USES OF PTHrP ANALOGUE IN REDUCING FRACTURE RISK

Abstract

To provide uses of a PTHrP analogue in reducing the fracture risk.SOLUTION: A method for preventing or reducing non-vertebral bone fractures in a subject in need of preventing or reducing non-vertebral bone fractures comprises administering to the subject a therapeutically effective amount of a polypeptide of SEQ ID NO:1.SELECTED DRAWING: None

Description

Technical Field

[0001] Related Applications This application claims priority to U.S. Provisional Patent Application No. 62 / 127,729, filed Mar. 3, 2015; U.S. Provisional Patent Application No. 62 / 165,841, filed May 22, 2015; U.S. Provisional Patent Application No. 62 / 201,564, filed Aug. 5, 2015; U.S. Provisional Patent Application No. 62 / 239,733, filed Oct. 9, 2015; and U.S. Provisional Patent Application No. 62 / 278,762, filed Jan. 14, 2016, which are hereby incorporated by reference in their entireties, including the drawings.

[0002] The present invention relates to the use of PTHrP analogs in reducing fracture risk.

Background Art

[0003] Background As our population ages, osteoporotic fractures are expected to have a high impact on the health of our population. Today, it is estimated that over 20 million Americans suffer from osteoporosis, and 1.5 million osteoporotic fractures occur each year in the United States (1). In patients with established osteoporosis, currently available medical treatments can only moderately reduce the risk of clinical non-spinal fractures (2, 3). Currently, the mainstay of osteoporosis treatment is the use of oral and intravenous bisphosphonates. These drugs function by suppressing bone resorption, but also reduce bone formation (4). Teriparatide (TPTD, hPTH(1-34)) is the only currently available anabolic agent and acts by mechanisms that include stimulation of new bone formation (with resorption) and remodeling of the internal bone microstructure (5-7). The effect of teriparatide on bone mineral density (BMD) is superior to bone resorption inhibitors at the spine, but the effect at the hip is more modest and often delayed until the second year of a 2-year course of treatment (8, 9). Hip fractures are particularly common in osteoporotic patients, and there is a need to develop new treatments for improving BMD and reducing the risk of hip fractures in osteoporotic patients.

[0004] Furthermore, patients with high cortical bone porosity may have a higher risk of fracture even with slightly low or normal BMD (10). Therefore, it is also necessary to develop new treatments not only to improve BMD but also to improve bone microstructure and reduce fracture risk.

Prior Art Documents

Non-Patent Documents

[0005]

Non-Patent Document 1

Summary of the Invention

Problems to be Solved by the Invention

[0006] The problem of the present invention is to provide the use of PTHrP analogs in reducing fracture risk.

Means for Solving the Problems

[0007] Overview The present invention provides a method for preventing or reducing fractures in a subject, comprising the step of administering a therapeutically effective amount of PTHrP or an analog thereof to a subject in need of fracture prevention or reduction. In certain embodiments, the PTHrP analog has the amino acid sequence set forth in SEQ ID NO: 1: abaloparatide having Ala Val Ser Glu His Gln Leu Leu His Asp Lys Gly Lys Ser Ile Gln Asp Leu Arg Arg Arg Glu Leu Leu Glu Lys Leu Leu Aib Lys Leu His Thr Ala ([Glu 22,25 , Leu 23,28,31 , Aib 29 , Lys 26,30 hPTHrP(1-34)NH2). Aib is α-aminoisobutyric acid, i.e., 2-aminoisobutyric acid.

[0008] In certain embodiments, the subject has diabetes (e.g., type 2 diabetes). In certain embodiments, the subject has osteoporosis.

[0009] In certain embodiments, the method further comprises administering to the subject a therapeutically effective amount of an antiresorptive agent (e.g., alendronate).

[0010] The present invention provides a method for preventing or reducing non-spinal fractures in a subject, comprising administering a therapeutically effective amount of PTHrP or an analog thereof to a subject in need of prevention or reduction of non-spinal fractures. In certain embodiments, the PTHrP analog is abaloparatide. In certain embodiments, the non-spinal fracture is a hip or wrist fracture. In certain embodiments, the method further comprises administering to the subject a therapeutically effective amount of an antiresorptive agent (e.g., alendronate).

[0011] The present invention provides a method for preventing or reducing spinal fractures in a subject, comprising administering a therapeutically effective amount of PTHrP or an analog thereof to a subject in need of prevention or reduction of spinal fractures. In certain embodiments, the PTHrP analog is abaloparatide. In certain embodiments, the method further comprises administering to the subject a therapeutically effective amount of an antiresorptive agent (e.g., alendronate).

[0012] A method for improving BMD and / or trabecular bone score (TBS) in a subject in need thereof is provided, the method comprising administering to the subject a therapeutically effective amount of PTHrP or an analog thereof (e.g., abaloparatide).

[0013] That is, the gist of the present invention relates to the following. Item 1 Use of abaloparatide in the manufacture of a medicament for increasing bone density in male subjects with osteoporosis and a high risk of fractures, said use being for subcutaneous administration of 80 μg of abaloparatide to male subjects daily. Item 2 The use according to item 1, wherein the male subject experiences an increase in bone mineral density (BMD) of at least 2.9% in the lumbar spine after 24 weeks of treatment. Item 3 The use according to item 1 or 2, wherein the male subject experiences an improvement in bone mineral density (BMD) and / or trabecular bone score (TBS) in non-spinal bones. Item 4 The use according to item 3, wherein the BMD increases by at least 3% at the hip, wrist, or both the hip and wrist. Item 5 The use according to item 3, wherein the male subject experiences an increase in TBS of at least 1.2% after 12 weeks of treatment. Item 6 The use according to any one of items 1 to 5, wherein the male subject experiences prevention of non-spinal fractures. Item 7 The use according to any one of items 1 to 6, wherein the male subject experiences a reduction in the risk of non-spinal fractures. Item 8 The use according to item 7, wherein the risk of non-spinal fractures is reduced by 30% to 70% compared to the risk in male subjects not treated with abaloparatide. Item 9 The use according to any one of items 1 to 8, wherein the male subject experiences a reduction in the risk of vertebral fractures. Item 10 The use according to item 9, wherein the risk of vertebral fracture is reduced by 50% to 95% compared to the risk in male subjects not treated with abaloparatide. Item 11 The use according to any one of items 1 to 10, wherein the male subject experiences prevention of vertebral fracture. Item 12 The use according to any one of items 1 to 11, wherein the male subject has diabetes. Item 13 The use according to item 12, wherein the diabetes is type II diabetes. Item 14 The use according to any one of items 1 to 13, wherein the male subject has high cortical bone porosity. Item 15 The use according to any one of items 1 to 14, wherein the male subject has normal BMD before the start of abaloparatide administration. Item 16 The use according to any one of items 1 to 15, wherein the male subject has a BMD T-score of at least about -1 before abaloparatide administration. Item 17 The use according to any one of items 1 to 16, wherein abaloparatide is administered as a pharmaceutical composition having a pH in the range of 4.5 to 5.6.

Advantages of the Invention

[0014] The present invention can provide the use of a PTHrP analog in reducing the risk of fracture.

Brief Description of the Drawings

[0015]

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Mode for Carrying Out the Invention

[0016] Detailed Description The following description of the invention is merely intended to illustrate various aspects of the invention. Thus, the specific changes described are not considered to be limitations on the scope of the invention. It will be apparent to those skilled in the art that various equivalents, changes, and modifications can be made without departing from the scope of the invention, and it is understood that such equivalent aspects are included in the invention.

[0017] The term "parathyroid hormone-related protein (PTHrP)" as used herein refers to native human PTHrP (hPTHrP) and fragments thereof. The sequence of native hPTHrP(1-34) is: Ala Val Ser Glu His Gln Leu Leu His Asp Lys Gly Lys Ser Ile Gln Asp Leu Arg Arg Arg Phe Phe Leu His His Leu Ile Ala Glu Ile His Thr Ala (SEQ ID NO: 2). PTHrP is a protein that has homology with PTH at the amino terminus that binds to the same G protein-coupled receptor. Despite the common receptor (PTHR), PTH mainly functions as an endocrine regulator of calcium homeostasis, and PTHrP plays an important paracrine role in mediating endochondral bone development (11). The different effects of these proteins may be related not only to different tissue expression but also to different receptor-binding properties (12-14). Over the past few years, PTHrP has been studied as a potential treatment for osteoporosis. The results of these studies have been combined, and some suggest that intermittent administration of high doses of PTHrP increases bone formation without simultaneously stimulating bone resorption, while others report a moderate stimulation of bone resorption and significant hypercalcemia (15-17).

[0018] A "fragment" of hPTHrP refers to a polypeptide that has a sequence containing less than full complementarity of the amino acids found in hPTHrP but induces a similar biological response. Typically, fragments for use in the methods and compositions provided in the present invention have a C-terminus truncated and are in the range of 30-40 residues in length. In particular, hPTHrP(1-34), and its analogs having substitutions at 1-15 are useful in the methods and compositions of the present invention.

[0019] As used herein, an "analog" of PTHrP refers to a polypeptide having about 1 to about 20, about 1 to about 15, or about 1 to about 10 substitutions, additions, or insertions, or combinations thereof, that are accepted in the art for PTHrP (i.e., for hPTHrP or a fragment thereof), with a total combination of substitutions, additions, and insertions not exceeding 20. As used herein, "insertion" includes the insertion of an amino acid between two existing amino acids in a peptide chain. As used herein, "addition" means the addition of an amino acid to the N-terminus or C-terminus of a peptide chain. As used herein, "substitution" means the substitution of an amino acid for an existing amino acid in a peptide chain. As used herein, an "art-accepted" substitution, insertion, or addition is one that a person of ordinary skill in the art would predict would maintain or increase the biological and / or hormonal activity of the peptide and would not act detrimentally on the biological activity of the peptide. Art-accepted substitutions include, for example, the substitution of one amino acid for another amino acid that is chemically or biologically similar, such as the substitution of one hydrophobic amino acid for another hydrophobic amino acid. PTHrP analogs are described with respect to their modifications from the native sequence of hPTHrP.

[0020] Examples of PTHrP analogs include, but are not limited to, abaloparatide. Abaloparatide was selected to retain potential anabolic activity with reduced bone resorption, low calcium mobilization ability, and improved stability at room temperature (18). Studies conducted in animals have shown significant anabolic activity for the PTHrP analog abaloparatide, demonstrating the opposite of bone loss in rats and monkeys with ovariectomy-induced osteopenia (19, 20).

[0021] As described in the following examples, subjects treated with abaloparatide showed a significant reduction in certain fractures compared to subjects treated with placebo or teriparatide.

[0022] When compared to subjects treated with placebo, subjects treated with abaloparatide unexpectedly showed a statistically significant reduction in major osteoporotic fractures, clinical fractures, new vertebral fractures, and nonvertebral fractures in the 18-month trial (see, e.g., Example 1, Table 1).

[0023] Subjects treated with teriparatide showed a statistically significant reduction in new vertebral fractures compared to the placebo group. Subjects treated with abaloparatide unexpectedly showed a statistically significant reduction in major osteoporotic fractures compared to subjects treated with teriparatide.

[0024] Subjects treated with abaloparatide also unexpectedly showed a significant reduction in the risk of nonvertebral fractures (e.g., wrist fractures) and clinical fractures (see, e.g., Example 1, Table 1). Abaloparatide further was found to significantly reduce the risk of major osteoporotic fractures and any clinical fractures, regardless of baseline fracture probability, using the Fracture Risk Assessment Tool (FRAX) in postmenopausal women.

[0025] Subjects treated with abaloparatide showed a significant increase not only in BMD but also in TBS (see, e.g., Example 4). TBS is a gray-scale textural analysis applied to vertebral DXA images that has been shown to be related to trabecular microarchitecture and bone strength. TBS is also a predictor of vertebral and hip fracture vulnerability in postmenopausal women independent of BMD and other major clinical risk factors. Thus, TBS captures additional patients at risk of fractures that are overlooked by BMD alone (35) and, together with BMD, captures bone strength more accurately.

[0026] Lower BMD is generally associated with a higher risk of fracture, but normal or slightly above normal BMD does not necessarily indicate a lower risk of fracture. For example, subjects with type 2 diabetes may have a high risk of fracture (especially at the hip and / or wrist), despite having a higher BMD (21). One factor underlying the discrepancy between relatively normal BMD and high fracture risk may be the higher cortical bone porosity in subjects with diabetes (e.g., type 2 diabetes). For example, subjects with type 2 diabetes may have up to twice the cortical bone porosity of controls (21). In certain embodiments, the treatment methods provided in the present invention may be advantageous for subjects with diabetes and / or subjects with higher cortical bone porosity.

[0027] Subjects treated with abaloparatide for 18 months unexpectedly showed a significant increase in BMD at the total hip and femoral neck compared to subjects treated with teriparatide (see, e.g., Example 1, Tables 4-5). Abaloparatide showed a statistically significant increase in lumbar BMD at 6 and 12 months and a non-statistically significant increase in BMD at 18 months compared to teriparatide (see, e.g., Example 1, Tables 4-5). Without wishing to be bound by any theory, the earlier increase in the bone formation marker P1NP in subjects treated with abaloparatide compared to subjects treated with teriparatide may contribute to the earlier effect of abaloparatide on BMD (see, e.g., Example 1, FIG. 6A, and Example 3, FIG. 14B). For the CTX marker (bone resorption), subjects treated with abaloparatide showed an earlier return to baseline at 18 months compared to subjects treated with teriparatide (see, e.g., Example 1, FIG. 6B).

