Avexitide for treatment of hyperinsulinemic hypoglycemia

Abstract

To provide methods of treating hyperinsulinemic hypoglycemia (HH), including post-bariatric hypoglycemia (PBH).SOLUTION: The present invention provides a method of treating one or more of hyperinsulinemic hypoglycemia (HH), fasting hyperinsulinemic hypoglycemia, insulinoma, or hypoglycemia / NIPHS, the method comprising subcutaneously administering to the subject a buffered liquid formulation comprising avexitide at a concentration of between 2-90 mg / mL.SELECTED DRAWING: Figure 1

Description

[Technical field]

[0001] Cross References This application claims priority to U.S. Provisional Application No. 62 / 745,915 (filed October 15, 2018), U.S. Provisional Application No. 62 / 746,229 (filed October 16, 2018), and U.S. Provisional Application No. 62 / 823,493 (filed March 25, 2019), each of which is incorporated herein by reference.

[0002] Reference to sequence listing submitted as a text file via EFS-WEB An official copy of the Sequence Listing has been submitted electronically via EFS-Web as an ASCII formatted Sequence Listing in a file created on October 11, 2019 (file name "1152075-002410PC_SL.TXT", file size 735 bytes) and is attached hereto. The Sequence Listing contained in this ASCII format document is a part of this specification and is incorporated herein by reference in its entirety. [Background technology]

[0003] Insulin is a hormone secreted to keep blood sugar levels from rising. Abnormally increased insulin secretion can lead to severe hypoglycemia that can result in seizures, brain damage, and death. Glucagon-like peptide-1 (GLP-1) is a gastrointestinal hormone that is released from L-cells in the intestine after a meal and binds to the GLP-1 receptor on beta cells in the pancreas, promoting the release of insulin.

[0004] Post-bariatric hypoglycemia (PBH), a form of hyperinsulinemic hypoglycemia (HH), is a rare disorder with no approved pharmacological therapy and is believed to be mediated primarily by excessive postprandial secretion and / or action of GLP-1 due to altered nutrient transport after bariatric surgery. PBH often manifests as postprandial hypoglycemia and can lead to life-threatening neuronal tissue glucose deprivation, including loss of consciousness, seizures, cognitive impairment, and death. Quality of life can be significantly reduced, with many patients unable to care for themselves or others, work, drive, or be left alone. To date, there is no approved pharmacological therapy for PBH. Summary of the Invention [Problem to be solved by the invention]

[0005] Approximately 200,000-250,000 bariatric surgeries are performed annually in the United States. As the number of bariatric surgeries to treat severe obesity increases, so does the number of people experiencing PBH. Thus, there is an increasing demand for therapies that safely and effectively reduce hyperinsulinemic hypoglycemia and PBH. [Means for solving the problem]

[0006] In one aspect, a method of treating hyperinsulinemic hypoglycemia (HH), including post-bariatric hypoglycemia (PBH), is provided. In some embodiments, the method comprises subcutaneously administering to a subject with PBH a buffered liquid formulation comprising abexitide at a concentration of at least 30 mg / mL.

[0007] In some embodiments, avexitide is administered in a total daily dose of about 40 mg to about 90 mg or 30 mg to about 120 mg per day. In some embodiments, avexitide is administered in a total daily dose of about 60 mg or 120 mg. In some embodiments, avexitide is administered in a dose of about 45 mg BID or about 35-55 mg BID. In some embodiments, avexitide is administered in a total daily dose of about 90 mg QD, or about 60-120 mg per day. In some embodiments, avexitide is administered once a day (QD) or twice a day (BID).

[0008] In some embodiments, avexitide is administered at a dose of 45 mg BID. In some embodiments, the BID dosing regimen includes morning and evening administration, with the evening dose being administered at least about 12 hours after the morning dose. In some embodiments, the morning dose is administered at least about 60 minutes before a meal. In certain embodiments, avexitide is administered at 45 mg BID. In certain embodiments, the subject is administered about 30 mg to about 90 mg BID avexitide, and the subject does not need to fast after administration or delay their first meal of the day (including having their first meal at night).

[0009] The advantage of BID dosing is that the patient does not need to fast (or delay the first meal of the day) following dosing, since the trough concentration is usually within the concentration threshold (e.g., EC50) where the therapeutic response is optimal.

[0010] In certain embodiments, avexitide is administered at 45 mg to 120 mg QD. In certain embodiments, the subject is administered about 50 mg to about 100 mg QD of avexitide, and the subject is required to fast after administration or delay the first meal of the day. In one embodiment, the subject is required to fast overnight before the morning administration. In one embodiment, the subject is required to fast for about 45 to 90 minutes after the morning administration. In one embodiment, the subject is required to fast overnight before the morning administration and fast for about 45 to 90 minutes after the morning administration. The time to delay the meal can be about 30 minutes to about 1.5 hours. In some embodiments, the delay is 60 minutes, or 45 to 60 minutes.

[0011] In some embodiments, avexitide is administered at a dose of 90-120 mg QD. In some embodiments, the QD dosing regimen includes administering avexitide in the morning. In some embodiments, avexitide is administered about 60 minutes before a meal, such as the first meal of the day. In some embodiments, avexitide is administered about 30 minutes to about 90 minutes before a meal. In certain embodiments, avexitide is administered at 45 mg QD.

[0012] In some embodiments, the formulation comprises abexitide at a concentration of 30 mg / mL to 180 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration of 30 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration of 90 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration of 100 to 120 mg / mL. In some embodiments, the formulation has a pH of about 5.5. In some embodiments, the formulation comprises a sodium acetate buffered liquid. In some embodiments, the formulation comprises a tonicity adjuster. In some embodiments, the tonicity adjuster comprises mannitol.

[0013] In some embodiments, the subject has previously undergone Roux-en-Y gastric bypass surgery. In some embodiments, the subject has previously undergone vertical sleeve gastrectomy (VSG) or biliary pancreatic diversion (BPD), upper gastrointestinal surgery, gastrectomy + / - RYGB revision, esophagectomy, fundoplication, etc.

[0014] In some embodiments, avexitide is administered for at least 30 days. In some embodiments, avexitide is administered for acute use for less than 30 days. In some embodiments, avexitide is administered for less than 30 days and until one or more of glucose and insulin levels are stabilized. In some embodiments, avexitide is administered for at least 45 days, or at least 90 days, or at least 180 days. In some embodiments, avexitide is administered for 30 days to 5 years.

[0015] In some embodiments, the treatment reduces the number and / or severity of symptoms of postprandial neuroglycopenia in the subject. In some embodiments, the treatment improves postprandial blood glucose nadir. In some embodiments, the treatment reduces the postprandial insulin peak. In some embodiments, the treatment reduces the rate of hypoglycemia in the subject. In some embodiments, the treatment reduces the rate of severe hypoglycemia in the subject. In some embodiments, the treatment reduces "severe hypoglycemia" (as defined by the ADA, requiring third party assistance). In other embodiments, the treatment reduces the "rate of hypoglycemia-induced CNS damage." In some embodiments, administration of abexitide provides a clinically meaningful improvement in one or more of hypoglycemia-induced CNS damage, severe hypoglycemia, postprandial insulin peak, rate of severe hypoglycemia, or postprandial blood glucose nadir.

[0016] Further aspects and embodiments are disclosed below. [Brief description of the drawings]

[0017] The present disclosure is described in detail below with reference to the accompanying drawings.

[0018] [Figure 1] FIG. 1 shows a diagram of a clinical trial design for avexitide according to an embodiment of the present disclosure.

[0019] [Diagram 2] 1 shows the mean blood glucose levels (± standard deviation) during a 180-minute MMTT for placebo, avexitide 30 mg BID, and avexitide 60 mg QD treatment groups according to an embodiment of the present disclosure. The shaded bands at the bottom of the graph reflect glycemic rescue at glucose ≦50 mg / dL+ neuroglycopenia or glucose ≦40 mg / dL+ / − neuroglycopenia.

[0020] [Diagram 3] 1 shows the mean insulin concentrations (± standard deviation) during the 180 minute MMTT for placebo, avexitide 30 mg BID, and avexitide 60 mg QD treatment groups according to an embodiment of the disclosure.

[0021] [Figure 4] 1 shows adverse events observed in the placebo, avexitide 30 mg BID, and avexitide 60 mg QD treatment groups, and overall adverse events observed according to embodiments of the present disclosure.

[0022] [Diagram 5] The 30 mg BID and 60 mg QD doses of embodiments of the present disclosure demonstrate a significant reduction in hyperinsulinemic hypoglycemia and reduced need for rescue.

[0023] [Figure 6]13 demonstrates glycemic improvement in outpatients showing a reduction in the daytime percent time and number of episodes <70 mg / dL and <55 mg / dL as measured by the CGM of an embodiment of the present disclosure. In both graphs, the left data bar is placebo, the middle data bar is 30 mg BID, and the right data bar is 60 mg QD for each episode <70 mg / dL and <55 mg / dL. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0024] Detailed Description Introduction Avexitide is a 31 amino acid peptide that selectively targets and blocks GLP-1 receptors, normalizing insulin secretion by the pancreas, thereby reducing postprandial hypoglycemia. Avexitide treatment reduces postprandial (protein-induced) as well as fasting hyperinsulinemic hypoglycemia. Avexitide is also used to treat insulinoma and hypoglycemia / NIPHS. As disclosed herein, in a clinical study investigating the safety and durability of efficacy of subcutaneous administration of Avexitide for 28 days in subjects with refractory severe hypoglycemia after bariatric surgery, it was found that once-daily and twice-daily dosing regimens of Avexitide improved postprandial nadir glucose and fewer patients required glycemic rescue compared to placebo administration. Additionally, once-daily and twice-daily dosing regimens resulted in metabolic and clinical improvements in patients, including a reduction in the number of hypoglycemic episodes.

[0025] definition The terms used herein are merely for the purpose of describing certain embodiments and are not intended to be limiting. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by those skilled in the art to which this invention belongs. In this specification and claims, unless a contrary intention is apparent, referenced terms are defined to have the following meanings. In some cases, terms with commonly understood meanings are defined herein for clarity and / or ease of reference, and the inclusion of such definitions herein should not be interpreted as representing a substantial difference to the definition of the term as commonly understood in the art.

[0026] Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods and materials are now described. All technical and patent publications cited herein are incorporated by reference in their entireties.

[0027] All numerical designations, including ranges, e.g., pH, temperature, time, concentration, molecular weight, etc., are approximations and vary (+) or (-) by increments of 0.1 or 1.0, as appropriate (e.g., pH 5.4 or 5.5). It is understood, although not always expressly stated, that all numerical designations are preceded by the term "about." References to ranges include endpoints unless otherwise stated. For example, administering avexitide at a concentration of 30 mg / mL to 180 mg / mL includes administration of 30 mg / mL or 180 mg / mL.

[0028] The singular forms "a," "an," and "the" include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "a compound" includes a plurality of compounds.

[0029] The term "comprising" is intended to mean that the compounds, compositions and methods include the recited elements and do not exclude other elements. When used to define compounds, compositions and methods, "consisting essentially of" means excluding other elements that materially affect the basic and novel characteristics of the claimed invention. "Consisting of" means excluding any element, step, or ingredient not specified in the claim. Embodiments defined by each of these transitional phrases are within the scope of the invention.

[0030] "Avexitide," also known as "Exendin (9-39)," is a C 149 H 234 N 40 O 47Avexitide refers to a 31 amino acid peptide with the formula S and a molecular weight of 3369.8 daltons. Avexitide contains residues 9-39 of the GLP-1 receptor agonist exendin-4 and is a GLP-1 receptor antagonist with inverse agonist properties. See Montrose-Rafizadeh et al., Journal of Biological Chemistry, 272:21201-21206 (1997). The amino acid sequence of avexitide is: H-Asp-Leu-Ser-Lys-Gln-Met-Glu-Glu-Glu-Ala-Val-Arg-Leu-Phe-Ile-Glu-Trp-Leu-Lys-Asn-Gly-Gly-Pro-Ser-Ser-Gly-Ala-Pro-Pro-Pro-Ser-NH2 (SEQ ID NO: 1). The predicted isoelectric point of avexitide is 4.69, with a net charge of -1 at pH 6, increasing to a net charge of +4 at pH 3.0. As used herein, the term "avexitide" also encompasses pharma- ceutically acceptable salts of avexitide (exendin (9-39)), including, but not limited to, sulfate, hydrochloride, phosphate, sulfamate, acetate, citrate, lactate, tartrate, methanesulfonate, ethanesulfonate, benzenesulfonate, p-toluenesulfonate, cyclohexylsulfamate, and quinate. In some embodiments, avexitide is in the form of acetate or trifluoroacetate. Unless otherwise specified herein, avexitide acetate is used. Avexitide (exendin (9-39)) and its pharma-ceutically acceptable salts are commercially available (e.g., Bachem).

[0031] The term "formulation" or "pharmaceutical formulation" as used herein refers to a composition suitable for administration to a subject. A pharmaceutical formulation is sterile and preferably free of contaminants that may induce an undesirable response in a subject (e.g., the compounds in the pharmaceutical formulation are pharmaceutical grade). A pharmaceutical formulation can be designed for administration to a subject or patient in need thereof via various routes of administration, such as oral, intravenous, buccal, rectal, parenteral, intraperitoneal, intradermal, intramuscular, subcutaneous, inhalation, etc. In some embodiments, the pharmaceutical formulation described herein is formulated for subcutaneous administration.

[0032] As used herein, a "therapeutically effective amount" is an amount of an active ingredient (e.g., avexitide or a pharma- ceutically acceptable salt thereof) that eliminates, ameliorates, alleviates, or relieves the symptoms, or produces the clinical outcome for which it is administered.

[0033] As used herein, the terms "treatment" and "treating" refer to the administration of avexitide to treat HH (including, for example, post-bariatric surgery hypoglycemia, fasting hyperinsulinemic hypoglycemia, insulinoma, and hypoglycemia / NIPHS) and encompass any treatment of the disease in a human subject, including (a) reducing the risk, frequency or severity of hypoglycemic episodes in patients with a history of post-bariatric surgery hypoglycemia, (b) reducing the risk of developing post-operative hypoglycemia in subjects determined to be susceptible to post-bariatric surgery hypoglycemia (e.g., those who have undergone bariatric surgery but have not yet been diagnosed with post-operative hypoglycemia), (c) arresting the progression of the disease, and / or (d) relieving the disease, i.e., causing regression of the disease and / or alleviating one or more symptoms of the disease.

[0034] As used herein, the terms "administer" and "administration" refer to the introduction of a compound (e.g., avexitide), composition or agent into a subject or patient, such as a human. As used herein, the terms encompass both direct administration (e.g., self-administration or administration to a patient by a medical professional) and indirect administration (e.g., the act of prescribing a compound or composition to a subject).

[0035] "QD" and "BID" have their usual meaning of administering a composition (e.g., a buffered liquid formulation of abexitide) once a day or twice a day, respectively. In some embodiments, once a day administration (QD) means that at least 20 hours, at least 22 hours, or about 24 hours elapse between administrations. In some embodiments, once a day administration means administration about every 24 hours. In some embodiments, twice a day administration (BID) means that at least 4 hours, at least 6 hours, at least 8 hours, at least 10 hours, at least 11 hours, or about 12 hours elapse between administrations. In some embodiments, twice a day administration means administration about every 12 hours.

[0036] The terms "patient" and "subject" as used herein refer interchangeably to an individual (e.g., a human or non-human mammal). In some embodiments, the patient or subject has post-bariatric surgery hypoglycemia. In some embodiments, the patient or subject has previously undergone bariatric surgery (e.g., gastric bypass, vertical sleeve gastrectomy, biliary pancreatic diversion). In some embodiments, the subject has previously undergone a different upper gastrointestinal procedure (e.g., gastrectomy, esophagectomy, Nissen fundoplication). In some embodiments, the patient or subject has undergone vagotomy + / - pyloroplasty, Billroth, congenital microgastria. In other embodiments, the subject has a condition that accelerates ileal transit (early nutrient exposure to L-cells). In some embodiments, the subject has fasting hyperinsulinemic hypoglycemia. In some embodiments, the subject has an insulinoma. In some embodiments, the subject suffers from reactive hypoglycemia / NIPHS.

