Pharmaceutical compositions with Anti-rankl antibodies, calcium and vitamin d, suitable for treatment and / or prophylaxis of disorders of bone metabolism and therapy-induced side effects such as hypocalcemia

Abstract

To provide a composition for use in the treatment and / or prevention of treatment-induced side effects such as hypocalcemia caused by disorders of bone metabolism and the effects of anti-RANKL antibodies.SOLUTION: Provided is a pharmaceutical composition having anti-RANKL antibody, calcium and vitamin D.SELECTED DRAWING: None

Description

[Technical field]

[0001] The present invention relates to a method for treating hypocalcemia caused by disorders of bone metabolism and the action of anti-RANKL antibodies. Anti-RANKL antibodies, anti-RANKL antibodies, anti-RANKL antibodies, anti-RANKL antibodies The present invention relates to a pharmaceutical composition comprising calcium and vitamin D. [Background technology]

[0002] Osteoporosis, tumor disease (including cancer treatment-induced bone loss (CTIBL, cancer treatment-induced bone loss)), Treatment of disorders of bone metabolism such as Jet Sickness or hypocalcemia is an ongoing endeavor in medical research. Human bone is composed of hydroxyapatite (Ca 3 (PO 4 ) 2 · Ca(OH) 2 ) in the form of inorganic salts (mainly calcium and phosphate) combined with organic matrices. In principle, human bone physiology is based on the homeostatic regulation of bone tissue. Based on formation and resorption (bone turnover), bone shape is a continuous remodeling process Its formation and absorption are hormonally driven (estrogen and parathyroid hormone, essentially) (PTH), as well as signaling pathways (essentially RANKL (nuclear factor-k B activating receptor ligand) / OPG (osteoprotegerin) and Ca / PTH / vitamin During childhood, and especially adolescence, bone is lost more quickly than it is resorbed. However, as we age, especially in menopausal and postmenopausal women, the "net" bone mass decreases. Increased tendency towards absorption.

[0003] Throughout the human life course, bone is constantly subjected to physiological and mechanical stresses. be exposed and adapt accordingly. This was first reported in 1862 by Julius Wolff and has since formed the basis of the biomechanical understanding of bone. Wolff showed in his studies of the femoral head that the shape of bone adapts to its function and that bone degenerates if not continuously exposed to load. Thus, during the process of "remodeling", bone not exposed to load is resorbed, a phenomenon studied in bed rest studies of patients on strict bed rest for 60 days. On the other hand, bone exposed to strong mechanical load is strengthened along the lines of that force, as demonstrated by the example of

[0004] When force is applied to bone, in addition to the normal remodeling process, microdamage or disruptions in continuity (fractures) occur, with and without the formation of defects, which can heal without scarring. In the case of inorganic materials, repeated loading below the breaking point leads to material fatigue / material fatigue fracture, where small cracks form and propagate until they reach a critical size and the material breaks. As a semi-brittle material, bone can avoid fragmentation by absorbing energy by forming extremely small cracks (so-called microcracks). Microcracks were first reported by Harold Frost as early as 1960 and are distinct cracks 50 - 100 μm in length that mainly occur in the interstitial bone. Generally, in response to the corresponding biomechanical load, the

[0005] Generally, microcracks are constantly repaired and healed during the remodeling process and remain clinically undetected. Fractures cause apoptosis of osteocytes that release factors such as RANKL. These induce osteoclastic resorption and lead to osteoblastic bone regeneration. Fractures cause apoptosis of osteocytes that release factors such as RANKL. These induce osteoclastic resorption and lead to osteoblastic bone regeneration. Fractures cause apoptosis of osteocytes that release factors such as RANKL. These induce osteoclastic resorption and lead to osteoblastic bone regeneration. Fractures cause apoptosis of osteocytes that release factors such as RANKL. These induce osteoclastic resorption and lead to osteoblastic bone regeneration.

[0006] Healthy bone inhibits and repairs the progression of microdamage, whereas in aging bone, or for example, under remodeling inhibition by potent bone resorption inhibitors (e.g., bisphosphonates or anti-RANKL antibodies), accumulation and in some cases an increased fracture incidence can occur, e.g., in atypical femoral fractures. Healthy bone inhibits and repairs the progression of microdamage, whereas in aging bone, or for example, under remodeling inhibition by potent bone resorption inhibitors (e.g., bisphosphonates or anti-RANKL antibodies), accumulation and in some cases an increased fracture incidence can occur, e.g., in atypical femoral fractures. Healthy bone inhibits and repairs the progression of microdamage, whereas in aging bone, or for example, under remodeling inhibition by potent bone resorption inhibitors (e.g., bisphosphonates or anti-RANKL antibodies), accumulation and in some cases an increased fracture incidence can occur, e.g., in atypical femoral fractures. Healthy bone inhibits and repairs the progression of microdamage, whereas in aging bone, or for example, under remodeling inhibition by potent bone resorption inhibitors (e.g., bisphosphonates or anti-RANKL antibodies), accumulation and in some cases an increased fracture incidence can occur, e.g., in atypical femoral fractures.

[0007] Osteoblasts, osteoclasts, and osteocytes are mainly involved in the continuous bone regeneration process that occurs in bone remodeling. Osteoclasts can break down bone, and osteoblasts can regenerate bone. Osteoblasts, osteoclasts, and osteocytes are mainly involved in the continuous bone regeneration process that occurs in bone remodeling. Osteoclasts can break down bone, and osteoblasts can regenerate bone.

[0008] Finally, the role of osteocytes has not yet been fully elucidated. Osteocytes are highly differentiated cells of osteoblastic origin embedded in bone and are interconnected. Damage to the branches of osteocytes, e.g., in the case of the microcracks described above, first initiates osteoclastic resorption, followed by bone formation by osteoblasts. The interaction between osteoblasts, osteoclasts, and osteocytes is essentially controlled by the RANKL / OPG signaling pathway (osteoclast differentiation) and the WNT / DKK / SOST pathway (WNT is a signaling protein composed of the wingless (Wg) protein and the int-1 protein; DKK = Dickkopf; SOST = sclerostin protein symbol) (osteoblast differentiation). Finally, the role of osteocytes has not yet been fully elucidated. Osteocytes are highly differentiated cells of osteoblastic origin embedded in bone and are interconnected. Damage to the branches of osteocytes, e.g., in the case of the microcracks described above, first initiates osteoclastic resorption, followed by bone formation by osteoblasts. The interaction between osteoblasts, osteoclasts, and osteocytes is essentially controlled by the RANKL / OPG signaling pathway (osteoclast differentiation) and the WNT / DKK / SOST pathway (WNT is a signaling protein composed of the wingless (Wg) protein and the int-1 protein; DKK = Dickkopf; SOST = sclerostin protein symbol) (osteoblast differentiation). Finally, the role of osteocytes has not yet been fully elucidated. Osteocytes are highly differentiated cells of osteoblastic origin embedded in bone and are interconnected. Damage to the branches of osteocytes, e.g., in the case of the microcracks described above, first initiates osteoclastic resorption, followed by bone formation by osteoblasts. The interaction between osteoblasts, osteoclasts, and osteocytes is essentially controlled by the RANKL / OPG signaling pathway (osteoclast differentiation) and the WNT / DKK / SOST pathway (WNT is a signaling protein composed of the wingless (Wg) protein and the int-1 protein; DKK = Dickkopf; SOST = sclerostin protein symbol) (osteoblast differentiation). Finally, the role of osteocytes has not yet been fully elucidated. Osteocytes are highly differentiated cells of osteoblastic origin embedded in bone and are interconnected. Damage to the branches of osteocytes, e.g., in the case of the microcracks described above, first initiates osteoclastic resorption, followed by bone formation by osteoblasts. The interaction between osteoblasts, osteoclasts, and osteocytes is essentially controlled by the RANKL / OPG signaling pathway (osteoclast differentiation) and the WNT / DKK / SOST pathway (WNT is a signaling protein composed of the wingless (Wg) protein and the int-1 protein; DKK = Dickkopf; SOST = sclerostin protein symbol) (osteoblast differentiation). Finally, the role of osteocytes has not yet been fully elucidated. Osteocytes are highly differentiated cells of osteoblastic origin embedded in bone and are interconnected. Damage to the branches of osteocytes, e.g., in the case of the microcracks described above, first initiates osteoclastic resorption, followed by bone formation by osteoblasts. The interaction between osteoblasts, osteoclasts, and osteocytes is essentially controlled by the RANKL / OPG signaling pathway (osteoclast differentiation) and the WNT / DKK / SOST pathway (WNT is a signaling protein composed of the wingless (Wg) protein and the int-1 protein; DKK = Dickkopf; SOST = sclerostin protein symbol) (osteoblast differentiation). Finally, the role of osteocytes has not yet been fully elucidated. Osteocytes are highly differentiated cells of osteoblastic origin embedded in bone and are interconnected. Damage to the branches of osteocytes, e.g., in the case of the microcracks described above, first initiates osteoclastic resorption, followed by bone formation by osteoblasts. The interaction between osteoblasts, osteoclasts, and osteocytes is essentially controlled by the RANKL / OPG signaling pathway (osteoclast differentiation) and the WNT / DKK / SOST pathway (WNT is a signaling protein composed of the wingless (Wg) protein and the int-1 protein; DKK = Dickkopf; SOST = sclerostin protein symbol) (osteoblast differentiation). Finally, the role of osteocytes has not yet been fully elucidated. Osteocytes are highly differentiated cells of osteoblastic origin embedded in bone and are interconnected. Damage to the branches of osteocytes, e.g., in the case of the microcracks described above, first initiates osteoclastic resorption, followed by bone formation by osteoblasts. The interaction between osteoblasts, osteoclasts, and osteocytes is essentially controlled by the RANKL / OPG signaling pathway (osteoclast differentiation) and the WNT / DKK / SOST pathway (WNT is a signaling protein composed of the wingless (Wg) protein and the int-1 protein; DKK = Dickkopf; SOST = sclerostin protein symbol) (osteoblast differentiation). Finally, the role of osteocytes has not yet been fully elucidated. Osteocytes are highly differentiated cells of osteoblastic origin embedded in bone and are interconnected. Damage to the branches of osteocytes, e.g., in the case of the microcracks described above, first initiates osteoclastic resorption, followed by bone formation by osteoblasts. The interaction between osteoblasts, osteoclasts, and osteocytes is essentially controlled by the RANKL / OPG signaling pathway (osteoclast differentiation) and the WNT / DKK / SOST pathway (WNT is a signaling protein composed of the wingless (Wg) protein and the int-1 protein; DKK = Dickkopf; SOST = sclerostin protein symbol) (osteoblast differentiation). Finally, the role of osteocytes has not yet been fully elucidated. Osteocytes are highly differentiated cells of osteoblastic origin embedded in bone and are interconnected. Damage to the branches of osteocytes, e.g., in the case of the microcracks described above, first initiates osteoclastic resorption, followed by bone formation by osteoblasts. The interaction between osteoblasts, osteoclasts, and osteocytes is essentially controlled by the RANKL / OPG signaling pathway (osteoclast differentiation) and the WNT / DKK / SOST pathway (WNT is a signaling protein composed of the wingless (Wg) protein and the int-1 protein; DKK = Dickkopf; SOST = sclerostin protein symbol) (osteoblast differentiation).

