Method of treating or preventing spinal muscular atrophy

Abstract

To provide a method of treating or preventing spinal muscular atrophy.SOLUTION: There is provided a method of treating or preventing spinal muscular atrophy. The effective dosing regimen is described. A biomarker and a kit are also provided. For example, the present disclosure features dosing regimens for antisense compounds described herein that rapidly achieve and maintain higher antisense compound concentrations in patients with spinal muscular atrophy (SMA) (relative to the approved SPINRAZA(R) dosing regimen) and thus further enhance the efficacy of treatment.SELECTED DRAWING: None

Description

Technical Field

[0001] Cross - Reference to Related Applications This application claims priority to U.S. Provisional Patent Application No. 62 / 876,360, filed Jul. 19, 2019, the entire contents of which are incorporated herein by reference. Technical Field

[0002] The present disclosure generally relates to methods for the treatment and prevention of spinal muscular atrophy and effective dosing regimens.

Background Art

[0003] Spinal muscular atrophy (SMA) is a hereditary neurodegenerative disorder characterized by the atrophy of voluntary muscles in the limbs and trunk as a result of the loss of spinal motor neurons in the anterior horn of the spinal cord. SMA is an autosomal recessive genetic disease with an early - onset form and an incidence of 8.5 to 10.3 per 100,000 births. It is the most common single - gene cause of infant mortality and a major cause of pediatric morbidity in the United States. The natural course of SMA includes four major recognized phenotypes that depend on the age of onset and the motor abilities achieved. Type I SMA (infantile - onset SMA) is the most severe form, which presents at birth or within 6 months and generally dies within 2 years. Infants with type I SMA cannot sit or walk. Late - onset SMA can be divided into type II and type III SMA. Type II SMA (appearing between 6 months and 18 months of age) is an intermediate form, and patients can sit but cannot stand or walk. Patients with type III SMA generally develop SMA after 18 months of age, can sit and walk, but may become severely and progressively disabled. Adult - onset SMA or type IV SMA patients develop the disease after 18 years of age and have a normal average life expectancy.

[0004] The molecular basis of SMA is the loss of both copies of the survival motor neuron 1 (SMN1) gene, which encodes a protein that is part of a multi - protein complex thought to be involved in snRNP biogenesis and recycling. A nearly identical gene, SMN2, is present in a duplicated region of chromosome 5q13 and modulates disease severity. Expression of the normal SMN1 gene alone results in the expression of the survival motor neuron (SMN) protein. SMN1 and SMN2 potentially encode the same protein, but SMN2 contains a translationally silent mutation at position +6 of exon 7, which inefficiently causes exon 7 to be included in the SMN2 transcript. Thus, the major form of SMN2 is a truncated form lacking exon 7, which is unstable and inactive (Cartegni and Krainer, Nat. Genet., 30:377 - 384 (2002)). Expression of the SMN2 gene results in approximately 10 - 20% SMN protein and 80 - 90% unstable / non - functional SMNΔ7 protein. The SMN protein plays a well - established role in the construction of the spliceosome and may also be involved in mRNA transport in neuronal axons and nerve terminals.

[0005] Humans have variable copy numbers of the SMN2 gene (from 0 to 8 copies). Since the number of SMN2 copies expressed and the amount of full - length SMN protein obtained in SMA patients are correlated with the severity of the SMA disease, SMN2 is an important modifier of the disease phenotype. Antisense technology is an effective means for regulating the expression of one or more specific gene products, including alternative splicing products, and is uniquely useful for many therapeutic, diagnostic, and research applications. The principle underlying antisense technology is that an antisense compound that hybridizes to a target nucleic acid regulates gene expression activities such as transcription, splicing, or translation by one of several antisense mechanisms. The sequence specificity of antisense compounds makes them extremely attractive as tools for target identification and gene functionalization, as well as therapeutic agents for selectively regulating the expression of genes involved in disease. Certain antisense compounds complementary to SMN2 pre-mRNA are known in the art. See, for example, WO2007 / 002390. SPINRAZA® is an antisense compound approved at a recommended dose of 12 mg for the treatment of SMA in pediatric and adult patients in the United States, Europe, and other countries and regions throughout the world. At the approved 12 mg dose, SPINRAZA® has a solid safety profile and has provided very significant benefits to patients with SMA. In particular, in relation to the importance of early intervention in patients with the most severe forms of SMA, the Applicant considered that it would be beneficial to achieve and maintain higher concentrations of SPINRAZA® more rapidly in patients with SMA.

Prior Art Documents

Patent Documents

[0006]

Patent Document 1

Non-Patent Documents

[0007]

Non-Patent Document 1

Summary of the Invention

[0008] This application relates to methods of treating or preventing SMA. The disclosure features dosing regimens for antisense compounds described herein that rapidly achieve and maintain higher antisense compound concentrations in patients with SMA (compared to the approved SPINRAZA® dosing regimen), thereby further improving the efficacy of treatment.

[0009] In one aspect, the disclosure features a method for treating spinal muscular atrophy (SMA) in a human subject in need of treatment for spinal muscular atrophy (SMA). The method comprises administering to the human subject at least two loading doses of an antisense compound having the following structure:

Chemical formula

[0010] In another aspect, the disclosure features a method for increasing the level of survival motor neuron 2 (SMN2) messenger ribonucleic acid (mRNA) containing exon 7 in a human subject having a mutation associated with an SMN protein deficiency on chromosome 5q. The method comprises administering to the human subject at least two loading doses of an antisense compound having the following structure:

Chemical formula

[0011] In some examples, the above method further comprises administering at least one maintenance dose corresponding to about 28 mg of the antisense compound to a human subject by intrathecal injection (e.g., intrathecal bolus injection).

[0012] In some examples, the above method starts about 3 to 6 months (e.g., about 4 to 5 months; or about 4 months) after the administration of the second loading dose to a human subject by intrathecal injection (e.g., intrathecal bolus injection), and then continues once every about 3 to 6 months (e.g., about 4 to 5 months; or about 4 months), each time administering a maintenance dose of the antisense compound or a salt thereof described herein corresponding to about 28 mg of the antisense compound.

[0013] In some examples, the second loading dose is administered about 14 days after the administration of the first loading dose. In some examples, the second loading dose is administered 14 days after the administration of the first loading dose.

[0014] In certain examples, the method further comprises administering, by intrathecal injection (e.g., intrathecal bolus injection) to a human subject, a third loading dose of the antisense compound or a salt thereof described herein corresponding to about 50 mg of the antisense compound, about 10 to 20 days (e.g., about 10 to 18 days, about 12 to 16 days, or about 14 days) after administration of the second loading dose; and one or more maintenance doses of the antisense compound or a salt thereof described herein, each corresponding to about 28 mg of the antisense compound, starting about 3 to 6 months (e.g., about 4 to 5 months; or about 4 months) after administration of the third loading dose and continuing once every about 3 to 6 months (e.g., about 4 to 5 months; or about 4 months) thereafter. In some examples, the second loading dose is administered about 14 days after administration of the first loading dose, and the third loading dose is administered about 14 days after administration of the second loading dose. In certain examples, the second loading dose is administered 14 days after administration of the first loading dose, and the third loading dose is administered 14 days after administration of the second loading dose.