[0037] Treatment method In one aspect, a method for treating or preventing post-bariatric surgery hypoglycemia (PBH) is provided.In some embodiments, the method comprises subcutaneously administering to a subject with PBH a composition (e.g., a buffered liquid formulation disclosed in Section IV below) comprising avexitide at a concentration of at least 30mg / mL.As described herein, in some embodiments, treatment with avexitide prevents or reduces one or more symptoms, metabolic outcomes, and / or clinical outcomes of post-bariatric surgery hypoglycemia.

[0038] Patient population In some embodiments, the subject treated according to the methods described herein is a subject with post-bariatric hypoglycemia (PBH) who has undergone obesity treatment and / or related metabolic treatment, including but not limited to Roux-en-Y gastric bypass, vertical sleeve gastrectomy, placement of an endo-sleeve device, also called "endoluminal liner", such as the EndoBarrier Gastrointestinal Liner System, duodenal mucosal resurfacing (also called duodenectomy), biliary pancreatic transection with duodenal switch, partial duodenal bypass with duodenal-ileal or duodenal-jejunal anastomosis, vagus nerve blockade, and pyloroplasty.

[0039] Obesity treatments (e.g., bariatric surgery) typically involve any of the above: partially or completely bypassing the duodenum, and / or reducing nutrient exposure to the duodenum, increasing the rapidity of nutrient transit to the lower intestine (often especially the ileum), and / or increasing ileum exposure to nutrients. Bariatric surgery may be aimed at weight loss or metabolic benefits (such as reversing diabetes), or both. Such weight loss or metabolic treatments, referred to herein as "bariatric surgery", may enhance secretion of GLP-1 from the distal small intestine, especially the ileum, resulting in increased insulin secretion and, in some subjects, hypoglycemia. In some embodiments, the subject may be referred to as a "post-bariatric surgery" subject.

[0040] In another embodiment, the subject to be treated has previously undergone a related procedure.As a non-limiting example, in one embodiment, the subject to be treated has previously undergone a non-bacteriologic surgical procedure involving the gastrointestinal system (e.g., esophagectomy for the treatment of esophageal cancer, including but not limited to Nissen fundoplication, gastroesophageal reflux treatment, or gastrectomy, for example, for the treatment or prevention or treatment of gastric cancer), and thus may be referred to herein as "post-gastrointestinal surgery".

[0041] In some embodiments, the subject with hyperinsulinemic hypoglycemia has previously undergone Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG). In some embodiments, the subject to be treated has previously undergone obesity treatment or related metabolic treatment (e.g., RYGB or VSG) at least one year prior to initiating treatment.

[0042] Subjects with PBH can be identified by any suitable method. In some embodiments, PBH is diagnosed in post-bariatric surgery patients as the presence of pathological post-prandial hypoglycemia associated with inappropriate elevation of insulin (≧3 μU / mL) or C-peptide (≧0.6 ng / mL) during hypoglycemia (54 mg / dL glucose). In some embodiments, PBH is diagnosed in post-bariatric surgery patients by the presence of Whipple's triad, which has the following criteria: (1) occurrence of hypoglycemic symptoms (e.g., behavioral changes, confusion or cognitive impairment, seizures, loss of consciousness, and other neuroglycopenic symptoms); (2) hypoglycemia levels recorded at the time of symptom occurrence (e.g., <54 mg / dL; <70 mg / dL); (3) resolution of symptoms after blood glucose levels rise (e.g., within minutes). In some embodiments, PBH is diagnosed using active provocation tests, such as oral glucose tolerance test (OGTT) or mixed meal tolerance test (MMTT). The diagnostic criteria for PBH are also disclosed in Salehi et al., The Journal of Clinical Endocrinology & Metabolism, 2018, 103:2815-2826.

[0043] In some embodiments, the subject has refractory PBH. As used herein, a subject or patient with "refractory PBH" refers to a PBH patient receiving conventional treatment, such as dietary changes or the use of rescue glucagon, who still experiences (1) hypoglycemia that interferes with the patient's daily life, and / or (2) severe hypoglycemic episodes.

[0044] In some embodiments, the subject has severe PBH. As used herein, a subject or patient with "severe PBH" refers to a PBH patient who experiences severe hypoglycemia. As used herein, "severe hypoglycemia" is defined as hypoglycemic symptoms confirmed by self-glucose monitoring (SBGM) glucose ≦54 mg / dL (see IHSG 2017). As used herein, severe hypoglycemia is a severe event characterized by altered mental and / or physical functioning and requiring assistance from others for recovery (ADA, Diabetes Care 2019;42(Suppl. 1):S61-S70). In one embodiment, the rate of severe hypoglycemic episodes (e.g., hypoglycemia-induced CNS damage) is reduced. If SBGM is not obtained at the time of symptom onset or if the patient does not experience symptoms due to hypoglycemia unawareness, a corresponding continuous glucose monitor (CGM) reading is obtained. < 54 and / or neurological recovery after blood glucose levels return to normal. “Severe hypoglycemia” may also refer to episodes of hypoglycemia that require the assistance of others to administer rescue therapy (see Seaquist 2013).

[0045] Methods for identifying appropriate patient populations and patients are also described in PCT Patent Application Nos. PCT / US2016 / 033837 and PCT / US2017 / 062838, which are incorporated by reference herein in their entireties.

[0046] In some embodiments, the patient is a human patient. In some embodiments, the patient is an adult. In some embodiments, the patient is a minor.

[0047] Dosage regimen In some embodiments, avexitide is administered in a total daily dose ranging from about 40 mg to about 90 mg. For PBH and other upper GI types of HH, the adult dosage is about 45 mg BID, or 30 mg BID to 60 mg BID, or 60 mg QD to 120 mg QD, for example, a total daily dose of avexitide is about 40 mg to about 75 mg, about 40 mg to about 60 mg, about 50 mg to about 90 mg, about 45 mg to about 75 mg, about 60 mg to about 90 mg, or about 60 mg to about 75 mg. In some embodiments, avexitide is administered in a total daily dose of at least about 40 mg, for example, at least about 45 mg, at least about 50 mg, at least about 60 mg, or at least about 75 mg. In some embodiments, avexitide is administered in a total daily amount of about 40 mg, about 45 mg, about 50 mg, about 55 mg, about 60 mg, about 65 mg, about 70 mg, about 75 mg, about 80 mg, about 80 mg, about 85 mg, or about 90 mg.

[0048] In some embodiments, the subject is administered 0.375 mg / kg / dose or 0.75 mg / kg / day. In some embodiments, the subject is administered about 0.56 mg / kg / dose or about 1.125 mg / kg / day.

[0049] In some embodiments, subjects are administered 0.3-1.6 mg / kg / dose of avexitide BID.

[0050] In some embodiments, the subject is administered about 0.6-3.2 mg / kg / day BID or about 0.2-1.2 mg / kg / day, or about 0.6-3.6 mg / kg / day BID or TID. In some embodiments, the subject is administered 0.6-3.6 mg / kg / day TID.

[0051] In some embodiments, avexitide is administered by IV infusion and is administered at about 0.1-1.0 mg / kg / hour, or about 0.2-0.6 mg / kg / hour.

[0052] Infusion formulations of avexitide may contain albumin to prevent the peptide from adhering to tubing / bags, or may be diluted, for example with saline or other diluents, including tubing or bags with low absorbency.

[0053] The above dosage ranges are examples of adult dosage, neonatal and pediatric dosage, and may vary according to the age and weight of the patient, as known to those skilled in the pharmaceutical art.It will be understood that in some embodiments, dosage can be increased or decreased during the course of treatment.For example, a doctor can treat with a low dose or initial (starting) dose, increase the dose if the initial dose does not provide sufficient therapeutic effect, and maintain the initial dose if the initial dose provides sufficient therapeutic effect.

[0054] In some embodiments, a therapeutically effective amount of avexitide (or a pharma- ceutically acceptable salt thereof) is administered once a day (QD). QD administration is well known in the medical arts. In some embodiments, QD doses are administered (e.g., self-administered) about 24 hours apart (e.g., at 7 a.m. on consecutive days). However, shorter intervals (e.g., 8 a.m. and 6 a.m. on consecutive days) or longer intervals (e.g., 7 a.m. and 9 a.m. on consecutive days) are possible, provided that the intervals are at least about 18 hours. Preferably, the doses are at least about 20, 21, 22, 23, or 24 hours apart. Preferably, the intervals between doses are not more than 30 hours. Although once-daily administration is preferred, the doses can be administered more frequently (e.g., twice a day) or less frequently (e.g., once every other day).

[0055] In some embodiments, the avexitide formulation is administered twice a day (BID). BID (twice a day) administration is well known in the medical field. The formulation can be administered at a specific time of the subject's day or schedule, such as in the morning, afternoon, evening, night, before or during or after meals, before bedtime, etc. In some embodiments, the formulation is administered about every 12 hours. In some embodiments, the BID dose is administered (e.g., self-administered) about 12 hours apart (e.g., 7:00 a.m. and 7:00 p.m.). However, shorter (e.g., 8:00 a.m. and 6:00 p.m.) or longer (e.g., 7:00 a.m. and 10:00 p.m.) administration intervals are possible. In some embodiments, administrations are at least about 4 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, or 11 hours apart. Preferably, the administration interval is not more than about 15 hours. Methods for timing administration of BID administration are described, for example, in PCT Patent Application No. PCT / US2016 / 033837, which is incorporated herein by reference.

[0056] In some embodiments, the avexitide formulation is administered at a dose of about 20-65 mg BID or 20-45 mg BID (e.g., administered subcutaneously or by iv or sc infusion). In some embodiments, the avexitide formulation is administered at a dose of about 20 mg BID. In some embodiments, the avexitide formulation is administered at a dose of about 25 mg BID. In some embodiments, the avexitide formulation is administered at a dose of about 30 mg BID. In some embodiments, the avexitide formulation is administered at a dose of about 35 mg BID. In some embodiments, the avexitide formulation is administered at a dose of about 40 mg BID. In some embodiments, the avexitide formulation is administered at a dose of about 45 mg BID. In some embodiments, the avexitide formulation is administered at a dose of about 50 mg BID. In some embodiments, the avexitide formulation is administered at a dose of about 55 mg BID. In some embodiments, the avexitide formulation is administered at a dose of about 60 mg BID. In some embodiments, the avexitide formulation is administered at a dose of about 65 mg BID. In some embodiments, a formulation containing avexitide at a concentration of 30 mg / mL or more is administered at a dose of about 20 to 65 mg BID, for example, at a dose of about 30 mg BID. In some embodiments, the formulation contains avexitide at a concentration of about 15 mg / mL to 100 mg / mL, or about 2 mg / mL to about 100 mg / mL. In some embodiments, the formulation contains avexitide at a concentration of 90 mg / mL.

[0057] In some embodiments, the avexitide formulation is administered (e.g., subcutaneously) in a total daily dose of 40-60 mg or 100 mg or 120 mg, administered BID. In some embodiments, the avexitide formulation is administered in a total daily dose of 40 mg, administered BID (i.e., 20 mg BID). In some embodiments, the avexitide formulation is administered in a total daily dose of 50 mg, administered BID (i.e., 25 mg BID). In some embodiments, the avexitide formulation is administered in a total daily dose of 60 mg, administered BID (i.e., 30 mg BID). The avexitide formulation is administered in a total daily dose of 120 mg, administered BID (i.e., 60 mg BID).

[0058] In some embodiments, the avexitide formulation is administered (e.g., subcutaneously) at a dose of about 40-90 mg QD, such as about 60-90 mg QD or about 45-75 mg QD. In some embodiments, the avexitide formulation is administered at a dose of about 40 mg QD. In some embodiments, the avexitide formulation is administered at a dose of about 50 mg QD. In some embodiments, the avexitide formulation is administered at a dose of about 60 mg QD. In some embodiments, the avexitide formulation is administered at a dose of about 75 mg QD. In some embodiments, the avexitide formulation is administered at a dose of about 90 mg QD. In some embodiments, the avexitide formulation is administered at a dose of about 100 mg QD. In some embodiments, the avexitide formulation is administered at a dose of about 110 mg QD. In some embodiments, the avexitide formulation is administered at a dose of about 120 mg QD. In some embodiments, the avexitide formulation is administered at a dose of about 125 mg QD. In some embodiments, a formulation containing avexitide at a concentration of 30 mg / mL or more is administered at a dose of about 45 to 90 mg QD, for example, about 60 mg QD, about 75 mg QD, about 80 QD, about 85 QD, about 90 QD, about 100 QD, about 110 QD, or about 120 QD, or at a dose of about 45 QD to about 120 QD.

[0059] In some embodiments, the avexitide formulation is administered (e.g., subcutaneously) in a total daily dose of 60-90 mg and is administered QD. In some embodiments, the avexitide formulation is administered in a total daily dose of 60 mg and is administered QD (i.e., 60 mg QD). In some embodiments, the avexitide formulation is administered in a total daily dose of 70 mg and is administered QD (i.e., 70 mg QD). In some embodiments, the avexitide formulation is administered in a total daily dose of 75 mg and is administered QD (i.e., 75 mg QD). In some embodiments, the avexitide formulation is administered in a total daily dose of 80 mg and is administered QD (i.e., 80 mg QD). In some embodiments, the avexitide formulation is administered in a total daily dose of 90 mg and is administered QD (i.e., 90 mg QD). In some embodiments, the avexitide formulation is administered in a total daily dose of 120 mg and is administered QD (ie, 120 mg QD).

[0060] In some embodiments, the avexitide formulation is administered (e.g., subcutaneously) in a total daily dose of 60-90 mg, administered BID or QD. In some embodiments, the avexitide formulation is administered in a total daily dose of 60 mg, administered QD (i.e., 60 mg QD). In some embodiments, the avexitide formulation is administered in a total daily dose of 60 mg, administered BID (i.e., 30 mg BID). In some embodiments, the avexitide formulation is administered in a total daily dose of 70 mg, administered QD (i.e., 70 mg QD). In some embodiments, the avexitide formulation is administered in a total daily dose of 70 mg, administered BID (i.e., 35 mg BID). In some embodiments, the avexitide formulation is administered in a total daily dose of 80 mg, administered QD (i.e., 80 mg QD). In some embodiments, the avexitide formulation is administered at a total daily dose of 80 mg and is administered BID (i.e., 40 mg BID). In some embodiments, the avexitide formulation is administered at a total daily dose of 90 mg and is administered QD (i.e., 90 mg QD). In some embodiments, the avexitide formulation is administered at a total daily dose of 90 mg and is administered BID (i.e., 45 mg BID). In some embodiments, the avexitide formulation is administered at a total daily dose of 120 mg and is administered QD (i.e., 120 mg QD). In some embodiments, the avexitide formulation is administered at a total daily dose of 90 mg and is administered BID (i.e., 60 mg BID).

[0061] In some embodiments, the avexitide formulation is administered (e.g., subcutaneously) twice daily (BID) about 60 minutes before breakfast and dinner (or before the two main meals of the day). In some embodiments, the avexitide formulation is administered at least about 60 minutes before a meal (e.g., at least 60 minutes before breakfast and / or at least 60 minutes before dinner). In some embodiments, administration before breakfast and dinner (or before the two main meals of the day) is separated by at least about 6 hours. In some embodiments, administration of the formulation is not timed to coincide with meals.

[0062] In some embodiments, the avexitide formulation is administered once a day (QD) (e.g., subcutaneously) in the morning or evening to maximize coverage of breakfast and dinner. For example, in some embodiments, the formulation is administered after a late-night meal or early in the morning before breakfast (e.g., at least 60 minutes before breakfast).

[0063] Route of administration In some embodiments, a composition comprising avexitide (e.g., a buffered liquid formulation disclosed in Section IV below) is administered to a subject by subcutaneous administration (e.g., subcutaneous injection). Sites of injection or administration or injection by subcutaneous injection include, but are not limited to, injection into the thigh, abdomen, upper arm, or upper buttocks.

[0064] In some embodiments, a composition comprising avexitide (e.g., a buffered liquid formulation disclosed in Section IV below) is formulated for subcutaneous administration. In one embodiment, the avexitide composition is formulated for subcutaneous administration according to a once-daily (QD) or twice-daily (BID) dosing regimen.

[0065] Avexitide preparations In some embodiments, the therapeutic methods disclosed herein include administering a buffered liquid formulation comprising avexitide or a pharma- ceutically acceptable salt thereof. In some embodiments, the formulation comprises avexitide at a concentration of at least 30 mg / mL.