[0009] The main pathways involved in bone formation are the WNT pathway and the PTH signaling pathway for osteoblast differentiation. Differentiation from hematopoietic stem cells to osteoclasts is controlled via the RANKL / OPG signaling pathway.

[0010] Since bone functions as a calcium reservoir for the human body, it is critically involved in the homeostasis of calcium phosphate. Through bone formation and resorption, excess stored calcium can be stored from the blood or made available

[0011] as needed. In a variety of disorders of bone metabolism, this delicate balance is disrupted. The most frequent disorder of bone metabolism is osteoporosis. Other disorders affecting bone metabolism include Paget's disease, osteogenesis imperfecta, primary bone tumors, as well as multiple myeloma (plasma cell tumor), osteosarcoma and bone metastases. Complications caused by bone metastases / bone tumors are referred to in English as "skeletal related events" (SREs). The English term "skeletal related events" (SREs) includes acute events (e.g., pathologic fracture, spinal cord compression, bone pain or tumor-induced hypercalcemia) and

[0012] treatment interventions (e.g., radiotherapy or surgery on bone that can be performed in patients with bone metastases or primary bone tumors). Osteoporosis causes a decrease in bone density, which increases the risk of It is defined as a measurable decrease (core). When a fracture occurs, it is overt osteoporosis. Therefore, osteoporosis is a common systemic disorder of the bones that often manifests as fractures caused by incomplete trauma. In Germany, approximately 6 million people suffer from osteoporosis, a widespread and common disease, and osteoporosis patients experience over 720,000 fractures every year. Postmenopausal osteoporosis is by far the most frequent cause of vertebral and non-vertebral fragility fractures. The risk of fracture increases considerably with age. In the first 5 years after menopause, due to the cessation of estrogen production, bone mass resorption of varying severity is observed among individuals. Postmenopausal bone loss can be as much as 15% per year, and women with a low peak bone mass reach their first osteoporotic fracture very quickly.

[0013] Insufficient calcium supply and a lack of blood vitamin D levels ultimately lead to calcium absorption by the bones. Additional pathological mechanisms that directly or indirectly promote bone resorption with aging are also expected to exist. For example, the ability to absorb calcium ions from food decreases by approximately 50% by the age of 65 (compared to the young). Aging comorbidities (e.g., type 2 diabetes, kidney dysfunction, immobility, or treatment with glucocorticoids) have an additive effect on bone resorption and are thus just some examples of many risk factors shown to promote the potential progression of osteoporosis.

[0014]

[0015] Figure 1 clearly shows that only approximately one-third of the amount of calcium available in the digestive tract is absorbed. 65 - 70% of dietary calcium is excreted in the feces. ​​​​​​​​​​Furthermore, the absorption process itself can be positively or negatively affected by various factors. For example , foods containing high levels of phosphate can extremely inhibit calcium uptake.

[0016] The main hormones that regulate calcium homeostasis include, in addition to sex hormones (estrogen , testosterone), calcitonin, parathyroid hormone (parathyrin) and calcitriol (the active form of vitamin D3). Calcitriol is essential for enabling the absorption of calcium and phosphate in the small intestine. Furthermore, calcitriol enhances calcium reabsorption through the kidneys and stimulates bone mineralization (calcium uptake into the bone matrix).

[0017] For example, when the body excretes more calcium than it can absorb through the intestine , a negative calcium balance occurs. If this state persists over a long period , the results are increased bone resorption and secondary hyperparathyroidism. Parathyroid hormone is formed by the parathyroid glands to mobilize "deficient" calcium from the bone. As shown in Figure 2 , parathyroid hormone stimulates bone resorption and thus increases the blood calcium concentration. Therefore, the calcium concentration remains relatively constant in the blood at the expense of the bone, and in the case of calcium deficiency, the bone releases calcium to increase the calcium level in the blood.

[0018] Figure 3 is a diagram of age-related calcium reduction. At an early age of 40, a stealthy bone density decrease of 2-3% per year begins in both men and women. More than 20% of women After menopause, the annual rate of loss can increase significantly. Affected women often lose more than one-quarter of their bone mass(=calcium) in a relatively short period of time without noticing, and as a result, the risk of fractures later in life becomes extremely high. The disease 'osteoporosis' is often diagnosed too late, usually not until osteoporotic fractures, i.e. fractures without a traumatic event, occur, for example in the vertebrae, hip or wrist. Another underestimated problem in affected men and women over 50 years of age is the increasing calcium imbalance caused by a progressive negative calcium balance. As shown in Figure 4, with increasing age, the difference between the daily calcium requirement and the actual calcium intake from the digestive tract increases. The increase in calcium requirements associated with ageing is essentially influenced by the following factors: decreased calcium absorption in the digestive tract, a calcium-deficient diet (few dairy products), vitamin D deficiency, lack of exercise, the need to replenish the bone calcium store (formation of new bone mass), increased parathyroid hormone in the blood (increased bone resorption and calcium loss) or kidney dysfunction (decreased calcium reabsorption and relatively inactive vitamin D). Ultimately, to compensate for the natural loss of calcium through the skin and kidneys, and to maintain a constant blood calcium level necessary for survival, the human body has only two options. 1.) Mobilize calcium from the 'bone calcium store'. Disadvantage: The resorption of bone tissue required for this purpose can lead to a loss of stability and fractures in the long term.

[0019]

[0020]

[0021] ​​​​​​​​​​​​​​​

[0022] 2.) Sufficient absorption of calcium from the digestive tract and reabsorption of calcium in the kidneys. Both of these processes are controlled by vitamin D.

[0023] Biologically active form of vitamin D3 (1α,25-dihydroxycholecalciferol; calcitriol) promotes the absorption of calcium from the digestive tract into the blood. It reaches the maximum serum concentration within 3 to 6 seconds after ingestion. Overall, vitamin D promotes the uptake of calcium into the body. Overdose can lead to vitamin D intoxication because the body stores vitamin D. Vitamin D intoxication can result in severe demineralization of bones, and that demineralization can lead to fractures. At the same time, high serum calcium concentrations can result in abnormal calcification of a variety of soft tissues. Additionally, an increase in renal excretion of calcium can lead to kidney stones.

[0024] In vitamin D deficiency, dietary calcium reaching the blood is reduced due to decreased absorption from the intestine.

[0025] Deficiency of calcium and / or vitamin D is treated by supplementation with preparations containing calcium and vitamin D. However, the use of calcium and vitamin D is controversial. The tolerance of calcium is debated worldwide, and some scientists believe that calcium supplementation is a cardiovascular risk. Calcium is claimed to increase the risk of cardiovascular events such as heart attacks. In Germany, the result of this debate is not to supplement calcium frequently.

[0026] In osteoporosis, calcium deficiency means a worsening of the condition, along with an increased risk of fractures. This occurs.

[0027] In overt osteoporosis, bone mineral density is reduced (T-score: < -2.5), and fractures, such as 1 to 3 vertebral fractures, have already occurred.

[0028] Long-term glucocorticoid treatment can lead to glucocorticoid-induced or corticosteroid-induced severe osteoporosis, along with fractures. In the administration of > 5 mg of prednisone equivalent per day for > 3 months, preventive or therapeutic measures are recommended. In particular, during the first 6 months after the start of treatment, when the dose is significantly increased during its course, and in the case of long-term high-dose treatment, a significant decrease in bone density that should be taken into account can be expected. There are multiple causes for glucocorticoid-induced bone loss. At the start of treatment, glucocorticoids increase bone resorption. Steroids inhibit the proliferation and function of osteoblasts and increase their apoptosis. Thus, steroids decrease bone formation. At the same time, steroids bring about a negative calcium balance by inhibiting calcium intestinal absorption

[0029] A further disorder of bone metabolism is osteodystrophy deformans, osteitis deformans, Paget's syndrome or Paget's disease, known as Paget's disease. In this disorder with unknown causes, the possible etiologies under discussion are the influence of genes, viruses, and the environment. Paget's disease is associated with local increased bone remodeling, deformity, chronic pain, and It is a chronic disorder of bone metabolism characterized by a skeletal muscle oxidative stress process.