[0028] Furthermore, subjects treated with abaloparatide for 18 months followed by a bone resorption inhibitor (e.g., alendronate for 6 months) showed a significant reduction in fracture risk compared to subjects treated with placebo for 18 months followed by the same bone resorption inhibitor therapy (see, e.g., Example 1, Table 2).

[0029] In a subject in need of preventing or reducing fractures, improving bone mineral density (BMD), and / or improving trabecular bone score (TBS), methods, compositions, and kits for preventing or reducing fractures, improving BMD, and / or improving TBS using parathyroid hormone-related protein (PTHrP) or an analog thereof (e.g., abaloparatide) are provided in the present invention.

[0030] One aspect of the present disclosure relates to a method for preventing or reducing fractures in a subject, comprising administering a therapeutically effective amount of PTHrP or an analog thereof (e.g., abaloparatide) to the subject in need of preventing or reducing fractures. Exemplary fractures that may indicate a reduced fracture risk include, without limitation, major osteoporotic fractures (clinical vertebral, hip, femoral neck, or shoulder fractures, e.g., high or low trauma clinical fractures), non-vertebral fractures (e.g., wrist, femoral neck, etc.), clinical fractures (e.g., fractures confirmed by x-ray scan, radiologist's report, urgent care report, hospital discharge report, surgical report, hospital or clinic note, or other medical confirmation, with or without high trauma), and new vertebral fractures.

[0031] Another aspect of the present disclosure relates to a method for preventing or reducing non-vertebral fractures in a subject, comprising administering a therapeutically effective amount of PTHrP or an analog thereof (e.g., abaloparatide) to the subject in need of preventing or reducing non-vertebral fractures.

[0032] Another aspect of the present disclosure relates to a method for preventing or reducing vertebral fractures in a subject, comprising administering a therapeutically effective amount of PTHrP or an analog thereof (e.g., abaloparatide) to the subject in need of preventing or reducing vertebral fractures.

[0033] Another aspect of the present disclosure relates to a method for improving BMD and / or TBS in a subject in need thereof, the method comprising administering a therapeutically effective amount of PTHrP or an analog thereof (e.g., abaloparatide) to the subject. Examples of bones that may show improvement in BMD and / or TBS after administration include, but are not limited to, lumbar vertebrae, total hip, wrist, femur, cortical bone of the femur (femoral shaft), and / or femoral neck in the subject.

[0034] In certain embodiments, the treatment method provided in the present invention further comprises administering an antiresorptive agent therapy after a prolonged period of treatment with PTHrP or an analog thereof (e.g., abaloparatide). For example, provided in the present invention is a method for improving BMD and / or trabecular bone score TBS in a subject, the method comprising administering a therapeutically effective amount of PTHrP or an analog thereof (e.g., abaloparatide) to the subject for a certain period of time, and then administering a therapeutically effective amount of an antiresorptive agent to the subject. Examples of bones that may show improvement in BMD and / or TBS after administration include, but are not limited to, lumbar vertebrae, total hip, wrist, femur, cortical bone of the femur (femoral shaft), and / or femoral neck in the subject. Also provided in the present invention is a method for preventing or reducing fractures in a subject, the method comprising administering a therapeutically effective amount of PTHrP or an analog thereof (e.g., abaloparatide) to the subject for a certain period of time, and subsequently administering a therapeutically effective amount of an antiresorptive agent to the subject. Exemplary fractures that may show a reduction in fracture risk include, but are not limited to, major osteoporotic fractures, non-vertebral fractures (e.g., wrist, hip), clinical fractures, and new vertebral fractures. In these methods provided in the present invention that include administration of an antiresorptive agent after administration of a PTHrP analog, the administration of the PTHrP analog and the antiresorptive agent may overlap to some extent, i.e., the administration of the antiresorptive agent may be initiated while the subject is still receiving the PTHrP analog.

[0035] Selecting an appropriate bone resorption inhibitor therapy for the aspects and embodiments disclosed herein is within the scope of those skilled in the art. In some embodiments, bone resorption inhibitor therapies include monoclonal antibodies such as bisphosphonates, estrogen, selective estrogen receptor modulators (SERMs), calcitonin, cathepsin K inhibitors, and denosumab. In certain embodiments, the bone resorption inhibitor therapy can be a bisphosphonate such as alendronate.

[0036] As used herein, the term "subject in need thereof" refers to a mammalian subject, such as a human. In certain embodiments, the subject in need thereof has a higher risk of fracture than normal. In certain embodiments, the subject in need thereof has one or more conditions selected from the group consisting of low BMD and high cortical bone porosity. BMD can be measured by digital x-ray radiogrammetry (DXR) or other methods known in the art. As used herein, the term "low BMD" means a BMD T-score of ≦ about 2 or ≦ about -2.5 at one or more sites selected from the group consisting of the spine (e.g., lumbar spine), hip (e.g., total hip or femoral neck), and wrist. As used herein, the term "cortical bone porosity" means the fraction of cortical bone volume not occupied by bone. Cortical bone porosity can be measured by DXR or other methods known in the art using a recursive (climbing) algorithm starting from the outer region to provide an estimate of local minimum intensity ("holes") in the cortical bone region (10). The combined porosity measurements are derived from the area percentage of holes seen in the cortical portion relative to the total cortical area by taking the average of the entire bone included and scaling to reflect volume ratios rather than protruding regions. "High cortical bone porosity" means a porosity that is about 10%, about 15%, about 20%, about 50%, about 100%, or about 150% higher than that of healthy subjects of the same age group as a control. For example, a subject can have a cortical bone porosity of about 0.01256 and a control group can have a cortical bone porosity of about 0.01093 (10).Subjects with high cortical bone porosity may have a slightly low BMD, normal BMD, or a BMD slightly higher than normal BMD, such as at least about -2, at least about -1.5, at least about -1, at least about -0.5, at least about -0.25, at least about -0.2, at least about -0.1, at least about 0, about -2 to about 3, about -2 to about 2.5, about -2 to about 2, about -2 to about 1.5, about -2 to about 1, about -2 to about 0.5, about -2 to about 0.25, about -2 to about 0.2, about -2 to about 0.1, or about -2 to about 0 BMD T-score. For example, a subject with type 2 diabetes may have cortical bone porosity up to twice that of a control while having a normal or slightly higher BMD than normal BMD (21). Examples of subjects for whom such may be needed include, without limitation, women, women with osteoporosis and / or diabetes (e.g., type 1 or type 2 diabetes), postmenopausal women, postmenopausal women with osteoporosis and / or diabetes (e.g., type 1 or type 2 diabetes), and men with osteoporosis and / or diabetes (e.g., type 1 or type 2 diabetes).

[0037] As used herein, the term "therapeutically effective amount" refers to an amount of a compound or agent that, when a particular therapeutic context may require it, is required or sufficient to elicit the required or desired therapeutic and / or prophylactic response. In certain embodiments, a therapeutically effective amount is the amount of a composition that produces a maximal therapeutic effect. In other embodiments, a therapeutically effective amount produces a therapeutic effect lower than the maximal therapeutic effect. For example, a therapeutically effective amount can be an amount that produces a therapeutic effect while avoiding one or more side effects associated with the dosage that produces the maximal therapeutic effect. The therapeutically effective amount for a particular composition can vary depending on, but is not limited to, the characteristics of the therapeutic composition (e.g., activity, pharmacokinetics, pharmacodynamics, and bioavailability), the physiological state of the subject (e.g., age, weight, gender, type and stage of disease, medical history, general physical condition, responsiveness to a given dosage, and other medications present), the nature of any pharmaceutically acceptable carrier in the composition, and the route of administration. Persons skilled in the clinical and pharmaceutical arts can determine the therapeutically effective amount by routine experimentation, i.e., by monitoring the response of the subject to administration of the composition and adjusting the dosage. For further guidance, see, e.g., Remington: The Science and Practice of Pharmacy, 22nd Edition, Pharmaceutical Press, London, 2012 and Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12th Edition, McGraw-Hill, New York, NY, 2011 (the entire disclosures of which are incorporated herein by reference).

[0038] Examples of a therapeutically effective amount of PTHrP or an analog thereof (e.g., abaloparatide) include, without limitation, about 10 μg to about 250 μg, about 50 μg to about 200 μg, about 50 μg to about 150 μg, about 70 μg to about 100 μg, about 70 μg to about 90 μg, about 75 μg to about 85 μg, about 20 μg, about 40 μg, about 60 μg, about 80 μg, about 100 μg, about 120 μg, about 150 μg, about 200 μg, or about 250 μg. Other examples of a therapeutically effective amount of PTHrP or an analog thereof (e.g., abaloparatide) can include, without limitation, about 5 μg / kg or about 20 μg / kg. Depending on the particular bone resorption inhibitor, one of ordinary skill in the art can select a therapeutically effective amount of the bone resorption inhibitor. The amount of the bone resorption inhibitor can be further optimized when used in combination with or subsequent to the treatment with PTHrP or an analog thereof (e.g., abaloparatide).

[0039] In certain embodiments, PTHrP or an analog thereof (e.g., abaloparatide) is administered by subcutaneous injection or transdermal administration.

[0040] In certain embodiments, PTHrP or an analog thereof (e.g., abaloparatide) is administered for a fixed period. In other embodiments, administration is carried out until a specific treatment endpoint is achieved (e.g., in bones such as the vertebrae, hip, and / or femoral neck, the BMD increases by about 3% or more). Examples of suitable time frames for administration include, without limitation, 6 weeks, 12 weeks, 3 months, 24 weeks, 6 months, 48 weeks, 12 months, 18 months, or 24 months. In certain embodiments, PTHrP or an analog thereof (e.g., abaloparatide) is administered once a day, twice a day, three times a day, or more than three times a day. In other embodiments, administration can be done once every two days, once every three days, once every four days, once a week, or once a month. In certain embodiments, PTHrP or an analog thereof (e.g., abaloparatide) is administered once a day for 18 months.

[0041] In certain embodiments, the bone resorption inhibitor can be administered to a subject who has been receiving PTHrP or an analog thereof (e.g., abaloparatide) for an extended period. Following treatment with PTHrP or an analog thereof (e.g., abaloparatide), the bone resorption inhibitor is administered to the subject for a fixed period such as 6 weeks, 12 weeks, 3 months, 24 weeks, 6 months, 48 weeks, 12 months, 18 months, and 24 months. In certain embodiments, the bone resorption inhibitor is administered once a day, twice a day, three times a day, or more than three times a day. In other embodiments, the administration can be once every two days, once every three days, once every four days, once a week, once a month, or once a year. In certain embodiments, the bone resorption inhibitor is administered once a day for 6 months, 9 months, or 12 months. In certain embodiments, the administration of the PTHrP analog and the bone resorption inhibitor can overlap for a period, i.e., the administration of the bone resorption inhibitor can be initiated while the subject is still receiving the PTHrP analog.

[0042] As disclosed herein, subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) show a significant reduction in fractures compared to subjects not treated or treated with a placebo. In certain embodiments, subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) can show a reduction in fractures of at least about 10%, at least about 20%, at least about 30%, at least about 40%, at least about 50%, at least about 60%, at least about 70%, at least about 80%, at least about 90%, or about 100% compared to subjects not treated or treated with a placebo.

[0043] In certain embodiments, the method provided in the present invention reduces the risk of wrist fracture in a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) by about 40% to about 70%, about 50% to about 65%, about 55% to about 60% or at least about 58% compared to a subject not treated or treated with a placebo. In certain embodiments, the risk of wrist fracture in a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) is reduced by about 40% to about 80%, about 50% to about 75%, about 60% to about 75%, about 65% to about 75%, about 70% to about 75% or at least about 72% compared to a subject treated with teriparatide.

[0044] In certain embodiments, the method provided in the present invention reduces the major osteoporotic fracture risk in a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) by about 30% to about 80%, about 40% to about 80%, about 50% to about 75%, about 60% to about 75%, about 65% to about 75%, about 70% to about 75%, about 58% or at least about 71% compared to a subject treated with a placebo. In certain embodiments, the major osteoporotic fracture risk in a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) is reduced by about 40% to about 70%, about 50% to about 65%, about 55% to about 60% or at least about 57% compared to a subject treated with teriparatide.

[0045] In certain embodiments, the method provided in the present invention reduces the clinical fracture risk in a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) by about 30% to about 70%, about 35% to about 65%, about 40% to about 60%, about 40 to about 50% or at least about 45% compared to a subject not treated or treated with a placebo. In certain embodiments, the clinical fracture risk in a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) is reduced by about 15% to about 40%, about 20% to about 35%, about 20% to about 30%, about 20% to about 25% or at least about 23% compared to a subject treated with teriparatide.

[0046] In certain embodiments, the method provided in the present invention reduces the risk of new vertebral fractures in a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) by about 50% to about 95%, about 60% to about 95%, about 70% to about 90%, about 80% to about 88%, at least about 87% or at least about 86% compared to a subject not treated or treated with a placebo. In certain embodiments, a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) exhibits a risk of vertebral fractures that is reduced by about 15% to about 45%, about 20% to about 40%, about 25% to about 35% or at least about 30% compared to a subject treated with teriparatide.

[0047] In certain embodiments, the method provided in the present invention reduces the risk of non-vertebral fractures in a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) by about 30% to about 70%, about 35% to about 65%, about 40% to about 60%, about 40% to about 50%, about 51% or at least about 45% when compared to a subject not treated or treated with a placebo. In certain embodiments, the risk of non-vertebral fractures in a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) is reduced by about 15% to about 40%, about 20% to about 35%, about 20% to about 30%, about 20% to about 25% or at least about 24% compared to a subject treated with teriparatide.