[0015] In some examples, the above method involves administering to a human subject, by intrathecal injection (e.g., intrathecal bolus injection), a third loading dose of the antisense compound or a salt thereof described herein, corresponding to about 50 mg of the antisense compound, about 10 to 20 days (e.g., about 10 to 18 days, about 12 to 16 days, or about 14 days) after administration of the second loading dose; a fourth loading dose of the antisense compound or a salt thereof described herein, corresponding to about 50 mg of the antisense compound, about 10 to 20 days (e.g., about 10 to 18 days, about 12 to 16 days, or about 14 days) after administration of the third loading dose; and one or more maintenance doses of the antisense compound or a salt thereof described herein, each corresponding to about 28 mg of the antisense compound, starting about 3 to 6 months (e.g., about 4 to 5 months; or about 4 months) after administration of the fourth loading dose and continuing thereafter once every about 3 to 6 months (e.g., about 4 to 5 months; or about 4 months). In certain cases, the second loading dose is administered about 14 days after administration of the first loading dose, the third loading dose is administered about 14 days after administration of the second loading dose, and the fourth loading dose is administered about 14 days after administration of the third loading dose. In other cases, the second loading dose is administered 14 days after administration of the first loading dose, the third loading dose is administered 14 days after administration of the second loading dose, and the fourth loading dose is administered 14 days after administration of the third loading dose.

[0016] In another aspect, the present disclosure provides a method for treating SMA in a human subject in need of treatment for SMA. The method involves administering to the human subject the following structure:

Chemical formula

[0017] In another aspect, the disclosure relates to a method for increasing the level of SMN2 mRNA comprising exon 7 in a human subject having a mutation associated with SMN protein deficiency on chromosome 5q. The method comprises administering to the human subject the following structure:

Chemical formula

[0018] In another aspect, a method for treating spinal muscular atrophy (SMA) in a human subject in need of treatment for spinal muscular atrophy (SMA) is provided. The method involves administering to the human subject the following structure:

Chemical formula

[0019] In another aspect, the disclosure provides a method for increasing the level of SMN2 mRNA comprising exon 7 in a human subject having a mutation associated with SMN protein deficiency on chromosome 5q. The method comprises administering to the human subject the following structure:

Chemical formula

[0020] In some examples, the human subject has been previously administered at least 4 (e.g., 4, 5, 6, 7, 8, 9, 10) doses, at least 5 doses, at least 6 doses, at least 7 doses, at least 8 doses, at least 9 doses, or at least 10 doses of the antisense compound or a salt thereof described herein, and each of the at least 4, 5, 6, 7, 8, 9, or 10 previously administered doses corresponded to about 12 mg of the antisense compound.

[0021] In some examples of all of the above methods, the human subject has type I SMA; type II SMA; type III SMA; or type IV SMA. In other examples, the human subject is pre-symptomatic for SMA.

[0022] In some examples, the human subject is administered the antisense compound or a salt thereof described herein using a spinal subarachnoid anesthesia needle.

[0023] In some examples, the antisense compounds or salts thereof described herein are administered with an injection volume of 5.0 mL.

[0024] In some examples, the antisense compounds or salts thereof described herein are dissolved in phosphate buffered saline (PBS). In other examples, the antisense compounds or salts thereof described herein are dissolved in artificial cerebrospinal fluid (aCSF).

[0025] In certain examples, the salt of the antisense compound is a sodium salt.

[0026] In one example, the salt of the antisense compound has the following structure. [Chemical formula]

[0027] In some embodiments of the methods described herein, the method further comprises detecting neurofilament levels in a human subject before and / or after the start of treatment. The level of neurofilament can be used, for example, to determine whether a subject administered an antisense compound or a salt thereof described herein is responding to treatment and to determine an appropriate subsequent treatment for the subject.

[0028] In one embodiment, the method requires (i) measuring a first neurofilament level in a first biological sample obtained from a human subject before the start of treatment; (ii) administering to the human subject an antisense compound or a salt thereof described herein according to any one of the methods described herein; and (iii) measuring the neurofilament level in a next (e.g., second) biological sample obtained from the human subject after administering at least one loading dose.

[0029] In one embodiment, the method requires: (i) measuring a first neurofilament level in a first biological sample obtained from a human subject prior to the start of treatment; (ii) administering to the human subject an antisense compound or a salt thereof described herein according to any one of the methods described herein; and (iii) measuring a neurofilament level in a next (e.g., second) biological sample obtained from the human subject after all loading doses have been administered.

[0030] In one embodiment, the method requires: (i) measuring a first neurofilament level in a first biological sample obtained from a human subject prior to the start of treatment; (ii) administering to the human subject an antisense compound or a salt thereof described herein according to any one of the methods described herein; and (iii) measuring a neurofilament level in a next (e.g., second) biological sample obtained from the human subject after all loading doses and at least one maintenance dose of the antisense compound or a salt thereof described herein have been administered.

[0031] In one example, the next (e.g., second) neurofilament level is lower than the first neurofilament level (e.g., the second neurofilament level is reduced by at least 50% compared to the first neurofilament level), and the method further includes administering either another single loading dose or another single maintenance dose as described herein at respective dosing intervals as described herein.

[0032] In another example, the next (e.g., second) neurofilament level is equal to or higher than the first neurofilament level, and the method further includes administering to the human subject an additional dose of the antisense compound or a salt thereof described herein, wherein each of the additional doses of the antisense compound or a salt thereof has an increased amount and / or a shorter dosing interval compared to the last dose administered prior to measuring the next (e.g., second) neurofilament level.

[0033] In some embodiments, the neurofilament is a neurofilament heavy chain (NF-H, e.g., pNF-H), medium / intermediate chain (NF-M), or light chain (NF-L).

[0034] In some embodiments, the first and second biological samples are blood, serum, plasma, or cerebrospinal fluid.

[0035] The term "about" in relation to an amount, e.g., about X mg, means + / - 10%, so "about 50 mg" includes from 45 mg to 55 mg. The term "about" in relation to X days means + / - 3 days, so "about 10 days" includes from 7 to 13 days. The term "about" in relation to X months means + / - 1 week, so "about 4 months" includes 1 week before and after the 4-month time point.

[0036] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. In the practice or testing of the present invention, methods and materials similar or equivalent to those described herein can be used, but exemplary methods and materials are described below. All publications, patent applications, patents, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, this application, including definitions, will control. The materials, methods, and examples are illustrative only and not intended to be limiting.