[0066] In some embodiments, the formulation comprises about 2-180 mg / mL, about 2-90 mg / mL, about 2-20 mg / mL, about 2-29 mg / mL, about 1-20 mg / mL, about 30-150 mg / mL, about 30-120 mg / mL, about 30-90 mg / mL, about 30-60 mg / mL, about 30-70 mg / mL, about 40-180 mg / mL, about 40-120 mg / mL, about 45-90 mg / mL, about 45-75 mg / mL, about 60-180 mg / mL, about 60-120 mg / mL, about 60-90 mg / mL, or about 30-70 mg / mL ( For example, the formulation contains abexitide at a concentration of about 30 mg / mL, about 35 mg / mL, about 40 mg / mL, about 45 mg / mL, about 50 mg / mL, about 55 mg / mL, about 60 mg / mL, about 65 mg / mL, about 70 mg / mL, about 75 mg / mL, about 80 mg / mL, about 85 mg / mL, about 90 mg / mL, about 95 mg / mL, about 100 mg / mL, about 110 mg / mL, about 120 mg / mL, about 130 mg / mL, about 140 mg / mL, about 150 mg / mL, about 160 mg / mL, about 170 mg / mL, or about 180 mg / mL. In some embodiments, the formulation contains abexitide at a concentration of about 30 mg / mL. In some embodiments, the formulation contains abexitide at a concentration ranging from about 40 mg / mL to about 50 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration of about 45 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration ranging from about 30 mg / mL to about 60 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration ranging from about 30 mg / mL to about 90 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration ranging from about 45 mg / mL to about 90 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration of about 60 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration of about 75 mg / mL. In some embodiments, the formulation comprises abexitide at a concentration of about 90 mg / mL.

[0067] Treatment duration and treatment endpoints The subject may receive avexitide therapy for a predefined time, indefinitely, or until an endpoint is reached. Treatment may be continued daily or weekly for at least 2-3 months, 6 months, 1 year, or more. In some embodiments, the treatment period is at least 30 days, at least 60 days, at least 90 days, at least 120 days, at least 150 days, or at least 180 days. In some embodiments, treatment is continued for at least 6 months, at least 7 months, at least 8 months, at least 9 months, at least 10 months, at least 11 months, or at least 1 year. In some embodiments, treatment is continued for the patient's lifetime or until administration is no longer effective to provide a significant therapeutic effect.

[0068] In one embodiment, the subject is treated for no more than 30 days to stabilize glucose and insulin levels.

[0069] In some embodiments, treatment with avexitide therapy disclosed herein results in improvement of postprandial hypoglycemia.For example, in some embodiments, treatment with avexitide therapy results in an increase in the subject's postprandial plasma glucose nadir compared to baseline (e.g., compared to the subject's postprandial plasma glucose nadir before treatment begins, as measured during MMTT).In some embodiments, treatment with avexitide therapy disclosed herein results in improvement of postprandial neuroglycopenia or hypoglycemia symptoms.

[0070] In some embodiments, the treatment reduces the number and / or severity of symptoms of postprandial neuroglycopenia in the subject. In some embodiments, the treatment improves postprandial blood glucose nadir. In some embodiments, the treatment reduces the postprandial insulin peak. In some embodiments, the treatment reduces the rate of hypoglycemia in the subject. In some embodiments, the treatment reduces the rate of severe hypoglycemia in the subject. In some embodiments, the treatment reduces "severe hypoglycemia" (as defined by the ADA, requiring third party assistance). In other embodiments, the treatment reduces the "rate of hypoglycemia-induced CNS damage." In some embodiments, administration of abexitide provides a clinically meaningful improvement in one or more of the rate of hypoglycemia-induced CNS damage, severe hypoglycemia, postprandial insulin peak, rate of severe hypoglycemia, or postprandial blood glucose nadir.

[0071] In some embodiments, the avexitide formulation is administered (e.g., subcutaneously) twice daily (BID) about 60 minutes before breakfast and dinner (or before the two main meals of the day). In some embodiments, the avexitide formulation is administered at least about 60 minutes before a meal (e.g., at least 60 minutes before breakfast and / or at least 60 minutes before dinner). In some embodiments, administration before breakfast and dinner (or before the two main meals of the day) is separated by at least about 6 hours. In some embodiments, administration of the formulation is not timed to coincide with meals.

[0072] In some embodiments, the avexitide formulation is administered once a day (QD) (e.g., subcutaneously) in the morning or evening to maximize coverage of breakfast and dinner. For example, in some embodiments, the formulation is administered after a late-night meal or early in the morning before breakfast (e.g., at least 60 minutes before breakfast).

[0073] For example, in some embodiments, treatment with avexitide therapy results in a decrease in the number and / or severity of postprandial neuroglycopenic symptoms compared to baseline (e.g., compared to the number and / or severity of postprandial neuroglycopenic symptoms in the subject prior to initiation of treatment, as measured during an MMTT). In some embodiments, treatment with avexitide therapy disclosed herein results in an improvement in postprandial insulin response. For example, in some embodiments, treatment with avexitide therapy results in a decrease in peak postprandial insulin concentration compared to baseline (e.g., the subject's peak postprandial insulin concentration prior to initiation of treatment, as measured during an MMTT). In some embodiments, treatment with avexitide therapy disclosed herein results in an improvement in the patient's rate of hypoglycemia and / or rate of severe hypoglycemia. For example, in some embodiments, treatment with avexitide therapy results in a decrease in the rate of hypoglycemia and / or a decrease in the rate of severe hypoglycemia compared to baseline or to a placebo or other control (e.g., the subject's rate of hypoglycemia and / or severe hypoglycemia measured by self-glucose monitoring or continuous glucose monitoring). Treatment endpoints and methods for measuring treatment endpoints are also described in the Examples section below, e.g., in Table 1.

[0074] Physiologically acceptable buffer In some embodiments, the formulation comprises avexitide or a pharma- ceutically acceptable salt thereof in a physiologically acceptable buffer having a pH in the range of about 5 to about 6. In some embodiments, the buffer is compatible with subcutaneous administration. In some embodiments, the physiologically acceptable buffer is a buffer that results in the liquid formulation having a pH at or near physiological pH, or within a relatively narrow pH range near physiological pH (e.g., about 5.0 to about 8.0). In one embodiment, the buffered liquid formulation comprises a physiologically acceptable buffer having a pH greater than 5.0 to about 6. In some embodiments, the physiologically acceptable buffer has a pH greater than 5.0 to about 5.5. In one embodiment, the physiologically acceptable buffer has a pH in the range of 5.2 to 5.8 (e.g., 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, or 5.8). In one embodiment, the physiologically acceptable buffer has a pH in the range of 5.0 to 5.5 (e.g., 5.1, 5.2, 5.3, 5.4, or 5.5). In one embodiment, the physiologically acceptable buffer has a pH in the range of about 5.5 to about 6. In one embodiment, the physiologically acceptable buffer has a pH of about 5.5.

[0075] In one embodiment, the physiologically acceptable buffer comprises an acetate buffer, a citrate buffer, a phosphate buffer, a histidine buffer, or a mixture thereof. In one embodiment, the physiologically acceptable buffer comprises sodium acetate, potassium acetate, trisodium citrate, magnesium citrate, potassium citrate, potassium phosphate, or a mixture thereof. In one embodiment, the physiologically acceptable buffer comprises a buffering agent (e.g., sodium acetate) at a concentration of about 5 mM to about 30 mM, about 10 mM to about 30 mM, about 15 mM to about 30 mM, about 20 mM to about 30 mM, about 30 mM, or about 25 mM to about 30 mM (e.g., about 5 mM, about 8 mM, about 10 mM, about 12 mM, about 15 mM, about 18 mM, about 20 mM, about 22 mM, about 25 mM, about 28 mM, or about 30 mM). In some embodiments, the physiologically acceptable buffer comprises a buffering agent (eg, sodium acetate) at a concentration of at least 10 mM.

[0076] In some embodiments, the physiologically acceptable buffer comprises an acetate buffer. In some embodiments, the buffer is sodium acetate. In some embodiments, the buffer is potassium acetate. In some embodiments, the physiologically acceptable buffer comprises an acetate buffer (e.g., sodium acetate or potassium acetate) at a concentration of about 5 mM to about 30 mM, for example, about 10 mM to about 20 mM. In some embodiments, the physiologically acceptable buffer comprises an acetate buffer (e.g., sodium acetate or potassium acetate) at a concentration of about 10 mM.

[0077] In some embodiments, the physiologically acceptable buffer comprises a citrate buffer. In some embodiments, the buffer is trisodium citrate. In some embodiments, the buffer is magnesium citrate. In some embodiments, the buffer is potassium citrate. In one embodiment, the physiologically acceptable buffer comprises a citrate buffer (e.g., sodium citrate, magnesium citrate, or potassium citrate) at a concentration of about 5 mM to about 30 mM, e.g., about 10 mM to about 20 mM. In some embodiments, the physiologically acceptable buffer comprises a citrate buffer (e.g., sodium citrate, magnesium citrate, or potassium citrate) at a concentration of about 10 mM.

[0078] In one embodiment, the physiologically acceptable buffer comprises a phosphate buffer. In one embodiment, the physiologically acceptable buffer comprises potassium phosphate. In one embodiment, the physiologically acceptable buffer comprises potassium phosphate at a concentration of about 5 mM to about 30 mM, for example, about 10 mM to about 20 mM. In some embodiments, the physiologically acceptable buffer comprises a phosphate buffer (e.g., potassium phosphate) at a concentration of about 10 mM.

[0079] Tonicity adjuster In some embodiments, the buffer formulation comprises a tonicity adjuster. In some embodiments, the tonicity adjuster is mannitol, dextrose, glycerin, lactose, sucrose, trehalose, or mixtures thereof. In some embodiments, the tonicity adjuster is mannitol. The use of tonicity adjusters is well known in the medical field, and those skilled in the art can use one or more tonicity adjusters disclosed herein to provide liquid pharmaceutical formulations suitable for subcutaneous administration. See, for example, Pramanick et al., Pharma Times., Vol 45, No. 3, (2013);see also, Formulating Poorly Water Soluble Drugs, Williams, Watts, and Miller, eds., Springer Science and Business Media (2011).

[0080] In some embodiments, the tonicity adjusting agent or combination of tonicity adjusting agents has a concentration of about 20-75 mg / mL, about 20-60 mg / mL, about 25-55 mg / mL, about 30-75 mg / mL, about 30-50 mg / mL, about 35-45 mg / mL, about 40-45 mg / mL, about 45-75 mg / mL, or about 45-60 mg / mL (e.g., about 20 mg / mL, about 22 mg / mL, about 25 mg / mL, about 3 ... g / mL, about 28 mg / mL, about 30 mg / mL, about 32 mg / mL, about 35 mg / mL, about 38 mg / mL, about 40 mg / mL, about 42 mg / mL, about 45 mg / mL, about 48 mg / mL, about 50 mg / mL, about 52 mg / mL, about 55 mg / mL, about 58 mg / mL, about 60 mg / mL, about 65 mg / mL, about 70 mg / mL, or about 75 mg / mL. In some embodiments, the formulation comprises a tonicity adjusting agent in a concentration range of about 30 mg / mL to about 60 mg / mL.

[0081] In some embodiments, the tonicity adjusting agent comprises mannitol. In some embodiments, the mannitol is present at a concentration of about 40-50 mg / mL. In some embodiments, the mannitol is present at a concentration ranging from about 40 mg / mL to about 45 mg / mL. In some embodiments, the mannitol is present at a concentration of about 45 mg / mL. In some embodiments, the mannitol is present at a concentration of at least 45 mg / mL.

[0082] In one embodiment, the tonicity adjusting agent comprises dextrose, hi one embodiment, the dextrose is present in a concentration of about 20 mg / mL to about 60 mg / mL (e.g., about 20 mg / mL, about 40 mg / mL, about 45 mg / mL, or about 60 mg / mL).

[0083] In one embodiment, the tonicity adjusting agent comprises glycerin, hi some embodiments, the glycerin is present in a concentration of about 20 mg / mL to about 60 mg / mL (e.g., about 20 mg / mL, about 40 mg / mL, about 45 mg / mL, or about 60 mg / mL).

[0084] In one embodiment, the tonicity adjusting agent comprises lactose, hi one aspect, the lactose is present in a concentration of about 20 mg / mL to about 60 mg / mL (e.g., about 20 mg / mL, about 40 mg / mL, about 45 mg / mL, or about 60 mg / mL).

[0085] In one embodiment, the tonicity adjusting agent comprises sucrose. In some embodiments, the sucrose is present at a concentration of about 20 mg / mL to about 60 mg / mL (e.g., about 20 mg / mL, about 40 mg / mL, about 45 mg / mL, or about 60 mg / mL).

[0086] In one embodiment, the tonicity agent comprises trehalose. In one aspect, the trehalose is present at a concentration of about 20 mg / mL to about 60 mg / mL (e.g., about 20 mg / mL, about 40 mg / mL, about 45 mg / mL, or about 60 mg / mL).

[0087] In some embodiments, the buffer formulation comprises two or more tonicity adjusters. In some embodiments, the buffer formulation comprises two or more tonicity adjusters selected from the group consisting of mannitol, dextrose, glycerin, lactose, sucrose, and trehalose. In some embodiments, the buffer formulation comprises mannitol and at least one other tonicity adjuster.

[0088] Additional Additives In some embodiments, the formulation further comprises one or more additional additives, such as a preservative, a surfactant (e.g., polysorbate or poloxamer), or a coloring agent (e.g., pharma- ceutically acceptable dyes, inorganic pigments, and natural coloring agents). A wide variety of pharma-ceutically acceptable additives are known in the art. Pharmaceutically acceptable additives are well described in various publications, such as A. Gennaro (2000) "Remington: The Science and Practice of Pharmacy," 20th edition, Lippincott, Williams, & Wilkins; Pharmaceutical Dosage Forms and Drug Delivery Systems (1999) HC Ansel et al., eds., 7th ed., Lippincott, Williams, & Wilkins; and Handbook of Pharmaceutical Excipients (2000) AH Kibbe et al., eds., 3rd ed. Amer. Pharmaceutical Assoc., each of which is incorporated herein by reference.

[0089] In some embodiments, avexitide is formulated as disclosed in International Application Publication No. WO2018 / 094404, which is incorporated herein by reference.

[0090] Injectable preparations In some embodiments, the avexitide formulation is provided as a disposable prefilled syringe, for example, as a kit including a plurality of disposable prefilled syringes (e.g., 10, 20, 30, 40, 50, or 60 prefilled syringes). In some embodiments, the disposable prefilled syringe includes an avexitide formulation including avexitide at a concentration of at least 30 mg / mL, a tonicity adjuster, and a buffer having a pH in the range of 5.0-6.0. In some embodiments, the disposable prefilled syringe contains at least 20 mg (e.g., 20-90 mg, 30-75 mg, 30-60 mg, 40-90 mg, or 60-90 mg, e.g., 20 mg, 25 mg, 30 mg, 40 mg, 45 mg, 50 mg, 60 mg, 70 mg, 80 mg, or 90 mg). In some embodiments, the disposable prefilled syringe contains an amount of avexitide of at least 30 mg. In some embodiments, the avexitide formulation optionally further comprises a preservative.

[0091] In some embodiments, the avexitide formulation is provided in a pen injector. In some embodiments, the pen injector device is a glass device (e.g., a glass cartridge pen injector device). In some embodiments, the pen injector device is a disposable device. In some embodiments, the pen injector contains an avexitide formulation including avexitide at a concentration of at least 30 mg / mL, a tonicity adjuster, and a buffer having a pH in the range of 5.0-6.0. In some embodiments, the pen injector contains an avexitide formulation in an amount of at least 20 mg (e.g., 20-90 mg, 30-75 mg, 30-60 mg, 40-90 mg, or 60-90 mg, e.g., 20 mg, 25 mg, 30 mg, 40 mg, 45 mg, 50 mg, 60 mg, 70 mg, 80 mg, or 90 mg). In some embodiments, the pen injector contains an avexitide formulation in an amount of at least 30 mg. As a non-limiting example, a pen injector contains a formulation comprising about 30-75 mg of avexitide (e.g., about 30 mg or about 60 mg of avexitide), a tonicity adjuster, and a buffer having a pH ranging from about 5.0 to 6.0. In some embodiments, the avexitide formulation optionally further comprises a preservative.

