibia. In the tibia, cortical and trabecular bone parameters were evaluated. GYM329 treatment improved cortical cross-sectional thickness and mean total cross-sectional bone area (Figure 21), as well as bone volume, trabecular thickness, trabecular number, and trabecular separation (Figure 22).

[0208] The results of the preclinical studies described in a) seem to suggest that GYM329 may not have the desired results in SMA patients as a single treatment approach. The results described in b) suggest that GYM329, without effective treatment of splicing modifiers, may not have the desired results in SMA patients.

[0209] The results in part c) strongly suggest that pretreatment with an effective dose of an SMN splicing modifier followed by GYM329 treatment leads to unexpected results for SMA patients. As shown in part a), GYM329 alone has little effect on muscle.

[0210] In conclusion, this study demonstrates the potential benefit of GYM329 in SMA. The strongest effects of GYM329 were observed in milder SMA models, suggesting that prior rescue of innervation by SMN upregulation prior to co-treatment with GYM329 may be beneficial.

[0211] Example 2: A Phase II / III, two-part, open-label study will be conducted to investigate the safety, tolerability, pharmacokinetics, pharmacodynamics, and efficacy of risdiplam in combination with GYM329 in emergency pediatric participants (2-10 years old) with SMA.

[0212] This study consists of two parts:

[0213] Part 1: Exploratory dose-finding section Part 1 is a double-blind, randomized, placebo-controlled, exploratory study to evaluate the safety, pharmacokinetics, and pharmacodynamics of GYM329 in combination with risdiplam in emergency pediatric participants (ages 2-10) with SMA and to determine dose for Part 2 of the study. Efficacy of the combination treatment will be evaluated as an investigational objective.

[0214] Approximately 36 participants will be enrolled in Part 1 of the study, with 6 participants aged 2-4 years and 30 participants aged 5-10 years. Risdiplam-naive participants will be treated with risdiplam for at least 8 weeks in a run-in period (2:1, GYM329 + risdiplam: placebo + risdiplam) prior to randomization for the 24-week double-blind, placebo-controlled treatment period. Participants who have been treated with risdiplam for at least 8 consecutive weeks immediately prior to entering the study will either be immediately randomized to combination therapy or participate in the run-in period and continue to receive risdiplam monotherapy until randomization, as needed to complete the required number of patients in the cohort.

[0215] In participants aged 5-10 years, two GYM329 doses (7.4 mg [BW < 20 kg] or 10.6 mg [BW ≥ 20 kg] [low dose], and 24 mg [BW < 20 kg] or 36 mg [BW ≥ 20 kg] [high dose]) will be investigated using a staggered dose-escalation strategy to ensure safe conduct of the study in this pediatric population, as shown in Figure 23. The high dose is predicted to produce a median steady-state AUC (area under the concentration-time curve) of 385 μg × d / mL over a single 4-week dosing interval, which has been shown to be well tolerated in studies in healthy adult subjects, and is predicted to produce near-complete inhibition of total latent myostatin, free latent myostatin, and mature myostatin.

[0216] Participants aged 5 to 10 years will initially be randomized to GYM329 plus risdiplam or placebo plus risdiplam low-dose study treatment (Cohort A). Safety, tolerability, pharmacokinetics, and pharmacodynamics will be confirmed for all participants in Cohort A over at least one dosing interval (after participants have received at least the first two blinded doses of GYM329). Once randomization in Cohort A is complete, randomization to GYM329 plus risdiplam or placebo plus risdiplam high-dose study treatment (Cohort B) may begin. The GYM329 dose for Cohorts A, B, and Cmax will be adjusted from the currently projected dose level above based on emerging safety, PK, and PD data from Part 1. The objective of Cohorts B and C is to select a dose that achieves at least 90% inhibition of serum total latent myostatin, free latent myostatin, and mature myostatin.

[0217] Participants aged 2-4 years will be randomized only after both the low and high doses have been shown to be safe and well-tolerated over at least one dosing interval in participants aged 5-10 years, randomization of Cohort B is complete, and all participants in Cohort B have received at least the first two blinded doses of GYM329. Younger participants will then be randomized to GYM329 + risdiplam or placebo + risdiplam in Cohort C, with the dose selected to achieve similar PK (and PD) to the high dose (Cohort B) in older patients aged 5-10 years.

[0218] Once all participants in Cohort A and Cohort B have completed 24 weeks of treatment in the double-blind period and PK data spanning at least one dosing interval are available for all participants in Cohort C (all participants in Cohort C received the first two blinded doses of GYM329), the IMC will review all available safety, tolerability, PK, and PD data to select the GYM329 dose for Part 2 (pivotal dose). If the pivotal dose selected by the IMC differs from the dose in Cohort C, participants receiving GYM329 in this cohort will be switched to the selected pivotal dose in a blinded manner for the remainder of the 24-week double-blind period.

[0219] Once Part 1 participants complete the 24-week double-blind treatment period, all Part 1 participants will receive GYM329 + risdiplam combination therapy for 72 weeks as part of the open-label treatment period, as described in Section 1.2. If participants reach the end of the 24-week double-blind treatment period and a pivotal dose has not yet been determined, they will receive GYM329 at their respective treatment cohort dose until a pivotal dose is determined. Once a pivotal dose is selected, all Part 1 participants will switch to this pivotal dose. Upon completion of the open-label combination treatment period, participants will have the option to enter an open-label extension (OLE) period in which all participants will receive combination treatment for an additional 2 years, unless the combination is discontinued.

[0220] The study period for each participant enrolled in Part 1 will be divided as follows: Screening: Test day -30 to -2 Enrollment Run-in Day 1. Only applicable to patients participating in the risdiplam run-in period Risdiplam Run-in Period: Day 1 of Randomization (minimum 8 weeks for risdiplam-naive participants; participants treated with risdiplam for at least 8 consecutive weeks immediately prior to study entry may be immediately randomized to combination treatment or may participate in the run-in period and continue to receive risdiplam monotherapy until randomization, as needed to complete the required number of patients in the cohort.) Baseline (start of combination therapy): Baseline Day 1 Combined treatment period: 24 weeks (double-blind period) + 72 weeks (open-label treatment period) Open-label extension period: 2 years Safety follow-up: 3 months after the last dose of combination treatment. [Table 5] TIFF2024537864000007.tif230170

[0221] Part 2 Dose Selection Criteria PD criteria: ≥90% serum myostatin suppression (total latent myostatin, free latent myostatin, mature myostatin) A ≥ 2% difference between GYM329 + risdiplam and placebo + risdiplam in the change from baseline in skeletal muscle area of ​​contraction in the thigh or calf as assessed by magnetic resonance imaging (MRI) after 24 weeks (patients ≥ 5 years old). If a ≥ 2% difference in muscle growth is observed with both Part 1 doses of GYM329 + risdiplam compared to placebo + risdiplam, the bioactivity of the combination will be evaluated using data from dual-energy X-ray absorptiometry (DXA) scans, strength-related endpoints, and serum myostatin levels.