[0037] Other features and advantages of the present invention will become apparent from the following detailed description and the claims.

Brief Description of the Drawings

[0038]

Figure 1

Mode for Carrying Out the Invention

[0039] The present disclosure relates to methods for treating or preventing SMA using effective dosing regimens of antisense compounds or salts thereof as described herein. The methods are useful for the treatment and / or prevention of SMA in pediatric and adult patients.

[0040] Patients with SMA (types I, II, III, IV, and pre-symptomatic) can achieve greater improvement in motor function and motor milestone development with higher antisense drug exposure than that achieved by the current SPINRAZA® dosing regimen.

[0041] Antisense compound An example of an antisense compound for use in the present invention has the nucleobase sequence: TCACTTTCATAATGCTGG (SEQ ID NO: 1), each nucleoside has a 2'-O-(2-methoxyethyl) (MOE) modification, each internucleoside linkage of the oligonucleotide is a phosphorothioate linkage, and each "C" in the sequence is 5-methyl-cytosine.

[0042] The free acid form of this antisense compound (also called nusinersen) is shown below.

Chemical Formula

[0043] In some instances, salts of this antisense compound (e.g., pharmaceutically acceptable salts) are used. In certain cases, the salt may be sodium (also referred to as nusinersen sodium or nusinersen sodium salt). In other instances, the salt may be potassium.

[0044] Examples of salts of this antisense compound are shown below.

Chemical formula

[0045] The antisense compound is nusinersen, and its sodium salt is nusinersen sodium or nusinersen sodium salt. 2.40 mg of nusinersen is equivalent to 2.53 mg of nusinersen sodium salt. The dose of nusinersen sodium corresponding to 50 mg of nusinersen is 52.71 mg of nusinersen sodium salt. The dose of nusinersen sodium corresponding to 28 mg of nusinersen is 29.52 mg of nusinersen sodium salt. The dose of nusinersen sodium corresponding to 12 mg of nusinersen is 12.65 mg of nusinersen sodium salt.

[0046] The antisense compound or its salt may be prepared as a solution for injection by intrathecal administration.

[0047] The antisense compounds described herein can be used in human subjects in need thereof for treating or preventing SMA. In some instances, SMA is type I SMA. In other instances, SMA is type II SMA. In certain instances, SMA is type III SMA. In some instances, SMA is type IV SMA. In other instances, the human subject is pre-symptomatic for SMA.

[0048] Pharmaceutical composition The present disclosure also provides a pharmaceutical composition comprising an antisense compound or a salt thereof described herein. In certain examples, such a pharmaceutical composition comprises or consists of sterile saline and an antisense compound or a salt thereof. In some cases, such a pharmaceutical composition is a sterile buffered isotonic solution. In some cases, the pharmaceutical composition does not contain a preservative.

[0049] The antisense compound or a salt thereof described herein may be mixed with pharmaceutically acceptable active and / or inactive substances for the preparation of a pharmaceutical composition or formulation. The composition and method for the formulation of a pharmaceutical composition are determined by many criteria including, but not limited to, the route of administration, the degree of the disease, or the dose to be administered.

[0050] The antisense compound or a salt thereof may be utilized in a pharmaceutical composition by mixing such a compound with a suitable pharmaceutically acceptable diluent or carrier. In certain examples, the pharmaceutically acceptable diluent is phosphate buffered saline (PBS). In certain embodiments, the pharmaceutically acceptable diluent is artificial cerebrospinal fluid (aCSF).

[0051] In certain embodiments, the aCSF formulation has a pH of 7.2. The pH of the composition may be adjusted with hydrochloric acid or sodium hydroxide during formulation, if desired. In some examples, the pharmaceutical composition comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) at a concentration of about 10.0 mg / mL. In certain examples, the pharmaceutical composition comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) at a concentration of 10.0 mg / mL. In other examples, the pharmaceutical composition comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) at a concentration of about 5.6 mg / mL. In some examples, the pharmaceutical composition comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) at a concentration of 5.6 mg / mL. In certain examples, the pharmaceutical composition comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) at a concentration ranging from 3.6 mg / mL to 10.0 mg / mL. In other examples, the pharmaceutical composition comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) at a concentration ranging from 4.8 mg / mL to 10.0 mg / mL. In yet other examples, the pharmaceutical composition comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) at a concentration ranging from 5.6 mg / mL to 10.0 mg / mL.

[0052] In some examples, the pharmaceutical composition comprises about 50 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In some examples, the pharmaceutical composition comprises 50 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In other examples, the pharmaceutical composition comprises about 28 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In some examples, the pharmaceutical composition comprises 28 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In some examples, the pharmaceutical composition is formulated in PBS or aCSF. In certain examples, the pharmaceutical composition is formulated for intrathecal administration.

[0053] In one example, the present disclosure features a pharmaceutical composition comprising 50 mg of the antisense compound or a salt thereof disclosed herein in a volume of 5 mL of a pharmaceutical excipient (e.g., aCSF, PBS) such that the antisense compound concentration is 10 mg / mL. In certain examples, the pharmaceutical composition is formulated for intrathecal administration (e.g., intrathecal bolus injection).

[0054] In another example, the present disclosure features a pharmaceutical composition comprising 28 mg of the antisense compound or a salt thereof disclosed herein in a volume of 5 mL of a pharmaceutical excipient (e.g., aCSF, PBS) such that the antisense compound concentration is 5.6 mg / mL. In certain examples, the pharmaceutical composition is formulated for intrathecal administration (e.g., intrathecal bolus injection).

[0055] Pharmaceutical compositions containing the antisense compound include any pharmaceutically acceptable salt, ester, or salt of such an ester. Thus, for example, the present disclosure also encompasses pharmaceutically acceptable salts of the antisense compound, prodrugs, pharmaceutically acceptable salts of such prodrugs, and other biological equivalents. Suitable pharmaceutically acceptable salts include, but are not limited to, sodium and potassium salts.

[0056] Methods of treatment The present disclosure features a method of treating or preventing spinal muscular atrophy (SMA) in a human subject. In one example, the SMA is type I SMA. In another example, the SMA is type II SMA. In yet another example, the SMA is type III SMA. In another example, the SMA is type IV SMA. In certain examples, the human subject is pre-onset of SMA.

[0057] The present disclosure also provides a method of increasing the inclusion of exon 7 in the SMN2 messenger ribonucleic acid (mRNA) transcript and the production of full-length SMN protein in a human subject who has lost both functional copies of the SMN1 gene.

[0058] Also featured is a method for increasing exon 7 inclusion in SMN2 messenger ribonucleic acid (mRNA) transcripts in a human subject having a mutation in the SMN1 gene that leads to a functional SMN protein deficiency.