[0030] A primary solid tumor (e.g., breast, prostate, lung, bowel or bone cancer (e.g., osteosarcoma) Bone metastasis is when the tumor spreads to the bone, causing bone metastasis or bone damage. This is due to the migration of bone tumors, which can cause pain and fractures. This is due to increased resorption or excessive production of poor quality bone tissue, which reduces bone stability. Tumor-induced bone complications include high morbidity, high fracture rates, nerve entrapment, and in some cases It is characterized by excruciating pain. Large amounts of calcium are released from the bones and into the bloodstream. Tumor-induced hypercalcemia can occur in some cases, such as metastatic breast, prostate, and lung cancer. Patients with cancer, intestinal cancer or bone cancer (e.g., osteosarcoma) and moderate or severe bone pain (BPI-SF The number of patients with a score of ≥ 4 on the Simplified Pain Survey was the highest at over 80%, with neuralgia followed by 10% in approximately 10%, making this by far the most common symptom (Cle eland,CS et al.,Ann.Onc.2005,16:972-980 ).

[0031] The term "multiple myeloma" or "plasmocytoma" or "Kahrer's disease" refers to a tumor that is caused by the proliferation, differentiation, and proliferation of antibody-producing cells. This refers to a cancer of the bone marrow in which there is a rapid increase in malignant plasma cells. These malignant plasma cells are The disease progresses in a manner that is not recognized by the immune system, resulting in the formation of non-functional antibodies or portions thereof. It can be highly variable, has a moderately to highly aggressive course, and progresses rapidly if left untreated. The symptoms are caused by the proliferation of these cells or by the antibodies they produce. or fragments thereof, which themselves may enter the bloodstream. can manifest as bone pain, decreased bone mass, and fractures, along with increased calcium release, and can lead to tumor-induced hypercalcemia. While the white blood cell count decreases, many antibodies deposit in tissues, causing dysfunction of numerous organs, renal failure, and circulatory disorders. Drugs for treating bone metabolism disorders are known in the prior art. In the pharmaceutical treatment of osteoporosis, the main objective is to halt the pathological decrease in bone mass. The negative balance (the imbalance between bone tissue formation and absorption) can be compensated for, either by inhibiting osteoclasts (bone resorption) to suppress bone resorption or by stimulating osteoblasts (bone formation) anabolically. Only when the balance between the formation process and the resorption process is restored, and only when sufficient supply of calcium and vitamin D is ensured, can new bone mass be formed and the risk of osteoporotic fractures be reduced. To treat osteoporosis, on the one hand, osteoclastic bone resorption can be inhibited using anti-RANKL antibodies, and on the other hand, bone formation can be stimulated using anabolic agents. For this purpose, the recombinant 1-34 fragment of parathyroid hormone has been approved for the treatment of osteoporosis.

[0032] Bone resorption inhibitors such as anti-RANKL antibodies are currently the standard for treating metabolic bone disorders, and they require effective inhibition of bone resorption. This includes their use for treating osteoporosis (at very high doses and with shorter treatment intervals), as well as the use of this class of substances for the treatment and / or prevention of tumor-induced bone complications. and or anabolically Only when and can

[0033] For the treatment of osteoporosis, on the one hand, osteoclastic bone resorption can be inhibited using anti-RANKL antibodies, and on the other hand, bone formation can be stimulated using anabolic agents. is inhibited and, on the other hand,

[0034] bone formation can be stimulated using anabolic agents. This includes their use for treating osteoporosis (at very high doses and with shorter treatment intervals), as well as the use of this class of substances for the treatment and / or prevention of tumor-induced bone complications. for treating osteoporosis (at very high doses and with shorter treatment intervals), and for the treatment and / or prevention of tumor-induced bone complications.

[0035] An anti-RANKL antibody or a derivative thereof is usually used to treat the above-mentioned disorders (e.g., osteoporosis or tumor-induced bone disorders).

[0036] As a result of the use of an anti-RANKL antibody, calcium remains in the bone. This inhibits bone resorption by, for example, parathyroid hormone to varying degrees. This poses a risk of hypocalcemia. When the total calcium in the serum is less than 2.2 mmol / l (9 mg / dl), hypocalcemia exists. In the pharmaceutical inhibition of osteoclasts, the calcium concentration in the blood can only be balanced by supplying calcium from the outside (orally or intravenously). This is shown in Figure 5. PTH activates the release of calcium from the bone, which is inhibited by the inhibition of osteoclasts caused by the use of an anti-RANKL antibody. Therefore, an external calcium supply is essential.

[0037] The risk of hypocalcemia is significantly increased even in the presence of secondary hyperparathyroidism associated with vitamin D deficiency. In this generally existing state of vitamin D deficiency, a large amount of parathyroid hormone is secreted to maintain the balance of serum calcium concentration. Parathyroid hormone indirectly increases the plasma calcium concentration by activating osteoclasts.

[0038] Bone resorption inhibition treatment worsens this hypocalcemia because osteoclasts are inhibited.

[0039] In particular, in the oncological use of bone resorption inhibitors such as anti-RANKL antibodies, insufficient supply of calcium and / or vitamin D can deteriorate dramatically. PROLIA (denosumab 60 ​​​​​​​​​​​​For both Prolia (denosumab 60 mg) and XGEVA (denosumab 120 mg), due to their high bone resorption inhibitory potency, so-called "urgent safety information" that clearly instructs physicians that "calcium and vitamin D supplementation is necessary in all patients except those with existing hypercalcemia" was issued in September 2014.

[0040] The hypocalcemia thus caused can lead to cardiac arrhythmias, and in particularly severe cases, can be fatal if the hypocalcemia is not detected and treated promptly without delay. Furthermore, in the clinical management of outpatient patients, calcium levels are not measured at frequent intervals as test values, so hypocalcemia often remains undetected. To prevent treatment-induced adverse effects of hypocalcemia, the present invention proposes calcium and vitamin D supplementation in the use of anti-RANKL antibodies that can prevent hypocalcemia. In the clinical management of outpatient patients, calcium levels are not measured at frequent intervals as test values, so hypocalcemia often remains undetected. To prevent treatment-induced adverse effects of hypocalcemia, the present invention proposes calcium and vitamin D supplementation in the use of anti-RANKL antibodies that can prevent hypocalcemia. Since undetected deficiencies of calcium and vitamin D can negatively impact the overall results of bone resorption inhibitory treatment, such as treatment with anti-RANK L antibodies, if calcium and vitamin D supplementation is not provided during bone resorption inhibitory treatment, it can reduce the desired protection against new fractures or even increase the number of fractures. Since undetected deficiencies of calcium and vitamin D can negatively impact the overall results of bone resorption inhibitory treatment, such as treatment with anti-RANK L antibodies, if calcium and vitamin D supplementation is not provided during bone resorption inhibitory treatment, it can reduce the desired protection against new fractures or even increase the number of fractures.

[0041] Jaw osteonecrosis is listed as an adverse effect of anti-RANKL. Jaw osteonecrosis can occur in treatment with anti-RANK L antibodies, resulting in oral pain and non-healing wounds and can lead to jaw collapse. Jaw osteonecrosis is listed as an adverse effect of anti-RANKL. Jaw osteonecrosis can occur in treatment with anti-RANK L antibodies, resulting in oral pain and non-healing wounds and can lead to jaw collapse.

[0042] L antibodies, resulting in oral pain and non-healing wounds and can lead to jaw collapse. NKL antibodies, resulting in oral pain and non-healing wounds and can lead to jaw collapse. and can lead to jaw collapse.

[0043] As further harmful effects of bone resorption inhibition treatment, cardiovascular harmful effects such as cardiac arrhythmia, spasm and secondary hyperparathyroidism may occur.

SUMMARY OF THE INVENTION

PROBLEMS TO BE SOLVED BY THE INVENTION

[0044] The present invention solves these problems, treats disorders of bone metabolism better, or prevents these disorders, ensures optimal effects, and prevents or prevents treatment-induced harmful effects (such as hypocalcemia and / or inappropriate use), to provide a novel pharmaceutical composition of an anti-RANKL antibody and calcium and vitamin D and / or their derivatives.

MEANS FOR SOLVING THE PROBLEM

[0045] In a first embodiment, the present invention is used for treating osteoporosis, postmenopausal osteoporosis, overt osteoporosis, corticosteroid-induced osteoporosis, male or female osteoporosis, Paget's disease, and osteogenesis imperfecta, preventing fractures in the above disorders, and treating and / or preventing hypocalcemia induced by anti-RANKL antibody therapy. Regarding the use of a pharmaceutical composition containing an anti-RANKL antibody and / or its antigen-binding fragment and calcium and vitamin D, the pharmaceutical composition containing an anti-RANKL antibody and / or its antigen-binding fragment is more preferably 30 to 90 mg (20 to 60 mg / ml) in a solution of 1 to 2 ml, more preferably 50 to 70 mg, and even more preferably preferably 60 mg (60 mg / ml) in a solution of 1 ml. A pharmaceutical composition containing calcium and administered subcutaneously once a year or at six - month intervals, is orally administered at a dose of 400 - 600 mg per day, particularly preferably 500 mg per day, and vitamin D is orally administered at a dose of 800 - 1200 IU (International Units) of vitamin D per day, particularly preferably 1000 IU of vitamin D per day. It is orally administered at a dose of 400 - 600 mg per day, particularly preferably 500 mg per day. Vitamin D is orally administered at a dose of 800 - 1200 IU (International Units) of vitamin D per day, particularly preferably 1000 IU of vitamin D per day.