[0222] Safety standards: No evidence of GYM329-induced cardiac hypertrophy by echocardiography · No more than two patients treated with GYM329 in any cohort experience a Grade 3 or higher systemic infusion reaction (hypersensitivity, including anaphylaxis), unless clearly related to the study drug.

[0223] Part 2: A confirmation pivot that begins after a dose is selected based on data from Part 1. Part 2 is a double-blind, placebo-controlled, randomized (1:1, GYM329 + risdiplam: placebo + risdiplam) study to investigate the efficacy, safety, tolerability, pharmacokinetics, and pharmacodynamics of the combination of GYM329 and risdiplam in ambulatory pediatric participants (2-10 years old) with SMA.

[0224] Approximately 144 participants will be enrolled in Part 2 of the study. Up to 48 participants aged 7-10 years at screening will be enrolled.

[0225] Part 2 participants completed an 8-week run-in period with risdiplam monotherapy, followed by a 72-week double-blind treatment period in which patients were randomized to either GYM329 + risdiplam or placebo + risdiplam. Participants randomized to GYM329 received GYM329 at a dose (pivotal dose) selected based on data from Part 1 of the study. Once Part 2 participants completed the 72-week double-blind treatment period, they had the option to switch to the OLE period, in which all participants agreed to GYM329 + risdiplam combination treatment for an additional 2 years, unless the development of the combination treatment was discontinued. The Part 2 study scheme can be seen in Figure 24.

[0226] The primary efficacy objective of Part 2 of this study is to evaluate the efficacy of GYM329 in combination with risdiplam in emergency pediatric participants with SMA, as measured by change from baseline in the Modified Hammersmith Scale (RHS) total score after 72 weeks of combination treatment. Secondary efficacy outcomes and exploratory endpoints are shown in Table 6. [Table 6] TIFF2024537864000009.tif238170

[0227] The nature, frequency, severity, and timing of adverse events, serious adverse events, local and systemic infusion reactions, vital signs, laboratory parameters, ECG, and echocardiography will be assessed periodically by an unblinded iDMC.

[0228] Blood samples for evaluation of PK, PD and ADA data will be obtained from all participants.

[0229] The study period for each participant enrolled in Part 2 will be divided as follows: Screening: Day 30 of the study to Day 2 of the study Registration Introduction Date-1 Risdiplam induction period: Day 1 to Day 56 (8 weeks) Baseline (start of combination therapy): Baseline Day 1 Double-blind combination treatment period: 72 weeks Open-label extension period: 2 years Safety follow-up: 3 months after the last dose of combination treatment

[0230] The activity schedule and sample collection schedule are shown in Tables 5 and 7. [Table 7] TIFF2024537864000011.tif221170 TIFF2024537864000012.tif233170 TIFF2024537864000013.tif232170 TIFF2024537864000014.tif234170 TIFF2024537864000015.tif233170 TIFF2024537864000016.tif234170 TIFF2024537864000017.tif231170 [Table 8] TIFF2024537864000019.tif233170 TIFF2024537864000020.tif233170 TIFF2024537864000021.tif232170 TIFF2024537864000022.tif233170 TIFF2024537864000023.tif230170 TIFF2024537864000024.tif231170 TIFF2024537864000025.tif236170

[0231] Dosage The proposed doses for each cohort in Part 1 of GYM329 are shown in Table 9. [Table 9]

[0232] Doses for Cohort A and Cohort B will be investigated in an alternating dose-escalation pattern to ensure safe implementation of the study in this pediatric patient population. Participants aged 5-10 years will initially be randomized to GYM329 + risdiplam or placebo + risdiplam low-dose study treatment (Cohort A). Once safety, pharmacokinetics, and pharmacodynamics have been confirmed for at least one dosing interval in all participants in Cohort A (after administering at least the first two blinded doses of GYM329), and randomization of Cohort A is complete, randomization to GYM329 + risdiplam or placebo + risdiplam high-dose study treatment (Cohort B) may begin.

[0233] Participants aged 2-4 years (Cohort C) will be randomized only if the doses administered to participants aged 5-10 years in both the low-dose and high-dose cohorts (Cohorts A and B) have been shown to be safe and well-tolerated for at least one dosing interval, Cohort B randomization is complete, and all participants in Cohort B have received at least the first two blinded doses of GYM329. These younger participants will then be randomized to either the GYM329 + risdiplam or placebo + risdiplam arms of Cohort C, with the goal of achieving the same PK (and PD) as the high-dose Cohort B in older patients.

[0234] Risdiplam will be administered once daily at a dose of 5 mg for participants with a BW ≥ 20 kg and at a dose of 0.25 mg / kg for participants with a BW < 20 kg, according to the approved dosing regimen.

[0235] Stopping criteria Stopping Rule Criteria for Part 1 of the Exam In Part 1, enrollment into the next planned cohort will not occur if any of the following criteria occur in the previous cohort: · More than two patients treated with GYM329 in a given cohort experience a Grade 3 or higher systemic infusion reaction (hypersensitivity, including anaphylaxis), unless clearly related to the study drug. More than two patients treated with GYM329 in a given cohort experience any of the following, unless shown to be unrelated to the study drug: Adverse events of the same type, grade 3 or higher Clinically significant abnormal vital signs of the same type Clinically significant test abnormalities of the same type Clinically significant changes in the same type of ECG

[0236] Individual Stopping Rules Participants must permanently discontinue GYM329 if any of the following apply to them: Grade 3 or higher systemic infusion reactions (hypersensitivity reactions, including anaphylaxis) Grade 3 or greater local injection site reaction

[0237] Participants must permanently discontinue GYM329 and / or risdiplam if they experience any of the following: Participants with ALT >3×ULN, ALP >2×ULN, and elevated bilirubin (>2×ULN) (i.e., "Hy's law" suspected to indicate risk of severe / profound liver dysfunction) and no other explanation. Significant and clinically relevant changes in laboratory parameters, ECG or vital signs that pose an unacceptable risk to the patient Any other findings, such as a serious adverse event or any other serious adverse event, that indicate treatment should be discontinued A medical condition that the investigator or sponsor determines may compromise the participant's safety if the participant continues to receive the investigational drug. A determination by the investigator or sponsor that discontinuing treatment is in the participant's best interest.