[0048] In certain embodiments, the methods provided in the present invention result in a significant increase in BMD at the lumbar spine, femoral neck, and total hip. In certain embodiments, the methods disclosed herein result in a significant increase in BMD at the lumbar spine, femoral neck, and total hip within one year after the first administration of PTHrP or an analog thereof (e.g., abaloparatide), as compared to subjects treated with teriparatide. In certain embodiments, the methods disclosed herein result in a significant increase in BMD at the femoral neck and total hip, as compared to subjects treated with teriparatide. In certain embodiments, the BMD at the lumbar spine of subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) can increase by at least about 2.9%, at least about 3%, at least about 5.2%, at least about 6%, at least about 6.7%, at least about 12.8%, from about 2% to about 8%, from about 6% to about 8%, from about 2% to about 7%, from about 6% to about 7%, from about 5.8% to about 7%, from about 2% to about 15%, from about 6% to about 15%, from about 2% to about 14%, from about 6% to about 14%, from about 2% to about 13%, from about 6% to about 13%, from about 2% to about 12.8%, from about 6% to about 12.8%, or from about 5.8% to about 12.8%. The BMD at the femoral neck of subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) can increase by at least about 2.2%, at least about 2.7%, at least about 3%, at least about 3.1%, at least about 4.5%, at least about 5%, at least about 6%, from about 1.5% to about 4%, from about 2% to about 4%, from about 2.5% to about 4%, from about 2% to about 3.5%, from about 1.5% to about 6%, from about 2% to about 6%, from about 2.5% to about 6%, from about 1.5% to about 5%, from about 2% to about 5%, from about 2.5% to about 5%, from about 1.5% to about 4.5%, from about 2% to about 4.5%, or from about 2.5% to about 4.5%. The BMD at the total hip of subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) can increase by at least about 1.4%, at least about 2.0%, at least about 2.6%, at least about 3%, at least about 3.5%, at least about 4%, at least about 4.5%, at least about 5%, at least about 5.5%, at least about 6%, at least about 7%, from about 0.6% to about 3%, from about 1% to about 3%, from about 1.5% to about 3%, from about 0.6% to about 3.5%, from about 1% to about 3.5%, from about 1.5% to about 3.5%, from about 0.It can increase by 6% to about 4%, about 1% to about 4%, about 1.5% to about 4%, about 2% to about 4%, about 0.6% to about 4.5%, about 1% to about 4.5%, about 1.5% to about 4.5%, about 2% to about 4.5%, about 0.6% to about 5%, about 1% to about 5%, about 1.5% to about 5%, about 2.0% to about 5%, about 0.6% to about 5.5%, about 1% to about 5.5%, about 1.5% to about 5.5%, about 2% to about 5.5%, about 0.6% to about 6%, about 1% to about 6%, about 1.5% to about 6%, about 2% to about 6%, about 0.6% to about 6.5%, about 1% to about 6.5%, about 1.5% to about 6.5%, about 2.0% to about 6.5%, about 0.6% to about 7%, about 1% to about 7%, about 1.5% to about 7% or about 2% to about 7%.

[0049] In certain embodiments, the subject is administered PTHrP or an analog thereof (e.g., abaloparatide) at a daily dose of 20 μg, 40 μg or 80 μg over 24 weeks. In certain embodiments, this administration results in a significant increase in BMD at the lumbar spine, femoral neck and total hip (see, e.g., FIG. 12). In certain embodiments, the BMD at the lumbar spine for subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) can increase by at least about 2.9%, at least about 3%, at least about 5.2%, at least about 6%, about 6.7%, at least about 2% to about 8%, at least about 6% to about 8%, at least about 6% to about 7% or about 5.8% to about 7%, the BMD at the femoral neck of subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) can increase by at least about 2.2%, at least about 2.7%, at least about 3.1%, about 2% to about 4%, about 1.5% to about 4%, about 2.5% to about 4% or about 2% to about 3.5%, and the BMD at the total hip of subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) can increase by at least about 1.4%, at least about 2.0%, at least about 2.6%, about 1% to about 3%, about 0.6% to about 3.5%, about 1% to about 3.5% or about 1.5% to about 3%.

[0050] In certain embodiments, the subject is administered PTHrP or an analog thereof (e.g., abaloparatide) at a daily dose of 20 μg, 40 μg, or 80 μg for 18 months, and then alendronate is administered at a dose of 10 mg / day or 70 mg / week (e.g., orally), 5 mg / day or 35 mg / week (e.g., orally), 15 mg / day or 105 mg / week (e.g., orally), 20 mg / day or 140 mg / week (e.g., orally), about 5 - about 20 mg / day or about 35 - about 140 mg / week (e.g., orally), about 5 - about 15 mg / day or about 35 - about 105 mg / week (e.g., orally), about 5 - about 10 mg / day or about 35 - about 70 mg / week (e.g., orally), or about 10 - about 20 mg / day or about 70 - about 140 mg / week (e.g., orally) for 6 months. In certain embodiments, this results in a significant increase in BMD at the lumbar spine, femoral neck, and total hip (see, e.g., FIG. 12). In certain embodiments, the BMD at the lumbar spine of subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) can increase by at least about 2.9%, at least about 3%, at least about 5.2%, at least about 6%, at least about 6.7%, at least about 12.8%, about 2% - about 8%, about 6% - about 8%, about 2% - about 7%, about 6% - about 7%, about 5.8% - about 7%, about 2% - about 15%, about 6% - about 15%, about 2% - about 14%, about 6% - about 14%, about 2% - about 13%, about 6% - about 13%, about 2% - about 12.8%, about 6% - about 12.8%, or about 5.8% - about 12.8%. The BMD at the femoral neck of subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) can increase by at least about 2.2%, at least about 2.7%, at least about 3%, at least about 3.1%, at least about 4.5%, at least about 5%, at least about 6%, about 1.5% - about 4%, about 2% - about 4%, about 2.5% - about 4%, about 2% - about 3.5%, about 1.5% - about 6%, about 2% - about 6%, about 2.5% - about 6%, about 1.5% - about 5%, about 2% - about 5%, about 2.5% - about 5%, about 1.5% - about 4.5%, about 2% - about 4.5%, or about 2.5% - about 4.5%. The BMD at the total hip of subjects treated with PTHrP or an analog thereof (e.g., abaloparatide) is at least about 1.4%, at least about 2.0%, at least about 2.It can increase by 6%, at least about 3%, at least about 3.5%, at least about 4%, at least about 4.5%, at least about 5%, at least about 5.5%, at least about 6%, at least about 7%, from about 0.6% to about 3%, from about 1% to about 3%, from about 1.5% to about 3%, from about 0.6% to about 3.5%, from about 1% to about 3.5%, from about 1.5% to about 3.5%, from about 0.6% to about 4%, from about 1% to about 4%, from about 1.5% to about 4%, from about 2% to about 4%, from about 0.6% to about 4.5%, from about 1% to about 4.5%, from about 1.5% to about 4.5%, from about 2% to about 4.5%, from about 0.6% to about 5%, from about 1% to about 5%, from about 1.5% to about 5%, from about 2.0% to about 5%, from about 0.6% to about 5.5%, from about 1% to about 5.5%, from about 1.5% to about 5.5%, from about 2% to about 5.5%, from about 0.6% to about 6%, from about 1% to about 6%, from about 1.5% to about 6%, from about 2% to about 6%, from about 0.6% to about 6.5%, from about 1% to about 6.5%, from about 1.5% to about 6.5%, from about 2.0% to about 6.5%, from about 0.6% to about 7%, from about 1% to about 7%, from about 1.5% to about 7% or from about 2% to about 7%.

[0051] In certain embodiments, the subject is treated with PTHrP or an analog thereof (e.g., abaloparatide) at a daily dose of 20 μg, 40 μg or 80 μg for 12 to 24 weeks. This dosing regimen of abaloparatide is shown herein to significantly increase the TBS in the treated subject, suggesting an improvement in trabecular bone microstructure. In certain embodiments, the TBS of a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) for 12 weeks increases by at least about 1.2%, at least about 1.7%, at least about 1.9%, from about 1% to about 2.5%, from about 1% to about 2%, from about 1.6% to about 2.5%, from about 1.7% to about 2.5%, from about 1.6% to about 2% or from about 1.7% to about 2%. In certain embodiments, the TBS of a subject treated with PTHrP or an analog thereof (e.g., abaloparatide) for 24 weeks increases by at least about 2.4%, at least about 2.7%, at least about 3.6%, from about 2% to about 4.5%, from about 2% to about 4%, from about 2.7% to about 4.5%, from about 2.7% to about 4%, from about 3% to about 4.5% or from about 3% to about 4%.

[0052] In certain aspects of the methods disclosed herein, PTHrP or an analog thereof (e.g., abaloparatide) is administered in combination with one or more additional osteoporosis treatments, including, for example, alendronate treatment. In these aspects, the additional osteoporosis treatment can be administered before, during, or after treatment with PTHrP or an analog thereof (e.g., abaloparatide). PTHrP or an analog thereof and the additional osteoporosis treatment can be administered separately or as part of the same composition. Administration of the two agents can be at the same time, or around the same time, for example, simultaneously, or the two agents can be administered at different times.

[0053] In certain aspects, PTHrP or an analog thereof (e.g., abaloparatide) and / or the additional osteoporosis treatment is administered in a pharmaceutical composition as an active ingredient(s). Such pharmaceutical composition can further include a pharmaceutically acceptable carrier. As used herein, "pharmaceutically acceptable carrier" refers to a pharmaceutically acceptable material, composition, or vehicle involved in the transport or delivery of the desired compound or molecule from one tissue, organ, or part of the body to another tissue, organ, or part of the body. A pharmaceutically acceptable carrier can include various components, including, but not limited to, liquid or solid fillers, diluents, excipients, solvents, buffers, encapsulating materials, surfactants, stabilizers, fillers or dyes, or some combination thereof. Each component of the carrier must be "pharmaceutically acceptable" such that it is compatible with the other components of the composition and suitable for contact with any tissue, organ, or part of the body that it may encounter, meaning that the component does not possess a risk of toxicity, irritation, allergic response, immunogenicity, or any other complication that unduly affects its therapeutic benefit.

[0054] Examples of pharmaceutically acceptable carriers that can be used in combination with the composition provided by the present invention include, but are not limited to, (1) sugars such as lactose, glucose, sucrose or mannitol, (2) starches such as corn starch and potato starch, (3) cellulose and its derivatives such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate, (4) powdered tragacanth, (5) malt, (6) gelatin, (7) talc, (8) excipients such as cocoa butter and suppository wax, (9) oils such as peanut oil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil and soybean oil, (10) glycols such as propylene glycol, (11) polyols such as glycerin, sorbitol, mannitol and polyethylene glycol, (12) esters such as ethyl oleate and ethyl laurate, (13) disintegrants such as agar or calcium carbonate, (14) buffers or pH adjusters such as magnesium hydroxide, aluminum hydroxide, sodium chloride, sodium lactate, calcium chloride and phosphate buffer, (15) alginic acid, (16) pyrogen-free water, (17) isotonic saline, (18) Ringer's solution, (19) alcohols such as ethyl alcohol and propanol, (20) paraffin, (21) lubricants such as talc, calcium stearate, magnesium stearate, solid polyethylene glycol or sodium lauryl sulfate, (22) coloring agents or dyes, (23) lubricants such as colloidal silicon dioxide, talc and starch or tricalcium phosphate, (24) other non-toxic compatible substances used in pharmaceutical compositions such as acetone, and (25) combinations thereof.

[0055] In certain embodiments, abaloparatide is administered as a pharmaceutical composition having a pH in the range of about 2 to about 7, about 4.5 to about 5.6 or about 5.1.

[0056] As used herein, the term "about" means within 10% of the recited value or range of values.

[0057] One skilled in the art will understand that the various aspects described herein can be combined. For example, the steps of the various methods of treatment disclosed herein can be combined to achieve a satisfactory or improved level of treatment.

[0058] The following examples are provided to better illustrate the claimed invention and are not intended to limit the scope of the invention. To the extent specific materials are described, they are for illustrative purposes only and are not intended to limit the invention. One skilled in the art can develop equivalent means or reactants without undue experimentation and without departing from the scope of the invention. It is understood that many modifications can be made to the techniques described herein while still remaining within the scope of the invention. It is the intention of the invention that such modifications be included within the scope of the invention.

Example

[0059] Example Example 1. Evaluation of the PTHrP analog abaloparatide for use in reducing fractures in postmenopausal women with osteoporosis. In postmenopausal women with or without osteoporosis, an ACTIVE Phase 3 fracture prevention trial of abaloparatide was conducted. The subjects included were treated for 18 months with 80 micrograms (μg) of abaloparatide, a matching placebo, or the approved daily dose of 20 μg of teriparatide. In all patient groups, the ACTIVE trial evaluated the fracture rate, fracture risk, BMD, and bone turnover biomarkers (e.g., CTX and P1NP). Eligible subjects in the abaloparatide treatment group and the placebo treatment group continued with an extension trial (ACTIVExtend), in which the subjects received approved alendronate treatment for osteoporosis management for 6 months and the fracture incidence was evaluated.