[0046] In a further example, the present invention is for preventing bone - related complications, particularly pathological fractures, radiation of bone, spinal cord compression, bone surgery, bone metastasis, pain in bone metastasis, nerve entrapment or deformities caused by one or more solid tumors, e.g., breast cancer, prostate cancer, lung cancer or multiple myeloma, and for preventing fractures in the above - mentioned disorders, and for use in the treatment and / or prevention of hypocalcemia induced by anti - RANKL antibody therapy. Regarding the use of a pharmaceutical composition containing an anti - RANKL antibody and / or its antigen - binding fragment and calcium and vitamin D, the anti - RANKL antibody and / or its antigen - binding fragment is preferably 60 - 180 mg in a solution of 1 - 3 ml, more preferably 80 - 150 mg, even more preferably 120 mg (70 mg / ml) of anti - RANKL antibody in a solution of 1.7 ml, administered subcutaneously for at least 3 - 4 weeks, 400 - 600 mg of calcium per day, particularly preferably 500 mg of calcium per day is orally administered, and 800 - 1200 IU of vitamin D per day, particularly preferably 1000 IU of vitamin D per day is orally administered. The anti - RANKL antibody and / or its antigen - binding fragment is preferably 60 - 180 mg in a solution of 1 - 3 ml, more preferably 80 - 150 mg, even more preferably 120 mg (70 mg / ml) of anti - RANKL antibody in a solution of 1.7 ml, administered subcutaneously for at least 3 - 4 weeks. Calcium at a dose of 400 - 600 mg per day, particularly preferably 500 mg of calcium per day is orally administered, and vitamin D at a dose of 800 - 1200 IU per day, particularly preferably 1000 IU of vitamin D per day is orally administered. It is characterized by that 400 - 600 mg of calcium per day, particularly preferably 500 mg of calcium per day is orally administered, and 800 - 1200 IU of vitamin D per day, particularly preferably 1000 IU of vitamin D per day is orally administered. Calcium at a dose of 400 - 600 mg per day, particularly preferably 500 mg of calcium per day is orally administered, and vitamin D at a dose of 800 - 1200 IU per day, particularly preferably 1000 IU of vitamin D per day is orally administered. It is characterized by that 400 - 600 mg of calcium per day, particularly preferably 500 mg of calcium per day is orally administered, and 800 - 1200 IU of vitamin D per day, particularly preferably 1000 IU of vitamin D per day is orally administered.

[0047] Furthermore, the present invention, in a further aspect, relates to the treatment of treatment - induced adverse effects in the above - mentioned examples. Use of various calcium compounds and vitamin D in the treatment and / or prevention, and also relates to the use of pharmaceutically suitable excipients and solvents.

[0048] The following drawings and examples are for illustrative purposes only and do not limit the present invention to said drawings or examples. shall not be so limited.

Brief Description of the Drawings

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BEST MODE FOR CARRYING OUT THE INVENTION

[0063] The anti-RANKL antibody is a very effective bone resorption inhibitor and is used for the treatment of bone metabolism disorders. Despite its effectiveness, treatment with the anti-RANKL antibody has considerable adverse effects. Sometimes, it is accompanied by severe adverse effects. The present invention provides a pharmaceutical composition that substantially improves the efficacy and safety of treatment with an anti-RANKL antibody. These pharmaceutical compositions contain calcium and vitamin D in addition to the anti-RANKL antibody. The anti-RANKL antibody binds to RANKL. RANKL is a transmembrane protein but can also exist as a soluble protein. RANKL plays a decisive role in the formation, function, and

[0064] survival of osteoclasts. In multiple myeloma and bone metastasis, osteoclast activity stimulated by RANKL increases. This leads to increased bone resorption. The sequence of the human RANKL protein is shown in FIG. 6. This protein exists in various isoforms. Isoform 2 lacks amino acids 1-73, and isoform 3 lacks amino acids 1-47.

[0065] The anti-RANKL antibody interferes with the RANK-RANKL interaction. Thereby, the number and function of osteoclasts decrease, and bone resorption decreases. The term "anti-RANKL antibody" includes any RANKL-binding molecule that binds to at least one epitope of RANKL such that osteoclast activation is reduced or inhibited, and thus affects the activity of RANKL, i.e., blocks or reduces the binding of RANKL to RANK. The selected human amino acid sequence of RANKL is shown in FIG. 6 (SEQ ID NO: 7).

[0066] The term "epitope" refers to the binding site on an antigen, in this case, specifically for the anti-RANKL antibody .

[0067] The term "anti-RANKL antibody" includes all RANKL-binding molecules that bind to at least one epitope of RANKL so that osteoclast activation is decreased or inhibited, and thus affects the activity of RANKL, that is, blocks or decreases the binding of RANKL to RANK. The selected human amino acid sequence of RANKL is shown in FIG. 6 (SEQ ID NO: 7). The term "epitope" refers to the binding site on an antigen, in this case, specifically for the anti-RANKL antibody and which affects the activity of RANKL, that is, blocks or reduces the binding of RANKL to RANK. All such RANKL-binding molecules are included. The selected human amino acid sequence of RANKL is shown in FIG. 6 (SEQ ID NO: 7).

[0068] The term "epitope" refers to the binding site on an antigen, in this case, specifically for the anti-RANKL antibody Refers to the binding site on RANKL to which it binds. An epitope typically contains at least 3 amino acids, usually at least 5, or for example 8-10 amino acids, and binds to the amino acid primary sequence of RANKL. Depending on the three-dimensional structure of RANKL, the epitope can also bind to amino acids that are not consecutive to each other but are placed close to each other due to its three- dimensional structure.

[0069] The term "specifically binds" means that an antibody can interact with at least 2, preferably 3, more preferably 4 amino acids of a certain epitope, for example according to the "lock and key principle".

[0070] The term "specific" means that an antibody binds to the RANKL molecule but does not essentially bind to other proteins or molecules. An antibody may cross-react with RANKL molecules of other species. However, an antibody should not bind to other molecules such as RANK for example. Binding is generally considered specific when the binding affinity exceeds 10 -5 M. The specific binding affinity is preferably approximately 10 ~10 -11 ~10 -8 M (KD), more preferably approximately 10 ~10 -11 ~10 -9 M.

[0071] The term "does not essentially bind" means that the anti-RANKL antibody of the present invention does not bind to any other protein, in particular, it shows less than 30%, preferably 2 0%, more preferably less than 10% cross-reactivity with another protein or molecule, in particular, it shows less than 9, 8, 7,

[0072] The term "polypeptide" has the same meaning as the term "protein". A protein comprises one or more amino acids linked to each other by covalent bonds. A protein may undergo post - translational modifications such as glycosylation, which is generally known in the art.

[0073] The term "antibody" includes proteins having one or more antigen - binding domains that are at least partially encoded by an immunoglobulin gene or a part thereof. An "immunoglobulin" is an "antibody". An antibody typically comprises a glycosylated trimer (protein) composed of two light chains, each approximately 25 kDa, and two heavy chains, each approximately 50 kDa. There are two types of light chains in an antibody: lambda and kappa. These light chains are each composed of one variable domain and one constant domain, which are called VL and CL, respectively. Depending on the amino acid sequence of the constant region of the heavy chain, immunoglobulins are divided into five classes, A, D, E, G and M, some of which are further divided into subgroups, for example, IgG1, IgG2, IgG3, IgG4, IgA1 and IgA2. Each heavy chain has one domain, three variable domains in the case of IgG and IgA, or four constant domains in the case of IgM and IgE. Similarly, these are called VH and CH1, CH2, CH3.

[0074] IgM antibodies contain 10 antigen - binding sites. The basic unit is composed of two heavy H chains and two light L chains. IgM is produced as the first immunoglobulin during an immune response. ​​​​​​​​​​​​​​​Activates the complement system. Endogenous, naturally produced IgM antibodies are secreted by B1 cells (CD20 + , CD20 + , CD27 + , CD43 + and CD70 + cells). In addition to preventing invading microorganisms, IgM antibodies are involved in tissue homeostasis through the clearance of apoptotic cells and modified cells using complement-dependent mechanisms. They inhibit inflammatory processes and remove modified cells.

[0075] IgA antibodies contain 2 to 5 of the four-chain units that can form units together with the J chain. I gA can exist as a monomer (i.e., just one molecule) or a dimer (two molecules joined at the long ends of the antibodies). In the case of a dimer, this is the so-called secretory IgA (s IgA).

[0076] Each light chain contains an N-terminal variable (V) domain (VL) and a constant domain (CL). Each heavy chain contains one N-terminal V domain (VH), three or four C domains (CH), and one hinge region.

[0077] The constant domains of the antibody are not directly involved in antigen binding but can have various effector functions, for example, in antibody-dependent cytotoxicity . When an antibody exhibits cytotoxicity, it should preferably be of the IgG1 subtype, and the IgG4 subtype does not have this ability.

[0078] The binding of VH and VL forms the antigen-binding site. Each L chain is linked to the H chain via a covalent disulfide bridge, and the two H chains are linked by 1 or are linked to each other by several disulfide bridges. The VH and VL domains form a framework for three regions containing hypervariable sequences, complementarity-determining regions, CDRs, and four regions (FR1, FR2, FR3, and FR4) with relatively highly conserved sequences that form the framework for the three regions. The CDRs are essentially involved in the interaction between the antigen and the antibody. The CDRs are more specifically designated as CDR1, CDR2, and CDR3. Therefore, the CDR regions of the heavy chain are designated as H1, H2, and H3, and the CDR regions of the light chain are designated as L1, L2, and L3. The term "variable" refers to a part of the immunoglobulin domain, such as the variable domain, that has variability in the sequence and defines the specificity and binding affinity of a particular antibody. The variability is not uniformly distributed in the antibody and is concentrated in the respective subdomains of the light and heavy chains, and these subdomains are referred to as hypervariable regions or CDRs. The less conserved or non-hypervariable regions of the variable domain are the so-called framework regions (FR), and they often have a beta-sheet structure. The FR regions and the CDRs form the structure that the antigen recognizes and binds to (Kabat E.A., Wu T.T., Perry H., Gottesman K., and Foeller C. (1991) Sequences of Proteins of Immunological Interest, Fifth Edition. NIH Publication No. 91-3242). The constant domains are not directly involved in antigen-antibody binding.

[0079]

[0080] ​​​​​​​​​​​​mediates other reactions (e.g., antibody-dependent cell cytotoxicity and cell-mediated cytotoxicity, as well as complement activation). is mediated).