[0238] Participants must discontinue both procedures if the following applies: ・Current pregnancy · Failure to continue to comply with research requirements.

[0239] Test definition complete Participants were considered to have completed the study (Part 1 or Part 2) if they completed all phases of the study, including the final visit, as indicated in the schedule of activities for the study shown in Table 1.

[0240] The end of the study will be defined as the date of the last visit of the last participant in the study or the date the last data point required for statistical analysis (i.e., for the final analysis) or safety follow-up is received from the last participant in the study, whichever is later. The end of the study is expected to occur approximately 4 years after the last participant is enrolled in Part 2.

[0241] Additionally, the sponsor may decide to terminate the study at any time.

[0242] Participation period The total duration of study participation for each individual is expected to be approximately 4-4.5 years.

[0243] Study population Part 1: Approximately 36 acute care pediatric participants, ages 2 to 10, with SMA will be enrolled in this part of the trial.

[0244] Part 2: Approximately 144 acute pediatric participants aged 2-10 years with SMA will be enrolled in the pivotal part of the study. Up to 48 participants aged 7-10 years at screening will be enrolled.

[0245] Inclusion criteria Participants were eligible for inclusion in the study only if all of the following criteria were true: Participants aged 2 to 10 years at the time of screening. Participants with a confirmed genetic diagnosis of 5q-autosomal recessive SMA Symptomatic SMA disease as determined by the investigator's clinical judgment Ambulatory participants (where ambulatory is defined as being able to walk / run 10 meters within 30 seconds at the time of screening) Participants who have previously received SMA disease-modifying therapy may be included, provided that: - Onasemnogene abeparvovec has been administered at least 90 days prior to screening. Participants should be tapered off corticosteroids before receiving risdiplam. In addition, participants should have normal liver function tests, coagulation parameters, platelets, and troponin-I levels performed 90 days after onasemnogene abeparvovec administration or at least 1 month after corticosteroid tapering, whichever occurs later. - The last dose of nusinersen was administered at least 90 days prior to screening - Risdiplam will be switched to a non-investigational medication (NIMP) provided by the institution Participants have a legally authorized representative to consent as described in Appendix 1, which includes an informed consent form and adherence to the requirements and limitations described in this protocol. In addition, consent must be obtained, whenever possible. Participants who are able and willing to comply with the study protocol and complete all study procedures, measurements, and visits For women of childbearing potential or who reach childbearing potential during the study: Participants who have a negative blood pregnancy test at screening and agree to abstain (abstain from heterosexual intercourse) or practice contraception as defined below: Women must remain abstinent or use at least two methods of contraception (with a 1% failure rate) during the treatment period and both 17 months after the last dose of GYM329 and 28 days after the last dose of risdiplam. Women are considered of fertile potential if they are postmenstrual, have not reached postmenopausal status (≥12 consecutive months of amenorrhea with no identified cause other than menopause), and are not permanently infertile due to surgery (i.e., removal of the ovaries, fallopian tubes, and / or uterus) or another cause determined by the investigator (e.g., Mullerian induction). The definition of fertility may be adapted to align with local guidelines or regulations.

[0246] Examples of contraceptive methods with annual failure rates <1% include bilateral tubal ligation, male sterilization, hormonal contraceptives that block ovulation, hormone-releasing intrauterine devices, and copper intrauterine devices.

[0247] The reliability of sexual abstinence should be assessed with respect to the duration of the clinical trial and the individual's preferred usual lifestyle. Cyclic abstinence (e.g., calendar, ovulation, symptom-thermal, or postovulatory methods) and abstinence are not adequate contraceptive methods. If required by local guidelines or regulations, information regarding locally accepted appropriate contraceptive methods and the reliability of abstinence will be included in the local informed consent form. For males expected to reach sexual maturity during the study: Participants who agree to abstain (refrain from heterosexual intercourse) or use a contraceptive method and agree to refrain from sperm donation, as defined below: For non-pregnant female partners of fertile potential, men must remain abstinent or use condoms in combination with an additional method of contraception with a combined failure rate of 1% per year for the duration of treatment and for 4 months after the last dose of risdiplam or GYM329. Men must refrain from donating sperm during this period. For pregnant female partners, the man must remain abstinent or use condoms to prevent exposure to the embryo during treatment and for 28 days after the last dose of risdiplam and 4 months after the last dose of GYM329.

[0248] The reliability of sexual abstinence should be assessed with respect to the duration of the clinical trial and the individual's preferred usual lifestyle. Cyclic abstinence (e.g., calendar, ovulation, symptom-thermal, or postovulatory methods) and abstinence are not adequate contraceptive methods. If required by local guidelines or regulations, information regarding locally accepted appropriate contraceptive methods and the reliability of abstinence will be included in the local informed consent form.