[0060] The reduction in fracture risk and hazard ratio (HR) were obtained from the Kaplan-Meier (KM) curves. The abaloparatide treatment group showed a significant reduction in the risk of non-vertebral fractures (e.g., wrist) and clinical fractures (excluding fingers, toes, sternum, patella, skull, and facial bones). Compared to the placebo group, the abaloparatide treatment group showed a statistically significant reduction between both the ACTIVE trial and the ACTIVE Extend trial in major osteoporosis fractures, clinical fractures, new vertebral fractures, and non-vertebral fractures (Tables 1 and 2). Compared to subjects treated with placebo, subjects treated with teriparatide showed a statistically significant reduction in fractures only in new vertebral fractures, but not in major osteoporosis fractures, clinical fractures, or non-vertebral fractures (Table 1). Furthermore, abaloparatide showed a statistically significant reduction compared to teriparatide in major osteoporosis fractures and wrist fractures. In fact, the teriparatide group showed a higher fracture risk for wrist fractures than the placebo group.

Table 1

Table 2

[0061] BMD and bone turnover biomarkers (CTX and P1NP) were also evaluated in all patient groups to compare the effects of abaloparatide vs teriparatide.

[0062] In all tested sites including the spine (e.g., lumbar spine), hip, and femoral neck, patients treated with abaloparatide for 18 months and then with alendronate for 6 months showed a significant increase in BMD (Figure 9). In the abaloparatide treatment group, more patients achieved the BMD threshold response as shown in Table 7 compared to the placebo group.

[0063] Abaloparatide also showed a statistically significant increase in BMD compared to teriparatide over the 18 - month ACTIVE trial in total hip BMD and femoral neck BMD (Tables 4 - 5). Abaloparatide showed a statistically significant increase in BMD compared to teriparatide at the lumbar spine at 6 and 12 months, but the increase in BMD was not statistically significant at 18 months (Tables 4 - 5).

[0064] The abaloparatide group (squares) showed a more rapid increase (by about 1 month) in the P1NP marker (bone formation) compared to the teriparatide group (triangles) (Figure 6A). For the CTX marker (bone resorption), abaloparatide (squares) showed a more rapid return compared to the teriparatide group (triangles) (Figure 6B).

[0065] Study design: The ACTIVE pivotal Phase 3 fracture prevention trial for the PTHrP analog abaloparatide, study BA058 - 05 - 003 (see ClinicalTrials.gov), was a randomized, double - blind, placebo - controlled trial in postmenopausal osteoporotic women randomized to receive one of 18 - month daily doses of 80 micrograms (μg) of abaloparatide, a matching placebo, or the approved daily dose of 20 μg of teriparatide. Treatment with 80 μg daily dose of abaloparatide or placebo remained blinded for all groups throughout the study. The teriparatide used was a patented pre - filled drug and a combination of non - repackable devices. As such, its identity could not be blinded to the treating physicians and patients once use was initiated. The study medications were self - administered daily by subcutaneous injection for up to 18 months. All included patients also received calcium and vitamin D supplementation from the time they were included in the study until the end of the treatment period. Patients were recommended to continue these supplements during the one - month follow - up period.

[0066] The trial was completed in March 2013 by 2,463 patients at 28 medical centers in 10 countries in the United States, Europe, South America, and Asia. The details of the baseline characteristics of the selected patients are shown in Table 3 below.

Table 3

[0067] Women aged 49 to 86 years (inclusive) who had been postmenopausal for at least 5 years or otherwise healthy ambulatory women who agreed to the trial enrollment criteria and provided written informed consent were included in the trial. Women included in the trial had a BMD T-score of ≤ -2.5 by dual-energy X-ray absorptiometry (DXA) at the lumbar spine or hip (femoral neck), radiographic evidence of ≥ 2 mild or ≥ 1 moderate lumbar or thoracic vertebral fractures, or a history of a fracture of the distal forearm, upper arm, sacrum, pelvis, hip, thigh, or tibia due to minor trauma in the past 5 years. Postmenopausal women over 65 years of age who met the aforementioned fracture criteria but had a T-score < -2.0 were also included. Women over 65 years of age who did not meet the fracture criteria could also be included if their T-score was < -3.0. All patients were in good general health as determined by medical history, physician examination (including vital signs), and clinical laboratory tests. This trial population included a patient population that reflected the types of patients with severe osteoporosis seeking actual treatment by specialists.

[0068] As described in the ACTIVE Protocol, the primary efficacy endpoint was the number of patients treated with abaloparatide who had incident vertebral fractures at the end of treatment compared to patients who received placebo. A priori specified secondary efficacy parameters included, among other endpoints, the reduction in the incidence / risk of non-vertebral fractures, the change in BMD at the lumbar spine, hip, and femoral neck from baseline to the end of treatment when evaluated by DXA and compared to teriparatide, and the number of hypercalcemia events among abaloparatide-treated patients at the end of treatment when compared to teriparatide.

[0069] The safety evaluations conducted in the ACTIVE trial included physician examinations, vital signs, 12 preceding electrocardiograms or ECGs, or clinical laboratory tests, as well as monitoring and recording of adverse events. Specific safety evaluations included determination of serum calcium before and after (4 hours) administration, determination of creatinine clearance, post-dose ECG evaluation at selected visits, and evaluation of postural hypotension (60 minutes after dosing) at selected clinical visits.

[0070] Each of the patients in the abaloparatide 80 μg and placebo groups in the Phase 3 ACTIVE trial was eligible to continue into the extension trial (ACTIVExtend), during which patients received alendronate treatment approved for osteoporosis management. An important endpoint for the abaloparatide development program was the reduction in incident vertebral and non-vertebral fractures up to 24 months in all randomized patients, including those treated with abaloparatide and placebo, and all patients were treated with alendronate in ACTIVExtend.

[0071] The ACTIVExtend trial included administration of alendronate (10 mg / day or 70 mg / week, oral) to patients for 6 months, followed by treatment with abaloparatide 80 μg / day for 18 months (N = 558). Data were collected at month 25. The placebo group was also treated with alendronate for the same period (N = 581).

[0072] Results Fracture Risk Reduction At the second endpoint compared to placebo, abaloparatide achieved a statistically significant 43% reduction in fracture risk (p = 0.0489, 95% CI = 0.32–1.00) in the subset of adjudicated patients with nonvertebral fractures (placebo group: n = 33, fracture rate 4.0%; and abaloparatide group: n = 18, fracture rate 2.2%) (Figure 4A), a statistically significant 43% reduction (p = 0.0165, 95% CI = 0.35–0.91) in the subset of adjudicated clinical fractures including both vertebral and nonvertebral fractures (placebo group: n = 49, fracture rate 6.0%; and abaloparatide group: n = 27, fracture rate 3.3%) (Figure 2A), and a statistically significant difference in time to first incident nonvertebral fracture in both the subset of adjudicated nonvertebral fractures (Figure 4B) and the subset of patients with clinical fractures (Figure 2B). The open-label teriparatide [rDNA origin] injection treatment group achieved a 28% reduction in fracture risk (p = 0.2157, 95% CI = 0.42–1.22) in the subset of adjudicated patients with nonvertebral fractures (Figure 4A) and a 29% reduction (95% CI = 0.46–1.09) in the subset of adjudicated clinical fractures (Figure 2A) compared to placebo. The reduction in fracture risk observed in the abaloparatide treatment group was not statistically significant compared to open-label teriparatide (Figure 2A and 4A, and Table 1).

[0073] Alternatively, with the exception of worsening vertebral fractures, the primary endpoint of reduction in incident vertebral fractures including only new vertebral fractures was implemented (Figures 3A and 3B). Using this analysis, at the primary endpoint of reduction in new vertebral fractures (excluding worsening), abaloparatide (N = 690, n = 4, fracture rate 0.58%) achieved a statistically significant 86% reduction compared to the placebo treatment group (N = 711, n = 30, fracture rate 4.22%) (*: p < 0.0001) (Figure 3A). The open-label teriparatide injection treatment group (N = 717, n = 6, fracture rate 0.84%) showed a statistically significant 80% reduction in new vertebral fractures (excluding worsening) compared to the placebo treatment group (*: p < 0.0001) (Figure 3A).

[0074] As shown in Figures 1A and 1B, 18 months after treatment, abaloparatide unexpectedly showed a significant 70% reduction in the risk of major osteoporotic fractures (95% CI = 0.15 - 0.61) compared to placebo (Figure 1A, *: p = 0.0004, abaloparatide vs placebo), and a significant 55% reduction in the risk of major osteoporotic fractures compared to the teriparatide group (Figure 1A, †: p = 0.0309, abaloparatide vs teriparatide). However, the risk of major osteoporotic fractures in the group treated with teriparatide showed a statistically non-significant 33% reduction compared to placebo (p = 0.135, 95% CI = 0.39 - 1.14). The risk of major osteoporotic fractures was significantly reduced by abaloparatide compared to teriparatide (HR 0.45, p = 0.0309, 95% CI = 0.21 - 0.95). Abaloparatide also showed a significantly improved effect on major osteoporotic fractures at 18 months compared to teriparatide. As shown in Figures 1C and 1D, at 25 months, patients (N = 558) who were treated with abaloparatide for 18 months and then alendronate for 6 months showed a significant 58% reduction in the risk of major osteoporotic fractures (p = 0.0122) compared to placebo (N = 581) treated with alendronate only without prior treatment with abaloparatide. Figure 1E shows that patients (N = 558) who were pre-treated with abaloparatide for 18 months during 6 months of alendronate treatment had a reduced risk of major osteoporotic fractures (n = 2) compared to placebo (N = 581, n = 4) treated with alendronate only without prior treatment with abaloparatide.

[0075] As shown in Figures 2A and 2B, at 18 months, abaloparatide unexpectedly showed a significant 43% reduction in the risk of clinical fractures compared to placebo (p = 0.0165). Abaloparatide also showed an improved effect on clinical fractures compared to teriparatide at 18 months. As shown in Figures 2C and 2D, at 25 months, patients treated with abaloparatide for 18 months followed by 6 months of alendronate treatment showed a significant 45% reduction in the risk of clinical fractures compared to placebo treated with alendronate alone without prior treatment with abaloparatide (p = 0.0210).

[0076] As shown in Figures 3A and 3B, at 18 months, abaloparatide unexpectedly showed a significant 86% reduction in the incidence of new vertebral fractures compared to placebo (p < 0.0001). Abaloparatide also showed an improved effect on new vertebral fractures compared to teriparatide (80% reduction) at 18 months (p < 0.0001). Figure 3B further shows that patients treated with abaloparatide had no vertebral fractures during the 6 - month alendronate treatment period.

[0077] As shown in Figures 4A and 4B, at 18 months, abaloparatide unexpectedly showed a significant 43% decrease in the risk of non-vertebral fractures compared to placebo (p = 0.0489). Teriparatide showed a non-significant decrease (28%) in the risk of non-vertebral fractures compared to placebo (p = 0.2157). Abaloparatide also showed an improved effect on non-vertebral fractures compared to teriparatide at 18 months. As shown in Figures 4C and 4D, at 25 months, patients who were treated with abaloparatide for 18 months and then continued alendronate treatment for an additional 6 months (N = 558) showed a significant 52% decrease in the risk of non-vertebral fractures compared to placebo (N = 581) treated with alendronate only without prior treatment with abaloparatide (p = 0.0168). Figure 4E shows that during the 6 months of alendronate treatment, patients who were pre-treated with abaloparatide for 18 months (N = 558) had a reduced risk of non-vertebral fractures (n = 3) compared to placebo (N = 581, n = 7) treated with alendronate only without prior treatment with abaloparatide.

[0078] BMD and Bone Turnover Biomarkers Figure 5A shows the changes in wrist BMD in all patient groups: placebo (diamonds), patients treated with abaloparatide (squares), and patients treated with teriparatide (triangles). In comparison with teriparatide, abaloparatide unexpectedly showed a significant improvement in BMD maintenance at 18 months at the ultra-distal radius.

[0079] Figures 6A and 6B show the changes in bone turnover markers: CTX (bone resorption) and P1NP (bone formation) in all patient groups: placebo (diamond), patients treated with abaloparatide (square), and patients treated with teriparatide (triangle). Figures 6A and 6B show that for the P1NP marker (bone formation), abaloparatide (square) showed a faster increase at about 1 month compared to teriparatide (triangle), and for the CTX marker (bone resorption), abaloparatide (square) showed a faster return at 18 months compared to teriparatide (triangle).

[0080] The comparative analysis of abaloparatide versus teriparatide was completed after the following BMD secondary endpoints using the Mixed-Effect Model for Repeated Measures (MMRM) method for the repeated measures shown in Table 4 below: [Table 4]

[0081] The comparative analysis of the PTHrP analog abaloparatide and teriparatide was completed after the following BMD secondary endpoints using the ANCOVA approach shown in Table 5 below: [Table 5]

[0082] Bone resorption: Changes in bone resorption showed a significant difference between patients treated with abaloparatide and those treated with teriparatide. At all time points, CTX was significantly increased in the teriparatide group compared to the abaloparatide-treated group. Abaloparatide showed a transient increase in CTX levels compared to placebo, while teriparatide showed a sustained increase in CTX levels compared to placebo. The difference in CTX levels between the abaloparatide and teriparatide groups may indicate different "anabolic windows" between the two treatments. At 18 months, CTX levels in the group treated with abaloparatide were statistically significant compared to placebo, while teriparatide showed higher levels compared to placebo.

[0083] Bone formation: Changes in bone turnover showed a different pattern from those of bone resorption. P1NP levels in the teriparatide group were higher than those in the group treated with abaloparatide, but the difference in P1NP levels was not as significant as the difference in CTX levels. P1NP levels in both treatment groups were significantly higher than those of placebo at all time points.