[0059] Furthermore, the present disclosure relates to a method for increasing the level of SMN2 mRNA containing exon 7 in a human subject having a mutation associated with or leading to an SMN protein deficiency on chromosome 5q. The human subject may be homozygous gene deleted, have a substitution, or be a compound heterozygote.

[0060] The method includes administering to a human subject in need thereof the antisense compound or a salt thereof (e.g., sodium salt) described herein. The human subject may be an adult or a pediatric subject.

[0061] In one example, the human subject is administered a dose of the antisense compound or a pharmaceutically acceptable salt thereof useful for treating SMA by intrathecal injection into the human subject. The intrathecal administration may be by lumbar puncture (i.e., spinal tap). The administration may be by bolus injection. In one example, the administration is by intrathecal bolus injection.

[0062] In one example, the antisense compound administered to the human subject comprises or consists of the nucleobase sequence set forth in SEQ ID NO: 1, each internucleoside linkage of the oligonucleotide is a phosphorothioate linkage, each nucleoside of the oligonucleotide is a 2'-MOE nucleoside, and each C is 5-methylcytosine.

[0063] In certain examples, when the subject is less than 1 week old, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is less than 1 month old, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is less than 3 months old, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is 6 months old or less, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is over 6 months old, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is less than 1 year old, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is less than 2 years old, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is less than 15 years old, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is over 15 years old, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is between 1 and less than 18 years old, a first dose of the antisense compound or a salt thereof described herein is administered. In certain examples, when the subject is 18 years old or older, a first dose of the antisense compound or a salt thereof described herein is administered.

[0064] In certain examples, the human subject has 1 SMN2 copy number. In other examples, the human subject has 2 SMN2 copy numbers. In some examples, the human subject has 3 SMN2 copy numbers. In other examples, the human subject has 4 SMN2 copy numbers. In certain examples, the human subject has 5 SMN2 copy numbers.

[0065] In some examples, the antisense compounds or salts thereof described herein are administered as an intrathecal bolus injection. In some examples, the antisense compounds or salts thereof described herein are administered as a single intrathecal bolus lumbar puncture injection. In certain embodiments, the volume of the intrathecal bolus lumbar puncture injection is 5 mL.

[0066] Dosing regimen The present disclosure features an enhanced or high dosing regimen of the antisense compounds or salts thereof described herein for the treatment or prevention of SMA. In some examples, the dosage of the antisense compound or salt thereof (e.g., sodium salt) used to treat or prevent SMA corresponds to an antisense compound described herein that is greater than 12 mg and less than or equal to 50 mg. In certain examples, the dosage of the antisense compound or salt thereof (e.g., sodium salt) used to treat or prevent SMA corresponds to an antisense compound described herein of about 13, about 14, about 15, about 16, about 17, about 18, about 19, about 20, about 21, about 22, about 23, about 24, about 25, about 26, about 27, about 28, about 29, about 30, about 31, about 32, about 33, about 34, about 35, about 36, about 37, about 38, about 39, about 40, about 41, about 42, about 43, about 44, about 45, about 46, about 47, about 48, about 49, or about 50 mg. In other examples, the dosage of the antisense compound or salt thereof (e.g., sodium salt) used to treat or prevent SMA corresponds to an antisense compound described herein of 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, or 50 mg. In certain embodiments, the dosage is administered (e.g., intrathecally) as a volume of 5 mL (e.g., of aCSF or PBS). In some examples, the dosage is administered by bolus injection. In one example, the dosage is administered by intrathecal bolus injection.

[0067] In some instances, a human subject in need thereof is administered the antisense compound or a salt thereof described herein at a dose corresponding to 18 to 50 mg of the antisense compound in a 5 mL volume of administration. In other instances, a human subject in need thereof is administered the antisense compound or a salt thereof described herein at a dose corresponding to 24 to 50 mg of the antisense compound in a 5 mL volume of administration. In certain instances, a human subject in need thereof is administered the antisense compound or a salt thereof described herein at a dose corresponding to 28 to 50 mg of the antisense compound in a 5 mL volume of administration. In yet another instance, a human subject in need thereof is administered the antisense compound or a salt thereof described herein at a dose corresponding to 50 mg of the antisense compound in a 5 mL volume of administration. In some instances, the dose of the antisense compound or a salt thereof described herein is administered by bolus injection. In one instance, the dose of the antisense compound or a salt thereof described herein is administered by intrathecal bolus injection. In certain cases, the antisense compound or a salt thereof described herein in aCSF or PBS is administered.

[0068] The dosing regimen may include administering to a human subject (e.g., intrathecally) at least two times (e.g., 2, 3, 4, 5 times), about two times, or two loading doses of the antisense compound or a salt thereof (e.g., sodium salt) described herein corresponding to about 50 mg of the antisense compound used to treat or prevent SMA, followed by a maintenance dose of the antisense compound or a salt thereof (e.g., sodium salt) described herein corresponding to about 28 mg of the antisense compound used to treat or prevent SMA. In some examples, each loading dose corresponds to 50 mg of the antisense compound described herein. In some examples, each maintenance dose corresponds to 28 mg of the antisense compound described herein. In some examples, the loading doses are administered 10 to 20 days apart (e.g., 10 to 18 days apart, 12 to 16 days apart, every other week), and the maintenance dose is administered 3 to 6 months (e.g., 4 to 5 months or about 4 months) after the last loading dose, and then every 3 to 6 months thereafter. In some cases, two loading doses are administered. In some cases, three loading doses are administered. In still other cases, four loading doses are administered. In certain examples, the loading dose is administered 10 to 18 days apart, and the maintenance dose is administered 3 to 6 months after the last loading dose, and then every 3 to 6 months thereafter. In some examples, the loading dose is administered 12 to 16 days apart, and the maintenance dose is administered 3 to 6 months after the last loading dose, and then every 3 to 6 months thereafter. In other examples, the loading doses are administered 10 to 20 days apart (e.g., every other week), and the maintenance dose is administered 3 to 6 months after the last loading dose, and then every 3 to 6 months thereafter. In certain examples, the loading dose is administered 14 days apart, and the maintenance dose is administered 3 to 6 months after the last loading dose, and then every 3 to 6 months thereafter. In some examples, the maintenance dose(s) is / are administered 4 to 5 months after the last loading dose, and then every 4 to 5 months thereafter. In some examples, the maintenance dose(s) is / are administered about 4 months after the last loading dose, and then every about 4 months thereafter. In some examples, the maintenance dose(s) is / are administered 4 months after the last loading dose, and then every 4 months thereafter.In some examples, a maintenance amount is administered at least 2 times, at least 3 times, at least 4 times, at least 5 times, at least 6 times, at least 7 times, at least 8 times, at least 9 times, at least 10 times, at least 11 times, or at least 12 times.