[0249] Exclusion criteria Participants will be excluded from the study if any of the following criteria apply: Participants who participated concurrently or previously in any investigational drug or device study within 90 days prior to screening, or who had a drug half-life of 5 half-lives, whichever was longer (excluding participants who completed a risdiplam study or who participated in a nusinersen or onasemnogene-abeparvovec study). Participants receiving or previously receiving both anti-myostatin drugs Part 1 participants aged 5-10 years only: Participants with contraindications to MRI scanning (including but not limited to claustrophobia, presence of cardiac or internal metallic foreign bodies such as pacemakers, prosthetic heart valves, cochlear implants, spinal rods, intracranial vascular clips, insulin pumps, etc.), difficulty maintaining a supine position for extended periods, or other clinical history or examination findings that pose a potential risk in combination with MRI. Participants with any history of cell therapy Participants who had been hospitalized for a pulmonary event within the past two months or were scheduled for hospitalization at screening Participants who had undergone surgery for scoliosis or hip fusion within 6 months prior to screening or who were scheduled for surgery within the next 9 months (Part 1) or 21 months (Part 2) Participants with unstable gastrointestinal, renal, hepatic, endocrine or cardiovascular disease that is considered clinically significant Participants with clinically significant ECG abnormalities as measured by the mean of triplicate measurements indicating a safety risk for the participant or cardiovascular disease (e.g., heart failure, coronary artery disease, cardiomyopathy, congestive heart failure, family history of congenital long QT syndrome, family history of sudden death) from screening (e.g., QT interval corrected by use of Bazett's formula [QTcB] 460 ms for children up to 10 years of age; QTcB is used because Bazett's correction is more appropriate in children). Participants with clinically significant abnormal echocardiographic findings at screening Participants who had suffered from any major illness within one month prior to screening Participants who received any multidrug and toxin extrusion (MATE1 / 2K) substrate within 2 weeks prior to screening Participants who have used any of the following medications within 90 days prior to screening: riluzole, valproic acid, hydroxyurea, sodium phenylbutyrate, butyric acid derivatives, creatine, carnitine, growth hormone, anabolic steroids, probenecid, acetylcholinesterase inhibitors, medications that may increase or decrease muscle strength, or medications with known or suspected histone deacetylase (HDAC) inhibitory effects (participants taking inhaled corticosteroids administered via either a nebulizer or inhaler will be permitted in the study). Part 2 only: Participants who have recently (less than 6 months before screening) started treatment with oral salbutamol or another oral beta2-adrenergic agonist are not allowed. Participants who have been taking oral salbutamol (or another beta2-adrenergic agonist) for less than 6 months before screening and have tolerated it well are allowed. The beta2-adrenergic agonist dose should remain as stable as possible throughout the study. The use of inhaled beta2-adrenergic agonists (e.g., for the treatment of asthma) is allowed. Participants with clinically significant abnormalities in laboratory test results, such as ALT levels >1.5-fold the upper limit of normal (ULN), unless the elevated ALT level is deemed to be of muscle origin (i.e., in the absence of other evidence of liver disease) supported by elevated creatine kinase and LDH. Out-of-range creatine kinase levels should be reviewed in light of the participant's underlying SMA pathology; elevated levels by themselves do not disqualify the participant from the study. In the case of uncertain or questionable results, tests performed during screening may be repeated prior to enrollment (Run-in Day 1) to confirm eligibility. Participants with confirmed or suspected hypersensitivity (e.g., anaphylactic reaction) to GYM329 or risdiplam or any component of their formulations (see Pharmacy Manual) Participants with concomitant diseases or conditions that may interfere with the conduct of the study or whose treatment may interfere with the conduct of the study or pose an unacceptable risk to participants in this study Participants with a history of any malignant tumor Participants with a history of clinically relevant anaphylactic reactions requiring inotropic support Participants with any abnormal skin condition, pigmentation or lesions in the area intended for SC injection (abdomen) that would prevent visualization of potential injection site reactions to GYM329 Participants who have undergone immobilization, surgery, fractures, or trauma to the upper or lower limbs within 90 days prior to screening Female participants who are pregnant, nursing, or intend to become pregnant either during the study or within 17 months after the last dose of GYM329 or within 28 days after the last dose of risdiplam. Women of childbearing potential must have a negative serum pregnancy test result within 14 days prior to enrollment (Run-in Day -1) or baseline (if Part 1 participants have not completed the enrollment visit).

[0250] Lifestyle Considerations Meals and dietary restrictions There are no meal or dietary restrictions in this study.

[0251] activity Physical therapy, occupational therapy, and other forms of exercise therapy are acceptable, and the frequency and intensity should remain the same during the clinical trial.

[0252] Contraceptive conditions During the study, participants who have reached puberty must use birth control or take other precautions.

[0253] Study treatment administered In this protocol, "study treatment" refers to all treatments assigned to participants as part of this study (i.e., blinded and open-label GYM329, blinded GYM329-matching placebo, and open-label risdiplam). Table 6 provides a description of the study treatments for this study. [Table 10]

[0254] GYM329 GYM329 is supplied in a 3 mL glass vial containing 80 mg / mL and must be prepared for administration under appropriate sterile conditions. The solution should be diluted as needed and filtered prior to injection using a needle filter. The ready-to-inject solution should preferably be used immediately. Detailed instructions are provided in the Pharmacy Manual.

[0255] GYM329 will be administered by SC injection into the abdomen every 4 weeks. The dose in Part 1 will range from 0.3 to 0.5 mL depending on the dose (see Table 5). Each injection should be administered in a separate location within the rotational quadrant of the abdomen at each study visit where this treatment is administered. GYM329 will be administered at the clinical site by on-site staff. GYM329 will be administered after all pre-administration assessments have been conducted and criteria for a temporary delay in administration have been discussed (see Section 6.6). Participants will be monitored at the study site for at least 6 hours after the first two doses and for 2 hours (or longer if deemed necessary by the investigator / study site staff) for subsequent doses.

[0256] Only participants enrolled in the study may receive GYM329, only authorized staff may dispense GYM329, and only authorized staff or trained study personnel may administer the study medication.

[0257] Overdosage or incorrect administration of GYM329 should be documented on the study medication administration electronic case report form (eCRF). Adverse events related to overdosage or incorrect administration of GYM329 should be recorded on the adverse event eCRF.

[0258] An accurate record of GYM329 received at, dispensed from, and disposed of from the study site should be recorded in the Medication Accountability Diary.

[0259] For information regarding the handling and accountability of GYM329, including preparation and storage, please refer to the Pharmacy Manual and GYM329 Investigator Brochure.

[0260] Guidelines for the medical management of local and systemic injection reactions are provided in Appendix 5. Use of medications to treat these events must be recorded on the eCRF as concomitant medications.

[0261] Risdiplam Risdiplam is supplied as a powder to be made into an oral solution. Each bottle contains 60 mg of risdiplam, which is diluted with purified water or water for injection to produce an oral solution containing 0.75 mg / mL of risdiplam.

[0262] All participants in this study will receive risdiplam while participating in the treatment portion of the study. Risdiplam will be administered once daily using a provided reusable oral syringe at a dose of 5 mg for participants weighing ≥ 20 kg and 0.25 mg / kg for participants weighing < 20 kg. The sponsor will provide an oral syringe for participants / caregivers to administer the solution.

[0263] After all pre-treatment evaluations have been performed, the first dose of risdiplam will be administered at the clinical site. Throughout the study, risdiplam should be taken orally once daily at home after breakfast at approximately the same time each day.

[0264] On site visit days when risdiplam PK sampling is planned, risdiplam will be administered at the clinical site to allow for pre- and post-dose blood draws (see Section 1.3). On these days, participants should have their usual breakfast at home before coming to the site. If there is a long time between this meal and risdiplam administration, participants will be given a snack on site before risdiplam administration.

[0265] Participants should drink water after taking risdiplam to ensure it has been swallowed. If risdiplam gets on the skin, the area should be washed with soap and water.