[0084] Figure 7 shows the changes in BMD at the spine in all patient groups: placebo (diamond), patients treated with abaloparatide (square), and patients treated with teriparatide (triangle). Abaloparatide showed a significantly greater increase in BMD at the lumbar spine at 6 and 12 months compared to teriparatide.

[0085] Figure 8 shows the changes in BMD at non-spinal sites (total hip and femoral neck) in all patient groups: placebo (diamond), patients treated with abaloparatide (square), and patients treated with teriparatide (triangle). At all time points, abaloparatide and teriparatide showed significantly greater increases in BMD compared to placebo. Abaloparatide showed significantly greater increases in BMD at the total hip and femoral neck at 6, 12, and 18 months compared to teriparatide. Furthermore, there was a delay of approximately 6 months in the teriparatide group compared to the abaloparatide-treated group to achieve the same level of increase in BMD at the total hip and femoral neck. Therefore, abaloparatide achieved significant results in rapid BMD response.

[0086] At 6 months, 19.1% of subjects treated with abaloparatide showed an increase in BMD of >3% at all three sites (lumbar spine, total hip, and femoral neck) compared to 0.9% for the placebo group and 6.5% for the teriparatide group. At 12 months, 33.2% of the abaloparatide treatment group had an increase in BMD of >3% compared to the placebo group (1.5%) or the teriparatide group (19.8%). At 18 months, 44.5% of the abaloparatide treatment group had an increase in BMD of >3% compared to the placebo group (1.9%) or the teriparatide group (32.0%). All differences were statistically significant, p < 0.0001.

[0087] Figure 9 shows that patients treated with abaloparatide for 18 months and then with alendronate for 6 months showed significant increases in BMD at all tested sites including the spine (e.g., lumbar spine), hip, and femoral neck.

[0088] Furthermore, Table 6 shows the percentage of patients with an increase in BMD at the spine, hip, and femoral neck at 25 months. More patients in the abaloparatide treatment group achieved the BMD threshold response.

Table 6

[0089] Effect: Figure 4B shows the Kaplan-Meier curves for time to first incident non-vertebral fracture (excluding fingers, toes, sternum, patella, skull, and facial bones) by treatment group in the intent-to-treat population. Figure 2B shows the Kaplan-Meier curves for time to first incident clinical fracture (excluding fingers, toes, sternum, patella, skull, and facial bones) by treatment group in the intent-to-treat population. The Kaplan-Meier curves show a significant reduction in the risk of non-vertebral and clinical fractures in the group treated with abaloparatide.

[0090] Safety: The ACTIVE trial also evaluated several potential safety measures, including blood calcium levels, orthostatic hypotension, nausea, dizziness, and injection site reactions. Adverse events (AEs) reported at ≥5% in any treatment group were summarized in Table 7 below for the groups treated with placebo, abaloparatide, and teriparatide, respectively. [Table 7]

[0091] Each of the abaloparatide group and the teriparatide group had a statistically significantly higher percentage of hypercalcemia events compared to the placebo group, and the abaloparatide group had a statistically significantly lower percentage of hypercalcemia events compared to the teriparatide group (p = 0.006).

[0092] Safety measures were also conducted in a population of 1133 patients treated with alendronate during the ACTIVExtend trial. Adverse events in patients treated with alendronate are detailed in Table 8 below. Abaloparatide demonstrated a favorable and well-tolerated safety profile. [Table 8]

[0093] Example 2. Effect of the PTHrP analog abaloparatide for the prevention of major osteoporotic fractures or any fracture. This example shows the effect of the PTHrP analog abaloparatide on the baseline fracture risk using the FRAX tool.

[0094] Fracture risk assessment and FRAX are specifically well-known in the art (see, e.g., Unnanuntana et al., 「Current Concepts Review: The Assessment of Fracture Risk」, J. Bone Joint Surg Am. 92: 743-753 (2010), the contents of which are incorporated by reference in their entirety). Briefly, FRAX is a predictive tool for assessing an individual's fracture risk by integrating non-BMD clinical risk factors, such as age, gender, weight, height, previous fracture, parental hip fracture, current smoking, alcohol, or glucocorticoid, rheumatoid arthritis, and secondary osteoporosis, in addition to or alternatively to femoral neck BMD. FRAX can estimate the likelihood of hip fracture over 10 years and major osteoporotic fractures (clinical vertebral, forearm, hip, or shoulder fractures) over 10 years by country.

[0095] Baseline clinical risk factors (e.g., age, BMI, previous fracture, glucocorticoid use, rheumatoid arthritis, smoking, and maternal hip fracture history) were entered into country-specific FRAX models, and the 10-year probability of major osteoporotic fractures was calculated with or without femoral neck BMD. The interaction between the probability of major osteoporotic fractures and treatment efficacy was examined by Poisson regression.

[0096] 821 women randomized to placebo and 824 women on abaloparatide were followed for up to 2 years. At baseline, the 10-year probability of a major osteoporotic fracture was in the range of 2.3–57.5% (along with BMD). Treatment with abaloparatide was associated with a 69% reduction in major osteoporotic fractures (MOF) compared to placebo treatment (95% CI: 38–85%). The risk of any clinical fracture (AF) was reduced by 43% (95% CI: 9–64%). The hazard ratio for the effect of abaloparatide on fracture outcomes increased with fracture probability and did not change significantly (p > 0.30 for MOF and p = 0.11 for AF (Figure 10)). Similar results for interaction were seen when calculating FRAX probability without including BMD.

[0097] Therefore, abaloparatide significantly reduced the risk of major osteoporotic fractures and any clinical fractures in postmenopausal women, regardless of baseline fracture probability.

[0098] Example 3. Effect of the PTHrP analog abaloparatide on BMD at the lumbar spine, total hip, and femoral neck in postmenopausal women with osteoporosis. Patients and Methods Study Subjects Healthy postmenopausal women aged 55–85 years (based on 5 years of amenorrhea and elevated serum levels of FSH) were enrolled in the study if they met one of the following definitions of osteoporosis. 1) DXA-derived BMD T-score ≤−2.5 at the lumbar spine or femoral neck or total hip. 2) DXA-derived BMD T-score ≤−2.0 with a history of fracture of the forearm, humerus, vertebrae, skull, pelvis, hip, femur, or tibia due to low trauma within the previous 5 years. 3) DXA-derived BMD T-score ≤−2.0 with additional osteoporosis risk factors, such as age 65 years or older or a strong maternal history of osteoporosis (fracture related to osteoporosis as determined by BMD criteria or osteoporosis defined as such).

[0099] Women should have a body mass index (BMI) of 18.5 - 33 kg / m 2 and normal levels of serum calcium, PTH (1 - 84), 25 - hydroxyvitamin D, phosphorus, and alkaline phosphatase, as well as normal cardiovascular parameters (normal ECG, systolic blood pressure ≥ 100 and ≤ 155 mmHg, diastolic blood pressure ≥ 40 and ≤ 95 mmHg).

[0100] Women with a history of osteosarcoma or other bone disorders (e.g., Paget's disease or osteomalacia), radiation therapy, malabsorption, nephrolithiasis, urolithiasis, renal insufficiency (serum creatinine > 1.5 mg / dL), or any medical condition that could interfere with the conduct of the study were excluded. Women with spinal abnormalities that would interfere with the assessment of BMD and women who had experienced bilateral hip replacement were also excluded. With regard to medications, subjects were excluded if they had been treated with calcitonin, estrogen, estrogen derivatives, selective estrogen receptor modulators, tibolone, progestin, anabolic steroids, or daily glucocorticoids in the past 6 months, had received bisphosphonates or strontium in the past 5 years, or had received parathyroid hormone or its analogs, fluoride, gallium nitrate, or denosumab previously.

[0101] Study design This trial (ClinicalTrials.gov #NCT00542425) was a randomized, parallel-group, multi-site, dose-finding, double-blind, placebo-controlled trial conducted at 30 research facilities in the United States, Argentina, India, and the United Kingdom. All subjects provided written informed consent before initiating any study procedures. Subjects were screened for eligibility and randomized to one of the following 24-week self-administered treatment groups: daily placebo subcutaneous injection, daily subcutaneous injection of the PTHrP analog abaloparatide (20 μg, 40 μg, or 80 μg), or daily subcutaneous injection of 20 μg of teriparatide (Forteo®; Eli Lilly). All subjects received supplemental calcium (500 - 1000 mg) and vitamin D (400 - 800 IU) with each local administration. Patients and investigators remained blinded to treatment with abaloparatide and placebo throughout the trial, but patients randomized to teriparatide were not blinded as they were required to use a commercially available drug and delivery device. BMD was assessed by DXA at baseline and 3 and 6 months after treatment initiation. Biochemical markers of bone turnover, serum abaloparatide levels, and anti-abaloparatide antibody formation measurements were obtained during the treatment period. Blood calcium levels were evaluated 4 and 24 hours after drug administration. Subjects were monitored for adverse events (AEs) and local tolerance at the injection site at each visit. Clinical and laboratory safety parameters, electrocardiograms were also measured at each study visit.

[0102] Measurement Dual-energy X-ray absorptiometry: DXA scans were obtained at each local site, then the scans were subjected to quality control review and sent to a central imaging reader (BioClinica Inc., Newton, PA) for analysis according to each manufacturer's guidelines. Scans performed during the treatment period were acquired using the same device as that used for the baseline scan. Instrument Quality Control (device standardization and phantom correction) was performed over time at each test site and reviewed by a central reader.

[0103] Biochemical markers of bone turnover: Morning fasting blood samples (drawn 24 hours after the last injection if teriparatide was taken) were obtained at each visit. Serum osteocalcin (OC) was measured by an electrochemiluminescence assay (Roche Diagnostics, Basel, Switzerland) with intra-assay coefficients of variation (CVs) of 1.8% and 4.8%, respectively. The amino-terminal propeptide of type 1 procollagen (P1NP) in serum was measured by a radioimmunoassay (Orion Diagnostica, Espoo, Finland) with inter-assay and intra-assay CVs of 4.5% and 5.5%, respectively. The β-C-terminal telopeptide of type 1 collagen (CTX) in serum was measured by an electrochemiluminescence assay (Roche Diagnostics, Basel, Switzerland) with inter-assay and intra-assay CVs of 3.8% and 6.9%, respectively.

[0104] Statistical analysis Efficacy and safety were evaluated using all randomized patients who received at least one dose of the investigational drug. Descriptive statistics were used to summarize baseline characteristics and safety. The primary efficacy endpoint was the change in BMD and bone turnover markers from baseline to 24 weeks. A mixed model repeated measures analysis of the change at each visit was used to analyze the efficacy endpoint, including treatment group, study visit, and the interaction of treatment by visit as fixed effects. The variance-covariance matrix between visits was considered unstructured. Starting with the 80 mg group, then in a sequential manner to 40 mg and finally 20 mg, this model was used to evaluate the comparison of mean change from baseline for each abaloparatide dose vs placebo at 24 weeks. This model was also used to perform the comparison of teriparatide vs placebo. Due to the skewedness of the percent change from baseline in the bone marker results, the median and interquartile range were reported. For comparisons of treatment, the bone marker results were log-transformed prior to performing the mixed model repeated measures analysis. A linear contrast of the three abaloparatide dose groups and the placebo group using the same model excluding the teriparatide group was tested to evaluate the dose-response relationship of increasing doses of abaloparatide and increasing efficacy response. In a post-hoc analysis, the inventors also evaluated the number (%) of patients who achieved >3% BMD at the spine, femoral neck, and total hip at 24 weeks of treatment only in the placebo, teriparatide, and abaloparatide 80 μg groups. A 3% threshold was selected based on the accuracy of the DXA scanner of approximately 1% corresponding to the least significant change (LSC) in BMD at the 95% confidence limit of 3%, and a previous responder analysis was confirmed (22 - 28). The responder analysis included only patients with both baseline and 24-week BMD measurements (valid-completers). The difference in the number (%) of responders between treatment groups was evaluated by chi-square test. All hypotheses were tested at a two-sided 5% significance level. Since this was a Phase II dose-response hypothesis generation study, p-values were not adjusted for multiple comparisons.For the statistical analysis, the SAS System version 8.2 (SAS Institute Inc.) was used.

[0105] Extension trial While the trial was ongoing, a 24-week extension was added to the protocol as a correction. To be eligible for the extension, the trial subjects had to be within 2 weeks of receiving their last treatment dose. A total of 69 patients were eligible for the extension, of which 55 continued treatment up to 48 weeks (placebo group n = 11, abaloparatide 20 μg n = 13, abaloparatide 40 μg n = 10, abaloparatide 80 μg n = 7, teriparatide 20 μg n = 14). BMD was measured again at the 48-week visit.

[0106] Results Figure 11 shows the trends of the trial subjects. Of the 222 randomized patients, all but 1 received at least one dose of the study drug, 191 patients (86%) had their BMD measured at 12 weeks, and 184 patients (83%) completed the trial through the 24-week visit. The subjects in the 5 treatment groups were similar with respect to demographic and clinical characteristics including baseline BMD measurements and levels of biochemical markers of bone turnover.

[0107] Bone mineral density Figure 12 shows the changes in BMD at 24 weeks at the lumbar spine (Figure 12A), femoral neck (Figure 12B), and total hip (Figure 12C) in the various treatment groups: patients treated with placebo (squares), patients treated with 20 μg of abaloparatide (triangles), patients treated with 40 μg of abaloparatide (inverted triangles), patients treated with 80 μg of abaloparatide (diamonds), and patients treated with teriparatide (filled circles).