[0092] In some embodiments, the avexitide formulation is provided in single or multiple dose glass vials or ampoules for administration using a syringe, such as in a glucagon emergency kit. In some embodiments, the avexitide formulation is provided as an injectable solution in a single dose tray that includes a vial of the avexitide formulation described herein (e.g., a formulation comprising about 20-90 mg of avexitide (e.g., 30-75 mg, 30-60 mg, 40-50 mg, 40-90 mg, or 60-90 mg of avexitide), an isotonicity adjuster, and a buffer having a pH in the range of 5.0-6.0, and optionally an appropriate amount of an antimicrobial preservative), a vial connector, a syringe, and one or more needles.

[0093] In some embodiments, each dose is administered in a total injection volume ranging from 0.25 to 2 mL. In some embodiments, each dose is administered in a total volume ranging from about 0.1 mL or even 0.05 mL, with most subjects receiving injection volumes ranging from 0.25 to 1.5 mL, or 0.5 to 1 mL, or even 0.7, 0.1 mL, or even 0.05 mL to 1 mL.

[0094] As used below, a reference to a series of embodiments should be understood as a reference to each of those embodiments (e.g., "embodiments 1-4" should be understood as "embodiments 1, 2, 3, or 4").

[0095] Embodiment 1 is a method of treating one or more of hyperinsulinemic hypoglycemia (HH), fasting hyperinsulinemic hypoglycemia, insulinoma, or hypoglycemia / NIPHS comprising subcutaneously administering to a subject a buffered liquid formulation comprising avexitide at a concentration of 2-90 mg / mL.

[0096] Embodiment 2 is the method of embodiment 1, wherein avexitide is administered for a period not exceeding 30 days.

[0097] Embodiment 3 is the method of embodiments 1 and 2, wherein abexitide is administered until one or both of the blood glucose and insulin levels are stabilized.

[0098] Embodiment 4 is the method of any of Embodiments 1-3, wherein the HH comprises post-bariatric hypoglycemia (PBH).

[0099] Embodiment 5 is the method of any of embodiments 1-4, wherein the subject has previously undergone one or more of Roux-en-Y gastric bypass, vertical sleeve gastrectomy (VSG), biliary-pancreatic diversion (BPD), upper gastrointestinal surgery, gastrectomy, esophagectomy, fundoplication, gastric bypass, vagotomy with pyloroplasty, vagotomy without pyloroplasty, or bile duct resection.

[0100] Embodiment 6 is the method of any of Embodiments 1-3, wherein the subject has congenital microgastoria or a condition that accelerates transit to the ileum.

[0101] Embodiment 7 is the method of any of Embodiments 1-6, wherein avexitide is administered in a total daily dose of about 40 mg to about 90 mg.

[0102] Embodiment 8 is the method of any of embodiments 1-6, wherein avexitide is administered in a total daily dose of about 40 mg to about 120 mg, or 30 mg to 60 mg BID, or 60 mg to 120 mg QD; or about 45 mg BID, or about 35 to 55 mg BID.

[0103] Embodiment 9 is the method of any of embodiments 1-6, wherein the total daily dose of avexitide administered is about 90 mg or about 90 mg QD, or about 60-120 mg / day.

[0104] Embodiment 10 is the method of any of embodiments 1-6, wherein the subject is administered 0.375 mg / kg / dose, or 0.56 mg / kg / dose, or 0.75 mg / kg / day, or about 1.125 mg / kg / day, or about 0.3-1.6 mg / kg / dose of avexitide BID; or about 0.6-3.2 mg / kg / day BID, or about 0.2-1.2 mg / kg / dose, or about 0.6-3.6 mg / kg / day BID; or about 0.6-3.6 mg / kg / day TID.

[0105] Embodiment 11 is the method of any of Embodiments 1-10, wherein avexitide is administered by IV infusion at about 0.1-1.0 mg / kg / hour, or about 0.2-0.6 mg / kg / hour.

[0106] Embodiment 12 is the method of any of Embodiments 2-11, wherein avexitide is administered in a total daily dose of about 60 or about 120 mg.

[0107] Embodiment 13 is the method of any of Embodiments 3-11, wherein abexitide is administered once daily (QD) or twice daily (BID).

[0108] Embodiment 14 is the method of any of embodiments 1-6, 9-11, and / or 13, wherein the subject is administered about 30 mg to about 90 mg BID of avexitide, and the subject is not required to fast or delay their first meal of the day following administration.

[0109] Embodiment 15 is the method of any of embodiments 1-6, 8, 10, 11, and / or 13, wherein avexitide is administered at 45 mg to 120 mg QD and the subject is required to fast or delay their first meal of the day following administration.

[0110] Embodiment 16 is the method of embodiment 15, wherein the delay is from about 30 minutes to about 1.5 hours.

[0111] Embodiment 17 is the method of embodiment 15 and / or 16, wherein the subject is required to fast overnight prior to the morning administration.

[0112] Embodiment 18 is the method of embodiments 15-17, wherein the subject is required to fast for about 45-90 minutes after the morning administration.

[0113] Embodiment 19 is the method of any of embodiments 15-18, wherein the subject is required to fast overnight prior to the morning dose and fast for about 45-90 minutes after the morning dose.

[0114] Embodiment 20 is the method of any of embodiments 1-6, wherein avexitide is administered at a dose of 30 mg BID or 45 mg BID.

[0115] Embodiment 21 is the method of embodiment 20, comprising administering in the morning and in the evening, wherein the evening administration is administered about 12 hours after the morning administration.

[0116] Embodiment 22 is the method of embodiment 21, wherein the morning dose is administered at least about 30 minutes to about 60 minutes before a meal.

[0117] Embodiment 23 is the method of any of embodiments 1-6, wherein abexitide is administered at a dose of 60 mg QD. Embodiment 24 is the method of embodiment 23, wherein abexitide is administered in the morning.

[0118] Embodiment 25 is the method of embodiment 23 and / or 24, wherein avexitide is administered at least about 30 minutes to about 90 minutes before the first meal of the day.

[0119] Embodiment 26 is the method of any of embodiments 1-25, wherein the formulation comprises abexitide in a concentration from 30 mg / mL to 180 mg / mL, or from 2 mg / mL to 29 mg / mL.

[0120] Embodiment 27 is the method of any of embodiments 1-25, wherein the formulation comprises abexitide in a concentration of 45 mg / mL to 90 mg / mL.

[0121] Embodiment 28 is the method of embodiment 26, wherein the formulation comprises abexitide in a concentration of 30 mg / mL.

[0122] Embodiment 29 is the method of embodiment 26, wherein the formulation comprises abexitide in a concentration of 90 mg / mL.

[0123] Embodiment 30 is the method of any of embodiments 1-29, wherein the formulation has a pH of about 5.5.

[0124] Embodiment 31 is the method of any of embodiments 1-30, wherein the formulation comprises a sodium acetate buffer.

[0125] Embodiment 32 is the method of any of embodiments 1-31, wherein the formulation comprises a tonicity adjusting agent.

[0126] Embodiment 33 is the method of embodiment 32, wherein the tonicity adjusting agent comprises mannitol.

[0127] Embodiment 34 is the method of any of embodiments 1-33, wherein avexitide is administered for not more than 30 days or for at least 30 days.

[0128] Embodiment 35 is the method of any of Embodiments 1-34, wherein treatment reduces the number and / or severity of symptoms of postprandial neuroglycopenia in the subject.

[0129] Embodiment 36 is the method of any of embodiments 1-35, wherein treatment improves the subject's postprandial glycemic nadir.

[0130] Embodiment 37 is the method of any of embodiments 1-36, wherein the treatment reduces the subject's postprandial insulin peak.

[0131] Embodiment 38 is the method of any of embodiments 1-37, wherein treatment reduces the rate of hypoglycemia in the subject.

[0132] Embodiment 39 is the method of embodiment 1, wherein the administration reduces the number and / or severity of symptoms of postprandial neuroglycopenia in the subject.

[0133] Embodiment 40 is the method of any of Embodiments 1-6, wherein administration improves the subject's postprandial nadir blood glucose level.

[0134] Embodiment 41 is the method of embodiment 40, wherein the subject's mixed meal tolerance test ("MMTT") glucose trough is significantly increased.

[0135] Embodiment 42 is the method of embodiment 41, wherein the mean plasma glucose nadir during MMTT provocation is increased by 21% to 25% for the subject compared to a control.

[0136] Embodiment 43 is the method of embodiment 40, wherein the subject requires less glycemic rescue following treatment compared to a control.

[0137] Embodiment 44 is the method of embodiment 39, wherein the subject has an increased postprandial peak blood glucose level, which corresponds to a significantly accelerated time to peak blood glucose level during administration of abexitide.

[0138] Embodiment 45 is the method of any of embodiments 1-44, wherein the administration reduces a post-prandial insulin peak in the subject.

[0139] Embodiment 46 is the method of embodiment 45, wherein the mean postprandial insulin peak during MMTT stimulation is reduced by about 21% to 23% in the subject compared to a control.

[0140] Embodiment 47 is the method of any of embodiments 1-46, wherein the peak levels of GLP-1 and glucagon are higher in the subject compared to a control.

[0141] Embodiment 48 is the method of any of embodiments 1-47, wherein the AUC values ​​of GLP-1 and glucagon during MMTT in the subject are higher compared to a control.

[0142] Embodiment 49 is the method of any of embodiments 1-48, wherein the subject experiences hypoglycemic episodes less frequently during abexitide treatment compared to a control.

[0143] Embodiment 50 is the method of any of embodiments 1-49, wherein the administration reduces the rate of hypoglycemia in the subject.

[0144] Embodiment 51 is the method of any of embodiments 1-50, wherein the administration reduces the rate of severe hypoglycemia in the subject.

[0145] Embodiment 52 is the method of any of embodiments 1-51, wherein the administration reduces severe hypoglycemia in the subject.

[0146] Embodiment 53 is the method of embodiment 52, wherein the severe hypoglycemia comprises a condition requiring the subject to receive assistance from a third party.

[0147] Embodiment 54 is the method of any of embodiments 1-53, wherein the administration reduces the rate of hypoglycemia-induced CNS damage in the subject.

[0148] Embodiment 55 is the method of any of embodiments 1-54, wherein administration provides a clinically meaningful improvement in the subject in one or more of the following: rate of hypoglycemia-induced CNS damage, severe hypoglycemia, postprandial insulin peak, severe hypoglycemia, or postprandial blood glucose nadir.

[0149] Embodiment 56 is the method of any of embodiments 1-55, wherein administration results in amelioration of postprandial hypoglycemia in the subject.

[0150] Embodiment 57 is the method of any of embodiments 1-56, wherein the administration results in an increase in nadir postprandial plasma glucose in the subject compared to baseline or a control.

[0151] Embodiment 58 is the method of any of Embodiments 1-58, wherein the administration results in amelioration of postprandial neuroglycopenic symptoms or hypoglycemic symptoms in the subject.

[0152] Embodiment 59 is the method of any of embodiments 1-59, wherein avexitide is administered twice daily (BID) about 60 minutes before the subject's morning and evening meals or before the subject's two main meals of the day.

[0153] Embodiment 60 is the method of any of embodiments 1-60, wherein avexitide is administered BID at least about 6 hours apart.

[0154] Embodiment 61 is the method of any of the preceding embodiments, wherein avexitide is administered in a total volume ranging from 0.25 to 2.0 mL; or in a total volume ranging from about 0.05 to 0.1 mL; or in an injection volume ranging from 0.25 to 1.5 mL, or 0.5 to 1 mL, or 0.7 to 1 mL, or 0.05 to 0.1 mL.

[0155] Embodiment 62 is the method of any of embodiments 1-61, wherein treatment reduces the rate of severe hypoglycemia in the subject.

[0156] Embodiment 63 is the method of any of embodiments 1-62, wherein treatment reduces the rate of hypoglycemia-induced CNS damage in the subject.

[0157] Embodiment 64 is the method of embodiment 63, wherein the hypoglycemia-induced CNS damage comprises one or more of the following signs or symptoms: cognitive decline, psychosis, impaired judgment, personality / behavioral changes, abnormal behavior, emotional lability, confusion, memory loss, delirium, changes in vision, blurred vision, double vision, difficulty speaking, dysarthria, nonsensical speech, incoordination, ataxia, focal or generalized movement disorders, excessive sleepiness (somnolence), stupor, fainting, loss of consciousness, convulsions, generalized or focal seizures, or coma.

[0158] Embodiment 65 is the method of embodiment 63, wherein the signs and symptoms associated with the minimum blood glucose concentration include one or more of loss of consciousness (LOC), dysarthria, visual changes (blurred vision, double vision), abnormal behavior, confusion, and loss of coordination.

[0159] Embodiment 66 is the method of any of embodiments 1-65, wherein the subject is resistant to dietary therapy.

[0160] Embodiment 67 is the method of any of embodiments 1-66, wherein avexitide is administered at a dose of 45 mg BID.

[0161] Embodiment 68 is the method of any of Embodiments 17-19, and 21, wherein the morning dose is administered about 30 minutes to about 90 minutes before a meal.

[0162] Embodiment 69 is the method of any of embodiments 1-68, wherein the treatment reduces the rate at which the subject requires rescue.

[0163] Embodiment 70 is the method of embodiment 69, wherein the rescue comprises administering glucagon to the subject with early blood glucose levels ≦50 mg / dL+ neuroglycopenia or blood glucose levels ≦40 mg / dL+ / − neuroglycopenia.

[0164] Embodiment 71 is the method of embodiment 69 and / or 70, wherein the subject experiences daily or weekly symptoms of hypoglycemia.

[0165] Embodiment 72 is the method of any of embodiments 1-71, wherein the subject's percentage time rate of hypoglycemia by CGM threshold is decreased following administration.

[0166] Embodiment 73 is any of the methods of embodiments 1-72, wherein the number of hypoglycemic episodes by CGM threshold in the subject is reduced following administration.

[0167] Embodiment 74 is the method of any of embodiments 1-73, wherein the subject experiences less disruption of daily activities compared to a control.

[0168] Embodiment 75 is the method of any of embodiments 1-74, wherein the average rate of hypoglycemia in the subject is reduced by about 30% to 60% for abexitide compared to the control.

[0169] Embodiment 76 is the method of any of embodiments 1-75, wherein the rate of hypoglycemia is an SBGM blood glucose level <70 mg / dL.

[0170] Embodiment 77 is the method of any of embodiments 1-76, wherein the average rate of clinically significant hypoglycemia in the subject is reduced by about 40% to 59% compared to a control.

[0171] Embodiment 78 is the method of embodiment 77, wherein the clinically significant hypoglycemia is any neurogenic hypoglycemic symptom / sign confirmed by an SBGM blood glucose value <55 mg / dL or as a hypoglycemic episode requiring the assistance of another person to provide rescue therapy.

[0172] Embodiment 79 is the method of any of embodiments 1-78, wherein the subject's rate of oral or G-tube rescue is substantially reduced.

[0173] Embodiment 80 is the method of any of embodiments 1-79, wherein the average percentage of time the subject is hypoglycemic during the daytime (8 am - midnight) is substantially reduced compared to a control.

[0174] Embodiment 81 is the method of embodiment 80, wherein the subject's mean percent time rates of blood glucose levels <70 mg / dL, <55 mg / dL, and <40 mg / dL are reduced by about 4-57% compared to a control.

[0175] Embodiment 82 is the method of embodiment 80 and / or 81, wherein the subject's mean percent time rates of blood glucose levels <70 mg / dL, <55 mg / dL, and <40 mg / dL are reduced by about 36-57% compared to a control.

[0176] Embodiment 83 is the method of embodiment 80 and / or 81, wherein the subject's mean percent time rates of blood glucose levels <70 mg / dL, <55 mg / dL, and <40 mg / dL are reduced by about 4-26% compared to a control.

[0177] Embodiment 84 is the method of any of embodiments 1-83, wherein the average number of hypoglycemic episodes lasting at least 10 minutes during daytime hours (8:00 AM to midnight) is substantially reduced in the subject compared to a control.

[0178] Embodiment 85 is the method of embodiment 84, wherein the mean number of hypoglycemic episodes (CGM values ​​lasting at least 10 minutes within a 3 hour period) of <70 mg / dL, <55 mg / dL, <40 mg / dL for the subject is reduced by about 28% to 53%, or about 23% to 29%, compared to a control.