[0081] The terms "CDR" or "CDRs" refer to complementarity determining regions (CDRs). As described above, CDRs are called CDR1-3, and CDRs of the light chain are called CDRL1, CD RL2 and CDRL3, and CDRs including the variable region of the heavy chain are called CDRH1, CDR H2 and CDRH3. CDRs contribute determinatively to the activity of the antibody. The exact lengths of CDRs are sometimes classified and numbered differently in various systems. CD Rs are specified below according to Kabat and Chothia. All systems have overlapping parts regarding the designation of hypervariable regions within the variable sequences (Kabat et al., Chothia et al., J. Mol. Biol., 1987, 196; 901 and MacCallum et al., J. Mol. Biol., 1996, 262:732); in this document, mainly Kabat numbering is referred to.

[0082] The terms "amino acid" or "amino acid residue" refer to alanine (Ala or A); arginine (Arg or R); asparagine (Asn or N); aspartic acid (Asp or D); cysteine (Cys or C), glutamine (Gln or Q); glutamic acid (Glu or E); glycine (Gly or G); histidine (His or H); isoleucine (Ile or I); leucine (Leu or L); lysine (Lys or K); methionine (Met or M); phenylalanine (Phe or F); proline (Pro or P); Serine (Ser or S); Threonine (Thr or T); Tri Tryptophan (Trp or W); Tyrosine (Tyr or Y); Valine (Val or V ) refers to amino acids known in the art selected from the group of, and modified amino acids, syn thetic amino acids or rare amino acids may also be used.

[0083] The term "hypervariable region" or "CDR" refers to segments of regions in the light (L) and heavy (H) chains of immunoglobulins that exhibit significant differences in amino acid sequence . They are regions of antibodies or T cell receptors involved in antigen recognition. CDRs are the most variable parts of the receptor and are involved in their diversity. The three complementarity-determining regions CDR1, CDR2, and CDR3 are loops at the ends of the V domain of the antibody. They are in direct contact with the antigen. In the prior art, at least two methods for identifying CDRs are known: an approach based on sequence variability between species (Kabat et al .) and another approach based on crystallographic studies of antigen-antibody complexes (Chothia, C. et al., J. Mol. Biol., 196:901-917 (1987)). Generally, it is preferred to identify CDRs according to the so-called Kabat numbering.

[0084] The term "framework region" is known to those skilled in the art and refers to a part of the variable region of an antibody that exists between the CDRs, which are hypervariable regions. Such framework regions are typically designated as framework regions 1-4 (FR1, FR2, FR3, and FR4), and in three-dimensional space, six CDRs (three from the light chain and three from the heavy chain) provide the antigen-binding surface. ​​A framework is formed for the three of

[0085] The present invention is considered to be interchangeable according to the Kabat numbering system, All anti-RA having an antigen-binding function, i.e., capable of binding to an RANKL epitope including NKL.

[0086] "Antibody" refers to monoclonal antibodies, polyclonal antibodies, monospecific antibodies, bispecific antibodies, bifunctional antibodies, single-chain antibodies, synthetic antibodies, recombinant antibodies, mutant antibodies, human antibodies, humanized antibodies or chimeric antibodies (Harlow and Lane, "Antibodies, A Laboratory Manual", CSH Pre ss, Cold Spring Harbor, USA) or derivatives that retain or essentially retain this binding ability. Domain antibodies (dAb) and nanobodies are also included in the term "antibody".

[0087] Bispecific or bifunctional antibodies are artificial hybrid antibodies having two different heavy / light chains and two different binding sites. This term and methods for making it are known to those skilled in the art (e.g., Songsivilai & Lachmann, Cli n. Exp. Immunol. 79: 315 - 321 (1990); Kostelny et al., J. Immunol. 148, 1547 - 1553 (1992).

[0088] The production of monoclonal antibodies is known in the prior art (e.g., Kohler and Milstein (1975), Nature, 256: 495 - 499); also Examples of such methods include so-called phage display (Ladner et al., U.S. Patent No. 5,223,409).

[0089] Preferred derivatives of these antibodies are, for example, chimeric antibodies comprising the variable regions of a mouse or rat and the constant region of a human. The term "antibody" includes bifunctional or bispecific antibodies and antibody constructs (e.g., Fv(scFv) composed of individual chains or antibody fusion proteins). The term "scFv" (single-chain Fv fragment) is known to those skilled in the art and is preferred because the fragment can be recombinantly produced.

[0090] Antibodies can be human antibodies or humanized antibodies. The term "humanized antibody" means that at least one antibody binding site (complementary determining region (CDR)), e.g., CDR3, preferably all six CDRs, are replaced by the CDRs of a human antibody of the desired specificity. Optionally, the non-human constant region of the antibody is replaced by the constant region of a human antibody. Methods for producing humanized antibodies are described, for example, in EP0239400A1 and WO90 / 07861.

[0091] Instead of humanized antibodies, human antibodies are provided. Transgenic animals, e.g., mice, can produce human antibodies that do not have typical mouse antibody sequences after immunization. They can form fully human antibodies (e.g., Jakobovits et al., Proc. Natl. Acad. Sci. USA, 90:2551 (1993)). Alternatively, so-called phage display technology can be used to isolate human antibodies or antigen-binding fragments It can be used to produce a tos. This technique is known in the prior art (McCa fferty et al., Nature 348:552-553(1990); J ohnson, Kevin S. and Chiswell, David J., Cur r. Opin. Struct. Biol. 3:564-571(1993)).

[0092] The term antigen-binding fragment refers to a fragment of an "antibody" as defined above, for example, separate light and heavy chains, Fab, Fab / c, Fv, scFv, Fd, dAb, Fab’, F(ab’)2. An antigen-binding fragment can include the variable region of the light chain and / or the variable region of the heavy chain, but does not necessarily include both at the same time.

[0093] Methods for producing and isolating antibodies are known in the prior art, for example, see Ha rlow and Lane; Antibodies: A Laboratory Ma nual, Cold Spring Harbor Laboratory, New Y ork(1988). Common antibody purification methods include salting out (e.g., using ammonium sulfate); ion exchange chromatography (e.g., carried out at neutral pH and eluted with a stepwise gradient increasing ionic strength, in a cation or anion exchange column); gel filtration chromatography (including gel filtration HPLC) and chromatography on an affinity resin (e.g., protein A, protein G, hydroxyapatite or anti-Ig ). Antibodies can also be purified on an affinity column containing an antigen segment. Preferred fragments are protein A CL sepharose After S4B chromatography, it is purified by chromatography on a DEAE Sepharose 4B ion exchange column. It is purified by chromatography.

[0094] The present invention also includes hybrid antibodies in which one pair of the H chain and the L chain is obtained from a first antibody and the other pair is obtained from the H chain and L chain of another second antibody. For the purposes of the present invention, the pair of L chain and H chain is derived from anti-RANKL. In one example, each L-H chain pair binds to various epitopes of the RANKL-specific antigen. Such hybrids can also be formed using humanized H chains or humanized L chains. The present invention also includes other bispecific antibodies, for example, antibodies comprising two distinct antibodies covalently bound via a constant region. The size of the antigen-binding fragment may be no more than the minimum size necessary to provide the desired function. It may, if desired, contain additional amino acid sequences native or of heterologous origin to the antigen-binding fragment. The anti-RANKL antigen-binding fragment may contain five contiguous amino acid residues from the antibody V region sequence. Also included are polypeptides containing 7 amino acid residues from the V region of the L chain or H chain of the antibody, more preferably, for example, 10 amino acid residues, more preferably, for example, 15 amino acid residues, more preferably, for example, 25 amino acid residues, more preferably, for example, 50 amino acid residues, more preferably, for example, 75 amino acid residues. Even more preferred are polypeptides containing the entire V region of the L chain or H chain of the antibody. For the purposes of the present invention, the pair of L chain and H chain is derived from anti-RANKL. In one example, each L-H chain pair binds to various epitopes of the RANKL-specific antigen. Such hybrids can also be formed using humanized H chains or humanized L chains. The present invention also includes other bispecific antibodies, for example, antibodies comprising two distinct antibodies covalently bound via a constant region. The size of the antigen-binding fragment may be no more than the minimum size necessary to provide the desired function. It may, if desired, contain additional amino acid sequences native or of heterologous origin to the antigen-binding fragment. The anti-RANKL antigen-binding fragment may contain five contiguous amino acid residues from the antibody V region sequence. Also included are polypeptides containing 7 amino acid residues from the V region of the L chain or H chain of the antibody, more preferably, for example, 10 amino acid residues, more preferably, for example, 15 amino acid residues, more preferably, for example, 25 amino acid residues, more preferably, for example, 50 amino acid residues, more preferably, for example, 75 amino acid residues. Even more preferred are polypeptides containing the entire V region of the L chain or H chain of the antibody.

[0095] Substitution involves changing or modifying one or more amino acid residues, for example, in the V region etc. It may, if desired, contain additional amino acid sequences native or of heterologous origin to the antigen-binding fragment. The anti-RANKL antigen-binding fragment may contain five contiguous amino acid residues from the antibody V region sequence. Also included are polypeptides containing 7 amino acid residues from the V region of the L chain or H chain of the antibody, more preferably, for example, 10 amino acid residues, more preferably, for example, 15 amino acid residues, more preferably, for example, 25 amino acid residues, more preferably, for example, 50 amino acid residues, more preferably, for example, 75 amino acid residues. Even more preferred are polypeptides containing the entire V region of the L chain or H chain of the antibody. For example, 10 amino acid residues, more preferably, for example, 15 amino acid residues, more preferably, for example, 25 amino acid residues, more preferably, for example, 50 amino acid residues, more preferably, for example, 75 amino acid residues. Also included are polypeptides containing 7 amino acid residues from the V region of the L chain or H chain of the antibody, more preferably, for example, 10 amino acid residues, more preferably, for example, 15 amino acid residues, more preferably, for example, 25 amino acid residues, more preferably, for example, 50 amino acid residues, more preferably, for example, 75 amino acid residues. Even more preferred are polypeptides containing the entire V region of the L chain or H chain of the antibody. The present invention also includes hybrid antibodies in which one pair of the H chain and the L chain is obtained from a first antibody and the other pair is obtained from the H chain and L chain of another second antibody.