[0069] In one example, a human subject in need thereof is an antisense compound or a salt thereof (e.g., sodium salt) shown below under the loading amount:

Chemical formula

[0070] In another example, a human subject in need thereof is a salt of the antisense compound shown under the loading dose:

Chemical formula

[0071] In one aspect, a human subject in need thereof (e.g., having or pre-symptomatic for SMA (any of types I to IV)) is administered a first loading dose of the antisense compound or a salt thereof described herein at a dose corresponding to about 50 mg (e.g., 50 mg) of the antisense compound on day 1, a second loading dose of the antisense compound or a salt thereof described herein at a dose corresponding to about 50 mg (e.g., 50 mg) of the antisense compound on about day 15, a first maintenance dose of the antisense compound or a salt thereof described herein at a dose corresponding to about 28 mg (e.g., 28 mg) of the antisense compound on about day 135, and one or more additional maintenance doses of the antisense compound or a salt thereof described herein at a dose corresponding to about 28 mg (e.g., 28 mg) of the antisense compound about 120 days after the first maintenance dose. In one example, a human subject in need thereof (e.g., having or pre-symptomatic for SMA (any of types I to IV)) is administered a first loading dose of the antisense compound or a salt thereof described herein at a dose corresponding to 50 mg of the antisense compound on day 1, a second loading dose of the antisense compound or a salt thereof described herein at a dose corresponding to 50 mg of the antisense compound on day 15, a first maintenance dose of the antisense compound or a salt thereof described herein at a dose corresponding to 28 mg of the antisense compound on any one day from day 134 to day 140, and one or more additional maintenance doses of the antisense compound or a salt thereof described herein at a dose corresponding to 28 mg of the antisense compound from 253 to 259 days after the first maintenance dose. In some embodiments, the antisense compound has the following structure. [Chemical formula]

[0072] In some embodiments, the salt of the antisense compound has the following structure. [Chemical formula]

[0073] In another aspect, the present disclosure features a dosing ramp-up regimen for a human subject in need thereof. This dosing ramp-up (bridging) regimen can effectively transition a subject who has received the approved 12 mg regimen of the antisense compound or a salt thereof described herein to a regimen that allows for increased CSF exposure. In one example, the dosing ramp-up regimen involves administering to a subject pre-dosed with the antisense compound or a salt thereof described herein at a dose equivalent to 12 mg of the antisense compound, a loading dose of the antisense compound or a salt thereof described herein equivalent to about 50 mg of the antisense compound. In some cases, the loading dose is a single intrathecal bolus injection. In some examples, the 50 mg loading dose is administered 4 months after the administration of the last 12 mg of the antisense compound or a salt thereof described herein. In some cases, after the 12 mg dose, a 50 mg dose is subsequently administered, followed by a 28 mg dose. In a specific example, one or more maintenance doses of the antisense compound or a salt thereof described herein are administered to the subject at a dose equivalent to 28 mg of the antisense compound, starting about 4 months after the loading dose. In some examples, the subject is administered the antisense compound or a salt thereof described herein at a dose equivalent to about 12 mg of the antisense compound at least once, at least twice, at least three times, at least four times, at least five times, or once, twice, three times, four times, or five times, prior to being given the loading dose. In some embodiments, the antisense compound has the following structure. [Chemical Formula]

[0074] In some examples, the salt of the antisense compound has the following structure. [Chemical Formula]

[0075] The dosages described herein are generally provided in a volume of about 5.0 mL. In one example, the administration volume is 5.0 mL. In some cases, the diluent is PBS. In other examples, the diluent is aCSF. In certain cases, the loading dose is administered to a human subject at a concentration of 10.0 mg / mL. In some cases, the maintenance dose is administered to a human subject at a concentration of 5.6 mg / mL.

[0076] The dosages are generally administered intrathecally, for example, by lumbar puncture. The dosages are generally administered as an intrathecal infusion (e.g., an intrathecal bolus infusion).

[0077] Biomarker Biomarkers of SMA that have diagnostic, prognostic, predictive, and pharmacodynamic value serve to facilitate determination of the timing of treatment initiation, response to intervention, treatment efficacy, and long-term outcome assessment. Such biomarkers include genetic, epigenetic, proteomic, electrophysiological, and imaging measurements. The present disclosure features the use of such biomarkers that facilitate detection of a disease state when compared to a healthy population, provide information regarding potential healthy outcomes, disease progression or recurrence risk, facilitate stratification of phenotypic severity, potentially identify responder and patient populations to treatment, confirm response to treatment, and / or monitor treatment efficacy.

[0078] In one embodiment, the biomarker is a neurofilament protein. Neurofilaments are the major cytoskeletal elements in nerve cells and play a role not only in conferring mechanical stability but also in determining axon diameter. Human neurofilaments are composed of three protein subunits, neurofilament light chain (NF-L), neurofilament medium / intermediate chain (NF-M), and neurofilament heavy chain (NF-H). These proteins share the same basic structure as other intermediate filament subunit proteins. Mammalian nervous system neurofilaments may also include the protein internexin, and peripheral nervous system neurofilaments may also include the protein peripherin. Thus, as used herein, "neurofilament protein" means NF-H, NF-M, NF-L, internexin, or peripherin. The SMA biomarker may be one or more of NF-H, NF-M, NF-L, internexin, and peripherin. In certain examples, the SMA biomarker is phosphorylated NF-H (pNF-H). In certain examples, the SMA biomarker is phosphorylated NF-L.

[0079] 1. In the nusinersen clinical trials in type 1 and 2 SMA and pre-symptomatic infants, plasma pNf-H was found to differ between SMA individuals and healthy controls. Initiation of treatment with nusinersen was associated with a rapid decline in pNf-H followed by stabilization at levels close to those of healthy controls. Thus, assessment of the level of neurofilaments (e.g., pNf-H and / or NfL) may be a useful biomarker before or during treatment.

[0080] The level of neurofilament can be used to determine whether a subject (e.g., a human) administered with the antisense compound or a salt thereof described herein is responsive to treatment. This can be evaluated by obtaining a first biological sample from the subject before treatment and a second biological sample from the subject after treatment, and measuring the level of neurofilament (e.g., NF-H, NF-M, or NF-L) in such samples. In one example, the level of neurofilament is the level of pNF-H.