[0179] Embodiment 86 is the method of any of embodiments 42, 43, 46-49, 57, 74, 75, 77, and 81-86, wherein the control comprises a comparison with the subject's nadir postprandial plasma glucose measured before the start of treatment or during an MMTT.

[0180] Embodiment 87 is the method of any of embodiments 42, 43, 46-49, 57, 74, 75, 77, and 81-86, wherein the control comprises a comparison with a control subject not administered the buffered liquid formulation. EXAMPLES

[0181] The following examples are offered to illustrate, but not to limit, the claimed invention.

[0182] Example 1: Clinical Study Protocol for the Treatment of Patients with PBH This example describes a phase 2 clinical protocol to study the efficacy, safety, and pharmacodynamic effects of avexitide in patients with post-bariatric surgery hypoglycemia (PBH). In particular, the protocol is a phase 2, multicenter, randomized, single-blind, placebo-controlled crossover study to evaluate the efficacy and safety of avexitide in patients with post-bariatric surgery hypoglycemia.

[0183] Avexitide was tested for the treatment of hypoglycemia associated with bariatric surgery (e.g., postoperative hypoglycemia ("PBH")). For further results of the study outlined in this Example 1, see the Examples below.

[0184] Efficacy: We aimed to assess the effect of avexitide on dietary therapy for postprandial hypoglycemia in patients with PBH. We also aimed to assess the safety and tolerability of avexitide. Other objectives were to assess the effect of avexitide on dietary therapy for postprandial signs and symptoms of neuroglycopenia; to assess the effect of avexitide on dietary therapy for postprandial hyperinsulinemia; to assess the rate of hypoglycemia; to assess the rate of severe hypoglycemia; to assess the rate of hypoglycemia prevention / rescue by glucagon; to assess the rate of hypoglycemia prevention / rescue by oral / gastrostomy tube intake; to assess postprandial glycemia including duration of hypoglycemia and duration of hyperglycemia; to assess nocturnal glycemia; to assess postprandial GLP-1 and glucagon levels; to assess quality of life / performance status: to assess the occurrence of anti-exendin antibodies (ADA); and to assess the pharmacokinetic exposure / response relationship of avexitide.

[0185] This was a phase 2, randomized, single-blind, placebo-controlled crossover study of avexitide in patients with refractory PBH. Eligible participants had a confirmed diagnosis of PBH and had at least two severe hypoglycemic episodes at screening during a 2-week run-in period: hypoglycemic symptoms confirmed by self-blood glucose monitoring (SBGM) glucose ≤ 54 mg / dL (IHSG 2017) (if SBGM was not available at the time of symptoms, severe hypoglycemia could be based on a corresponding continuous glucose monitor (CGM) reading ≤ 54 and / or neurological recovery after glucose levels returned to normal). Additionally, hypoglycemic episodes requiring assistance from another person to administer rescue therapy were considered severe hypoglycemia (Seaquist 2013).

[0186] Participants were randomly assigned in a 1:1 ratio to initially self-administer one of the following doses by subcutaneous (SC) injection: (1) placebo followed by avexitide, 30 mg q12h, or (2) placebo followed by avexitide, 60 mg qAM.

[0187] After 14 days of active drug treatment, patients receiving 30 mg q12 were changed to 60 mg qAM and patients receiving 60 mg qAM were changed to 30 mg q12.

[0188] On days 15, 29, and 43, participants underwent in-hospital mixed meal challenge test (MMTT) induction with simultaneous blood sampling and symptom assessment.

[0189] Patients were screened within 4 weeks of randomization and enrollment and were eligible based on the frequency of hypoglycemic episodes during that time. After eligibility based on the initial screening visit, patients could undergo a 2-week run-in period any time within the 28-day screening period.

[0190] The study consisted of three 14-day treatment periods, for a total of 42 days (see Figure 1). After randomization, patients received placebo for 14 days, followed by avexitide for 28 days. All patients received placebo and active treatment. Patients were informed that they would receive placebo during one of the three 14-day treatment periods, but not which one [single-blind]. In addition, patients received dietary advice and were expected to adhere to currently accepted PBH dietary guidelines throughout the entire treatment period. Patients returned to the study site for safety follow-up 30 days after the last dose of study drug. The planned duration of each individual patient's participation in the study is approximately 100 days at most.

[0191] Inclusion criteria included: ability to understand the study objectives and risks, willingness and ability to comply with scheduled visits, treatment plans, laboratory tests, procedures regarding the use of the CGM device, and other study assessments and procedures, and willingness and ability to provide written informed consent; age 18–65 years; body mass index (BMI) ≤ 40 kg / m2; stable weight, i.e., no change of ≥ 5% for at least 4 months; documented Roux-en-Y gastric bypass (RYGB) surgery ≥ 12 months prior to screening initiation; diagnosis of PBH documented in the medical chart, defined as: presence of pathological postprandial hypoglycemia with inappropriately elevated insulin (≥ 3 μU / mL) or C-peptide (≥ 0.6 ng / mL) at the time of hypoglycemia (≤ 54 mg / dL glucose); and at least two episodes of severe hypoglycemia during the 2-week screening run-in period; hypoglycemic symptoms confirmed by SBGM glucose ≤ 54 mg / dL (IHSG 2017) (If SBGM is not available at the time of symptoms, severe hypoglycemia may be based on a corresponding continuous glucose monitor (CGM) reading ≤54 and / or neurological recovery after blood glucose returns to normal). Additionally, any episode of hypoglycemia requiring the assistance of another person to administer rescue therapy is considered severe hypoglycemia (Seaquist 2013).

[0192] Patients were excluded from the study if they met any of the following criteria: Participation in another interventional clinical trial within 30 days prior to screening. Donation or loss of more than 500 mL of blood or blood products within 56 days prior to the first dose of investigational drug. Hypoglycemia before RYGB surgery (excluding hypoglycemia due to previous use of antihyperglycemic drugs). Patients with a history of or ongoing insulinoma or other causes of endogenous hyperinsulinism other than PBH (e.g., insulin autoimmune hypoglycemia). - Clinically significant active infection within 14 days prior to the first dose of study drug. · Clinically relevant acute or chronic psychiatric, renal, hepatic, pancreatic, cardiovascular, neurological, hematological or gastrointestinal abnormality (e.g., inflammatory bowel disease), or history of malignancy deemed cured less than 5 years ago (excluding adequately treated basal or squamous cell skin cancer, or in situ cervical cancer). Major surgery within 6 months prior to randomization. · History of other metabolic or bariatric surgery (e.g., vertical sleeve gastrectomy, gastric band). ·History of non-RYGB upper GI surgery (e.g., esophagectomy, gastrectomy, gastrostomy tube, etc.). Abnormal liver function defined as transaminase (alanine transaminase [ALT], aspartate transaminase [AST]) levels >2x the upper limit of normal (ULN) and / or bilirubin levels >2x the ULN at screening. Abnormal renal function defined as glomerular filtration rate (GFR) less than 60 mL / min / 1.73 m2 (calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula) at screening. - Abnormalities in electrolyte levels, such as potassium, magnesium, phosphorus, and sodium. Patients who have received any of the following drugs that may inhibit glucose metabolism for a period of less than 5 half-lives: - Hypoglycemic agents (e.g., insulin, sulfonylureas, meglitinides, metformin, thiazolidinediones [TZDs], dipeptidyl peptidase-4 [DPP-4] inhibitors, sodium-glucose transporter-2 [SGLT2] inhibitors, GLP-1 agonists); Alcohol (e.g. beer, wine, drinks containing spirits); Pentamidine; 〇Lithium. Fluoroquinolone antibiotics (e.g., ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin); Tramadol (chronic use of other opioids is permitted as long as the dose remains stable for the entire duration of the study). current use of acarbose, verapamil, diazoxide, or somatostatin analogues (e.g., octreotide, pasilotide, lanreotide); systemically or inhaled glucocorticoids (e.g., prednisone, prednisolone, methylprednisolone, beclomethasone, betamethasone, dexamethasone, hydrocortisone, triamcinolone) (excluding topically or nasally administered steroids); or 〇Acetaminophen.

[0193] Avexitide Injection 30 mg / mL is a sterile, clear, colorless solution provided as 1 mL of solution in a single-use 2 mL vial. This pharmaceutical composition consists of 30 mg / mL avexitide (active ingredient) in sodium acetate buffer containing mannitol as a tonicity modifier. A total of 1 mL of solution can be withdrawn from the vial for subcutaneous (SC) injection.

[0194] Avexitide injections are administered subcutaneously in the anterolateral aspect of the thigh.

[0195] If the patient exhibits symptoms of neuroglycopenia and blood glucose is ≦50 mg / dL, a final glucose / hormone blood sample is obtained and glycemic rescue measures are instituted to raise blood glucose. If the patient remains asymptomatic, blood sampling continues until (1) the patient exhibits symptoms of neuroglycopenia or (2) blood glucose falls to 40 mg / dL, at which point a final glucose / hormone blood sample is obtained and measures are instituted to raise blood glucose, regardless of whether symptoms are present.

[0196] Patients will fast during the MMTT until 180 minutes or the time of rescue, whichever occurs first, after which patients may consume a low carbohydrate snack / meal.

[0197] Efficacy Endpoints The efficacy endpoint is the magnitude of postprandial hypoglycemia, defined as the nadir of plasma glucose occurring within 3 hours of MMTT stimulation. The nadir of plasma glucose obtained after 14 days of avexitide and diet (treatment periods 2 and 3) will be compared with the values ​​after 14 days of placebo and diet (treatment period 1). In particular, the placebo-corrected nadir of plasma glucose will be calculated and evaluated for each patient.

[0198] Between- and within-subject variability will be derived for the primary efficacy endpoint.

[0199] Safety Endpoints Primary safety endpoints included evaluation of adverse events (e.g., treatment-emergent adverse events [TEAEs], serious adverse events [SAEs], TEAEs leading to discontinuation) and other safety assessments (e.g., clinical laboratory results, vital sign measurements).

[0200] Other endpoints Signs and Symptoms of Postprandial Neuroglycopenia The severity of neuroglycopenic symptoms in response to dietary challenge with the MMTT will be assessed based on a modified version of the EHSS questionnaire (MEHSS) including the severity-graded EHSS with an 11-point numerical rating scale (NRS) (0 = absent, 10 = worst possible). Neuroglycopenic symptoms are as defined by the EHSS (Hepburn 1991, Deary 1993).

[0201] The MEHSS questionnaire is completed by the patient approximately every 30 minutes during the 180-minute MMTT (or immediately prior to rescue therapy administration if earlier) on days 15 (treatment period 1), 29 (treatment period 2) and 43 (treatment period 3). The highest score of the severity grade recorded for each symptom between the observed peak plasma glucose and the end of the MMTT (or prior to rescue) is summed to generate a total score, which is used to assess the presence and severity of acute neuroglycolytic symptoms during each treatment period.

[0202] Peak Postprandial Insulin Response The maximum postprandial insulin concentration (placebo corrected) in response to meal challenge by MMTT after 14 days of active and dietary treatment (treatment periods 2 and 3) will be calculated and evaluated.

[0203] Requirement for glycemic rescue during MMTT Incidence of hypoglycemia Hypoglycemic symptoms confirmed by SBGM glucose <70 mg / dL; or, if SBGM is not obtained at the time of symptoms, hypoglycemia can be confirmed based on a corresponding CGM measurement <70 mg / dL.

[0204] Incidence rates were calculated as the number of unequivocal hypoglycemic episodes divided by the number of days in a given treatment period, normalized to a 2-week duration if the treatment period was not exactly 14 days.

[0205] Incidence of severe hypoglycemia Symptoms / signs of neuroglycopenia confirmed by SBGM glucose ≤ 54 mg / dL (IHSG 2017); if SBGM is not obtained at the time of neuroglycopenic symptoms, severe hypoglycemia can be documented based on a corresponding CGM reading ≤ 54 and / or neurological recovery after glucose returns to normal. Additionally, episodes of hypoglycemia requiring the assistance of another person to implement rescue therapy are considered severe hypoglycemia (Seaquist 2013).

[0206] Similarly, incidence rates were calculated as the total number of distinct severe hypoglycemic episodes divided by the number of days in a given treatment period, normalized to a 2-week period if the treatment period was not exactly 14 days.

[0207] Percentage of time postprandial blood glucose levels below 70 mg / dL as measured by CGM Percentage of time is calculated as the total number of CGM data points below 70 mg / dL divided by the total number of CGM data points obtained during a given treatment period.

[0208] Percentage of time postprandial blood glucose readings below 54 mg / dL as measured by CGM Percentage of time is calculated as the total number of CGM data points below 54 mg / dL divided by the total number of CGM data points obtained during a given treatment period.

[0209] Percentage of time postprandial blood glucose levels below 40 mg / dL as measured by CGM Percentage of time is calculated as the total number of CGM data points below 40 mg / dL divided by the total number of CGM data points obtained during a given treatment period.

[0210] Mean weighted glucose (MWG) measured 1-3 hours, 1-2 hours, and 2-3 hours after a meal using CGM MWG1-3h, MWG1-2h, and MWG2-3h are calculated as the total area under the concentration-time curve of blood glucose values ​​collected by the CGM during the corresponding time period divided by the actual time period (hours). The inear up / down trapezoidal method is used to calculate the area under the curve. - Mean amplitude of postprandial glycemic excursion (MAGE) 1-3 hours after meal as measured by CGM MAGE is defined as the average of the lowest to highest difference in these differences over the standard deviation of the CGM ratings over a 3-hour period. It is calculated using the method described in the original paper (Service 1970). Percentage of time glucose readings are above 180 mg / dL CGM measurement of 250 mg / dL Percentage of time is calculated as the total number of CGM data points within the range ≥ 180 mg / dL. 250 mg / dL divided by the total number of CGM data points obtained during a given treatment period. Percentage of time CGM glucose readings are above 250 mg / dL Percentage of time is calculated as the total number of CGM data points ≥ 250 mg / dL divided by the total number of CGM data points obtained during a particular treatment period. Percentage of time when glucose readings were below 70 mg / dL between midnight and 6 a.m. using CGM Percentage of time is calculated by dividing the total number of CGM data points < 70 mg / dL collected between 12:00 AM and 6:00 AM by the total number of CGM data points obtained between 12:00 AM and 6:00 AM for the given treatment period. Percentage of time when glucose readings were below 54 mg / dL between 12:00 am and 6:00 am using CGM Percentage of time is calculated by dividing the total number of CGM data points ≤ 54 mg / dL collected between 12:00 AM and 6:00 AM by the total number of CGM data points obtained between 12:00 AM and 6:00 AM for the given treatment period. Percentage of time when glucose readings were below 40 mg / dL between 12:00 am and 6:00 am using CGM Percentage of time is calculated by dividing the total number of CGM data points ≤ 40 mg / dL collected between 12:00 AM - 6:00 AM by the total number of CGM data points obtained between 12:00 AM - 6:00 AM for the given treatment period. -Rate of glucagon-induced hypoglycemia prevention / relief Rates are calculated as the number of specific hypoglycemic prevention / rescue episodes divided by the number of days in a specific treatment period, normalized to a 2-week period if the treatment period is not exactly 14 days. Rate of hypoglycemia prevention / relief by oral / G-tube feeding

[0211] Rates are calculated as the number of distinct hypoglycemic prevention / rescue episodes divided by the number of days in a given treatment period, normalized to a 2-week period if the treatment period is not exactly 14 days. Specific episodes of hypoglycemic prevention / rescue may be due, for example, to one or more of the following: Postprandial GLP-1 and glucagon levels during MMTT QOL measured by NSS, NOS, HSIS, HIS, and SF-36v2 Karnofsky performance status Development of anti-exendin antibodies (ADA) Pharmacokinetic exposure / response relationship of avexitide

[0212] Results include, but are not limited to, improved plasma glucose trough levels, reduced peak insulin concentrations, and no need for rescue during MMTT stimulation. In some embodiments, the patient shows improved postprandial hypoglycemia, e.g., increased postprandial plasma glucose trough compared to baseline. In some embodiments, the patient shows improved postprandial neuroglycopenic symptoms, e.g., reduced number and / or severity of postprandial neuroglycopenic symptoms compared to baseline. In some embodiments, the patient shows improved postprandial insulin response, e.g., reduced postprandial peak insulin concentration compared to baseline.