[0096] Substitution involves changing or modifying one or more amino acid residues, for example, in the V region etc. It may even be possible to completely re - design a certain region. The amino acid substitutions are preferably conservative substitutions that do not adversely affect the folding or functional properties of the peptide in the existing context. The group of functionally related amino acid residues where conservative substitutions can be made includes glycine / alanine, valine / isoleucine / leucine; asparagine / glutamine, aspartic acid / glutamic acid; serine / threonine / methionine; lysine / arginine and phenylalanine / tyrosine / tryptophan. Antibodies may be glycosylated, may not be glycosylated, may be post - translationally modified (e.g., acetylation and phosphorylation), or may be synthetically modified (e.g., attachment of a label group). Furthermore, anti - RANKL antibodies with altered amino acid sequences are provided. These alterations may include deletions, insertions, and substitutions of individual or multiple amino acids. For this reason, post - translation modifications may also be subject to changes. Changes in the CDRs of the light and heavy chains, particularly those in the hypervariable regions, are most useful, but changes in the FRs in the light chain and / or heavy chain may also be considered. If the CDR sequence contains 6 amino acids, 1 - 3 amino acids can be changed. If the CDR sequence contains 15 amino acids, 1 - 6 amino acids can be changed. When the CDR is changed in the light chain and / or heavy chain, the altered amino acid sequence should be at least 60%, more preferably 65%, even more preferably 70%, particularly preferably 75%, most preferably 80% identical to the original CDR sequence. For this reason, the identity with the original CDR

[0097]

[0098] ​​​​​​​​​​​​​​The degree depends on the length of each CDR. Including 5 amino acids and 1 modification The CDR, which is 80% identical, has a longer CDR with 1 amino acid modification The modification in is lower in percentage terms. Therefore, the CDR can have an identity different from the original CDR, for example, CDRH1 can be 90% identical, but CD RL2 is 83% identical.

[0099] Preferred modifications in the anti - RANKL antibody are shown in Table 1.

[0100]

Table 1

[0101] These are listed as examples and are preferably 60%, more preferably 65%, still more preferably 70%, still more preferably 75%, most preferably 80% identical to the original CDR sequence. Sequences that specifically bind to RANKL are included. Further moreover, methods regarding the modification of CDRs are known (for example, U.S. Patent No. 6,180,370 ; No. 5,693,762; No. 5,693,761; No. 5,585,089 and No. 5,530,101).

[0102] An example of the cDNA sequence for the heavy chain of the anti - RANKL antibody is shown in Figure 7 (SEQ ID NO: 1) here.

[0103] An example of the protein sequence for the heavy chain of the anti - RANKL antibody is shown in Figure 8 (SEQ ID NO: 2) here.

[0104] An example of the DNA sequence for the light chain of the anti - RANKL antibody is shown in Figure 9 (SEQ ID NO: 3) here.

[0105] An example of the protein sequence for the light chain of the anti-RANKL antibody is shown in FIG. 10 (SEQ ID NO: 4). It is shown in FIG. 10 (SEQ ID NO: 4).

[0106] An example of the protein sequence for the variable region of the heavy chain of the anti-RANKL antibody is shown in FIG. 11 (SEQ ID NO: 5).

[0107] An example of the protein sequence for the variable region of the light chain of the anti-RANKL antibody is shown in FIG. 12 (SEQ ID NO: 6).

[0108] An example of the protein sequence for RANKL is shown in FIG. 13 (SEQ ID NO: 7).

[0109] A further example of the protein sequence for the heavy chain of the anti-RANKL antibody is shown in FIG. 14 (SEQ ID NO: 8 ).

[0110] A further example of the protein sequence for the light chain of the anti-RANKL antibody is shown in FIG. 15 (SEQ ID NO: 9 ).

[0111] According to the present invention, antigen-binding fragments of the anti-RANKL antibody are also included.

[0112] Prolia (which contains denosumab, an anti-RANKL antibody approved as a pharmaceutical formulation) is sold by Amgen GmbH. It contains a 60 mg denosumab injection solution. Each filled syringe contains 60 mg of denosumab in 1 ml of solution (6 0 mg / ml). The recommended dose of Prolia is 60 mg administered as a single subcutaneous injection every 6 months (in the thigh, abdomen or upper arm). Prolia is used to treat osteoporosis in postmenopausal women to prevent vertebral and non-vertebral fractures, for osteoporosis and high To treat men with an increased risk of hip fracture to increase bone mineral density, and as combination therapy in women with breast cancer under adjuvant therapy with an aromatase inhibitor and in men with prostate cancer under hormonal ablation therapy, when there is an increased risk of hip fracture. It is used.

[0113] The pharmaceutical preparation Xgeva also contains an anti-RANKL antibody (denosumab, Amgen, and each injection vial contains 120 mg of denosumab in 1.7 ml of solution (70 mg / ml ). Xgeva is used to prevent bone-related complications (pathological fracture, irradiation of bone, spinal cord compression, or bone surgery) in adults with bone metastases due to solid tumors, and to treat adults and skeletally mature adolescents who have inoperable giant cell tumors of bone or for whom surgical resection may lead to severe morbid states. The summary of product characteristics only recommends sufficient intake of calcium and vitamin D, and the exact dosage is not indicated. A sufficient total daily calcium supply is 1000 mg. Since calcium is absorbed through the diet, the required daily amount can be achieved by consuming a calcium-rich diet. Calcium intakes above 2500 mg per day are considered problematic as they can increase the risk of kidney stone formation, among other reasons. Due to various reports of cardiovascular adverse effects attributed to excessive calcium intake, many patients

[0114] even during treatment with anti-RANKL antibodies refrained from consuming sufficient amounts of calcium. In many cases, this generally jeopardizes the outcome of treatment with anti-RANKL antibodies and is suboptimal.

[0115] Due to insufficient calcium supply or inhibition of calcium absorption from bone into the blood by anti- treatment with RANKL antibodies causes strong inhibition of bone resorption, leading to cardiovascular adverse effects.

[0116] This results in hypocalcemia, which causes cardiovascular adverse effects. In principle, this causes exactly the opposite of the desired result. High cardiovascular adverse effects occur due to calcium deficiency rather than excessive calcium supply, but this can be prevented by providing appropriate calcium supply during treatment with anti-RANKL

[0117] Supplementation with a pharmaceutical composition containing 1000 - 1500 mg of calcium per day in people consuming a diet containing sufficient calcium can lead to excessive calcium intake, thereby increasing the risk of cardiovascular adverse effects. In contrast to the study design that includes a daily dose of 1000 - 1500 mg of calcium in the product characteristics summary of Aclasta, the present invention provides lower doses to treat or prevent hypocalcemia and cardiovascular adverse effects.

[0118] On the one hand, to achieve a basic level of calcium in patients on a calcium-deficient diet, and on the other hand, to avoid excessive calcium supply, which is unacceptable for patients due to the above-mentioned risks, the preferred amount of calcium in the pharmaceutical composition is 400 - 600 mg of calcium per day, particularly preferably 500 mg of calcium per day. According to the results report of the National Consumption Study II conducted in Germany, 46% of men and 55% of women do not reach the Not taking sodium. In the 51 - 80 age group, the average calcium intake is in the range of 490 - 1790 mg of calcium per day.

[0119] According to the summary of the product characteristics of Xgeva, in combination with 400 IU of vitamin D per day, 500 mg of calcium should be taken per day. The research on Xgeva was conducted on patients in the United States. In the United States, many foods (such as milk, orange juice, various breads or breakfast cereals) are fortified with vitamin D. In Germany and the EU, since this is usually different from the fact, according to the present invention, more than 800 - 1200 IU of vitamin D per day, particularly preferably 1000 IU of vitamin D per day is provided. A larger amount of vitamin D can potentially promote the transport of a smaller amount of calcium from the

[0120] gastrointestinal tract into the blood, so that even with a smaller amount of calcium, a sufficient serum calcium level can be achieved. Therefore, in contrast to the summary of the product characteristics for Xgeva, a combination therapy using an anti - RANKL antibody, 400 - 600 mg of calcium and 800 - 1200 IU of vitamin D per day is provided for the prevention and treatment of hypocalcemia. Thus, with an increase in vitamin D, a low calcium dose of 400 - 600 mg, preferably 500 mg of calcium per day

[0121] is guaranteed to maintain a standard level above 2.2 mmol / l (9 mg / dl) of calcium concentration. It is provided for vitamin D serum concentrations above nmol / l serum).

[0122] In severe deficiency (<10 ng / ml serum), 200,000 IU over 10 days, subsequently, replacement at 20,000 IU per week should be performed. In marked deficiency (10 - 20 n g / ml serum), after an initial replacement of 100,000 IU, 20,000 IU / week maintenance should be performed. In the case of normal deficiency (21 - 30 ng / ml serum), 2 0,000 IU / week replacement should be performed. Once normal vitamin D levels are reached (31 - 60 ng / ml serum), daily replacement according to the invention of 800 - 1200 IU, particularly preferably 1000 IU of vitamin D according to the invention should be performed.

[0123] In the administration of the pharmaceutical composition according to the invention of anti - RANKL antibody and calcium, supplementation with 40 0 IU of vitamin D is not sufficient to maintain vitamin D levels in the normal range of 31 - 60 ng / ml serum.

[0124] Therefore, hypocalcemia is prevented using the pharmaceutical composition according to the invention of anti - RANKL antibody, calcium and vitamin D.

[0125] According to the invention, an anti - RANKL antibody - containing pharmaceutical composition for treating osteoporosis, postmenopausal osteoporosis, overt osteoporosis, corticosteroid - induced osteoporosis, male or female osteoporosis, Paget's disease, osteogenesis imperfecta, preventing fractures in the above - mentioned disorders, and for use in the treatment and / or prevention of hypocalcemia induced by anti - RANKL antibody therapy is preferably 30 - 90 mg (20 - in a solution of 1 - 2 ml in a solution of 1 - 2 ml and is preferably 30 - 90 mg (20 - ​60 mg / ml), more preferably 50 - 70 mg, even more preferably, preferably is administered subcutaneously once a year or every six months at a dose of 60 mg (60 mg / ml) in 1 ml of solution.

