Methods for treating CLN2 disease in pediatric subjects

Abstract

To provide methods for treating CLN2 disease in pediatric subjects.SOLUTION: Provided herein are methods of treating neuronal ceroid lipofuscinosis (CLN2) disease in a subject less than 3 years old. In exemplary embodiments, the method comprises administering to the subject a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) in an amount effective to treat the CLN2 disease in the subject. Also provided are methods of delaying the onset of CLN2 disease, or a symptom thereof, in a subject less than 3 years old. In exemplary embodiments, the method comprises administering to the subject a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) in an amount effective to delay the onset of the CLN2 disease or symptom in the subject.SELECTED DRAWING: None

Description

[Technical Field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority to U.S. Provisional Patent Application No. 62 / 893,535, filed August 29, 2019, which is incorporated herein by reference.

[0002] Incorporation by Reference of Electronically Submitted Materials The computer-readable nucleotide / amino acid sequence listing, hereinafter identified as the 8,177 byte ASCII (text) file named "54735_Seqlisting.txt", filed concurrently herewith and created on August 27, 2020, is incorporated by reference in its entirety.

[0003] The present disclosure relates to methods of treating neuronal ceroid lipofuscinosis (CLN2) disease in subjects under the age of 3 and methods of delaying the onset of CLN2 or its associated physiological symptoms. [Background technology]

[0004] Neuronal ceroid lipofuscinosis (CLN2) is a rare genetic disorder characterized by a deficiency of the lysosomal enzyme tripeptidyl peptidase-1 (TPP1), caused by mutations in the TPP1 gene. CLN2 disease is inherited as an autosomal recessive disorder with an estimated incidence of 0.5 per 100,000 live births. In the absence of TPP1, lysosomal storage materials normally metabolized by the enzyme accumulate in many organs, including the central nervous system, resulting in the neurodegenerative symptoms typical of CLN2 disease. Untreated CLN2 disease progression is well characterized, and the natural history of the disease is highly consistent and predictable, as demonstrated by natural history data from independent patient populations in North America and Europe.

[0005] CLN2 disease primarily has a "classic" late infantile phenotype. Children with CLN2 disease typically present with the first symptoms, usually by approximately age 3 years. Most commonly, CLN2 patients experience their first unprovoked seizures and begin to lag behind in acquiring normal language milestones. By age 3 years, all patients exhibit one or more signs of the disease, including seizures, dementia, motor loss, movement disorders, blindness, clumsiness, ataxia, and cognitive decline. From the onset of clinical symptoms, the disease course is rapid and progressive, generally resulting in complete loss of language, cognition, ambulation, fine motor skills, bulbar function, and vision within 2–4 years, leaving patients immobile, mute, and blind. Patients remain in a vegetative state until death, which usually occurs between the ages of 6 and 12 years.

[0006] Two quantitative rating scales have been developed by expert clinicians to assess the severity of CLN2 disease and have been adopted in natural history trials: (1) the Hamburg scale (Steinfeld et al., Am J Med Genet. 2002;112(4):347-54) and (2) the Weill Cornell Medical College (WCMC) scale (Worgall et al., Neurology. 2007;69(6):521-35). The structure and assessment methods of the two scales are similar. Both scales measure the loss of previously achieved important neurological milestones in CLN2 patients, and each unit lost on the disease rating scale represents a fundamental milestone of progressive decline.

[0007] Analysis of the disease course in untreated children affected by CLN2 reveals that after disease onset, all language and ambulation are predictably lost within three years, with an average loss of 2.1 milestone events per year (i.e., 2.1 points on the Disease Rating Scale). Language decline typically precedes ambulation; e.g., the first year is characterized by loss of intelligible speech and progression to ataxic gait, the second year is characterized by loss of ambulation and intelligible language, and the third year is characterized by loss of all movement or communication.