[0213] Example 2: PREVENT Phase 2 Clinical Trial for the Treatment of Patients with PBH This example describes the results of a Phase 2 clinical trial (PREVENT) evaluating the efficacy and safety of 28-day administration of avexitide in patients with PBH, conducted according to the protocol disclosed in Example 1 above.

[0214] Eighteen patients with refractory severe PBH were enrolled at five academic centers and administered as outpatients in the PRVENT trial. All patients received placebo subcutaneous (SC) injections for 14 days in a single-blind fashion, followed by avexitide 30 mg SC formulation (as above) administered twice daily (BID) for 14 days and 60 mg once daily (QD) for 14 days. Active dosing, double-blind, crossover design for a total of 28 days.

[0215] As shown in Table 1 and Figure 5 below, the primary efficacy endpoint of improvement in postprandial glucose nadir during the mixed meal tolerance test (MMTT) was statistically significant for avexitide 30 mg BID (57.1 vs 47.1 mg / dL; p=0.001) and 60 mg QD (59.2 vs 47.1 mg / dL; p=0.0002), with fewer participants requiring glycemic rescue during each active dosing regimen than during placebo. Glucose measurements were taken for each treatment group at specific time points during the MMTT, as described in Example 1. Mean blood glucose values ​​at different time points are shown in Figure 2.

[0216] The end point of reduction in postprandial insulin peak during MMTT was also statistically significant for avexitide 30 mg BID (349.5 vs. 454.5 μIU / mL; p<0.03) and 60 mg QD (357.2 vs. 454.5 μI / mL; p=0.04) (see Table 1 below and Figure 5). Insulin measurements were taken for each treatment group at specific time points during the MMTT as described in Example 1. The mean insulin levels at different time points are shown in Figure 3. [Table 1]

[0217] Patients' metabolic and clinical status in the outpatient setting throughout the entire treatment period was assessed through the use of electronic diary (eDiary) and continuous glucose monitoring (CGM). Participants were trained by on-site personnel on the use of the eDiary at the beginning of the screening run-in period (Visit 2a) and continued the eDiary throughout the three treatment periods. All episodes of hypoglycemic symptoms / signs were recorded in the eDiary with the following information about each hypoglycemic episode: self-blood glucose monitor (SBGM) reading; actions taken to treat or prevent the episode (oral intake, glucagon, etc.); and whether assistance from others was required and whether anything was eaten or drunk within 3 hours of the episode. The rate of hypoglycemia was assessed and defined as hypoglycemic symptoms confirmed by SBGM glucose <70 mg / dL. Rates were calculated as the number of specific hypoglycemic episodes divided by the number of days in a specific treatment period, normalized as a 2-week period if the treatment period was not exactly 14 days. The incidence of severe hypoglycemia was assessed and defined as symptoms / signs of neuroglycopenia confirmed by SBGM glucose <55 mg / dL (IHSG 2017). Furthermore, hypoglycemic episodes requiring the assistance of others to administer rescue therapy were considered as severe hypoglycemia (Seaquist 2013). Similarly, rates were calculated as the total number of specific severe hypoglycemic episodes divided by the number of days in a specific treatment period, normalized as a 2-week period if the treatment period was not exactly 14 days.

[0218] Metabolic and clinical improvements were observed during avexitide compared to placebo, as indicated by reduced rates of hypoglycemia, severe hypoglycemia, and rescue (Tables 3-5). Rescue rates used here are the number of episodes of unequivocal hypoglycemia prevention / rescue, including those assisted by a third party, divided by the number of days in a given treatment period, normalized to a 2-week period if the treatment period was not exactly 14 days. Patients had fewer episodes of hypoglycemia (symptoms of hypoglycemia confirmed by self-blood glucose monitor (SBGM) concentrations <70 mg / dL) and severe hypoglycemia (symptoms of neuroglycopenia confirmed by SBGM concentrations <55 mg / dL) during both avexitide dosing regimens compared to placebo (Table 2). These results were supported by CGM data (Table 3). As shown in Table 4, the incidence of severe hypoglycemia (adjusted for placebo) was significantly reduced with avexitide 30 mg BID (-0.89 + / - 0.36 episodes / 14 days, p=0.0267) and 60 mg QD (-1.35 + / - 0.36 episodes / 14 days, p=0.0020). Additionally, episodes of hypoglycemia confirmed as postprandial in nature, defined as occurring within 3 hours of eating, and severe hypoglycemia were evaluated. The incidence of postprandial and severe hypoglycemia (adjusted for placebo) was significantly lower during both avexitide dosing regimens compared to placebo. In particular, the incidence of severe postprandial hypoglycemia (adjusted for placebo) was significantly reduced with avexitide 30 mg BID (-0.94 episodes / 14 days, p=0.0172) and 60 mg QD (-1.2 episodes / 14 days, p=0.0038) (Table 4). As shown in Table 4, hypoglycemic rescue rates based on eDiary records were significantly reduced during avexitide treatment. Mean pooled rates of self- or third-party rescue of hypoglycemia among placebo, 4.87; avexitide 30 mg BID, 3.34 (p=0.0614); and avexitide 60 mg QD 1.83 (p=0.0013); mean pooled rates of third-party rescue of hypoglycemia among placebo, 0.63; avexitide 30 mg BID, 0.28 (p=0.1194); and avexitide 60 mg QD, 0.24 (p=0.0856).Most rescues were self-managed without third-party assistance. Thus, the rate of third-party rescue was low overall. Nevertheless, the results suggest a reduced need for third-party rescue with avexitide treatment.

[0219] These results obtained by the patients' eDiaries were also supported by the CGM results, as shown in Table 3, which showed a reduction in the percentage time of hypoglycemia and the number of hypoglycemic episodes during the day (8:00 am to midnight). [Table 2] [Table 3] [Table 4]

[0220] Avexitide was well tolerated. There were no treatment-emergent serious adverse events and no participant withdrawals. Adverse events were usually mild to moderate in severity. The most common adverse events were injection site bruising, nausea, and headache, all of which were less frequent during each avexitide treatment period than during the placebo treatment period (Figure 4).

[0221] Example 3: Phase 2 Clinical Trial for the Treatment of Patients with PBH Table 5 describes the severity of the disorder in patients enrolled in the above Phase 2 clinical trial. The study enrolled patients with severe, refractory post-bariatric surgery hypoglycemia. Nearly half of all participants (44.4%) reported a history of loss of consciousness, 11.1% reported a history of seizures, and 16.7% reported a history of hospitalization due to PBH. 95% of participants reported daily or weekly symptoms of hypoglycemia. All patients were refractory to dietary therapy, 83% were refractory to medical nutrition therapy, and three study participants had resorted to surgical intervention for the treatment of severe, refractory PBH. [Table 5]

[0222] Figure 5 shows that treatment with avexitide 30 mg BID and 60 mg QD reduced the need for rescue during MMTT stimulation and led to a significant reduction in hyperinsulinemic hypoglycemia. The primary efficacy endpoint of the PREVENT trial was a higher mean postprandial plasma glucose nadir (corrected for placebo) during MMTT stimulation, which was met with statistical significance by each of the two dosing regimens evaluated. Consistent with these results, fewer subjects required glycemic rescue during treatment with each avexitide dosing regimen than during placebo.

[0223] A significant reduction in postprandial hyperinsulinemia, as measured as postprandial insulin response to MMTT (corrected by placebo), was also observed with both dosing regimens. Hyperinsulinemia induced by increased GLP-1-mediated incretin effect in PBH patients was effectively attenuated by GLP-1 antagonism, demonstrating the targeted therapeutic approach of avexitide.

[0224] Figure 6 shows glycemic improvements in outpatients, showing a reduction in the percent time and number of daytime episodes below 70 and CGM readings below 55 mg / dL. Daytime as used here is from 8:00 AM to midnight. Episodes are per 14 days and are defined as CGM readings below threshold for at least 10 minutes within a 3-hour period. These results, collected by blinded CGM, support both the effects on glycemic levels observed during in-clinic MMTT assessments and the clinical and metabolic improvements captured by the patients' eDiaries, and overall demonstrate a reduction in biochemical and pathological hypoglycemia during both dosing regimens of avexitide treatment compared to placebo.

[0225] The study showed a low incidence of anti-drug antibodies (ADA): one of 18 participants showed a low positive titer of ADA, although no related AEs were observed and there were no differences in the endpoints measured for this participant.

[0226] Outpatient 28-day treatment demonstrated clinically meaningful improvements including: reduced severity of postprandial hyperinsulinemic hypoglycemia, reduced incidence of hypoglycemia and severe hypoglycemia, reduced rescue rate, and reduction in percent time of hypoglycemia and number of hypoglycemic episodes.

[0227] In some cases, higher exposures of 45 mg BID, 60 mg QD showed more substantial reductions in hypoglycemia rates, severe hypoglycemia rates, and rescue rates compared to lower dose regimens (30 BID), providing potential improvements in daytime coverage (see Table 3).

[0228] Example 4 For the study described in Example 2, all patients completed treatment: 17 were included in the efficacy analysis. Compared with placebo, both avexitide regimens significantly increased MMTT glucose nadir: least squares (LS) mean glucose nadir (corrected for placebo) was 10.10 mg / dL (95% confidence interval [CI], 4.770 to 15.438; P = .0011) for avexitide q12h and 12.19 mg / dL (95% CI, 6.854 to 17.521; P = .0002) for avexitide qAM. The mean postprandial insulin peak (corrected for placebo) in LS was -104.53 μIU / mL (95% CI, -196.689 to -12.380; P = 0.0288) with avexitide q12h and -96.29 μIU / mL (95% CI, -18.446 to -4.137; P = 0.0417) with avexitide qAM. Consistent with the MMTT results, clinically significant outpatient hypoglycemic episodes occurred less frequently during avexitide treatment. Avexitide was well tolerated, with no treatment-related serious adverse events or withdrawals.

[0229] As shown in Table 6, patients were female, relatively young (mean 44.3 years), mostly white (94.4%) and non-Hispanic (88.9%), with a mean BMI of approximately 30 kg / m2 after RYGB. Patient baseline disease characteristics reflected the severe and refractory nature of PBH in the study population. Nearly half of participants reported a history of hypoglycemia-induced loss of consciousness (44.4%), and nearly all (94.4%) reported daily or weekly hypoglycemic episodes. Three patients (16.7%) had been hospitalized for hypoglycemia. Two patients (11.1%) reported a history of hypoglycemia-induced seizures, of which one patient (5.6%) reported monthly seizures.

[0230] During the run-in period, all eligible patients were confirmed to be resistant to dietary therapy. Most patients (83.3%) had received pharmacological treatment with off-label use of at least one agent for the treatment of PBH, and three patients had undergone additional surgical procedures to treat PBH (two patients had a gastrostomy tube placement; one patient had a RYGB revision). [Table 6]

[0231] As shown in Table 7 and Figure 5, compared with placebo treatment, mean plasma glucose nadirs during MMTT stimulation increased by more than 21% (57 mg / dL vs. 47 mg / dL) and 25% (59 mg / dL vs. 47 mg / dL) with avexitide 30 mg q12h and avexitide 60 mg qAM treatment, respectively, corresponding to fewer participants requiring glycemic rescue with avexitide versus placebo-stimulated MMTT. The true nadir with placebo may be lower than the measured nadir (47 mg / dL) due to the higher rate of glycemic rescue. Despite the higher rescue rate during the MMTT with placebo, LS mean postprandial plasma glucose nadirs during the stimulated MMTT (corrected for placebo) showed statistically significant increases in glucose nadirs with both avexitide 30 mg q12h (LS mean, 10.10 mg / dL; 95% CI, 4.770 to 15.438; P = .0011) and avexitide 60 mg qAM (LS mean, 12.19 mg / dL; 95% CI, 6.854 to 17.521; P = .0002). Thus, the primary endpoint was met. There was no statistically significant effect of treatment sequence or duration (P ≥ .2 and P ≥ .8, respectively). The difference in LS means between treatment with avexitide 60 mg qAM versus avexitide 30 mg q12h was small (2.08, 95% CI -3.238 to 7.405) and not statistically significant.

[0232] As shown in Table 7, additional glycemic parameters provided complementary results and were consistent with the mechanism of action of avexitide. Fasting plasma glucose concentrations remained within the normal range throughout all treatment periods, and postprandial peak glucose values ​​increased during avexitide 60 mg qAM treatment but not during avexitide 30 mg q12h treatment. AUC 0-180min Glucose increased significantly during both avexitide treatments, primarily due to increases in late plasma glucose concentrations during avexitide treatment versus placebo treatment.

[0233] As shown in Table 7 and Figures 3 and 5, mean postprandial insulin peaks during MMTT stimulation were reduced by 23% (349.5 μIU / mL vs. 454.5 μIU / mL) with avexitide 30 mg q12h and by more than 21% (357.2 μIU / mL vs. 454.5 μIU / mL) with avexitide 60 mg qAM treatment compared with placebo treatment. LS mean postprandial insulin peaks during MMTT stimulation (corrected for placebo) showed statistically significant reductions in insulin peaks with avexitide 30 mg q12h (LS mean = -104.53 μIU / mL, P = 0.0288) and avexitide 60 mg qAM (LS mean = -96.29 μIU / mL, P = 0.0417). Neither treatment sequence nor duration had a statistically significant effect (P ≥ 0.7 and ≥ 0.6, respectively). The LS mean difference between avexitide 30 mg q12h and avexitide 60 mg qAM treatment was small (8.24) and not statistically significant.

[0234] GLP-1 and glucagon Fasting GLP-1 and glucagon levels were similar across avexitide 30 mg q12h and 60 mg qAM treatment compared with placebo treatment. Peak GLP-1 and glucagon levels were higher in the avexitide group, as were GLP-1 and glucagon AUC values ​​during the MMTT (Table 7). Neuroglycopenic symptoms [Table 7]

[0235] The mean rates of hypoglycemia (defined as hypoglycemic episodes confirmed by SBGM glucose <70 mg / dL) were reduced by 30% and >60% for avexitide 30 mg q12h and avexitide 60 mg qAM, respectively, compared with placebo. The mean rates of hypoglycemic LS (corrected for placebo) were substantially lower during treatment with avexitide 30 mg qAM (-1.24 (P=0.0720)) and significantly lower during treatment with avexitide 60 mg qAM (-2.51 (P=0.0014)) (Table 8).

[0236] The mean rates of clinically significant hypoglycemia (defined as symptoms / signs of neuroglycopenia confirmed by SBGM glucose <55 mg / dL or as a hypoglycemic episode requiring assistance from another person to administer rescue therapy) were reduced by 40% with avexitide 30 mg q12h and 59% with avexitide 60 mg qAM compared with placebo. The mean rates of severe hypoglycemic LS (corrected for placebo) were statistically significantly lower with both avexitide dosing regimens: -0.95 with avexitide 30 mg q12h (P = 0.0194); -1.42 with avexitide 60 mg qAM (P = 0.0015) (Table 8).

[0237] As shown in Table 8, rescue rates by oral or G-tube feeding were substantially reduced with avexitide. With self-rescue, mean (placebo-corrected) rescue rates were substantially lower with avexitide 30 mg q12h treatment (-1.60, P = 0.0614) and statistically significantly lower with avexitide 60 mg qAM treatment (-3.13, P = 0.0013). With third-party assistance, mean (placebo-corrected) rescue rates were substantially lower with avexitide 30 mg q12h (-0.34, P = 0.1194) and avexitide 60 mg qAM (-0.38, P = 0.0856).

[0238] All patients were provided with access to a glucagon emergency kit, but no patient used glucagon as a means of preventing / relieving hypoglycemia at any time during the study.

[0239] As shown in Figure 6, the mean percent time with hypoglycemia during the daytime (8 AM to midnight) was substantially reduced during avexitide 30 mg q12h and 60 mg qAM treatment compared to placebo treatment. Specifically, the mean percent time with glucose values ​​<70, <55, and <40 mg / dL was reduced by 36%, 49%, and 57%, respectively, during avexitide 30 mg q12h treatment and by 26%, 24%, and 4% during avexitide 60 mg qAM treatment. The mean percent time with glucose values ​​below the CGM threshold between midnight and 8 AM was not substantially different between avexitide and placebo treatment, although a small increase in the percent time with glucose values ​​<55 mg / dL was observed during avexitide 60 mg qAM treatment between 12 AM and 4 AM. This suggests breakthrough episodes of postprandial hypoglycemia in the early morning when plasma concentrations of avexitide were declining.