[0108] Lumbar BMD: At 24 weeks, lumbar BMD (±SD) increased by 1.6 ± 3.4% in the placebo group, 5.5 ± 4.1% in the teriparatide group, and 2.9 ± 2.6%, 5.2 ± 4.5%, and 6.7 ± 4.2% in the abaloparatide 20, 40, and 80 μg groups, respectively. Compared with placebo, the increases in BMD in the abaloparatide 40 and 80 μg groups and the teriparatide group were statistically significant (p < 0.001). The difference in the increase in BMD between the abaloparatide 80 μg group and the teriparatide group was not statistically significant. Furthermore, the effect of abaloparatide on lumbar BMD showed a significant dose-response (linear trend) (p < 0.001).

[0109] Femoral neck BMD: At 24 weeks, BMD of the femoral neck increased by 0.8 ± 4.8% in the placebo group, 1.1 ± 4.6% in the teriparatide group, and 2.7 ± 4.0%, 2.2 ± 4.4%, and 3.1 ± 4.2% in the abaloparatide 20, 40, and 80 μg groups, respectively. Compared with placebo, the increase in femoral neck BMD in the 80 μg group was statistically significant (p = 0.036), but no significant difference in the increase in BMD was found between the placebo-treated subjects and those treated with either teriparatide, abaloparatide 20 μg, or abaloparatide 40 μg. The difference in the increase in femoral neck BMD between the abaloparatide 80 μg group and the teriparatide group was not statistically significant (p = 0.066).

[0110] Total hip BMD: At 24 weeks, total hip BMD increased by 0.4 ± 3.1% in the placebo group, 0.5 ± 3.9% in the teriparatide group, and 1.4 ± 2.6%, 2.0 ± 3.7%, and 2.6 ± 3.5% in the abaloparatide 20, 40, and 80 μg groups, respectively. Compared with placebo, total hip BMD increased only in the abaloparatide 80 μg group (p = 0.007). Furthermore, the increase in BMD at the total hip was significantly greater in both the abaloparatide 40 μg and abaloparatide 80 μg groups than in the teriparatide group (p = 0.047 and p = 0.006, respectively).

[0111] Response to treatment The results of responder analysis are shown in Figure 13. The percentage of subjects with >3% BMD increase at the lumbar spine was greater in the abaloparatide group (80 μg dose, 86%) than in the placebo group (36%) (*p<0.001), but not greater than in the teriparatide group (70%) (p=0.092) (Figure 13A). Furthermore, more women treated with abaloparatide had a >3% total hip BMD increase (37%) than women treated with teriparatide (16%, p<0.02) or placebo (15%, p<0.04) (Figure 13C). No statistically significant difference was seen in the percentage of women experiencing a >3% BMD increase at the femoral neck in any of the three groups (Figure 13B).

[0112] Biochemical markers of bone turnover Figure 14 shows the 24-week changes in serum biochemical markers of bone formation (P1NP (Figure 14B), OC (Figure 14C)) and bone resorption (CTX, Figure 14A) in various treatment groups: patients treated with placebo (squares), patients treated with 20 μg abaloparatide (triangles), patients treated with 40 μg abaloparatide (inverted triangles), patients treated with 80 μg abaloparatide (diamonds), and patients treated with teriparatide (filled circles). a: p<0.002 vs placebo at 24 weeks. b: p<0.003 vs teriparatide at 24 weeks.

[0113] Bone formation: In the abaloparatide groups at 40 μg and 80 μg (and the teriparatide group), P1NP began to increase at week 1. After 24 weeks, the median (interquartile range) of P1NP increased by 55 (-2, 160)% in the 40 μg abaloparatide group, 52 (0, 158)% in the 80 μg abaloparatide group, and 98 (21, 184)% in the teriparatide group (all changes were statistically significantly different from placebo, which decreased by 20 (7, 28)%, p < 0.001). P1NP increased more in the teriparatide group than in the 20 μg abaloparatide group (p < 0.001), but the increase was not significantly different when compared to the two higher abaloparatide dose groups. The pattern of change in OC was generally similar to that observed in P1NP. For both markers, the effect of abaloparatide showed a significant dose response (linear slope) (p < 0.001).

[0114] Bone resorption: The changes in bone resorption showed a slightly different pattern from bone formation, not clearly increasing until 12 weeks. After 24 weeks, the median (interquartile range) of CTX had an increase of 32 (-13, 77)% in the 40 μg abaloparatide group, 23 (-9, 86)% in the 80 μg abaloparatide group, and 76 (13, 130)% in the teriparatide group (all changes were statistically significantly different from placebo, which decreased by 7 (-19, 26)%). CTX increased more in the teriparatide group than in either abaloparatide group (p < 0.003). In contrast to the bone formation markers, no gradual increase in CTX was seen between the 40 μg and 80 μg abaloparatide groups.

[0115] Safety During the 24-week treatment period, treatment-emergent adverse events (TEAEs) were reported in 164 of 221 patients (74%). The percentage of patients experiencing TEAEs was similar across treatment groups at 71%, 72%, 74%, 76%, and 78% in the placebo, abaloparatide 20, 40, and 80 μg, and teriparatide groups, respectively. TEAEs that were possibly or probably related to the study treatment, as considered by the investigators, were reported in 66 of 221 patients (30%) at 27%, 21%, 35%, 38%, and 29% in the placebo, abaloparatide 20, 40, and 80 μg, and teriparatide groups, respectively. The incidence of headache was numerically higher with abaloparatide 40 μg and 80 μg compared to placebo, at 7%, 5%, 14%, and 13% of patients in the placebo, abaloparatide 20, 40, and 80 μg groups, respectively, and was similar for teriparatide (13%). Dizziness was also highest with abaloparatide 80 μg, at 4%, 0%, 9%, 11%, and 4% in the placebo, abaloparatide 20, 40, and 80 μg, and teriparatide groups, respectively. Most injection site reactions were mild or moderate in intensity and were similar in the abaloparatide and teriparatide treatment groups. Most TEAEs were mild to moderate in severity. Eight patients (4%) experienced at least one event that was severe in intensity during the 24-week study, and the incidence of severe events was similar across treatment groups. Severe events included back and chest pain (placebo group), influenza, ascites, and ovarian epithelial cancer (abaloparatide 20 μg group, diagnosed 14 days after treatment), headache (abaloparatide 40 μg group), dyspepsia, syncope, diarrhea, and upper abdominal pain (abaloparatide 80 μg group), and arthralgia and joint disorder (teriparatide group). One severe event, syncope in a patient in the abaloparatide 80 μg group, was evaluated as possibly related to the study treatment and the event resolved within 1 day and was reported not to require treatment. All other severe events were reported as not related to the study treatment.The major TEAE were reported in 1 patient (2%) in the placebo treatment group with acute bronchitis, in 1 patient with ovarian cancer with ascites in the abaloparatide 20 μg assigned group and in 3 patients (1%) with diverticulitis in the abaloparatide 80 μg group. None were classified as treatment-related and no deaths were reported. Seven patients (3%), including 1 patient (2%) each in the abaloparatide 20 μg and 40 μg groups, 3 patients (7%) in the abaloparatide 80 μg group and 2 patients (4%) in the teriparatide group, were discontinued due to AE. No clinically significant differences were seen between the placebo and active treatment groups for ECG parameters.

[0116] Hypercalcemia Serum calcium levels of ≥ 10.5 mg / dL were observed 4 hours after dosing in 1 patient (2%) in the placebo group, 3 patients (7%) in the abaloparatide 20 μg group, 6 patients (14%) in the abaloparatide 40 μg group, 5 patients (11%) in the abaloparatide 80 μg group and 18 patients (40%) in the teriparatide group. The incidence of hypercalcemia at 4 hours was higher in teriparatide than in each abaloparatide group (p < 0.01). When measured 24 hours after the last injection, serum calcium levels of ≥ 10.5 mg / dL were observed in 1 patient (2%) in the placebo group, 2 patients (5%) in the abaloparatide 20 μg group, 3 patients (7%) in the abaloparatide 40 μg group, 4 patients (9%) in the abaloparatide 80 μg group and 7 patients (16%) in the teriparatide group (no significant differences between groups). The highest value obtained in all patients 4 hours after dosing was 10.5, 11.0, 11.2, 11.6 and 12.6 mg / dL in the placebo, abaloparatide 20 μg, abaloparatide 40 μg, abaloparatide 80 μg and teriparatide groups, respectively. The highest value obtained in all patients 24 hours after dosing was 10.7, 11.3, 11.1, 10.7 and 11.2 mg / dL in the placebo, abaloparatide 20 μg, abaloparatide 40 μg, abaloparatide 80 μg and teriparatide groups, respectively.

[0117] Antibody formation After 24 weeks, 16 patients (12%) who received abaloparatide showed low positive (≤1:20) anti - abaloparatide antibody titers. The number and types of AEs in this group were similar to those of the overall AE population. No immune - related events were reported in antibody - positive patients. One antibody - positive patient in the abaloparatide 40 μg group had evidence of in vitro abaloparatide neutralizing activity at 24 weeks, but there was no clear evidence of efficacy attenuation (a 9.3% increase in all analyzable spinal BMD at 24 weeks) or related safety events in this patient.

[0118] Extension study The baseline demographics and baseline characteristics of the extension population were similar to those of the entire study cohort, and the number of subjects per treatment group was 7 - 14 women. At 48 weeks, lumbar BMD increased by 0.7%, 5.1%, 9.8%, 12.9%, and 8.6% in the placebo, abaloparatide 20, 40, and 80 μg groups, and the teriparatide group, respectively. Total hip BMD increased by 0.7%, 1.9%, 2.1%, 2.7%, and 1.3% in the placebo, abaloparatide 20, 40, and 80 μg groups, and the teriparatide group, respectively. Femoral neck BMD increased by 1.0%, 3.9%, 1.8%, 4.1%, and 2.2% in the placebo, abaloparatide 20, 40, and 80 μg groups, and the teriparatide group, respectively. When small numbers were given to the extension study, there were no significant differences between the groups other than for spinal BMD, which increased more in the abaloparatide 40 μg, abaloparatide 80 μg, and teriparatide groups compared to placebo.

[0119] As with the full cohort, tolerability was similar across all groups with treatment-related TEAE occurring in 36%, 31%, 30%, 29% and 21% of the placebo, abaloparatide 20 μg, 40 μg and 80 μg, and teriparatide groups, respectively. The most common AEs were arthralgia and urinary tract infection (15% each), bronchitis, influenza and nasopharyngitis (9% each), and anemia, back pain, dizziness, dyslipidemia, hypercalciuria and injection site hematoma (7% each). One SAE of joint swelling was reported in a patient who received placebo, and one SAE of outpatient visit for repair of bilateral femoral hernia, which was not related to treatment, was reported in a patient who received abaloparatide 80 μg. One patient in the abaloparatide 40 μg group was discontinued due to moderate syncope classified by the investigator as possibly related to abaloparatide.

[0120] Discussion In this study, abaloparatide for 24 weeks increased BMD at the lumbar spine, femoral neck and total hip. The magnitude of these increases was large compared with currently available therapies. At the lumbar spine, a dose-response relationship between abaloparatide and increased BMD was shown at the test doses. Furthermore, at the hip, abaloparatide at daily doses of 40 μg and 80 μg increased BMD more than currently marketed teriparatide at a daily dose of 20 μg. Additionally, in women receiving abaloparatide at 80 μg / day, BMD loss at the femoral neck and hip was less than in women receiving teriparatide 20 μg daily. Finally, the BMD changes observed in the limited population enrolled in the extension study suggest that the BMD increased by abaloparatide is relatively linear during the first year of treatment.

[0121] The physiological mechanisms of the different BMD effects observed with abaloparatide 80 μg vs. teriparatide 20 μg are not clear. Both bone formation and bone resorption were stimulated by abaloparatide treatment, but the magnitude of these increases was lower than that with teriparatide (even at higher doses tested). Of note, the increase in bone formation markers at 24 weeks was approximately 50% higher in the teriparatide group than in the abaloparatide 80 μg group, and the increase in the resorption marker (CTX) was 100% higher. Thus, the higher formation-to-resorption ratio in women treated with abaloparatide may have been a contributing factor to the different effects of these two agents on BMD. Furthermore, previous studies have suggested that the early effects of PTH and teriparatide at cortical sites such as the hip and radius are due to increased intracortical bone remodeling that results in increased cortical porosity (29 - 32). The increase in the rate of bone resorption after treatment with the PTHrP analog abaloparatide is more restricted and delayed compared with PTH, so the earlier increase in BMD at sites with a higher proportion of cortical bone may also have been the result of an absolute low rate of intracortical resorption due to lower cortical porosity. It should be noted that the increase in cortical porosity at anatomically cortical-rich sites in patients treated with teriparatide is not related to the observation that it may be due to a decrease in estimated bone strength and improvement in trabecular microstructure (29 - 33). Whether the abaloparatide-induced increase in hip BMD, with an associated increase in trabecular bone as demonstrated by a large vertebral BMD increase, is associated with a higher increase in estimated bone strength is under investigation. Studies evaluating cortical and trabecular microstructure by in vivo imaging or bone biopsy may be useful to better define the effects of abaloparatide on bone quality.

[0122] The molecular mechanism underlying the difference between teriparatide and abaloparatide is unknown but may be related to differences in the affinity of the two drugs for specific conformations of the PTHR, as shown for PTH and PTHrP (12–14). Specifically, PTHrP activity at the PTHR is restricted to the cell surface, but teriparatide has been reported to remain bound to the PTHR, associate with G protein, and translocate to internal cell structures, potentially acting as a persistent and active ternary complex. Whether these different receptor interactions contribute to the differences between PTH and PTHrP when used pharmaceutically, or whether the effects of abaloparatide are also influenced by post-PTHR-binding physiology that differs, is not yet clear.