[0081] In certain examples, the first biological sample(s) may be taken from the subject at any time prior to treatment, e.g., one week before, several days before, one day before, several hours before, one hour before, or less than one hour before administering the antisense compound or a salt thereof described herein. Similarly, the second biological sample(s) may be taken from the subject at any time after the application of treatment, e.g., less than one hour after, one hour after, several hours after, one day after, several days after, one week after, several weeks after, one month after, two months after, three months after, four months after, five months after, six months after, seven months after, or eight months after administering the antisense compound or a salt thereof described herein. A decrease in the neurofilament level after the start of treatment indicates the effectiveness of the treatment. In such a case, continuation of the treatment therapy is indicated (e.g., administering a further dose of the antisense compound at the same or less amount as the last dose administered before measuring the second neurofilament level and / or at the same or longer dosing interval as the last dose administered before measuring the second neurofilament level). A lack of decrease in the neurofilament level after the start of treatment indicates the need to change the dose and / or dosing interval of the treatment (e.g., administering a further dose of the antisense compound in an increased amount and / or at a shorter dosing interval as compared to the last dose administered before measuring the second neurofilament level) or the lack of effectiveness of the treatment. In the latter case, discontinuation of the treatment may be suggested and the use of a different SMA therapy(ies) may be considered.

[0082] The level of neurofilament can be evaluated by measuring the level of RNA or protein. In some examples, the level of pNF-H is measured. The concentration of the target neurofilament protein(s) can be measured using any method known in the art, such as an immunoassay. Non-limiting examples of such methods include enzyme-linked immunosorbent assay, radioimmunoassay, chemiluminescent immunoassay, electrochemiluminescent immunoassay, latex turbidimetric immunoassay, latex photometric immunoassay, immunochromatographic assay, and Western blotting. In certain embodiments, the concentration of the target protein(s) is measured by mass spectrometry.

[0083] In certain examples, the neurofilament level (e.g., pNF-H) in the first biological sample is greater than 300 pg / mL, greater than 400 pg / mL, greater than 500 pg / mL, greater than 600 pg / mL, greater than 700 pg / mL, greater than 800 pg / mL, greater than 900 pg / mL, greater than 1,000 pg / mL, greater than 1,500 pg / mL, greater than 2,000 pg / mL, greater than 3,000 pg / mL, greater than 4,000 pg / mL, or greater than 5,000 pg / mL. In certain embodiments, the neurofilament level measured in the next (e.g., second) biological sample is lower than the neurofilament level measured in the first biological sample. In some embodiments, the neurofilament level measured in the next (e.g., second) biological sample shows a decrease of more than 30% (e.g., 31%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 80%, 85%, 90%, or 95%) relative to the neurofilament level measured in the first biological sample.

[0084] In another embodiment, the SMA biomarker is any one of those described in WO2011 / 032109.

[0085] In another embodiment, the SMA biomarker is any one of those described in WO2019197954.

[0086] In another embodiment, the SMA biomarker is any one of those described in WO2019 / 122125.

[0087] In another embodiment, the SMA biomarker is any one of those described in WO2019 / 147960.

[0088] In yet another embodiment, the SMA biomarker is any one or more of COMP, DPP4, SPP1, CLEC3B, VTN, and AHSG.

[0089] In some embodiments, any combination(s) of the aforementioned biomarkers are assayed from a sample of a subject (e.g., a human).

[0090] Kit The present disclosure also features a kit for treating spinal muscular atrophy, comprising the antisense compound described herein or a salt thereof (e.g., sodium salt). In some examples, the kit comprises at least one pharmaceutical composition comprising about 50 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt) and at least one pharmaceutical composition comprising about 28 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In some examples, the kit comprises at least one pharmaceutical composition comprising 50 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt) and at least one pharmaceutical composition comprising 28 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In some examples, the kit comprises at least one pharmaceutical composition comprising about 50 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In some examples, the kit comprises at least one pharmaceutical composition comprising 50 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In other examples, the kit comprises at least one pharmaceutical composition comprising about 28 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In some examples, the kit comprises at least one pharmaceutical composition comprising 28 mg of the antisense compound described herein or a salt thereof (e.g., sodium salt). In some examples, the pharmaceutical composition is formulated in PBS or aCSF. In some examples, the kit comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) diluted in 5 mL of PBS or aCSF. In some examples, the kit comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) at a concentration of 10 mg / mL. In some examples, the kit comprises the antisense compound described herein or a salt thereof (e.g., sodium salt) at a concentration of 5.6 mg / mL. In certain examples, the kit comprises a pharmaceutical composition formulated for intrathecal administration. In some examples, the kit comprises a pharmaceutical composition formulated for intrathecal bolus injection.

[0091] In one example, the kit may include the antisense compound described herein or a salt thereof (e.g., sodium salt) in lyophilized form, a diluent (e.g., PBS, aCSF) in a certain volume (e.g., 5 to 10 mL), a syringe for injection, and / or instructions for use.

[0092] In one example, the kit may include at least one single-dose vial containing 5 mL of a pharmaceutical composition, the pharmaceutical composition containing 50 mg of the antisense compound described herein or a salt thereof, such that the concentration of the antisense compound in the single-dose vial is 10 mg / mL.

[0093] In one example, the kit may include at least one single-dose vial containing 5 mL of a pharmaceutical composition, the pharmaceutical composition containing 28 mg of the antisense compound described herein or a salt thereof, such that the concentration of the antisense compound in the single-dose vial is 5.6 mg / mL. In some examples, the kits described herein further include a syringe for injection and / or instructions for use.

[0094] In one example, the kit may include: (i) at least one single-dose vial containing 5 mL of a pharmaceutical composition, the pharmaceutical composition containing 50 mg of the antisense compound described herein or a salt thereof, such that the concentration of the antisense compound in the single-dose vial is 10 mg / mL; and (ii) at least one single-dose vial containing 5 mL of a pharmaceutical composition, the pharmaceutical composition containing 28 mg of the antisense compound described herein or a salt thereof, such that the concentration of the antisense compound in the single-dose vial is 5.6 mg / mL. In some examples, the kits described herein further include a syringe for injection and / or instructions for use.

[0095] The following examples are provided to more fully illustrate the invention claimed and should not be construed as limiting the scope of the present invention. To the extent specific materials are recited, they are for illustrative purposes only and are not intended to limit the present invention. One of ordinary skill in the art can develop equivalent means or reactants without undue experimentation and without departing from the scope of the present invention.

Example

[0096] Example 1: Nusinersen Population PK / PD Analysis In the nusinersen clinical trials in subjects with SMA, subjects who received treatment before or shortly after the onset and diagnosis of SMA symptoms generally had a better outcome than those who had a longer disease duration at the start of treatment. In the infantile-onset SMA trials, the majority of deaths among nusinersen-treated infants occurred within the first two months of the trial, before completion of the loading regimen and attainment of steady-state nusinersen concentrations. Given the rapid decline associated with type I SMA and the importance of early treatment, achieving higher nusinersen concentrations more rapidly may further improve the efficacy of nusinersen and prevent or further mitigate disease progression in patients with SMA. The results of the infantile-onset SMA trials combined with the results of placebo-controlled trials in subjects with late-onset SMA support that greater benefit is conferred by achieving therapeutic concentrations earlier in the disease process, as subjects in both trials with a shorter disease duration at the time of trial enrollment had a better outcome than those with a longer disease duration.