[0008] Recombinant human tripeptidyl peptidase-1 (rhTPP1) is being developed as a potential treatment for CLN2 disease. The rhTPP1 protein is produced in cell culture as a proenzyme with no enzymatic activity. Upon uptake into lysosomes, the proenzyme is autoactivated at acidic pH (and by lysosomal proteases). The mature native TPP1 protein is a lysosomal serine protease and the only known mammalian member of the sedolisin (serine-carboxyl peptidase) family, characterized by a highly conserved Ser-Glu-Asp (SED) catalytic triad. The catalytic triad of rhTPP1 is formed by S456, E253, and D341. The enzyme's primary activity is as a tripeptidyl exopeptidase with broad substrate specificity. Activity of the enzyme on its substrate results in the sequential release of tripeptides from the N-terminus of the protein substrate (Oyama et al., J Biochem. 2005;138(2):127-34). A secondary, significantly weaker endoproteolytic activity with an optimum pH of 3 has also been reported (Lin et al., J Biol Chem. 2001;276(3):2249-55). The only commercially available treatments for CLN2 are symptomatic and supportive, and there are currently no approved treatment options to slow or stop the relentless progression of CLN2, much less reverse the deleterious effects of the disease (Mole, SE, and Williams, RE, 2010, GeneReviews; Chang et al., in The Neuronal Ceroid Lipofuscinoses (Batten (2011, Oxford University Press). Preservation of motor, language, and / or visual skills in these children would be of clinically meaningful benefit to both patients and parents / caregivers. Therefore, new therapies for CLN2 that reduce or prevent the decline in physiological function associated with the disease are needed. [Prior art documents] [Non-patent literature]

[0009] [Non-Patent Document 1] Steinfeld et al.,Am J Med Genet.2002;112(4):347-54 [Non-patent document 2] Worgall et al.,Neurology.2007;69(6):521-35 Summary of the Invention [Means for solving the problem]

[0010] The present disclosure relates to a method for treating CLN2 disease or one or more symptoms associated with CLN2 disease in a subject. In an exemplary embodiment, the subject is under 3 years of age. In an exemplary embodiment, the method includes administering to the subject a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) in an amount effective to treat CLN2 disease in the subject. The present disclosure also relates to a method for delaying the onset of CLN2 disease or a symptom thereof in a subject. In an exemplary embodiment, the subject is under 3 years of age. In an exemplary embodiment, the method includes administering to the subject a formulation comprising rhTPP1 in an amount effective to delay the onset of CLN2 disease or a symptom thereof in the subject. In an exemplary embodiment, the formulation is administered to the subject via intracerebroventricular, intrathecal, or intraocular administration. In an exemplary example, the formulation is administered once every two weeks. In various embodiments, the formulation is administered by infusion at a rate of about 2.5 mL per hour. In various examples of the methods of the present disclosure, a dose of about 300 mg or less is administered to the subject. In an exemplary embodiment, the subject is greater than or about 2 years old, and optionally is administered a dose of about 300 mg of rhTPP1. In various embodiments, the subject is greater than or about 1 year old and less than 2 years old, and optionally is administered a dose of about 200 mg of rhTPP1. In an exemplary embodiment, each of the first, second, third, and fourth doses administered to the subject (e.g., greater than 1 year old or about 1 year old and less than 2 years old) is about 200 mg of rhTPP1, and each of the fifth and subsequent doses administered to the subject is greater than about 200 mg of rhTPP1. In an exemplary example, each of the fifth and subsequent doses administered to the subject is about 300 mg of rhTPP1. In various embodiments, the subject is greater than or about 6 months old and less than 1 year old, and optionally is administered a dose of about 150 mg of rhTPP1. In various embodiments, the subject is less than 6 months old, and optionally, the subject is administered with about 100mg of rhTPP1.In exemplary embodiments, the subject shows reduced TPP1 enzyme activity based on blood test.In exemplary example, the subject is the sibling of the individual diagnosed with CLN2.In exemplary embodiments, the subject has a total score of about 3 to about 6 points on the motor and language subscales. In exemplary embodiments, the subject has not received prior treatment with stem cell therapy, gene therapy, or enzyme replacement therapy. In exemplary examples, the method includes administering an antihistamine, with or without an antipyretic, to the subject prior to administration of rhTPP1, optionally about 30 to about 60 minutes prior to administration of rhTPP1. In various embodiments, the formulation includes rhTPP1 and at least one pharmaceutically acceptable carrier, diluent, or excipient. In various examples, the formulation includes disodium hydrogen phosphate pentahydrate, monosodium phosphate monohydrate, sodium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or a combination thereof. In various examples, the method includes administering a flush solution to the subject after administering the formulation. In various embodiments, the flush solution comprises disodium hydrogen phosphate pentahydrate, monosodium phosphate monohydrate, sodium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or a combination thereof. In various embodiments, the treatment period is at least 10 weeks, at least 20 weeks, at least 40 weeks, at least 80 weeks, or at least 96 weeks.