[0240] The mean percent time blood glucose levels were above 250 mg / dL was less than 1% and similar for all three treatment groups.

[0241] Number of hypoglycemic episodes The mean number of hypoglycemic episodes lasting at least 10 minutes during the day (8:00 AM to midnight) was substantially reduced during avexitide 30 mg q12h and 60 mg qAM treatment compared to placebo treatment. Specifically, the mean number of hypoglycemic episodes <70, <55, and <40 mg / dL (CGM values ​​lasting at least 10 minutes within a 3-hour period) was reduced by 28%, 43%, and 53% during avexitide 30 mg q12h treatment and 23%, 29%, and 24% during avexitide 60 mg qAM treatment, respectively, during that time. The mean number of episodes during the midnight to 8:00 AM period was not substantially different during avexitide 30 mg q12h and 60 mg qAM treatment versus placebo treatment (Figure 6).

[0242] Quality of life Results from the NOS questionnaire showed that compared with placebo, patients treated with avexitide 30 mg q12h and 60 mg qAM, respectively, experienced fewer instances of loss of consciousness, less need for third-party assistance, and less interruption of daily activities. [Table 8]

[0243] Data collected by the NOS questionnaire (designed to assess the effect of avexitide treatment on the occurrence of severe neuroglycopenic outcomes by patient recall at the end of each treatment period) matched well with the eDiary data, indicating that compared with placebo treatment, patients had fewer instances of loss of consciousness, less need for third-party assistance, and less interruption of daily activities while receiving avexitide treatment. [Table 9]

[0244] Example 5 Event Ruling In certain embodiments of studies with an endpoint measuring severe hypoglycemic events, particularly in cases where outside assistance is required but not available, the following describes a procedure for adjudication of severe hypoglycemic events.

[0245] Definitions / criteria for severe hypoglycemic events The American Diabetes Association (ADA) Standards of Medical Care in Diabetes recommends the classification of hypoglycemia, as shown in Table 10 (ADA 2019; Agiostratidou et al. 2017). [Table 10]

[0246] The study will capture level 2 and level 3 hypoglycemia, as well as signs and symptoms of hypoglycemia-induced central nervous system (CNS) impairment (neurogly- openic signs / symptoms specific to cognitive / physical dysfunction), primarily via patient electronic diaries.

[0247] Level 3, severe hypoglycemia, is a subset of hypoglycemia-induced CNS damage and represents a high level of dysfunction. It is important to note that patients may need assistance but may not always receive it (e.g., help may not be available).

[0248] Because classification of severe hypoglycemic events is somewhat subjective, especially when external assistance is needed but not available, all potential severe hypoglycemic events will be judged according to the definitions and criteria outlined below.

[0249] Criteria for determining whether third-party assistance is required: The patient is unable to administer rescue therapy independently and requires assistance from another person, including preparing, obtaining, or administering the rescue therapy. Patients will experience any of the following consequences of neuroglycopenia: seizures (focal or generalized); loss of consciousness (LOC); obtundation / coma; stroke-like signs or symptoms, including movement disorders and / or speech disorders. Patients experience neuroglycopenic outcomes and require external assistance to prevent injury. Patient requires hypoglycemic rescue by a medical professional (e.g., emergency medical personnel). · The patient experiences an adverse event (AE) that, based on source documentation, is believed to be due to hypoglycemia. The following AEs are investigated: accidents, injuries, falls, loss of consciousness / fainting, seizures, hypoglycemia. · A patient is admitted with hypoglycemia. The patient has a BG concentration measurement less than 40 mg / dL.

[0250] Example 6 The study described in Example 2 enrolled a total of 18 patients: 8 randomly assigned to the sequence placebo / avexitide 30 mg q12h / avexitide 60 mg qAM and 10 to the sequence placebo / avexitide 60 mg qAM / avexitide 30 mg q12h, and all 18 completed each treatment period and the study.

[0251] All patients were women. Most were white (94.4%) and not Hispanic or Latino (88.9%). Mean weight, height, and BMI were 81 kg, 165 cm, and 30 kg / m2, respectively.

[0252] The overall mean time since RYGB surgery was 93.5 months (range 16-198), and the overall mean time from RYGB surgery to the first experience of hypoglycemic symptoms was 35.7 months (range 2-144 months). Nearly half of the patients had experienced episodes of hypoglycemia-induced loss of consciousness (44.4%). Nearly all patients (94.5%) experienced hypoglycemic symptoms daily (7, 38.9%) or weekly (10, 55.6%). One patient (5.6%) reported monthly symptoms. Three patients (16.7%) had been hospitalized for hypoglycemia. Two patients (11.1%) reported a history of hypoglycemic-induced seizures, of which one patient (5.6%) reported monthly seizures.

[0253] Most patients had been following medical nutrition therapy (currently accepted guidelines for the treatment of PBH) for several years. During the run-in period, all eligible patients were confirmed to be refractory to medical nutrition therapy. As per the protocol, all patients continued their dietary therapy during the study. Most patients (15, 83.3%) were receiving medical therapy with off-label use of at least one drug for PBH, and three patients had undergone additional surgical procedures to treat PBH (two patients had gastrostomy tube placement; one patient had RYGB revision). No patients had a history of type 2 diabetes.

[0254] Level of exposure and compliance with treatment Treatment assignments were placebo, avexitide 30 mg q12h, or avexitide 60 mg qAM administered on most days of treatment (mean days, 14.3, 13.8, and 14.3, respectively). Compliance with the study treatment regimens was high, averaging 96.3%, 99.9%, and 98.3%, respectively.

[0255] Endpoint Analysis Magnitude of postprandial hypoglycemia: The primary efficacy endpoint was met by both avexitide regimens. Mean postprandial plasma glucose nadirs (corrected for placebo) during stimulated MMTT showed a statistically significant increase in glucose nadirs with both avexitide 30 mg q12h (LS mean = 10.10 mg / dL, p = 0.0011) and avexitide 60 mg qAM (LS mean = 12.19 mg / dL, p = 0.0002).

[0256] Peak postprandial insulin response: Mean postprandial insulin peaks (corrected for placebo) during MMTT stimulation showed a statistically significant decrease in insulin peak with avexitide 30 mg q12h (LS mean = -104.53 μIU / mL, p = 0.0288) and avexitide 60 mg qAM (LS mean = -96.29 μIU / mL, p = 0.0417).

[0257] Need for glycemic rescue: The proportion of patients requiring glycemic rescue in response to MMTT stimulation was lower during treatment with avexitide 30 mg q12h (23.5%) and 60 mg qAM (11.8%) than during treatment with placebo (35.3%).

[0258] Signs and symptoms of postprandial neuroglycopenia: There were no statistically significant differences in reported experience of postprandial neuroglycopenic symptoms during MMTT stimulation as measured by the MEHSS.

[0259] Rates of hypoglycemia: The mean rate of hypoglycemia (adjusted for placebo) was substantially lower during treatment with avexitide 30 mg q12h at -1.24 (p=0.0720) and significantly lower during treatment with avexitide 60 mg qAM at -2.51 (p=0.0014).

[0260] Rates of severe hypoglycemia: The mean rates of severe hypoglycemia (corrected for placebo) were statistically significantly lower during both avexitide dosing regimens: avexitide 30 mg q12h, -0.95 (p=0.0194), avexitide 60 mg qAM, -1.42 (p=0.0015).

[0261] Rate of hypoglycemic prevention / rescue with glucagon: No patients used glucagon as a means of hypoglycemic prevention or rescue during the study.

[0262] Rates of hypoglycemic prevention / rescue by oral / G-tube feeding: Mean self-rescue rates (adjusted for placebo) were substantially reduced with avexitide 30 mg q12h (-1.60, p=0.0614)) and significantly reduced with avexitide 60 mg qAM (-3.13, p=0.0013). Mean third-party assisted rescue rates (adjusted for placebo) were substantially reduced with avexitide 30 mg q12h (-0.34, p=0.1194)) and avexitide 60 mg qAM (-0.38, p=0.0856).

[0263] Percentage of time with glucose readings < 70 mg / dL, < 55 mg / dL, or < 40 mg / dL from 8 AM to midnight and midnight to 8 AM as measured by CGM: From 8AM to midnight, the mean percent time blood glucose was below the CGM threshold was lower with avexitide 30mg q12h and avexitide 60mg qAM compared to placebo treatment, respectively: <70mg / dL, 5.0% and 5.8% vs. 7.8%; <55mg / dL, 1.1% and 1.6% vs. 2.1%; <40mg / dL, 0.23% and 0.52% vs. 0.54%. Between midnight and 8 am, the mean percentage of time that blood glucose was below the CGM threshold was not substantially different for avexitide 30 mg q12h and 60 mg qAM treatment versus placebo treatment: <70 mg / dL, 9.0% and 11.9% vs. 9.7%; <55 mg / dL, 2.2% and 3.2% vs. 2.4%; and <40 mg / dL, 0.53% and 0.82% vs. 0.54%.

[0264] Percentage of time with glucose measurements ≥ 180 mg / dL and ≤ 250 mg / dL or ≥ 250 mg / dL as measured by CGM: The mean percent time with blood glucose levels ≥ 180 mg / dL and ≤ 250 mg / dL was higher with avexitide 30 mg q12h (4.0%) and avexitide 60 mg qAM (4.3%) compared with placebo (2.8%). The percent time with blood glucose levels > 250 mg / dL was < 1% and similar for avexitide and placebo treatments.

[0265] Fasting glucose, glucose peak, difference between glucose peak and nadir, rate of glucose decline from peak to nadir, and AUC glucose during MMTT stimulation: Mean fasting plasma glucose levels were normal with avexitide 30 mg q12h ID (87.5 mg / dL), avexitide 60 mg qAM (84.6 mg / dL), and placebo (83.8 mg / dL). Mean plasma glucose peaks were similar with avexitide 30 mg q12h (218.2 mg / dL) and higher with avexitide 60 mg qAM (224.5 mg / dL) compared with placebo (211.8 mg / dL). Time to peak blood glucose was similar with avexitide 30 mg qAM (37.9 min) and shorter with avexitide 60 mg qAM (34.4 min) compared with placebo (39.9 min). The mean differences in blood glucose peak to trough were similar: Avexitide 30 mg q12h (-161.1 mg / dL); Avexitide 60 mg qAM (-165.4 mg / dL); Placebo (-164.6 mg / dL). · AUC glucose from 0 to 3 h was higher with avexitide 30 mg q12h (319.96 h·mg / dL) and 60 mg qAM (338.06 h·mg / dL) treatment compared with placebo (286.89 h·mg / dL) treatment.

[0266] Fasting and postprandial GLP-1 and glucagon levels during MMTT: Fasting GLP-1 levels were similar in avexitide 30 mg q12h and 60 mg qAM treatments compared with placebo treatment (12.7 and 12.7 vs. 12.5 pg / mL, respectively). Peak GLP-1 levels were higher in the avexitide groups (413 and 397 vs. 326 pg / mL), as were GLP-1 AUC values ​​during MMTT (0–180 min, 331 and 351 vs. 277 h pg / mL). Fasting glucagon levels were similar in avexitide 30 mg q12h and 60 mg qAM treatment and placebo treatment (156 and 157 vs. 156 pg / mL, respectively). Peak glucagon levels were higher in the avexitide groups (197 and 183 vs. 179 pg / mL), as were glucagon AUC values ​​during the MMTT (0–180 min, 467 and 484 vs. 423 h pg / mL).

[0267] QOL measured by questionnaire: Improvements were observed during placebo and avexitide treatment across the NSS, HIS, HSIS, and SF-36v2 questionnaires, with no clear differences observed. Results from the NOS questionnaire showed that compared with placebo, patients treated with avexitide 30 mg q12h and 60 mg qAM, respectively, had fewer instances of loss of consciousness, less need for third-party assistance, and less interruption of daily activities.

[0268] KPS values ​​were similar with avexitide 30 mg q12h and 60 mg qAM treatment compared with placebo treatment (83.5 and 87.1 vs. 82.4, respectively).

[0269] Pharmacokinetics (PK) Evidence of systemic plasma exposure to avexitide was observed in all patients following repeated SC dosing of avexitide 30 mg q12h and avexitide 60 mg qAM.

[0270] Mean predose plasma avexitide levels were higher with avexitide 30 mg q12h treatment compared with avexitide 60 mg qAM treatment.

[0271] Mean T of avexitide after SC administration of avexitide 30 mg q12h (5.06 hours) and avexitide 60 mg qAM (5.88 hours) max No clear differences in values ​​were observed.

[0272] Plasma exposure after avexitide 60mg qAM treatment (C avg , C max , and AUC 0-t ) were consistently greater than those observed after avexitide 30 mg q12h treatment: mean plasma C max Values ​​were 357 vs. 613 ng / mL, respectively; mean plasma AUC after treatment with avexitide 30 mg q12h and avexitide 60 mg qAM 0-t The values ​​were 2035 vs. 2854 ng·h / mL, respectively. avg A similar trend was observed for the values.

[0273] safety Overall TEAEs - Similar proportions of patients experienced TEAEs during placebo (77.8%) and avexitide 60 mg qAM (72.2%) treatment, whereas fewer patients experienced TEAEs during avexitide 30 mg q12h treatment (38.9%). The most common AEs (reported by ≥20% of patients) for the placebo, avexitide 30 mg q12h, and avexitide 60 mg qAM regimens, respectively, were injection site bruising (38.9%, 0, and 5.6%), headache (22.2%, 5.6%, and 5.6%), and nausea (22.2%, 11.1%, and 16.7%).

[0274] Intensity of TEAEs - The maximum intensity of TEAEs was mild for 33.3% of patients, moderate for 44.4%, and severe for 11.1%. A total of 68 TEAEs were reported, with most events being mild (43, 63%) or moderate (23, 34%), and there were two severe events (2, 3%), each of which was considered unrelated to the procedure or study drug and resolved with treatment, respectively.

[0275] Deaths, serious, and major TEAEs: There were no deaths or treatment-related serious TEAEs. No patients discontinued the study as a result of TEAEs. One SAE was reported that was thought to be unrelated to the study treatment or procedures (severe near-syncope).

[0276] Laboratory Tests and Physical Examination. No clinically significant changes were noted in chemistry or hematology results, vital signs, or weight changes.

[0277] Anti-drug antibodies – One patient developed low positive titers for anti-drug antibodies. No TEAEs were associated with this.

[0278] Compared with placebo administered for 14 days, avexitide 30 mg q12h for 14 days and 60 mg qAM for 14 days demonstrated consistent improvements across multiple clinical and metabolic parameters measured in the inpatient setting with MMTT stimulation and in the outpatient setting with eDiary, SBGM, and blinded CGM. Most notably, compared with placebo, avexitide treatment resulted in the following clinical and metabolic findings:

[0279] Increased postprandial glucose nadir during MMTT stimulation.

[0280] Decreased postprandial peak insulin during MMTT stimulation.

[0281] Decreased need for rescue during MMTT provocation.

[0282] Reduced incidence of hypoglycemia and severe hypoglycemia collected by eDiary.

[0283] Decreased hypoglycemic rescue rate collected by eDiary.

[0284] Reduction in percent daytime hours of hypoglycemia as indicated by CGM.

[0285] Reduction in the number of daytime episodes of hypoglycemia as shown by CGM.

[0286] Although the PK profile could not be fully characterized, avexitide 30 mg q12h provided potentially improved and sustained plasma avexitide exposure covering the evening and early morning (predose) whereas avexitide 60 mg qAM provided higher daytime exposure.

[0287] Both dosing regimens were well tolerated, with no treatment-related serious adverse events or participant withdrawals. Adverse events were generally mild and transient, and no clinically important safety signals were observed.

[0288] Overall, the strength and consistency of the data as a whole, combined with the tolerability and safety data, demonstrate a clear and robust treatment benefit and support the continued development of avexitide for the treatment of PBH.

[0289] Example 7 Avexitide 90mg / mL is a sterile, clear, colorless solution, supplied in a single-use 3mL vial as 0.5mL of solution. This pharmaceutical composition consists of 90mg / mL avexitide (active ingredient) in sodium acetate buffer with mannitol as an excipient. A total of 0.5mL of solution can be withdrawn from the vial for SC injection.

[0290] Avexitide injections are administered subcutaneously in the anterolateral aspect of the thigh.