[0266] Risdiplam should be taken immediately after it is drawn up into the oral syringe. If it is not taken within 5 minutes, the oral syringe should be discarded and a new dose prepared.

[0267] Only participants enrolled in the study may receive risdiplam, only authorized staff may supply risdiplam, and only authorized staff, trained study personnel, or trained participants / caregivers may administer risdiplam.

[0268] Risdiplam overdose or incorrect administration should be documented on the Investigational Drug Administration eCRF. Adverse events related to risdiplam overdose or incorrect administration should be recorded on the Adverse Events eCRF.

[0269] An accurate record of risdiplam received at, dispensed from, and disposed of by the study site should be recorded in the Medication Accountability Diary.

[0270] For information regarding the handling of risdiplam, including preparation and storage, and reporting requirements, please refer to the Pharmacy Manual and the Risdiplam Investigator Brochure.

[0271] placebo A placebo of identical appearance, composition (except for GYM329), and volume identical to GYM329 will be administered by SC injection to all participants randomized to placebo plus risdiplam and will be administered at the same dose regimen (every 4 weeks).

[0272] Combination therapy Any concomitant medications and / or vaccines, including over-the-counter or prescription drugs, vitamins, and / or herbal supplements, from 30 days prior to study screening through the study completion or early discontinuation visit must be reported to the investigator and recorded in the "Concomitant Medications" eCRF with the following information: ·Reason for use Date of administration, including start and end dates Dosage information, including dose and frequency

[0273] Any non-pharmacological interventions (e.g., individual psychotherapy, cognitive behavioral therapy, physical therapy, and rehabilitation therapy) used by participants in addition to protocol-defined treatments from 30 days prior to study screening through the study completion or early discontinuation visit must be reported to the investigator and recorded on the "Non-pharmacological Interventions" eCRF.

[0274] If there are any questions regarding concomitant or previous treatments, the medical monitor should be contacted.

[0275] Permitted Treatments Examples of acceptable medicines include (except as prohibited below): Treatment with oral salbutamol or another beta-2 adrenergic agonist taken by mouth is permitted as long as it is introduced at least 6 months before screening and is well tolerated by the participant. Use of inhaled beta2-adrenergic agonists (e.g., for the treatment of asthma) Inhaled corticosteroids Other inhaled medications for obstructive airway diseases (e.g., anticholinergics and antiallergics) Other systemic medications for obstructive airway disease (e.g., leukotriene receptor antagonists) Laxatives and other medications for functional gastrointestinal disorders pain relievers containing opioids (e.g., hydromorphone or codeine) Antibiotics (excluding the following) Antihistamines Proton pump inhibitors Any medication required to treat a local or systemic injection reaction · The use of local analgesia at the GYM329 SC injection site may be provided to all participants according to local guidelines.

[0276] Unless otherwise specified below, for any chronic treatment (defined as a minimum of 8 weeks of treatment), participants should be on a stable regimen for 6 weeks prior to screening and should remain on a stable regimen throughout the double-blind period of the study (weight / age-related dose adjustments for chronic treatment are allowed).

[0277] Prohibited treatments All medications (prescription and over-the-counter [OTC]) taken within 30 days of study screening will be recorded on the appropriate eCRF.

[0278] Administration of nusinersen, whether in a clinical trial or medical setting, within 90 days prior to screening and throughout the study is expressly prohibited.

[0279] MATE1 / 2K substrates are explicitly prohibited for two weeks prior to screening and throughout the study.

[0280] Use of the following therapies is prohibited during the study and for at least 90 days prior to screening: Riluzole Valproic acid Hydroxyurea Sodium phenylbutyrate Butyrate derivatives Creatine Carnitine Growth hormone Anabolic steroids probenecid Acetylcholinesterase inhibitors Chronic oral or parenteral use of corticosteroids unless needed to manage injection reactions (use of inhaled corticosteroids is acceptable) Drugs that are expected to increase or decrease muscle strength or that have known or suspected HDAC inhibitory activity

Claims

1. Risdiplam for use in treating, preventing, delaying progression and / or ameliorating SMA, particularly in a patient, when used in combination with an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5 and CDRL3 comprises the sequence set forth in SEQ ID NO:

6.

2. Risdiplam for use in the treatment of SMA in combination with an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO:

6.

3. 3. Risdiplam for use in the treatment of SMA according to claim 1 or 2, wherein the anti-myostatin antibody inhibits activation of myostatin.

4. 3. Risdiplam for use in the treatment of SMA according to claim 1 or 2, wherein the anti-myostatin antibody blocks the proteolytic release of mature myostatin.

5. Risdiplam for use in the treatment of claim 1 or 2, wherein the anti-myostatin antibody comprises a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7 and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO:

8.

6. Risdiplam for use in the treatment of claim 1 or 2, wherein the anti-myostatin antibody comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 7 and a light chain variable region comprising the amino acid sequence of SEQ ID NO:

8.

7. Risdiplam for use in the treatment of claim 1 or 2, wherein the anti-myostatin antibody comprises a heavy chain region comprising the amino acid sequence of SEQ ID NO: 9 and a light chain region comprising the amino acid sequence of SEQ ID NO:

10.

8. 3. Risdiplam for use in the treatment of claim 1 or 2, wherein the anti-myostatin antibody is GM329.

9. 3. Risdiplam for use in the treatment of claim 1 or 2 in a patient, particularly a patient in need thereof, particularly wherein the patient is a human, such as a male or female human.

10. 3. Risdiplam for use in treatment according to claim 1 or 2, wherein the patient being treated has been initially treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before the first dose of the antibody is administered to the patient.

11. 3. Risdiplam for use in treatment according to claim 1 or 2, wherein the total daily dose of risdiplam is administered to said patient at 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients over 2 years of age weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

12. 3. Risdiplam for use in the treatment of claim 1 or 2, wherein the anti-myostatin antibody is administered to the patient at a dose of 7.4 mg or 24 mg for patients older than 2 years and weighing less than 20 kg, and 10.6 mg or 36 mg for patients weighing 20 kg or more, and in particular, the antibody is administered to the patient at a dose of 24 mg for patients older than 2 years and weighing less than 20 kg, and 36 mg for patients weighing 20 kg or more, every 4 weeks.

13. 3. The method of claim 1, wherein the anti-myostatin antibody is administered every four weeks.

14. 3. Risdiplam for use in the treatment of claim 1 or 2, wherein the patient has SMA.

15. 3. Risdiplam for use in the treatment of claim 1 or 2, wherein the SMA is SMA Type I, SMA Type II or SMA Type III.