[0011] The foregoing summary is not intended to define all aspects of the invention; other features and advantages of the present disclosure will become apparent from the following detailed description, including the drawings. It should be understood that this entire document is intended to be related as a unified disclosure, and that all combinations of features described herein are contemplated, even if the combinations of features do not appear together in the same sentence, paragraph, or section of this disclosure. Furthermore, the present disclosure includes, as additional aspects, all embodiments of the present invention that are narrower in scope in any way than the variations specifically referenced above. With respect to aspects of the present disclosure described or claimed as "a" or "an," these terms should be understood to mean "one or more" unless the context clearly dictates a more limited meaning. With respect to elements described as one or more within a set, it should be understood that all combinations within the set are contemplated. When aspects of the present disclosure are described as "comprising" a feature, it is also contemplated that the embodiment "consists of" or "consists essentially of" that feature. Additional features and variations of the present disclosure will be apparent to those skilled in the art from the entirety of this application, and all such features are contemplated as aspects of the present disclosure. [Brief explanation of the drawings]

[0012] [Figure 1] The amino acid sequence of the rhTPP1 proenzyme is shown, lacking the associated signal peptide. The prosegment of the enzyme is the first 176 amino acid residues, and the mature enzyme is 368 amino acids long, starting at position 177. [Figure 2] Clinical progression of untreated subjects with CLN2 disease in a natural history trial is shown, with Hamburg motor and language composite scores ranging from 0 to 6 as a function of patient age. Median, quartiles, and 10% / 90% distributions are shown, along with the mean and 95% confidence interval. [Figure 3A][Figures 3A-3F] Depict clinical assessments of 24 patients accrued during the treatment period, showing Hamburg motor and language composite scores ranging from 0 to 6. Open circles represent CLN2 scores obtained at or before the first 300 mg infusion of rhTPP1, while closed circles represent CLN2 scores obtained after the first 300 mg infusion of rhTPP1. Both the total score (circles) and the contributions of motor / gait (squares) and language (triangles) to the total score are shown. Analysis day 1 is the day of the first infusion. [Figure 3B] Same as above. [Figure 3C] Same as above. [Figure 3D] Same as above. [Figure 3E] Same as above. [Figure 3F] Same as above. [Figure 4A] [Figures 4A-4I] Comparison of the change in CLN2 score from nine patients treated with rhTPP1 to matched untreated natural history patients, according to the Hamburg Motor and Language Composite Score Scale (denoted by the prefix "HAM") of 0 to 6. Results for treated patients are shown as solid lines in each panel, compared to results for matched untreated natural history patients, which are shown as dashed lines. [Figure 4B] Same as above. [Figure 4C] Same as above. [Figure 4D] Same as above. [Figure 4E] Same as above. [Figure 4F] Same as above. [Figure 4G] Same as above. [Figure 4H] Same as above. [Figure 4I] Same as above. [Figure 5] The distribution of clinical changes from baseline during the patient-matched treatment period in matched untreated natural history patients (circles) compared with study subjects (squares) is shown. [Figure 6A][Figures 6A-6I] Shows the change in CLN2 scores between nine patients treated with rhTPP1 and matched untreated natural history patients on the Hamburg Motor / Speech / Vision Total Scale Disease Rating Scale ranging from 0 to 9. Results for treated patients are shown as solid lines in each panel compared to results for matched untreated natural history patients, which are shown as dashed lines. [Figure 6B] Same as above. [Figure 6C] Same as above. [Figure 6D] Same as above. [Figure 6E] Same as above. [Figure 6F] Same as above. [Figure 6G] Same as above. [Figure 6H] Same as above. [Figure 6I] Same as above. [Figure 7] Cerebrospinal fluid volumes (upper panel) and percentages (lower panel) measured for all 24 patients during the treatment period are shown. Each line represents one patient. [Figure 8A] [Figures 8A-8L] Brain volumes of 24 treated patients. White matter volume (upper panel) and ratio (lower panel) are shown as the difference between total brain volume (dash-dotted line) and CSF and gray matter (dashed line), with gray matter shown as the difference between CSF and gray matter (dashed line) and CSF (solid line). [Figure 8B] Same as above. [Figure 8C] Same as above. [Figure 8D] Same as above. [Figure 8E] Same as above. [Figure 8F] Same as above. [Figure 8G] Same as above. [Figure 8H] Same as above. [Figure 8I] Same as above. [Figure 8J] Same as above. [Figure 8K] Same as above. [Figure 8L] Same as above. [Figure 9A][Figures 9A and 9B] The mean change in CLN2 score for patients treated with rhTPP1 and untreated natural history patients is shown. Figure 9A shows the CLN2 score for 23 patients treated with 300 mg of rhTPP1 for 48 weeks (dashed line) and the untreated natural history cohort of 41 subjects (solid line). Figure 9B shows the change in CLN2 score from baseline for 23 patients treated with 300 mg of rhTPP1 for 48 weeks. [Figure 9B] Same as above. [Figure 10A] [Figures 10A-10L] Clinical assessments of 24 patients occurring during the treatment period are shown, showing the Hamburg (left panel) motor (square), language (triangle), seizure (cross), and visual acuity composite scores (diamonds) ranging from 0 to 12, and the combined WCMC (right panel) gait (square), language (triangle), myoclonus (cross), and feeding (diamond) composite score ranging from 0 to 12. Open circles represent the sum of CLN2 scores obtained at or before the first 300 mg infusion of rhTPP1, and closed circles represent the sum of CLN2 scores obtained after the first 300 mg infusion of rhTPP1. [Figure 10B] Same as above. [Figure 10C] Same as above. [Figure 10D] Same as above. [Figure 10E] Same as above. [Figure 10F] Same as above. [Figure 10G] Same as above. [Figure 10H] Same as above. [Figure 10I] Same as above. [Figure 10J] Same as above. [Figure 10K] Same as above. [Figure 10L] Same as above. [Figure 11-1]