[0097] Example 2: Exposure-Response Relationship In the course of the nusinersen clinical development program, an exploratory exposure-response analysis was conducted using data on 14 infants with onset SMA who were given nusinersen. The results of this analysis showed a statistically significant positive correlation between nusinersen CSF exposure and motor function. A dose-related trend was observed in the performance of the subjects' motor milestones, with greater and earlier improvement in subjects given a 12 mg loading dose compared to those given a 6 mg loading dose on days 1, 15, and 85. All subjects were given a maintenance dose of 12 mg every 4 months after day 85. The separation of the response curves for the two cohorts began around day 29 and became greater over the course of the study period.

[0098] Greater improvement in motor function was also observed in infants with onset SMA who received more frequent dosing (a 12 mg loading dose on days 1, 15, 29, and 64, and a 12 mg maintenance dose every 4 months).

[0099] In a study investigating the relationship between nusinersen exposure and clinical response, data from infants with onset SMA (subjects with a diagnosis or onset of symptoms at <6 months of age) were used. Analyses were conducted to characterize the quantitative PK / PD relationship of nusinersen and to determine whether higher nusinersen exposure was associated with additional efficacy in the infant-onset SMA population. Overall, the PK / PD relationship between the observed CSF C トラフ and the motor function efficacy endpoint (change from baseline on CHOP-INTEND) appeared to follow an Emax relationship (Figure 1).

[0100] Model predictions suggested that a CSF C of 23 ng / mL トラフ would achieve 90% of the observed maximum response. This estimated concentration was the observed CSF C achieved at steady state with the approved 12 mg dosing regimen. トラフ(Approximately 10 ng / mL) is approximately 2-fold higher. These results suggest that increased CNS exposure (up to 20 ng / mL) may lead to clinical effects that exceed the levels observed in previous clinical trials. Furthermore, this higher clinical exposure is supported by the existing clinical safety and tolerability observed in other trials (maximum mean [SD] CSF C of 31.3 [24.8] ng / mL), トラフ ) as well as the preclinical safety results in non-human primates (data not shown).

[0101] The above PK / PD relationship was mainly demonstrated in the infantile-onset SMA population because lower drug exposures (approximately 4.77 ng / mL on Day 273 of the trial) of the limited data and lower dosing regimens with lower frequency in the late-onset population were used. However, subjects with late-onset SMA who received the approved (more frequent) dosing regimen had a similar CSF C トラフ concentration (approximately 10 ng / mL on Day 302) as subjects with infantile-onset SMA in the same trial (10.7 ng / mL on Day 302). It is expected that the positive PK / PD relationship observed in subjects with infantile-onset SMA would be the same across SMA types and patient age groups that share similar mechanisms of disease and drug action. This is supported by a preliminary analysis (data not shown) of another study that showed a positive correlation between CSF C トラフ and the total motor milestone score in subjects with infantile-onset or late-onset SMA who were given nusinersen as four loading doses of 12 mg, followed by maintenance doses of 12 mg every 4 months.

[0102] Example 3: Loading Dose Optimization PK simulations were performed with the aim of identifying loading dose regimens that would result in more rapid and higher drug exposure in the target (approximately two-fold increase) with fewer intrathecal (IT) doses. These simulations were performed after 2 years of treatment for both the infant-onset and late-onset SMA populations and were based on a population PK model developed using data from patients aged ≤6 months to 18 years with infant-onset, late-onset, or pre-symptomatic SMA. Since previous modeling had shown that a dosing frequency of every 4 months maintained the CSF concentration achieved at steady state the most, no evaluation of the maintenance dosing frequency was performed.

[0103] Clinical CSF C トラフ Simulations were performed to evaluate additional dosing scenarios with higher doses and lower loading dose frequencies using the predicted CSF PK profiles with a target concentration of 20 ng / mL and a reference dosing regimen of 24 mg of nusinersen (maintenance doses every 4 months following 4 loading doses). As described above, since previous modeling had shown that a dosing frequency of every 4 months maintained the CSF concentration achieved at steady state the most, no further evaluation of the maintenance dosing frequency was performed. Assuming PK linearity, PK simulations were performed using a population PK model developed from patients aged ≤6 months to 18 years for both the infant-onset and late-onset SMA populations after 2 years of treatment. For the reference dosing regimen, both 28 mg administered as 3 loading doses (every other week) and 50 mg administered as 2 loading doses (every other week), each followed by a maintenance dose of 28 mg every 4 months, were confirmed to reach the desired CSF C トラフ (approximately 20 ng / mL) more rapidly at the end of the loading period. Nusinersen 28 mg administered as 3 loading doses (every other week) had a predicted CSF maximum concentration (Cmax) equivalent to the reference dosing regimen, while the 50 mg dosing regimen surprisingly exceeded the predicted Cmax from the reference dosing regimen. Non-human primate safety studies evaluating the safety of both 28 and 50 mg were conducted, supporting the use of these doses.

[0104] Example 4: Exemplary dosing regimens ● A first loading dose of nusinersen sodium administered at a dose equivalent to 50 mg of nusinersen; ● A second loading dose of nusinersen sodium administered at a dose equivalent to 50 mg of nusinersen 10 to 20 days; 10 to 18 days; 12 to 16 days; or 14 days after the administration of the first loading dose; ● Optionally, a third and / or fourth loading dose of nusinersen sodium at a dose equivalent to 50 mg of nusinersen administered 10 to 20 days; 10 to 18 days; 12 to 16 days; or 14 days after the administration of the second or third loading dose; ● One or more maintenance doses of nusinersen sodium administered at a dose equivalent to 28 mg of nusinersen, starting about 3 to 6 months; 4 to 5 months; or 4 months after the administration of the last loading dose and then continuing to be administered once every about 3 to 6 months, 4 to 5 months, or 4 months. Volume of administration: 5 mL Diluent: aCSF or PBS Administration: Intrathecal bolus injection

[0105] Example 5: Example dosing regimen An exemplary intensified or high-dose regimen for the antisense compound or a salt thereof described herein for use in a human subject in need thereof (e.g., infantile-onset SMA, late-onset SMA, adult-onset SMA, pre-onset SMA subjects) is shown below. Loading dose: A dose of nusinersen sodium equivalent to 50 mg of nusinersen administered on days 1 and 15; Maintenance dose: A dose of nusinersen sodium equivalent to 28 mg of nusinersen, starting 4 months after the second loading dose and then administered every 4 months thereafter. Volume of administration: 5 mL Vehicle: aCSF or PBS Administration: Intrathecal bolus injection

[0106] Example 6: Dose escalation (bridging) dosing regimen PK modeling and simulations were also used to evaluate potential dose escalation regimens to effectively transition subjects already on the approved nusinersen 12 mg dosing regimen. The goal of these evaluations was to increase CSF exposure in these subjects to the target concentration (approximately 20 ng / mL) brought about by an intensified or higher dosing regimen.