16. 3. Risdiplam for use in the treatment of SMA according to claim 1 or 2, wherein the patient being treated has been initially treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before the anti-myostatin is first administered.

17. Risdiplam is 1-10% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2 to 15% by weight, in particular 4 to 6% by weight, of a buffer system, in particular a buffer system selected from citrate, malate, maleate, or tartrate, more in particular malate or tartrate, most in particular tartrate; or the corresponding acid of a buffer system as the sole acidifying agent, in particular tartaric acid; 40 to 90% by weight of a diluent, in particular mannitol or a mixture of mannitol and isomalt, more particularly mannitol; 0.5 to 4% by weight of an antioxidant, specifically ascorbic acid; 0.2 to 2% by weight of a stabilizer, specifically edetate disodium; 0.5 to 2% by weight of a lubricant, specifically PEG 6000; 1 to 8% by weight, in particular 1 to 4% by weight, of a preservative chosen from potassium sorbate or sodium benzoate; 0-3% by weight of a sweetener, particularly sucralose or sodium saccharin, most particularly sucralose; and - 0-20% by weight of flavoring, in particular strawberry flavoring or vanilla flavoring, 3. Risdiplam for use in the treatment of claim 1 or 2, administered in a pharmaceutical composition in which the total amount of ingredients does not exceed 100% by weight.

18. Risdiplam is 1-5% by weight of risdiplam or a pharmaceutically acceptable salt thereof; - 2 to 8% by weight, in particular 4 to 6% by weight, of a tartrate buffer system; 60-75% by weight of mannitol as a first diluent and 10-15% by weight of isomalt as a second diluent; 0.5 to 1.5% by weight of ascorbic acid as an antioxidant; 0.25 to 0.75% by weight of disodium edetate as a stabilizer; 0.5-2% by weight of PEG 6000 as a lubricant; 1 to 8% by weight, in particular 1 to 4% by weight, of sodium benzoate as a preservative; 0.5 to 1% by weight of sucralose as a sweetener; and - 5 to 10% by weight of strawberry flavoring; 3. Risdiplam for use in the treatment of claim 1 or 2, administered in a pharmaceutical composition in which the total amount of ingredients does not exceed 100% by weight.

19. A combination of risdiplam and an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO:

6.

20. The combination described in claim 19 for use in treating, preventing, delaying progression and / or ameliorating SMA, wherein the anti-myostatin antibody comprises a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7 and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO:

8.

21. The combination of claim 19, wherein the anti-myostatin antibody comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 7 and a light chain variable region comprising the amino acid sequence of SEQ ID NO:

8.

22. The combination of claim 19, wherein the anti-myostatin antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 9 and a light chain comprising the amino acid sequence of SEQ ID NO:

10.

23. 20. The combination according to claim 19 in a patient, particularly a patient in need thereof, particularly wherein said patient is a human being, such as a male or female human being.

24. 20. The combination of claim 19, wherein the patient being treated has been initially treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before the first dose of the antibody is administered to the patient.

25. 20. The combination of claim 19, wherein a total daily dose of risdiplam is administered to said patient at 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

26. The combination of claim 19, wherein the anti-myostatin antibody is administered to the patient at a dose of 7.4 mg or 24 mg for patients older than 2 years and weighing less than 20 kg, and 10.6 mg or 36 mg for patients weighing 20 kg or more, and particularly wherein the antibody is administered to the patient at a dose of 24 mg for patients older than 2 years and weighing less than 20 kg, and 36 mg for patients weighing 20 kg or more, every 4 weeks.

27. 20. The combination of claim 19, wherein the anti-myostatin antibody is GM329.

28. 20. The combination of claim 19, wherein the anti-myostatin antibody is administered every four weeks.

29. 20. The combination of claim 19, wherein the patient has SMA.

30. 20. The combination of claim 19, wherein the SMA is SMA Type I, SMA Type II, or SMA Type III.

31. Risdiplam is 1-10% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2 to 15% by weight, in particular 4 to 6% by weight, of a buffer system, in particular a buffer system selected from citrate, malate, maleate, or tartrate, more in particular malate or tartrate, most in particular tartrate; or the corresponding acid of the buffer system as the sole acidifying agent, in particular tartaric acid; 40 to 90% by weight of a diluent, in particular mannitol or a mixture of mannitol and isomalt, more particularly mannitol; 0.5 to 4% by weight of an antioxidant, specifically ascorbic acid; 0.2 to 2% by weight of a stabilizer, specifically edetate disodium; 0.5 to 2% by weight of a lubricant, specifically PEG 6000; 1 to 8% by weight, in particular 1 to 4% by weight, of a preservative chosen from potassium sorbate or sodium benzoate; 0-3% by weight of a sweetener, particularly sucralose or sodium saccharin, most particularly sucralose; and - 0-20% by weight of flavoring, in particular strawberry flavoring or vanilla flavoring, 20. The combination of claim 19, administered in a pharmaceutical composition in which the total amount of ingredients does not exceed 100% by weight.

32. Risdiplam is 1-5% by weight of risdiplam or a pharmaceutically acceptable salt thereof; - 2 to 8% by weight, in particular 4 to 6% by weight, of a tartrate buffer system; 60-75% by weight of mannitol as a first diluent and 10-15% by weight of isomalt as a second diluent; 0.5 to 1.5% by weight of ascorbic acid as an antioxidant; 0.25 to 0.75% by weight of disodium edetate as a stabilizer; 0.5-2% by weight of PEG 6000 as a lubricant; 1 to 8% by weight, in particular 1 to 4% by weight, of sodium benzoate as a preservative; 0.5 to 1% by weight of sucralose as a sweetener; and - 5 to 10% by weight of strawberry flavoring; 20. The combination of claim 19, administered in a pharmaceutical composition in which the total amount of ingredients does not exceed 100% by weight.

33. For treating, preventing, slowing the progression and / or ameliorating SMA in a subject in need thereof A pharmaceutical composition comprising risdiplam, The patient a) treating with said pharmaceutical composition for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks; and then b) the pharmaceutical composition is administered in combination with an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO: 6; Pharmaceutical compositions.

34. For the treatment, prevention, slowing of progression and / or amelioration of SMA, 1. A pharmaceutical composition comprising an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO: 6, A pharmaceutical composition administered in combination with risdiplam.

35. The pharmaceutical composition of claim 33 or 34, wherein the anti-myostatin antibody comprises a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7 and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO:

8.

36. The pharmaceutical composition of claim 33 or 34, wherein the anti-myostatin antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 9 and a light chain comprising the amino acid sequence of SEQ ID NO:

10.