[0023] FIG. 11 shows a table of clinical laboratory assessments and events examined in the clinical trials described in Examples 4-10. [Figure 11-2] Same as above. [Figure 12] A table listing the Hamburg LINCL scale is shown. [Figure 13]1 shows the median (range) PK parameters of cerliponase alfa at single doses of 30, 100, and 300 mg via ICV infusion. [Figure 14] Median (range) PK parameters of ceriponase alfa after 300 mg QOW via ICV infusion are shown. [Figure 15] Figure 1 shows the mean concentration-time profiles of seriponase alfa in CSF and plasma after 300 mg QOW by ICV infusion. Time 0 represents the start of the infusion. SD = stable dosing phase. [Figure 16] Figure 1 shows patient- and visit-matched CSF versus plasma exposure of cerliponase alfa at 300 mg ICV QOW. [Figure 17a] [Figures 17A-17D] Patient characteristics and serliponase alfa PK in CSF and plasma are shown. Individual patient data are indicated by circles. Figure 17A: Gender; Figure 17B: Baseline Age; Figure 17C: Baseline Weight; Figure 17D: Baseline CLN2 Score. Boxes represent the interquartile range (IQR) between the first (Q1) and third (Q3) quartiles. Bars within boxes represent medians. Whiskers represent minimum and maximum values ​​excluding outliers (i.e., values ​​outside the standard span of the data, defined as the range from Q1 - 1.5*IQR to Q3 + 1.5*IQR; open circles). [Figure 17b] Same as above. [Figure 17c] Same as above. [Figure 17d] Same as above. [Figure 18a] [Figures 18A-18B] Individual visit-concordant PK of seriponase alfa and ADA status. Figure 18a, CSF; Figure 18b, plasma / serum. Patients with a negative ADA response at the study visit are shown with an open circle, and patients with a positive ADA response at the study visit are shown with a closed circle. [Figure 18b] Same as above. [Figure 19]Changes from baseline in the CLN2 Clinical Rating Scale and the motor and speech function composite score for CSF seronegative pharmacokinetics (SPS) are shown. Individual patient data are represented by circles. The boxes represent the interquartile range (IQR) between the first (Q1) and third (Q3) quartiles, the bars within the boxes represent the median, and the whiskers represent the minimum and maximum values ​​excluding outliers (i.e., values ​​outside the standard span of the data, defined as the range from Q1 - 1.5*IQR to Q3 + 1.5*IQR; open circles). DETAILED DESCRIPTION OF THE INVENTION