[0126] According to the present invention, a pharmaceutical composition containing an anti - RANKL antibody is useful in the field of oncology for treating and / or preventing bone - related complications, particularly, solid tumors, particularly breast cancer, prostate cancer, lung cancer, intestinal cancer or bone cancer (osteosarcoma) induced bone - related complications, pathological fractures, radiation of bone, spinal cord compression or bone surgery, bone metastases, pain in bone metastases, nerve entrapment, deformities caused by one or more solid tumors (e.g., breast cancer, prostate cancer, lung cancer or multiple myeloma), and for preventing fractures in the above - described disorders, and for treating and / or preventing hypocalcemia induced by anti - RANKL antibody therapy, preferably, 60 - 180 mg, more preferably 80 - 150 mg, even more preferably 120 mg (70 mg / ml) of the anti - RANKL antibody in a solution of 1 - 3 ml, especially in a solution of 1.7 ml, is administered subcutaneously for at least 3 - 4 weeks.

[0127] According to the present invention, the pharmaceutical composition listed above is used, where the anti - RANKL antibody is a monoclonal antibody, polyclonal antibody, monospecific antibody, bispecific antibody, bifunctional antibody, single - chain antibody, synthetic antibody, recombinant antibody, mutant antibody, human antibody, humanized antibody or chimeric antibody, IgG, IgA, IgM or IgE antibody, antigen - binding fragment or antibody construct (e.g., individual chains or antibody fusion proteins or fragments thereof, In particular, it comprises Fv (scFv), Fab, Fab / c, composed of separate light and heavy chains, Fv, scFv, Fd, dAb, Fab’ or F(ab’)2, wherein the tag ment comprises the variable region of the light chain and / or the variable region of the heavy chain.

[0128] The term "calcium" includes all known calcium compounds that may be pharmaceutically acceptable, including, but not limited to, in particular the following: calcium citrate, further names: tricalcium citrate, TCC, dicalcium tricalcium citrate tri-calcium di-[2-hydroxy-1,2,3-propanetricarboxylate -tetrahydrate, E333, C H 12 H 10 Ca 3 O 14 , CAS number: 813-94-5 ( anhydrous), 5785-44-4 (tetrahydrate); calcium gluconate monohydrate (C 12 H 2 2 CaO 14 ·H 2 O, CAS number: 299-28-5 (anhydrous) and 66905-23 -5 (monohydrate)); calcium gluconate lactate, a double salt of lactic acid and gluconic acid in the form of a mixture, further names: CLG, calcium gluconate lactate, lactogluconic acid calcium E327, E578, CAS number: 11116-97-5, 814-80-2 (calcium lactate pentahydrate), 18016-24-5 (calcium gluconate monohydrate) or calcium carbonate CaCO ), CAS number: 471-34-1, calcium phosphate, calcium di 3 hydrogen phosphate, calcium hydrogen phosphate, calcium hydrogen phosphate dihydrate, calcium acetate ), calcium dihydrogen phosphate, calcium hydrogen phosphate, calcium hydrogen phosphate dihydrate, calcium acetate Calcium ascorbate, calcium chloride, calcium glucoheptonate, glycerol Calcium phosphate and / or calcium sulfate.

[0129] The term "vitamin D" includes vitamin D or its derivatives, and these include, in particular In particular, vitamin D3 (cholecalciferol, C 27 H 44 O, CAS number: 67-97- 0), calcitriol (1,25-dihydroxyvitamin D3, 1α,25-dihydro xycholecalciferol, 1,25(OH) 2 vitamin D3, 1,25(OH) 2 D3 ,(5Z,7E)-(1S,3R)-9,10-secocholesta-5,7,10(19)- triene-1,3,25-triol, CAS number: 32222-06-3) or 1α ,25-dihydroxycholecalciferol (biologically active form of vitamin D3), alph acalcidol (1α-hydroxyvitamin D3), 24,25-dihydroxyvitamin D3 or calcifediol (25-hydroxyvitamin D3 25-hydroxycole calciferol, CAS number: 19356-17-3, IUPAC name: (6R)-6- [(1R,3aR,4E,7aR)-4-[(2Z)-2-[(5S)-5-hydroxy -2-methylidene-cyclohexylidene]ethylidene]-7a-methyl-2,3,3a, 5,6,7-hexahydro-1H-inden-1-yl]-2-methyl-heptan-2- ol), vitamin D2 (3β,5Z,7E,22E)-9,10-secoergosta-5 ,7,10(19),22-tetraen-3-ol, calciferol, ergocal calciferol, CAS number: 50-14-6 or their biological forms are mentioned, but , but not limited to these.

[0130] Both vitamin D preparations and anti-RANKL antibodies (denosumab, Prolia and Xgeva , Amgen Inc.) and calcium are commercially available, and the methods for producing them are known to those skilled in the art.

[0131] In a further example, the pharmaceutical composition is for the treatment and / or prevention of the adverse effects of anti-RANKL antibodies, in particular osteonecrosis of the jaw associated with oral pain , non-healing wounds leading to jaw collapse, hypocalcemia, cardiovascular adverse effects such as arrhythmia , spasm and secondary hyperparathyroidism.

[0132] In one example, the anti-RANKL antibody in the amount shown above is provided as an injection solution of 1 - 3 ml in a pharmaceutically acceptable solution (e.g. an isotonic saline solution or an isotonic sorbitol-sodium acetate-polysorbate solution , an isotonic sorbitol-sodium acetate solution, an isotonic glucose solution or another pharmaceutically suitable isotonic solution of a suitable pH).

[0133] In a further example, calcium and vitamin D are combined with pharmaceutically suitable excipients, in particular lactose, starch, acidifying agents, in particular citric acid and malic acid, acid regulators, in particular sodium bicarbonate and sodium carbonate, humectants, in particular sorbitol, xylitol and inulin, separating agents, in particular tricalcium phosphate, fatty acids, in particular magnesium salts, in particular magnesium stearate, natural and natural-identical and other flavorings and fragrances flavoring substances, sweeteners, in particular sodium cyclamate, aspartame and saccharin Thorium, maltodextrin, pigments, particularly, red beet juice powder and riboflavin -5'-phosphate, silicon dioxide, particularly, highly dispersed, silicon dioxide hydrate, phenylalanine lanine, gum arabic, sucrose, gelatin, corn starch, soybean oil, glycerol DL-alpha tocopherol, isomalt, sodium bicarbonate, sodium dihydrogen carbonate sodium citrate, sodium dihydrogen citrate, sodium carboxymethylcellulose, asulam potassium sodium ascorbate, triglycerides, particularly, medium-chain triglyceride along with and / or provided in a pharmaceutically compatible liquid, particularly, water, isotonic saline or a glucose solution.

[0134] In a further example, an anti-RANKL antibody, calcium and vitamin D are, if necessary together with pharmaceutically suitable excipients and / or liquids, particularly, effervescent tablets, swallowable tablets or capsules, chewable tablets, effervescent granules, ready-to-use granules, drinking solutions, drops sublingual sprays, infusion liquid concentrates, immediate infusion liquids, injection liquid concentrates, injection liquids or filled syringes, provided individually or in combination.

Example

[0135] Vitamin D deficiency is a common diagnosis in orthopedic clinics. At the start of treatment, 89 out of 423 patients showed vitamin D deficiency below the standard value of 20 ng / ml serum or 50 nmol / l. The maintenance dose was 1000 IU of vitamin D per day. A maintenance dose of 400 IU of vitamin D per day was not sufficient to maintain the vitamin D concentration at the standard level. Table 2 shows that a maintenance dose of 1000 IU of vitamin D... It is shown to be suitable for maintaining vitamin D levels within the normal range.

[0136]

Table 2

Examples

[0137] Furthermore, the vitamin D levels of 37 more patients were analyzed. At the start of treatment, approximately 51 %(n = 19) of the patients had vitamin D deficiency [25(OH)VitD serum concentration < 30 ng / ml blood serum or 75 nmol / l]. In 27% (n = 10) of the patients, the 25(OH) VitD serum concentration was less than 20 ng / ml serum or 50 nmol / l (= severe vitamin D deficiency). The left column of each of Table 3 below shows the daily calcium intake in the diet, in mg. A daily intake of less than 1000 mg in the diet results in a negative calcium balance. This leads to secondary hyperparathyroidism and loss of bone tissue. A daily supply of calcium of less than 500 mg is associated with an increased risk of fractures other than vertebral fractures.

[0138]

Table 3

Examples

[0139] The so-called "chair stand test" (standing test) was performed on 3 patients.

[0140] With the chair stand test (standing test), it is possible to measure the strength and fall risk of the subject. The subject folds their arms in front of their chest and stands at a normal height (approximately Rise from a chair with a seat height of 46 cm and sit down 5 times as quickly as possible without using your hands. If the patient is unable to do this, count the number of successful attempts rather than the number of seconds. If the patient takes longer than 10 - 11 seconds, that patient must be assumed to be at high risk of falling.

[0141] Table 4: Before starting treatment with 60 mg of anti - RANKL antibody / denosumab (Prolia) + 500 mg of calcium + 1000 IE of vitamin D3, the chair - rising test was performed in 3 osteoporotic patients (left column), and then repeated for 6 months (central column). The improvement is shown in percentage units in the right column.

[0142]

Table 4

[0143] The treatment reduced the risk of falling by 11 - 29%.

Example

[0144] The data from cancer patients (prostate cancer) in Table 5 below shows the serum levels of calcium and vitamin D3 in the administration of 120 mg of denosumab (anti - RANKL antibody, Xgeva) every 4 weeks and the oral administration of 500 mg of calcium and 1000 IU of vitamin D3 per day.