37. 35. The pharmaceutical composition of claim 33 or 34, wherein the patient is administered a total daily dose of risdiplam of 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

38. 35. The pharmaceutical composition of claim 33 or 34, wherein the antibody is administered to the patient every four weeks at a dose of 7.4 mg or 24 mg for patients older than 2 years and weighing less than 20 kg, and 10.6 mg or 36 mg for patients weighing 20 kg or more, in particular the antibody is administered to the patient every four weeks at a dose of 24 mg for patients older than 2 years and weighing less than 20 kg, and 36 mg for patients weighing 20 kg or more.

39. 35. The pharmaceutical composition of claim 33 or 34, wherein the patient has SMA Type I, SMA Type II, or SMA Type III.

40. 35. A pharmaceutical composition according to claim 33 or 34 in a patient, particularly a patient in need thereof, particularly wherein said patient is a human being, such as a male or female human being.

41. 35. The pharmaceutical composition of claim 34, wherein the patient being treated has been initially treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before the first dose of the antibody is administered to the patient.

42. 35. The pharmaceutical composition of claim 33 or 34, wherein a total daily dose of risdiplam is administered to the patient at 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

43. The pharmaceutical composition of claim 33 or 34, wherein the anti-myostatin antibody is administered to the patient at a dose of 7.4 mg or 24 mg for patients older than 2 years and weighing less than 20 kg, and 10.6 mg or 36 mg for patients weighing 20 kg or more, and particularly wherein the antibody is administered to the patient at a dose of 24 mg for patients older than 2 years and weighing less than 20 kg, and 36 mg for patients weighing 20 kg or more, every 4 weeks.

44. The pharmaceutical composition of claim 33 or 34, wherein the anti-myostatin antibody is GM329.

45. 35. The pharmaceutical composition of claim 33 or 34, wherein the anti-myostatin antibody is administered every four weeks.

46. 35. The pharmaceutical composition of claim 33 or 34, wherein the patient has SMA.

47. 35. The pharmaceutical composition of claim 33 or 34, wherein the SMA is SMA Type I, SMA Type II, or SMA Type III.

48. 1 to 10% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2 to 15% by weight, in particular 4 to 6% by weight, of a buffer system, in particular a buffer system selected from citrate, malate, maleate, or tartrate, more in particular malate or tartrate, most in particular tartrate; or the corresponding acid of the buffer system as the sole acidifying agent, in particular tartaric acid; 40 to 90% by weight of a diluent, in particular mannitol or a mixture of mannitol and isomalt, more particularly mannitol; 0.5 to 4% by weight of an antioxidant, specifically ascorbic acid; 0.2 to 2% by weight of a stabilizer, specifically edetate disodium; 0.5 to 2% by weight of a lubricant, specifically PEG 6000; 1 to 8% by weight, in particular 1 to 4% by weight, of a preservative chosen from potassium sorbate or sodium benzoate; 0-3% by weight of a sweetener, particularly sucralose or sodium saccharin, most particularly sucralose; and - 0-20% by weight of flavoring, in particular strawberry flavoring or vanilla flavoring, 34. The pharmaceutical composition of claim 33, wherein the total amount of ingredients does not exceed 100% by weight.

49. 1 to 5% by weight of risdiplam or a pharmaceutically acceptable salt thereof; - 2 to 8% by weight, in particular 4 to 6% by weight, of a tartrate buffer system; 60-75% by weight of mannitol as a first diluent and 10-15% by weight of isomalt as a second diluent; 0.5 to 1.5% by weight of ascorbic acid as an antioxidant; 0.25 to 0.75% by weight of disodium edetate as a stabilizer; 0.5-2% by weight of PEG 6000 as a lubricant; 1 to 8% by weight, in particular 1 to 4% by weight, of sodium benzoate as a preservative; 0.5 to 1% by weight of sucralose as a sweetener; and - 5 to 10% by weight of strawberry flavoring; 34. The pharmaceutical composition of claim 33, wherein the total amount of ingredients does not exceed 100% by weight.

50. Use of risdiplam in the manufacture of a medicament for the treatment of SMA, wherein a subject treated with risdiplam is further treated with an anti-myostatin antibody, comprising an anti-myostatin antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO:

6.

51. The use described in claim 50, wherein the anti-myostatin antibody comprises a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7 and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO:

8.

52. The use described in claim 50, wherein the anti-myostatin antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 9 and a light chain comprising the amino acid sequence of SEQ ID NO:

10.

53. Risdiplam and GYM329 for use in the treatment, prevention, slowing of progression and / or amelioration of SMA.

54. Risdiplam and GYM329 for use in treating, preventing, slowing the progression of and / or ameliorating SMA in a patient.

55. 55. Risdiplam and GYM329 for use according to claim 53 or 54, wherein the patient to be treated has already been treated with risdiplam.

56. 55. Risdiplam and GYM329 for use according to claim 53 or 54, wherein the patient being treated has been initially treated with risdiplam for at least 2 weeks, particularly at least 3 weeks, more particularly at least 4 weeks, even more particularly at least 6 weeks, and most particularly at least 8 weeks before GYM329 is initially administered with risdiplam.

57. 1. Risdiplam for use in treating, preventing, delaying the progression of and / or ameliorating SMA in a patient when used in combination with an antibody comprising an antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5 and CDRL3 comprises the sequence set forth in SEQ ID NO:

6.

58. 58. The risdiplam for use in treatment of claim 57, comprising a VH having at least 90% sequence identity to the amino acid sequence of SEQ ID NO: 7, and a VL having at least 90% sequence identity to the amino acid sequence of SEQ ID NO:

8.

59. 58. The risdiplam for use in treatment of claim 57, wherein the antibody comprises a heavy chain variable region comprising the amino acid sequence of SEQ ID NO:7 and a light chain variable region comprising the amino acid sequence of SEQ ID NO:

8.

60. Risdiplam for use in the treatment of claim 57, wherein the anti-myostatin antibody comprises a heavy chain comprising the amino acid sequence of SEQ ID NO: 9 and a light chain comprising the amino acid sequence of SEQ ID NO:

10.

61. 58. Risdiplam for use in treatment according to claim 57, wherein the patient is being treated.

62. Use of risdiplam and GYM329 in treating SMA in patients.

63. 63. The use of claim 62, wherein the patient is a human (such as a male or female human).

64. 63. The use of claim 62, wherein the SMA is SMA Type I, SMA Type II or SMA Type III.