[0123] The incidence of AEs was similar between groups, and most events were of mild or moderate intensity. Positive anti - abaloparatide antibody titers with low titers (≤1:20) were reported in 16 patients treated with abaloparatide, but no immune - related events were reported. Among 5 patients in the 80 μg daily dose group who developed antibodies during the first 24 weeks of exposure, all but 1 had an antibody titer of 1:1, and none became newly positive during the extended period. The relatively low incidence of hypercalcemia observed in abaloparatide - treated subjects was also noteworthy. This may be due to the low bone resorption rate observed in abaloparatide patients, but different effects in the kidney cannot be excluded.

[0124] In summary, 24 weeks of abaloparatide, particularly at a subcutaneous daily dose of 80 μg, increased BMD at the spine and hip in a potentially clinically meaningful way. The abaloparatide - induced increase in lumbar BMD was substantial, and the increase in BMD at the total hip was greater than that of both placebo and teriparatide, similar to the rate of patient response at the hip and femoral neck. This ability to increase BMD, along with the demonstrated safety data, low incidence of hypercalcemia, and room - temperature stability of the PTHrP analog abaloparatide, supports the continuation of the investigation of abaloparatide as a promising anabolic treatment for postmenopausal osteoporosis.

[0125] Example 4. Effect of the PTHrP analog abaloparatide on trabecular bone score (TBS) at the lumbar spine, total hip, and femoral neck in postmenopausal women with osteoporosis. To evaluate the effect of the PTHrP analog abaloparatide on trabecular bone microstructure as indirectly assessed by TBS, 222 postmenopausal osteoporotic women (55 - 85 years old) randomized to receive daily subcutaneous injections of placebo, abaloparatide 20 μg, abaloparatide 40 μg, abaloparatide 80 μg, or teriparatide (TPTD) 20 μg for 24 weeks were blindly evaluated for TBS (TBS Calculator v2.2, Medimaps group, Plan-les-Ouates, Geneva, Switzerland) at 0, 12, and 24 weeks. Differences between groups in mean percent change in TBS were evaluated by unpaired t-test.

[0126] Results: Of the 221 treated women, 77 women could not be evaluated because the DXA scanner was not compatible with the TBS software. Subjects in the 5 treatment groups (N = 145) were similar with respect to demographic and clinical characteristics including baseline BMD measurements and levels of biochemical markers of bone turnover. After 12 weeks, TBS significantly increased by +1.2%, +1.7%, +1.9%, and +1.5% in the abaloparatide 20 μg, abaloparatide 40 μg, abaloparatide 80 μg, and TPTD groups, respectively, and decreased by -0.2% in the placebo group (PBO). The 12-week mean percent increase in TBS in the abaloparatide 40 μg and abaloparatide 80 μg treatment groups was significantly higher than that in the placebo group (both p = 0.05). After 24 weeks, TBS increased by +2.4%, +2.7%, +3.6%, and +2.6% in the abaloparatide 20 μg, abaloparatide 40 μg, abaloparatide 80 μg, and TPTD groups, respectively, and decreased by -1.1% in the placebo group (PBO). The 24-week increase in TBS was significantly higher in all treatment groups compared to the change in the placebo group (p < 0.005).

[0127] Summary: Treatment with abaloparatide for 24 weeks significantly improved trabecular bone microstructure as indirectly evaluated by TBS. When combined with the effect of abaloparatide on BMD, these results support further investigation of abaloparatide as an anabolic therapy in postmenopausal osteoporosis.

[0128] Example 5. Effects of the PTHrP analog abaloparatide on vertebral and femoral BMD, microstructure, and strength in ovariectomized (OVX) osteoporotic rats. The bone anabolic effect of daily administration of the PTHrP analog abaloparatide for 6 weeks to adult ovariectomized (OVX) osteoporotic rats was evaluated. Bone mass in OVX osteoporotic rats underwent a marked increase in response to abaloparatide treatment. The increase in bone mass was observed not only in the trabecular bone fraction in the lumbar vertebrae and femurs, but also in the cortical bone of the femurs (femoral shaft). These dose-dependent increases in bone mass were associated with improvement of bone microstructure and increases in bone biochemical properties.

[0129] Materials and Methods Animals All procedures, protocols, and study designs were reviewed, approved, and monitored by the Radius Health Institutional Care and Use Committee (IACUC). Ten-week-old female Sprague-Dawley rats (Charles River Laboratories) were individually housed in ventilated polycarbonate cages with free access to diet and water. The environment was maintained at 18 - 26 °C, 30 - 70% relative humidity, and a 12-hour light / dark cycle.

[0130] Study Design Twelve-week-old Sprague-Dawley rats were subjected to either sham operation or ovariectomy (OVX), and left untreated for 8 weeks (bone depletion period). Osteoporotic OVX rats (n = 20 - 24 / group) were treated once daily by subcutaneous injection (SC) with vehicle (0.9% NaCl), abaloparatide 5 μg / kg, or abaloparatide 20 μg / kg for 6 weeks. Sham rats were treated with vehicle (n = 24). The outline of the study design is shown in Table 9.

Table 9

[0131] Bone densitometry (BMD) was measured in vivo by dual-energy x-ray absorptiometry (DXA) at the baseline of the study and at the end of 6 weeks. The animals were then anesthetized, and the femurs and L4 vertebrae were harvested, wrapped in ethanol-soaked gauze, and frozen at -20 °C for high-resolution CT (μCT) and biochemical tests.

[0132] Bone densitometry by dual-energy x-ray Rats were anesthetized with isoflurane, and in vivo bone mineral density (BMD) (grams per square centimeter) of the fourth lumbar vertebra (L4) and the entire femur was measured using DXA (PIXImus, GE-Lunar Corporation, Fitchburg, WI). BMD was measured at baseline and at the end of the 6-week dosing period.

[0133] Micro-computed tomography (μCT) measurements Quantitative micro-computed tomography (mCT40 μCT scanner, Scanco Medical AG, Basserdorf, Switzerland) was used ex vivo to evaluate trabecular bone morphology in the fourth lumbar vertebra and distal femoral metaphysis, and cortical bone geometry in the midshaft of the femur.

[0134] Scanning for the cancellous bone at the distal femoral diaphysis was started proximal to the level of the growth plate and extended distally up to 250 slices. Evaluation was performed at 150 slices starting from approximately 0.2 mm distal to the growth plate. The entire L4 vertebra was scanned to evaluate the cancellous bone and cortical bone within the growth plates of the skull and sacrum. The morphological parameters included bone volume fraction (BV / TV, %), bone volume (BV, mm 3 ), total volume (TV, mm 3 ), trabecular number (Tb.N, 1 / mm), trabecular thickness (Tb.Th, mm), trabecular separation (Tb.Sp, mm), connectivity density (Conn.D, 1 / mm 3 ), structure model index (SMI), and bone density (BD, mg / mm 2 ). At the femoral midshaft (cortical bone), 23 transverse CT slices were obtained to calculate the total volume (TV, mm 3 ), cortical bone volume (BV, mm 3 ), marrow volume (MV, mm 3 ), cortical thickness (Cort.Th, mm), and bone volume fraction (BV / TV, %).

[0135] Biomechanical tests The lumbar vertebra (L4) was mechanically assayed by compression testing. Fresh frozen vertebrae were thawed to room temperature, and then the posterior pedicles, spinous processes, and the cranial and sacral ends were removed to obtain vertebral body specimens with two parallel surfaces and a height of approximately 4 mm. The central-lateral and anterior-posterior widths of the cranial and sacral ends were measured for cross-sectional area calculation. The vertebra was placed between two platens and loaded at a constant displacement rate of 6 mm / min until failure on an Instron Mechanical Testing Instrument (Instron 4465 modified to 5500). The load-displacement curve was recorded by the instrument software (Bluehill v2.5, Instron). The position, stiffness, and energy absorbed at failure were manually selected from the load-displacement curve and calculated by the instrument software (Bluehill v2.5, Instron). The intrinsic properties, ultimate strength, elastic modulus, and toughness were calculated from the maximum load (N), stiffness (N / mm), energy absorbed (mJ), cross-sectional area, and height (mm).

[0136] pQCT was performed on the excised right femur using a Stratec XCT-RM and related software (Stratec Medizintechnik GmbH, Pforzheim, Germany; software version 5.40). Scans were taken at 50% of the total femoral length from the distal end of the femur. The position was confirmed using the scout view, and one 0.5-mm slice perpendicular to the long axis of the femoral shaft was obtained from each site. The scans were analyzed using a threshold for the delineation of the outer boundary. The axial area moment obtained from the pQCT scan was used to calculate the intrinsic strength parameters at the femoral shaft axis.

[0137] Regarding the three-point bending test of the femoral diaphysis axis, each right femur was placed on the lower fulcrum of the three-point bending fixation on the front side facing downward on an Instron Mechanical Testing Instrument (Instron 4465 modified to 5500). The distance between the two lower fulcrums was set at 14 mm. The upper load device was placed at the center of the femoral diaphysis axis. A load was applied at a constant deformation rate of 6 mm / min until the femur broke. The position of the maximum load, rigidity, and absorbed energy were manually selected from the load-deformation curve, and the values were calculated by the device software (Bluehill v2.5, Instron). The intrinsic properties, ultimate strength, elastic modulus, and toughness were calculated from the maximum load (N), rigidity (N / mm), absorbed energy (mJ), anterior-posterior diameter (mm), and moment of inertia (mm 4 ).

[0138] Regarding the cantilever compression test of the femoral neck, the proximal half of the femur was firmly placed on a fixed platform where the larger trochanter could grasp its notch cut. The test was conducted using an Instron Mechanical Testing Instrument (Instron 4465 modified to 5500). A stainless steel probe parallel to the femoral diaphysis axis was used to apply a load to the femoral head at a constant deformation rate of 6 mm / min until failure. The position of the maximum load (N), rigidity (N / mm), and absorbed energy (mJ) were manually selected from the load-deformation curve and calculated by the device software (Bluehill v2.5, Instron).

[0139] Statistical analysis The results are presented as mean and standard deviation. Statistical analysis was performed using ANOVA, followed by Tukey's multiple comparison test (Graphpad Instat, Cary, NC; release 9.1). All comparisons made in the context are statistically significant (p < 0.05) unless stated otherwise.

[0140] Results Bone mineral density At the end of the bone resorption period, total femur BMD was significantly decreased in OVX compared to Sham rats (11%, p < 0.001 vs. Sham, data not shown). BMD values in OVX-treated control rats remained decreased compared to intact sham rats 6 weeks after treatment (14% decrease, p < 0.001 vs. Sham).

[0141] Bone mineral density (BMD) was measured by DXA at baseline (before start of dosing) and after 6 weeks of daily treatment with vehicle or abaloparatide. Treatment of OVX rats with abaloparatide 5 μg / kg or abaloparatide 20 μg / kg resulted in significant increases in BMD at the spine compared to baseline (27% and 39% respectively, p < 0.001 vs. baseline, Figure 15A). Six weeks of treatment with abaloparatide resulted in a significant dose-dependent increase in spine BMD compared to OVX-Veh (28% and 33% for abaloparatide 5 μg / kg and abaloparatide 20 μg / kg respectively, p < 0.001 vs. OVX-Veh, Figure 15B). Abaloparatide treatment not only repaired OVX-induced bone loss but also increased BMD to levels higher than Sham control values with treatment at abaloparatide 20 μg / kg (p < 0.001 vs. Sham).

[0142] Total femur BMD increased significantly and dose-dependently by 21% and 27% respectively compared to baseline with abaloparatide 5 μg / kg and abaloparatide 20 μg / kg (p < 0.001 vs. baseline, Figure 15C). A similar increase in BMD from baseline was observed in the femoral diaphysis (Figure 15E). Abaloparatide treatment resulted in a significant dose-dependent increase in BMD for the total femur and femoral midshaft compared to OVX-Veh control rats and Sham control rats (p < 0.001 vs. OVX-Veh, p < 0.001 vs. Sham, Figures 14D and 14F). Collectively, these data demonstrated a significant increase in bone mass in response to abaloparatide treatment.

[0143] Bone microstructure Consistent with the BMD measurements, OVX was associated with significant bone deterioration, particularly in the trabecular bone fraction (Figure 16, Tables 7 and 8). Compared to Sham control rats, OVX-Veh rats had 36% lower BV / TV in vertebral trabecular bone (Figure 16A, Table 8, p < 0.001 vs. Sham). Furthermore, Tb.N, Tb.Th, and BD were lower in the vertebrae of OVX-Veh rats, along with higher Tb.Sp, compared to Sham control rats (Table 10).

Table 10

[0144] In the trabecular bone fraction of the distal femur, BV / TV was 71% lower in OVX-Veh rats compared to Sham rats (Figure 16B, Table 9, p < 0.001 vs. Sham). Tb.N, Tb.Th, and Conn.D were lower in OVX-Veh rats compared to Sham control rats (Table 11). OVX also decreased cortical bone, and BV / TV and Ct.Th of the femoral shaft were significantly lower in OVX-Veh rats than in Sham control rats (Table 13, p < 0.01 vs. Sham).