[0291] The endpoint was a reduction in the incidence of hypoglycemia-induced central nervous system (CNS) damage by avexitide in post-bariatric hypoglycemia (PBH). Unlike other tissues (muscle, liver, etc.), the CNS requires a continuous supply of glucose. Although the brain can increase glucose transport rates, this compensatory mechanism may be insufficient to maintain adequate glucose concentrations in the brain when blood glucose levels are extremely low.

[0292] When the CNS is deprived of glucose, the following signs and symptoms may occur: Cognitive impairment, mental disorders, impaired judgment Personality / behavioral changes, abnormal behavior, emotional instability Confusion, memory loss, delirium Changes in vision, blurred vision, double vision Difficulty speaking, dysarthria, meaningless speech -Loss of coordination, ataxia Localized or generalized movement disorders Excessive sleepiness (somnolence), stupor, near-fainting Loss of consciousness convulsions, generalized or focal seizures, and / or ·coma

[0293] In the study described in Example 2, when patients reported hypoglycemic symptoms, the corresponding blood glucose value was confirmed as hypoglycemia. A total of 364 symptomatic episodes were recorded, of which 81% were associated with fingerstick blood glucose values ​​<70 mg / dL and 38% were associated with BG <54 mg / dL. Signs and symptoms most closely associated with the lowest blood glucose values ​​included loss of consciousness (LOC), dysarthria, visual changes (blurred vision, double vision), abnormal behavior, confusion, and incoordination.

[0294] All events of LOC and dysarthria were associated with very low BG concentrations (LOC: 31, 42, 45, and 52 mg / dL; dysarthria: 45 mg / dL). Blood glucose levels <54 mg / dL were confirmed in 66% of events where visual changes were reported, 64% of events where abnormal behavior was reported, 58% of events where confusion was reported, and 56% of events where coordination difficulties were reported. Conversely, these signs / symptoms were rarely reported when BG concentrations were ≥70 mg / dL (4–9%). The mean BG concentration for events where any of the following signs / symptoms were reported was 54 mg / dL: LOC; visual changes; abnormal behavior; confusion and incoordination difficulties. When none of these were present, the mean BG was 64 mg / dL. Using these terms, we were able to identify 83 (61%) of the 137 reported hypoglycemic events confirmed in the study in Example 2 with BG <54 mg / dL. A summary of these results is shown in Table 11. [Table 11]

[0295] Efficacy endpoint of reduction of hypoglycemia-induced CNS injury when any of the following signs / symptoms indicate CNS injury: Cognitive impairment, mental disorders, impaired judgment Personality / behavioral changes, abnormal behavior, emotional instability Confusion, memory loss, delirium Changes in vision, blurred vision, double vision Difficulty speaking, dysarthria, meaningless speech -Loss of coordination, ataxia Localized or generalized movement disorders Excessive sleepiness (somnolence), stupor, near-fainting Loss of consciousness convulsions, generalized or focal seizures, and / or ·coma

[0296] A reduction in the number of severe hypoglycemic events is also an endpoint, with all potential severe hypoglycemic events being adjudicated.

[0297] Although the invention described above has been described in some detail by way of illustration and example for purposes of clarity of understanding, it will be apparent to those skilled in the art that numerous modifications and variations of the invention can be made without departing from the spirit and scope of the invention. The specific embodiments described herein are offered by way of example only and are not meant to be limiting in any way. It is intended that the specification and examples be considered as exemplary only, with a true scope and spirit of the invention being indicated by the following claims.

[0298] All publications, patents, patent applications, or other documents cited herein are incorporated by reference in their entirety for all purposes to the same extent as if each individual publication, patent, patent application, or other document was individually indicated to be incorporated.

Claims

1. A method of treating one or more of hyperinsulinemic hypoglycemia (HH), fasting hyperinsulinemic hypoglycemia, insulinoma, or hypoglycemia / NIPHS comprising subcutaneously administering to a subject a buffered liquid formulation comprising avexitide at a concentration of 2-90 mg / mL.

2. 2. The method of claim 1, wherein avexitide is administered for a period not exceeding 30 days.

3. 3. The method of claim 1 or 2, wherein abexitide is administered until one or both of blood glucose and insulin levels are stabilized.

4. The method according to any one of claims 1 to 3, wherein the HH comprises post-bariatric hypoglycemia (PBH).

5. 5. The method of any of claims 1-4, wherein the subject has previously undergone one or more of the following: Roux-en-Y gastric bypass, vertical sleeve gastrectomy (VSG), biliary-pancreatic diversion (BPD), upper gastrointestinal surgery, gastrectomy, esophagectomy, fundoplication, gastric bypass, vagotomy with pyloroplasty, vagotomy without pyloroplasty, or bile duct resection.

6. The method of any one of claims 1 to 3, wherein the subject has congenital microgastoria or a condition of accelerated ileal transit.

7. 10. The method of claim 1, wherein avexitide is administered in a total daily dosage of about 40 mg to about 90 mg.

8. 10. The method of claim 1, wherein avexitide is administered in a total daily dosage of about 40 mg to about 120 mg, or 30 mg to 60 mg BID, or 60 mg to 120 mg QD; or about 45 mg BID or about 35 to 55 mg BID.

9. 2. The method of claim 1, wherein the total daily dose of avexitide administered is about 90 mg or about 90 mg QD, or about 60-120 mg / day.

10. 2. The method of claim 1, wherein the subject is administered 0.375 mg / kg / dose or 0.56 mg / kg / dose or 0.75 mg / kg / day or about 1.125 mg / kg / day, or about 0.3-1.6 mg / kg / dose of avexitide BID; or about 0.6-3.2 mg / kg / day BID, or about 0.2-1.2 mg / kg / dose, or about 0.6-3.6 mg / kg / day BID; or about 0.6-3.6 mg / kg / day TID.

11. 10. The method of claim 1, wherein avexitide is administered by IV infusion at about 0.1-1.0 mg / kg / hr, or about 0.2-0.6 mg / kg / hr.

12. 3. The method of claim 2, wherein avexitide is administered in a total daily dosage of about 60 or about 120 mg.

13. 4. The method of claim 3, wherein abexitide is administered once daily (QD) or twice daily (BID).

14. 13. The method of claim 1, wherein the subject is administered about 30 mg to about 90 mg BID of avexitide, and the subject does not need to fast or delay their first meal of the day following administration.

15. 13. The method of claim 1, wherein avexitide is administered at 45 mg to 120 mg QD and the subject is required to fast or delay their first meal of the day following administration.

16. The method of claim 15, wherein the delay is from about 30 minutes to about 1.5 hours.

17. 16. The method of claim 15, wherein the subject is required to fast overnight prior to morning administration.

18. 16. The method of claim 15, wherein the subject is required to fast for about 45-90 minutes following the morning administration.

19. 16. The method of claim 15, wherein the subject is required to fast overnight prior to the morning dose and fast for about 45-90 minutes after the morning dose.

20. 2. The method of claim 1, wherein avexitide is administered at a dose of 30 mg BID or 45 mg BID.

21. 21. The method of claim 20, comprising administering in the morning and in the evening, the evening administration being administered about 12 hours after the morning administration.

22. 22. The method of claim 21, wherein the morning dose is administered at least about 30 minutes to about 60 minutes before a meal.

23. 2. The method of claim 1, wherein avexitide is administered at a dose of 60 mg QD.

24. 24. The method of claim 23, wherein avexitide is administered in the morning.

25. 25. The method of claim 24, wherein avexitide is administered at least about 30 minutes to about 90 minutes before the first meal of the day.

26. 26. The method of any of claims 1-25, wherein the formulation comprises abexitide in a concentration of 30 mg / mL to 180 mg / mL, or 2 mg / mL to 29 mg / mL.

27. 26. The method of any of claims 1 to 25, wherein the formulation comprises abexitide in a concentration of 45 mg / mL to 90 mg / mL.

28. 27. The method of claim 26, wherein the formulation comprises abexitide at a concentration of 30 mg / mL.

29. 27. The method of claim 26, wherein the formulation comprises abexitide at a concentration of 90 mg / mL.

30. The method of any one of claims 1 to 29, wherein the formulation has a pH of about 5.

5.

31. The method of any one of claims 1 to 30, wherein the formulation comprises a sodium acetate buffer.

32. The method of any one of claims 1 to 31, wherein the formulation comprises a tonicity adjusting agent.

33. 33. The method of claim 32, wherein the tonicity adjusting agent comprises mannitol.

34. The method of any of claims 1-33, wherein avexitide is administered for less than or at least 30 days.

35. 35. The method of any of claims 1-34, wherein treatment reduces the number and / or severity of symptoms of postprandial neuroglycopenia in the subject.

36. 36. The method of any of claims 1-35, wherein treatment improves the subject's postprandial glycemic nadir.

37. 37. The method of any of claims 1-36, wherein treatment reduces the subject's post-prandial insulin peak.

38. The method of any of claims 1-37, wherein treatment reduces the rate of hypoglycemia in the subject.

39. 2. The method of claim 1, wherein administration reduces the number and / or severity of symptoms of postprandial neuroglycopenia in the subject.

40. 2. The method of claim 1, wherein administration improves the subject's postprandial minimum blood glucose level.

41. 41. The method of claim 40, wherein the subject's mixed meal tolerance test ("MMTT") glucose trough is significantly increased.

42. 42. The method of claim 41, wherein the mean plasma glucose nadir during MMTT provocation is increased by 21% to 25% for the subject compared to a control.

43. 41. The method of claim 40, wherein the subject requires less glycemic rescue following treatment compared to a control.

44. 40. The method of claim 39, wherein the subject has an increased postprandial blood glucose peak, which corresponds to a significantly accelerated time to blood glucose peak during administration of abexitide.

45. 2. The method of claim 1, wherein administration reduces the post-prandial insulin peak in the subject.

46. 46. ​​The method of claim 45, wherein the mean post-prandial insulin peak during MMTT stimulation is reduced by about 21% to 23% in the subject compared to a control.

47. 2. The method of claim 1, wherein peak levels of GLP-1 and glucagon are elevated in the subject compared to a control.

48. The method of claim 1, wherein the AUC values ​​of GLP-1 and glucagon during MMTT in the subject are higher compared to the control.

49. 2. The method of claim 1, wherein the subject experiences hypoglycemic episodes less frequently during abexitide treatment compared to a control.

50. 10. The method of claim 1, wherein administration reduces the rate of hypoglycemia in the subject.

51. 10. The method of claim 1, wherein administration reduces the rate of severe hypoglycemia in the subject.

52. 10. The method of claim 1, wherein administration reduces severe hypoglycemia in a subject.

53. 53. The method of claim 52, wherein severe hypoglycemia includes symptoms that require the subject to receive assistance from a third party.

54. 2. The method of claim 1, wherein administration reduces the rate of hypoglycemia-induced CNS damage in a subject.

55. 2. The method of claim 1, wherein administration provides a clinically meaningful improvement in the subject in one or more of the following: rate of hypoglycemia-induced CNS damage, severe hypoglycemia, postprandial insulin peak, severe hypoglycemia, or postprandial blood glucose nadir.

56. 10. The method of claim 1, wherein administration results in amelioration of postprandial hypoglycemia in the subject.

57. 10. The method of claim 1, wherein administration results in an increase in nadir postprandial plasma glucose in the subject compared to baseline or a control.

58. 2. The method of claim 1, wherein administration results in amelioration of postprandial neuroglycopenic or hypoglycemic symptoms in the subject.

59. 13. The method of claim 1, wherein avexitide is administered twice daily (BID) approximately 60 minutes before the subject's morning and evening meals or before the subject's two main meals of the day.

60. 2. The method of claim 1, wherein avexitide is administered BID at least about 6 hour intervals.

61. 10. The method of claim 1, wherein avexitide is administered in a total volume ranging from 0.25 to 2.0 mL; or in a total volume ranging from about 0.05 to 0.1 mL; or in an injection volume ranging from 0.25 to 1.5 mL, or 0.5 to 1 mL, or 0.7 to 1 mL, or 0.05 to 0.1 mL.

62. 62. The method of any of claims 1-61, wherein treatment reduces the rate of severe hypoglycemia in the subject.

63. 63. The method of any of claims 1-62, wherein treatment reduces the rate of hypoglycemia-induced CNS damage in the subject.

64. 64. The method of claim 63, wherein the hypoglycemia-induced CNS disorder comprises one or more of the following signs or symptoms: cognitive decline, psychosis, impaired judgment, personality / behavioral changes, abnormal behavior, emotional lability, confusion, memory loss, delirium, changes in vision, blurred vision, double vision, difficulty speaking, dysarthria, nonsensical speech, loss of coordination, ataxia, focal or generalized movement disorders, excessive sleepiness (somnolence), stupor, fainting, loss of consciousness, convulsions, generalized or focal seizures, or coma.

65. 64. The method of claim 63, wherein the signs and symptoms associated with a nadir blood glucose concentration include one or more of the following: loss of consciousness (LOC), dysarthria, visual changes (blurred vision, double vision), abnormal behavior, confusion, and incoordination.

66. 10. The method of claim 1, wherein the subject is resistant to dietary therapy.

67. 2. The method of claim 1, wherein avexitide is administered at a dose of 45 mg BID.

68. 22. The method of any of claims 17-19 and 21, wherein the morning dose is administered about 30 minutes to about 90 minutes before a meal.

69. 69. The method of any of claims 1-68, wherein treatment reduces the rate at which the subject requires rescue.

70. 70. The method of claim 69, wherein rescue comprises administering glucagon to the subject with early blood glucose levels ≦50 mg / dL + neuroglycopenia or blood glucose levels ≦40 mg / dL + / − neuroglycopenia.

71. 70. The method of claim 69, wherein the subject experiences daily or weekly symptoms of hypoglycemia.

72. 2. The method of claim 1, wherein the subject's percentage time rate of hypoglycemia according to CGM threshold is reduced following administration.

73. 2. The method of claim 1, wherein the number of hypoglycemic episodes by the subject's CGM threshold is reduced following administration.

74. 10. The method of claim 1, wherein the subject experienced less disruption of daily activities compared to a control.

75. 10. The method of claim 1, wherein the average rate of hypoglycemia in the subject is reduced by about 30% to 60% for avexitide compared to a control.

76. 76. The method of claim 75, wherein the rate of hypoglycemia is a SBGM blood glucose level < 70 mg / dL.

77. 10. The method of claim 1, wherein the mean rate of clinically significant hypoglycemia in the subject is reduced by about 40% to 59% compared to a control.

78. 78. The method of claim 77, wherein clinically significant hypoglycemia is any neurogenic hypoglycemic symptom / sign confirmed by an SBGM blood glucose value <55 mg / dL or as a hypoglycemic episode requiring the assistance of another person to administer rescue therapy.

79. 10. The method of claim 1, wherein the subject's rate of rescue by oral or G-tube ingestion is substantially reduced.

80. 10. The method of claim 1, wherein the average percentage of time the subject is hypoglycemic during the daytime (8 am to midnight) is substantially reduced compared to a control.

81. 81. The method of claim 80, wherein the subject's mean percentage of time with blood glucose levels <70 mg / dL, <55 mg / dL, and <40 mg / dL is reduced by about 4-57% compared to a control.

82. 81. The method of claim 80, wherein the subject's mean percent time of blood glucose levels <70 mg / dL, <55 mg / dL, and <40 mg / dL is reduced by about 36-57% compared to a control.

83. 81. The method of claim 80, wherein the subject's mean percentage of time with blood glucose levels <70 mg / dL, <55 mg / dL, and <40 mg / dL is reduced by about 4-26% compared to a control.

84. 10. The method of claim 1, wherein the mean number of hypoglycemic episodes lasting at least 10 minutes during daytime hours (8 am to midnight) is substantially reduced in the subject compared to a control.

85. 85. The method of claim 84, wherein the mean number of hypoglycemic episodes (CGM values ​​lasting at least 10 minutes within a 3 hour period) of < 70 mg / dL, < 55 mg / dL, < 40 mg / dL for the subject is reduced by about 28% to 53% or about 23% to 29% compared to a control.

86. The method of any of claims 42, 43, 46-49, 57, 74, 75, 77, and 81-85, wherein the control comprises a comparison with the subject's nadir post-prandial plasma glucose measured before the start of treatment or during the MMTT.

87. 87. The method of any of claims 42, 43, 46-49, 57, 74, 75, 77, and 81-86, wherein the control comprises a comparison with a control subject not administered the buffered liquid formulation.

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