65. 63. The use of claim 62, wherein a total daily dose of risdiplam is administered to the patient at 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

66. 63. The use of claim 62, wherein the antibody is administered to the patient every four weeks at a dose of 7.4 mg or 24 mg for patients older than 2 years and weighing less than 20 kg, and 10.6 mg or 36 mg for patients weighing 20 kg or more, particularly wherein the antibody is administered to the patient every four weeks at a dose of 24 mg for patients older than 2 years and weighing less than 20 kg, and 36 mg for patients weighing 20 kg or more.

67. 63. A package or kit comprising: (a) risdiplam, optionally in a container; and (b) a package insert, package label, instructions, or other labeling for use according to claim 62.

68. 68. The package or kit of claim 67, further comprising (c) GYM329.

69. An anti-myostatin antibody for use in the treatment, prevention, delay of progression and / or amelioration of SMA, particularly when used in combination with risdiplam in a patient, the antibody comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5 and CDRL3 comprises the sequence set forth in SEQ ID NO:

6.

70. An anti-myostatin antibody for use in the treatment of SMA in combination with risdiplam, comprising six complementarity determining regions (CDRs): CDRH1, CDRH2, CDRH3, CDRL1, CDRL2 and CDRL3, wherein CDRH1 comprises the sequence set forth in SEQ ID NO: 1, CDRH2 comprises the sequence set forth in SEQ ID NO: 2, CDRH3 comprises the sequence set forth in SEQ ID NO: 3, CDRL1 comprises the sequence set forth in SEQ ID NO: 4, CDRL2 comprises the sequence set forth in SEQ ID NO: 5, and CDRL3 comprises the sequence set forth in SEQ ID NO:

6.

71. An anti-myostatin antibody for use in the treatment of SMA described in claim 69 or 70, which inhibits the activation of myostatin.

72. An anti-myostatin antibody for use in the treatment of SMA described in claim 69 or 70, which blocks the proteolytic release of mature myostatin.

73. An anti-myostatin antibody for use in the treatment described in claim 69 or 70, comprising a VH having at least 90% sequence identity with the amino acid sequence of SEQ ID NO: 7, and a VL having at least 90% sequence identity with the amino acid sequence of SEQ ID NO:

8.

74. An anti-myostatin antibody for use in the treatment described in claim 69 or 70, comprising a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 7 and a light chain variable region comprising the amino acid sequence of SEQ ID NO:

8.

75. An anti-myostatin antibody for use in the treatment described in claim 69 or 70, comprising a heavy chain region comprising the amino acid sequence of SEQ ID NO: 9 and a light chain region comprising the amino acid sequence of SEQ ID NO:

10.

76. An anti-myostatin antibody for use in the treatment described in claim 69 or 70, which is GM329.

77. An anti-myostatin antibody for use in the treatment of a patient (particularly a patient in need of treatment) described in claim 69 or 70, particularly wherein the patient is a human (e.g., a male or female human).

78. An anti-myostatin antibody for use in treatment as described in claim 69 or 70, wherein the patient being treated has been initially treated with risdiplam for at least two weeks, particularly at least three weeks, more particularly at least four weeks, even more particularly at least six weeks, and most particularly at least eight weeks before the first dose of the antibody is administered to the patient.

79. The anti-myostatin antibody for use in treatment of claim 69 or 70, wherein the total daily dose of risdiplam is administered to the patient at 0.2 mg / kg for patients between 2 months and 2 years of age, 0.25 mg / kg for patients older than 2 years and weighing less than 20 kg, and 5 mg for patients weighing 20 kg or more.

80. The anti-myostatin antibody for use in treatment described in claim 69 or 70, wherein the dose of the anti-myostatin antibody is administered to the patient at a dose of 7.4 mg or 24 mg for patients over 2 years of age and weighing less than 20 kg, and at a dose of 10.6 mg or 36 mg for patients weighing 20 kg or more, and in particular, the dose of the antibody is administered to the patient at a dose of 24 mg for patients over 2 years of age and weighing less than 20 kg, and at a dose of 36 mg for patients weighing 20 kg or more every 4 weeks.

81. An anti-myostatin antibody for use in treatment according to claim 69 or 70, wherein the anti-myostatin antibody is administered every four weeks.

82. An anti-myostatin antibody for use in treatment according to claim 69 or 70, wherein the patient has SMA.

83. An anti-myostatin antibody for use in treatment according to claim 69 or 70, wherein the SMA is SMA type I, SMA type II or SMA type III.

84. Risdiplam is 1-10% by weight of risdiplam or a pharmaceutically acceptable salt thereof; 2 to 15% by weight, in particular 4 to 6% by weight, of a buffer system, in particular a buffer system selected from citrate, malate, maleate, or tartrate, more in particular malate or tartrate, most in particular tartrate; or the corresponding acid of the buffer system as the sole acidifying agent, in particular tartaric acid; 40 to 90% by weight of a diluent, in particular mannitol or a mixture of mannitol and isomalt, more particularly mannitol; 0.5 to 4% by weight of an antioxidant, specifically ascorbic acid; 0.2 to 2% by weight of a stabilizer, specifically edetate disodium; 0.5 to 2% by weight of a lubricant, specifically PEG 6000; 1 to 8% by weight, in particular 1 to 4% by weight, of a preservative chosen from potassium sorbate or sodium benzoate; 0-3% by weight of a sweetener, particularly sucralose or sodium saccharin, most particularly sucralose; and - 0-20% by weight of flavoring, in particular strawberry flavoring or vanilla flavoring, An anti-myostatin antibody for use in the treatment described in claim 69 or 70, administered in a pharmaceutical composition in which the total amount of components does not exceed 100% by weight.

85. Risdiplam is 1-5% by weight of risdiplam or a pharmaceutically acceptable salt thereof; - 2 to 8% by weight, in particular 4 to 6% by weight, of a tartrate buffer system; 60-75% by weight of mannitol as a first diluent and 10-15% by weight of isomalt as a second diluent; 0.5 to 1.5% by weight of ascorbic acid as an antioxidant; 0.25 to 0.75% by weight of disodium edetate as a stabilizer; 0.5-2% by weight of PEG 6000 as a lubricant; 1 to 8% by weight, in particular 1 to 4% by weight, of sodium benzoate as a preservative; 0.5 to 1% by weight of sucralose as a sweetener; and - 5 to 10% by weight of strawberry flavoring; An anti-myostatin antibody for use in the treatment described in claim 69 or 70, administered in a pharmaceutical composition in which the total amount of components does not exceed 100% by weight.

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