Table 11

[0145] Six weeks of treatment with abaloparatide improved bone microstructural properties in OVX rats, completely suppressed OVX-induced bone loss, and improved cortical and trabecular bone parameters to levels above those of OVX-Veh and Sham-Veh treated rats. Specifically, abaloparatide 20 μg / kg treated animals had significantly higher BV / TV in the vertebral trabecular bone fraction compared to OVX-Veh animals (77%, p < 0.001 vs. OVX-Veh, Figure 16A, Table 10) and Sham-Veh animals (14%, p < 0.001 vs. OVX-Veh, Figure 16A, Table 10). Treatment with abaloparatide 5 μg / kg increased BV / TV by 56% compared to OVX-Veh treatment (p < 0.001 vs. OVX-Veh). In the distal femur trabecular bone, treatment with abaloparatide 5 μg / kg and abaloparatide 20 μg / kg increased BV / TV by approximately 2.5-fold and 3.7-fold, respectively, compared to OVX-Veh (p < 0.001 vs. OVX-Veh, Figure 16B, Table 11). Tb.Th and Tb.N were significantly improved in the femur compared to vehicle-treated animals, with low Tb.Sp, good connectivity density, and high plate-like structure (SMI) (Table 11). Also, six weeks of treatment with abaloparatide 20 μg / kg improved femoral midshaft properties in OVX animals, and bone volume fraction (BV / TV) was significantly increased by 6% and 4% compared to those of OVX-Veh treatment (p < 0.05 vs. OVX-Veh, Table 11) and Sham-Veh control (p < 0.001 vs. Sham, Figure 16B, Table 11), respectively.

[0146] Treatment with abaloparatide 20 μg / kg also resulted in an increase in cortical thickness compared to OVX-Veh treatment (p < 0.05, Table 11).

[0147] Vertebral and femoral strength The maximum load and ultimate strength of L4 were approximately 28% lower in OVX-Veh rats compared to Sham control rats (p < 0.01, Table 12). By comparative testing of L4, rats treated with abaloparatide 5 μg / kg and abaloparatide 20 μg / kg had significantly higher mechanical test values for maximum load (170% and 180%, p < 0.05 and 0.01 respectively vs. OVX-Veh treated rat controls, Table 12), energy absorbed (280% and 290%, p < 0.001), ultimate strength (170% and 180%, p < 0.001), and toughness (270%, both groups, p < 0.001) compared to OVX-Veh treated rat controls. Furthermore, significant increases in the maximum load (126%, p < 0.05) and toughness (170%, p < 0.01) of the L4 vertebra were seen in OVX rats treated with abaloparatide 20 μg / kg compared to Sham control rats.

Table 12

[0148] The strength parameters of the femurs of OVX-Veh rats trended higher than those of Sham rats in terms of maximum load, energy, and toughness parameters by 8%, 25%, and 18% respectively, and were higher in OVX-Veh rats (p < 0.05 vs. Sham, Table 13).

Table 13

[0149] Femoral strength parameters in OVX-Veh rats that were higher than those in Sham controls measured in the first 1–12 weeks of the baseline have been reported previously in OVX rats (6). Treatment with abaloparatide 5 μg / kg and abaloparatide 20 μg / kg further improved the mechanical properties of the femur, with higher maximum load (110%, p < 0.05 vs. OVX-Veh, Table 13), ultimate strength (158%, p < 0.001 for OVX-Veh), and moment of inertia in the axis region (110%, p < 0.001 vs. OVX-Veh) compared to OVX control rats. Furthermore, treatment with abaloparatide 5 μg / kg and abaloparatide 20 μg / kg improved the mechanical properties of the femur with higher maximum load (19%, p < 0.001 vs. OVX-Veh, Table 13), stiffness (13%, p < 0.01 vs. OVX-Veh), energy (34% and 37% respectively, p < 0.001 vs. OVX-Veh), ultimate strength (7%, p < 0.05 vs. OVX-Veh), toughness (22% and 29% respectively, p < 0.05 vs. OVX-Veh), and moment of inertia in the axis region (15%, p < 0.01 vs. OVX-Veh) compared to Sham control rats. Cantilever compression of the femoral neck showed that the maximum load tolerated was 108% lower in OVX-Veh treated rats than in Sham rats (p < 0.01 vs. Sham, Table 13). OVX rats treated with abaloparatide 5 μg / kg and abaloparatide 20 μg / kg showed increased strength of the femoral neck with higher maximum load (23% and 16% respectively, p < 0.01 vs. OVX-Veh, Table 13) and energy (48%, p < 0.05 vs. OVX-Veh). Together, consistent with the increase in BMD and bone microstructure, the data indicated that abaloparatide treatment improved bone strength parameters in OVX rats.

[0150] Discussion The bone anabolic effect of daily administration of abaloparatide, an example of a synthetic PTHrP analog, was evaluated in adult ovariectomized osteoporotic rats. The results showed that abaloparatide treatment promoted an increase in bone mass, restored bone microstructure, and reversed the deterioration of bone mechanical properties associated with bone resorption and OVX-induced bone loss. Treatment with abaloparatide reversed bone mass and restored bone quality as shown by increased BMD, trabecular and cortical microstructure, and femoral neck and femoral shaft strength values in OVX rats treated with abaloparatide 6 weeks after treatment compared to OVX-Veh rats. Furthermore, treatment with abaloparatide resulted in values greater than those of the Sham-vehicle control group. These observations of significant bone anabolic activity after treatment with abaloparatide in the rat OVX-induced osteoporosis model are consistent with the increase in BMD seen in the effect of abaloparatide treatment in postmenopausal women with osteoporosis (e.g., Example 1).

[0151] The results of this study showed that 6 weeks of treatment with abaloparatide induced a significant dose-dependent increase in BMD of the trabecular bone fraction in the lumbar spine (28% and 33% for abaloparatide 5 μg / kg and 20 μg / kg, respectively) and femur (17% and 23% for abaloparatide 5 μg / kg and 20 μg / kg, respectively) compared to OVX-vehicle control rats. Evaluation of trabecular bone microstructure provided further insight into the nature of the abaloparatide-induced BMD increase. Dose-dependent increases were observed for abaloparatide 5 μg / kg and abaloparatide 20 μg / kg in bone volume fraction (BV / TV) in vertebral trabecular bone (57% and 78%, respectively) and trabecular bone of the distal femur (145% and 270%, respectively).

[0152] These increases were associated with increased trabecular bone thickness and trabecular bone number, with a concomitant decrease in trabecular bone separation, compared to OVX-vehicle-treated rats. The increase in bone mass and the increase in bone microstructural parameters in these trabecular bone fractions were associated with an increase in biochemical parameters. After 6 weeks of treatment, bone mass, microstructure, and biomechanics were normalized for most parameters compared to sham controls, and many parameters were significantly increased compared to Sham. These findings are consistent with the results of recently reported clinical trials (see, for example, Example 1) showing that abaloparatide treatment increases BMD in the lumbar spine and hip in women with osteoporosis as early as about 12 weeks of treatment. As shown in Example 1, the increase in BMD was greater than that observed with teriparatide (rhPTH(1-34)) at both the 12-week and 24-week time points. The increase in lumbar spine BMD with abaloparatide was significantly greater than that observed with 20 μg of teriparatide and was comparable to the PTH-induced bone gain previously reported in clinical trials (37).

[0153] The effects of abaloparatide treatment were seen in all regions of the femur, suggesting that the effect on BMD may include a positive effect on both the trabecular and cortical bone fractions. Indeed, cortical bone showed an approximately 8% increase in bone mass after 6 weeks of treatment with 5 μg / kg and 20 μg / kg of abaloparatide in OVX rats compared to OVX-vehicle-treated rats. The physiological mechanism of the BMD effect in cortical bone observed with abaloparatide treatment is not fully understood. Example 1 showed a significant increase in total hip BMD with abaloparatide treatment compared to teriparatide treatment. The higher formation-to-resorption ratio in abaloparatide-treated women may be a contributing factor to the different effects of these two agents on BMD. Previous studies have reported an increase in cortical bone porosity in the humerus with PTH treatment in OVX monkeys (38).

[0154] Furthermore, clinical studies have suggested that the early effect of PTH on cortical sites is to increase intracortical remodeling and result in increased cortical porosity (29, 31, 32, 39, 37). It is further suggested that the increase in the bone resorption rate after abaloparatide treatment is more restricted and delayed compared to PTH, and the increase in cortical BMD may also be the result of an absolute decrease in the intracortical resorption rate due to lower cortical porosity. Further experimental studies evaluating the effect of abaloparatide on cortical porosity provide further insight into the effect on cortical bone. The current study also showed an increase in abaloparatide-induced cortical BMD, along with an increase in trabecular bone microstructural parameters associated with increased bone strength. In short, these increases in bone parameters suggest a positive effect on bone quality.

[0155] The molecular mechanism by which abaloparatide exerts its anabolic effect is not fully understood but may have some similarity to the parent protein PTHrP. PTH and PTHrP share some sequence homology and may have arisen from duplication of a common ancestral gene, but each plays a different role in bone physiology. PTH, secreted by the parathyroid gland, acts in a classical endocrine fashion to promote osteoclastic bone resorption and calcium mobilization. In contrast, PTHrP functions as a paracrine regulator of bone formation. Despite these differences, both PTH and PTHrP increase intracellular cAMP concentrations by activating the same type 1 PTH / PTHrP receptor (PTHR), a G protein-coupled receptor (GPCR). However, continuous administration of PTH results in bone resorption exceeding formation, while continuous PTHrP administration preferentially stimulates formation (40, 41). Recent studies have provided a basis for the diverse actions of PTH and PTHrP in bone. Specifically, PTHrP activity at the PTHR is limited to the cell surface and results in a short-term intracellular cAMP burst. In contrast, the conformation associated with PTH stabilizes its binding to the receptor and its associated G protein, moves to the inner fraction of the cell, and results in sustained cAMP production (12, 14, 42, 43). The importance of ligands that form more stable complexes and more cAMP results in a greater catabolic response and an increase in blood calcium levels (13). In contrast, ligands such as PTHrP that transiently produce cAMP and mobilize calcium produce a greater anabolic effect than PTH.

[0156] Consistent with these reports, recent studies have evaluated the binding of abaloparatide to two different PTHR1 conformations. These findings suggest that the increased anabolic activity seen with abaloparatide treatment may result from binding to the R0 PTHR1, which is more selective than the RG conformation, compared to long-acting PTH (LA-PTH) or PTHrP (44). Further studies are needed to elucidate the molecular mechanism of abaloparatide that results in increased anabolic activity.

[0157] In summary, 6 weeks of abaloparatide treatment in OVX osteopenic rats increased bone mass and microstructural parameters, resulting in increased bone strength. This ability to increase BMD associated with improved bone quality in this preclinical model highlights the bone anabolic activity of abaloparatide and supports the continued investigation of abaloparatide as a promising therapy for the treatment of postmenopausal osteoporosis.

[0158] Reference All references in the disclosure listed below are hereby incorporated by reference in their entirety into the specification. [Table 14-1] [Table 14-2] [Table 14-3] [Table 14-4] [Table 14-5]

[0159] Aspects of the invention include the following. [1] A method for preventing or reducing non-vertebral fractures in a subject, comprising administering a therapeutically effective amount of the polypeptide of SEQ ID NO: 1 to a subject in need of prevention or reduction of non-vertebral fractures. [2] A method for improving bone mineral density (BMD) and / or trabecular bone score (TBS) in the non-vertebral bones of a subject, comprising administering a therapeutically effective amount of the polypeptide of SEQ ID NO: 1 to a subject in need of improvement of bone mineral density (BMD) and / or trabecular bone score (TBS). [3] The method according to [1] or [2], wherein the non-vertebral bone is selected from the group consisting of wrist bone and hip bone. [4] The method according to any one of [1] to [3], further comprising administering a therapeutically effective amount of a bone resorption inhibitor to the subject. [5] The method according to any one of [1] to [4], wherein the polypeptide of SEQ ID NO: 1 is administered by subcutaneous injection. [6] The method according to [5], wherein the therapeutically effective amount of the polypeptide of SEQ ID NO: 1 is 80 μg. [7] The method according to any one of [1] to [6], wherein the subject is female. [8] The method according to any one of [1] to [6], wherein the subject has osteoporosis. [9] The method according to any one of [1] to [6], wherein the subject has diabetes.

[10] The method according to [9], wherein the subject has type 2 diabetes.

[11] The method according to any one of [7] to

[10] , wherein the subject is a postmenopausal woman.

[12] The method according to any one of [1] to

[11] , wherein the subject has high cortical bone porosity.

[13] A method for preventing or reducing non-vertebral fractures in a subject, comprising the step of administering a therapeutically effective amount of the polypeptide of SEQ ID NO: 1 to a subject having high cortical bone porosity.

[14] The method according to

[13] , wherein the subject has normal BMD.

[15] The method according to

[13] , wherein the subject has a BMD T-score of at least about -1.

[16] The method according to any one of

[13] to

[15] , wherein the subject has diabetes.

[17] The method according to

[16] , wherein the subject has type 2 diabetes.

[18] The method according to any one of

[13] to

[17] , wherein the therapeutically effective amount is 80 μg.

[19] The method according to any one of [1] to

[18] , wherein the polypeptide of SEQ ID NO: 1 is administered by subcutaneous injection or transdermal delivery.

[20] The method according to [6] or

[18] , wherein the polypeptide of SEQ ID NO: 1 is administered by subcutaneous injection.

[21] The method according to [1], [2] or

[13] , wherein the method results in an increase in BMD of at least about 3% at one or more sites selected from the group consisting of the spine, hip and wrist.

Claims

【Claim 1】 A method for preventing or reducing non-spinal fractures in a subject in need thereof, comprising administering to the subject a therapeutically effective amount of the polypeptide of SEQ ID NO: 1.

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