[0145]

Table 5

[0146] The data from osteoporotic patients in Table 6 below shows the 60 mg of anti - RANK Administration of L antibody / denosumab (Prolia) and 500 mg of calcium and Calcium and vitamin D in a diet containing 1,000 IU of vitamin D3 per day The serum value of 3 is shown.

[0147] [Table 6]

[0148] Severe vitamin D deficiency, with a 25(OH) vitamin D serum concentration of <20 ng / ml This, according to the DVO guidelines, represents a high risk of fracture. The data in Example 4 show that the combination of the present invention reduces the 25(OH) bile acid level within 3 to 6 months. normalization of serum ATP levels to >20ng / ml or >20μg / l, and therefore This suggests that it may be suitable for reducing the risk of fracture.

[0149] Generally, calcium serum concentrations in patients with osteoporosis are within the normal range. In patients, blood calcium levels are elevated due to treatment (= tumor-induced hypercalcemia). The calcium phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate phosphate Therefore, patients consuming a calcium-deficient diet are at risk for hypocalcemia. High calcium intake. The present invention provides 500 mg of calcium supplementation per day, which provides a balanced calcium intake. lucium is provided.

[0150] High PTH levels (= secondary hyperparathyroidism) and anti-RANKL antibodies (denosmosis) Hypocalcemia induced by antiresorptive therapy with acetabular necrosis (AB) may be a risk factor for the development of jaw necrosis. Therefore, the present invention's supplementation with calcium and vitamin D is a risk factor for jaw necrosis. Reduce the risk.

[0151] The above data show that the combination according to the present invention normalizes the 25(OH) vitamin D serum concentration to over 20 ng / ml or 20 μg / l within 3 to 6 months and achieves a positive calcium balance in almost all patients. Patients showed no adverse effects, especially osteonecrosis of the jaw, non-healing wounds leading to jaw collapse, treatment-induced hypocalcemia, cardiovascular adverse effects (e.g., heart attack, atrial fibrillation, cardiac arrhythmia), secondary hyperparathyroidism, spasms and / or numbness. Moreover, there were no bone-related complications, especially those due to solid tumors, especially breast cancer, prostate cancer, lung cancer, bowel cancer or bone cancer (osteosarcoma), no (pathological) fractures, no radiation of the bone, no spinal cord compression or bone surgery, no bone metastases, no pain in bone metastases, no nerve entrapment, no deformities due to one or more solid tumors (e.g., breast cancer, prostate cancer, lung cancer or multiple myeloma).

[0152] ​

Claims

1. Osteoporosis, postmenopausal osteoporosis, overt osteoporosis, corticoid-induced osteoporosis, male or To treat osteoporosis in women, Paget's disease, osteogenesis imperfecta, and fractures in the above disorders. and to prevent hypocalcemia induced by anti-RANKL antibody therapy. -RANKL ANTIBODIES AND CALCIUM FOR USE IN THE TREATMENT AND / OR PROPHYLAXIS - Patent application and vitamin D, said pharmaceutical composition comprising an anti-RANKL antibody. The composition preferably contains 30-90 mg (20-60 mg / mL) in 1-2 ml of solution. ml), more preferably 50-70 mg, even more preferably 1 ml In solution, at a dose of 60 mg (60 mg / ml), administered subcutaneously once a year or at six-monthly intervals. The pharmaceutical composition containing calcium is administered at a dose of 400 to 600 mg per day, particularly preferably or 500 mg per day, and vitamin D is administered orally at a dose of 800 mg per day. Oral doses of up to 1200 IU of vitamin D, particularly preferably 1000 IU of vitamin D The use, characterized in that it is administered.

2. Bone-related complications, in particular solid tumors, in particular breast, prostate, lung, intestinal or bone cancer (osteometrium bone-related complications due to bone tumors, pathological fractures, bone irradiation, spinal cord compression or bone surgery, bone metastasis, pain in bone metastasis, nerve entrapment, one or more solid tumors, e.g. breast cancer, prostate cancer, For treating and / or preventing deformities resulting from lung cancer or multiple myeloma, and and for preventing fractures in the aforementioned disorders, as well as bone fractures induced by anti-RANKL antibody therapy. Anti-RANKL antibody for use in the treatment and / or prevention of hypocalcemia caused by Use of a pharmaceutical composition comprising calcium and vitamin D to treat an anti-RANK The L antibody is preferably present at 60-180 mg in 1-3 ml of solution, more preferably , 80 to 150 mg, and even more preferably 120 mg, especially in 1.7 ml of solution. g (70 mg / ml) subcutaneously for at least 3-4 weeks, with 400-400 mg / ml daily. 600 mg of calcium is orally administered daily, and particularly preferably 500 mg of calcium is orally administered daily. and 800 to 1200 IU of vitamin D per day, with 1000 IU per day being particularly preferred. The use, characterized in that vitamin D is administered orally.

3. The pharmaceutical composition prevents the adverse effects of the anti-RANKL antibody, in particular osteonecrosis of the jaw, collapse of the jaw, Non-healing wounds leading to hypocalcemia, adverse cardiovascular effects such as cardiac arrhythmias, seizures and dyslipidemia. The present invention is suitable for use in the treatment and / or prevention of secondary hyperparathyroidism. Use of the pharmaceutical composition according to claim 1 or 2.

4. The anti-RANKL antibody is characterized in that it comprises a heavy chain and a light chain, the heavy chain being represented by SEQ ID NO: 2 or SEQ ID NO:8, and the light chain comprises the amino acid sequence set forth in SEQ ID NO:4 or SEQ ID NO:

9. Use of the pharmaceutical composition according to any one of claims 1 to 3, comprising the amino acid sequence according to claim 9. For.

5. The anti-RANKL antibody comprises a heavy chain variable region having the amino acid sequence set forth in SEQ ID NO:5 and / or or comprising the variable region of the light chain of the amino acid sequence set forth in SEQ ID NO:

6. Use of the pharmaceutical composition according to any one of items 1 to 4.

6. The anti-RANKL antibody may be a monoclonal antibody, a polyclonal antibody, a monospecific antibody, , bispecific antibodies, bifunctional antibodies, single-chain antibodies, synthetic antibodies, recombinant antibodies, mutant antibodies, human Antibody, humanized antibody, chimeric antibody, IgG, IgA, IgM or IgE antibody, antigen binding Fragments or antibody constructs, such as individual chains or antibody fusion proteins or the like. Fragments of Fv (scFv), Fab, which are composed of separate light and heavy chains, , Fab / c, Fv, scFv, Fd, dAb, Fab' or F(ab')2 The fragment comprises the variable region of the light chain and / or the variable region of the heavy chain, Use of the pharmaceutical composition according to any one of claims 1 to 5.

7. Calcium is, in particular, calcium gluconate, calcium lactate, calcium gluconate monohydrate, milk Calcium citrate pentahydrate, calcium citrate, calcium citrate tetrahydrate, calcium carbonate Calcium phosphate, dibasic calcium phosphate, dibasic calcium phosphate, hydrogen phosphate Calcium dihydrate, calcium acetate, calcium ascorbate, calcium chloride, Calcium glycerophosphate and / or calcium sulfate Use of the pharmaceutical composition according to any one of claims 1 to 6, comprising

8. Vitamin D is in particular vitamin D and / or vitamin D3 and / or vitamin D2 and / or their derivatives, in particular calcitriol (1,25-dihydroxy Vitamin D3) or 1α,25-dihydroxycholecalciferol, alphacalciferol Dhol (1α-hydroxyvitamin D3), 24,25-dihydroxyvitamin D3, The claimed compound comprises luciferol, vitamin D2 and / or ergo-calciferol. Use of the pharmaceutical composition according to any one of items 1 to 7.

9. The composition according to claims 1 to 8, further comprising a pharma- ceutically suitable excipient and / or liquid or solvent. The pharmaceutical composition according to any one of claims 1 to 4.

10. The excipients for the pharmaceutical composition are lactose, starch, acidifiers, especially chloasella. Enic acid, malic acid, acidity regulators, especially sodium bicarbonate and sodium carbonate, moisturizers agents, in particular sorbitol, xylitol and inulin; separating agents, in particular tricalcium phosphate; fatty acids, especially magnesium salts, especially magnesium stearate, natural and Nature-identical and other flavors and flavorings, sweeteners, in particular sodium cyclamate aspartame and sodium saccharin, maltodextrin, colours, especially lemon Red beet juice powder and riboflavin-5'-phosphate, silicon dioxide, especially high molecular weight Dispersible, silicon dioxide hydrate, phenylalanine, gum arabic, sucrose, gelatin , corn starch, soybean oil, glycerol, DL-alpha tocopherol, isomalt , Sodium bicarbonate, Sodium dihydrogen carbonate, Sodium citrate, Sodium dihydrogen citrate thorium, carmellose sodium, acesulfame potassium, sodium ascorbate and / or pharmaceutical compatible Liquids, in particular water, isotonic saline solution, isotonic sorbitol-sodium acetate-polysorbate solution, isotonic sorbitol-sodium acetate solution, isotonic glucose solution, or a suitable 10. The composition according to claim 1 in an otherwise pharma- ceutical suitable isotonic solution at a suitable pH. Use of the pharmaceutical composition.

11. 11. The method of claim 1, wherein the solvent or liquid comprises water, isotonic saline or glucose solution. Use of the pharmaceutical composition according to any one of claims 1 to 5.

12. The pharmaceutical composition comprising an anti-RANKL antibody is in the form of an infusion solution, an infusion concentrate, a ready-to-use infusion solution or is provided as a pre-filled syringe and contains calcium and / or vitamin D as a solid or The pharmaceutical composition in liquid form may be an effervescent tablet, a swallowable tablet or capsule, a tube, or the like. Available as tablets, effervescent granules, ready-to-use granules, drinking solution, drops or sublingual spray. The drug according to any one of claims 1 to 11, provided individually or in combination. Use of the biological composition.

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