[0107] PK simulations identified dose escalation schemes that achieved higher target C more rapidly without requiring an additional loading period (maintaining a once every 4-month maintenance dosing interval) and without increasing risk to the patient. トラフ A variety of dosing regimens were evaluated for the purpose of identifying dose escalation schemes that would more rapidly achieve the higher target C without requiring an additional loading period (maintaining a once every 4-month maintenance dosing interval) and without increasing risk to the patient. All simulations were performed using an updated population PK model. Dose escalation regimens were simulated after 1 year of treatment with the approved 12 mg nusinersen dosing regimen, which included four 12 mg loading doses (on days 1, 15, 29, and 64) followed by two maintenance doses administered every 4 months. All dose escalation regimens followed a 4-month dosing frequency to match the 4-month maintenance dosing frequency of the approved 12 mg dosing regimen.

[0108] Examples of dose escalation regimens for use of the antisense compounds (e.g., nusinersen or its sodium salt) described herein in human subjects (e.g., infantile-onset SMA, late-onset SMA, adult-onset SMA, pre-symptomatic subjects for SMA) pre-administered with 12 mg nusinersen as needed, which can increase CSF exposure in the subject to a target concentration of approximately 20 ng / mL, are shown below. Loading dose: Dose of sodium nusinersen equivalent to 50 mg nusinersen administered on day 1; Maintenance dose: Dose of sodium nusinersen equivalent to 28 mg nusinersen administered starting 4 months after the loading dose and then every 4 months thereafter. Volume of administration: 5 mL Vehicle: aCSF or PBS Administration: Intrathecal bolus injection

[0109] Example 7: Other dosing escalation regimens Regimen 1 ● Four months after the last dose of nusinersen sodium corresponding to 12 mg of nusinersen, the patient is administered a loading dose of nusinersen sodium corresponding to 50 mg of nusinersen; further ● One or more maintenance doses of nusinersen sodium corresponding to 28 mg of nusinersen are then administered approximately once every four months. Volume of administration: 5 mL Vehicle: aCSF or PBS Administration: Intrathecal bolus injection

[0110] Regimen 2 ● Four months after the last dose of nusinersen sodium corresponding to 12 mg of nusinersen, the patient is administered a first loading dose corresponding to 28 mg of nusinersen; ● A second loading dose of nusinersen sodium corresponding to 50 mg of nusinersen is administered approximately four months after the first loading dose; further ● One or more maintenance doses of nusinersen sodium corresponding to 28 mg of nusinersen are then administered approximately every four months. Volume of administration: 5 mL Vehicle: aCSF or PBS Administration: Intrathecal bolus injection

[0111] Other embodiments Aspects of the invention are described along with its detailed description, but the foregoing description is intended to illustrate and not limit the scope of the invention as defined by the appended claims. Other aspects, advantages, and modifications are within the scope of the following claims. In certain embodiments, for example, the following are provided: (Item 1) A method for treating spinal muscular atrophy (SMA) in a human subject in need of treatment for spinal muscular atrophy (SMA), the method comprising administering to the human subject at least two loading doses of the following structure: [Chemical formula] administering an antisense compound having the following or a salt thereof, wherein the method comprises, by intrathecal injection to the human subject, (i) a first loading dose of the antisense compound or a salt thereof corresponding to about 50 mg of the antisense compound; and (ii) a second loading dose of the antisense compound or a salt thereof corresponding to about 50 mg of the antisense compound, administered about 10 to 20 days after administration of the first loading dose The method as described above. (Item 2) A method for increasing the level of survival motor neuron 2 (SMN2) messenger ribonucleic acid (mRNA) containing exon 7 in a human subject having a mutation associated with SMN protein deficiency on chromosome 5q, the method comprising administering to the human subject at least two loading doses of the following structure: [Chemical formula] administering an antisense compound having the following or a salt thereof, wherein the method comprises, by intrathecal injection to the human subject, (i) a first loading dose of the antisense compound or a salt thereof corresponding to about 50 mg of the antisense compound; and (ii) a second loading dose of the antisense compound or a salt thereof corresponding to about 50 mg of the antisense compound, administered about 10 to 20 days after administration of the first loading dose The method as described above. (Item 3) further comprising administering at least one maintenance dose by intrathecal injection to the human subject, wherein the at least one maintenance dose corresponds to about 28 mg of the antisense compound, the method according to item 1 or 2. (Item 4) The method further comprises administering, by intrathecal injection to the human subject, a maintenance amount of the antisense compound or a salt thereof, each corresponding to about 28 mg of the antisense compound, starting about 4 months after administration of the second loading dose and then continuing once every about 4 months, according to the method of item 1 or 2. (Item 5) The method according to item 4, wherein the second loading dose is administered about 14 days after administration of the first loading dose. (Item 6) The method comprises, by intrathecal injection to the human subject, (iii) the antisense compound or a salt thereof in a third loading dose corresponding to about 50 mg of the antisense compound, administered about 10 to 20 days after administration of the second loading dose; (iv) a maintenance amount of the antisense compound or a salt thereof, each corresponding to about 28 mg of the antisense compound, starting about 4 months after administration of the third loading dose and then continuing once every about 4 months and further comprising administering, according to the method of item 1 or 2. (Item 7) The method according to item 6, wherein the second loading dose is administered about 14 days after administration of the first loading dose, and the third loading dose is administered about 14 days after administration of the second loading dose. (Item 8) The method comprises, by intrathecal injection to the human subject, (iii) the antisense compound or a salt thereof in a third loading dose corresponding to about 50 mg of the antisense compound, administered about 10 to 20 days after administration of the second loading dose; (iv) the antisense compound or a salt thereof in a fourth loading dose corresponding to about 50 mg of the antisense compound, administered about 10 to 20 days after administration of the third loading dose; (v) a maintenance amount of the antisense compound or a salt thereof, each corresponding to about 28 mg of the antisense compound, starting about 4 months after administration of the fourth loading dose and then continuing once every about 4 months The method according to item 1 or 2, further comprising administering (Item 9) The method according to item 8, wherein the second loading dose is administered about 14 days after the administration of the first loading dose, the third loading dose is administered about 14 days after the administration of the second loading dose, and the fourth loading dose is administered about 14 days after the administration of the third loading dose. (Item 10) A method for treating spinal muscular atrophy (SMA) in a human subject in need of treatment for spinal muscular atrophy (SMA), the method comprising administering to the human subject the following structure:

Chemical formula

Chemical formula

Chemical formula

Claims

[Claim 1] The invention described in the specification.

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