[0013] The following definitions may be useful to aid those skilled in the art in understanding the present disclosure. Unless otherwise defined herein, scientific and technical terms used in this disclosure shall have the meanings commonly understood by those skilled in the art. Where a range of values ​​is provided, unless the context clearly indicates otherwise, each intervening value, to the tenth of the unit of the lower limit, between the upper and lower limits of that range, and any other stated or intervening value in that stated range, is understood to be encompassed within the scope of the invention. The upper and lower limits of these smaller ranges may independently be included within the smaller ranges, subject to any specifically excluded limit in the stated range.

[0014] The term "family history" refers to related subjects, e.g., siblings, parents, grandparents, great-grandparents, etc., who have been diagnosed with CLN2 disease.

[0015] The term "fragment" refers, in one embodiment, to a recombinant protein containing a portion of the rhTPP1 proenzyme amino acid sequence shown in SEQ ID NO:1 and FIG. 1. For example, a fragment can contain at least about 60%, at least about 70%, at least about 80%, at least about 90%, or at least about 95% of the amino acid sequence shown in SEQ ID NO:1. In another embodiment, a fragment includes the full-length (368 amino acids long, amino acids 177-544 of SEQ ID NO:1) mature TPP1 enzyme amino acid sequence shown in SEQ ID NO:2, a portion thereof, and / or at least the catalytic triad formed by amino acid residues S456, E253, and D341. The fragment retains catalytic activity. For example, the fragment exhibits tripeptidyl exopeptidase activity and / or catalytic activity that results in the sequential release of tripeptides from the N-terminus of a protein substrate. In certain aspects, a "fragment" of rhTPP1 proenzyme comprises at least 500 contiguous amino acids of SEQ ID NO: 1, at least 450 contiguous amino acids of SEQ ID NO: 1, at least 400 contiguous amino acids of SEQ ID NO: 1, at least 368 amino acids of SEQ ID NO: 1, at least 350 amino acids of SEQ ID NO: 1, or at least 300 contiguous amino acids of SEQ ID NO: 1. In other embodiments, a "fragment" of rhTPP1 proenzyme comprises at least 350 contiguous amino acids of SEQ ID NO: 2, at least 325 contiguous amino acids of SEQ ID NO: 2, at least 300 contiguous amino acids of SEQ ID NO: 2, at least 275 contiguous amino acids of SEQ ID NO: 2, at least 250 contiguous amino acids of SEQ ID NO: 2, or at least 200 contiguous amino acids of SEQ ID NO: 2.

[0016] The term "intraventricular" refers to administration of a composition into the ventricular system of the brain, for example, via injection, infusion, or implantation (eg, into the cavities of the brain).

[0017] The term "intraocular" refers to administration of a composition to the ocular region, for example, by injection, infusion, or implantation (e.g., into the eyeball) or topical / ophthalmic administration (e.g., using creams, ointments, gels, drops).

[0018] The term "intrathecal" refers to administration of a composition into the lumbar region (eg, into the subarachnoid space of the spinal cord), for example, by injection, infusion, or implantation.

[0019] The term "therapeutically effective" refers to any therapeutic benefit resulting from the treatment method of the present invention. For example, such an effect can be a beneficial effect manifested in an appropriate target tissue or organ, and such beneficial physiological effect can be compared to the physiological parameter measured in the absence of enzyme replacement therapy. Such a therapeutic effect can be the reduction or elimination of one or more clinical or subclinical signs of CLN2 disease. For example, a therapeutically effective treatment improves, reverses, delays, prevents, or reduces the deterioration of one or more physiological functions and / or neurological symptoms of CLN2, as described herein.

[0020] The terms "stable" or "stabilized" refer to a protein-containing formulation in which the protein component(s) therein essentially retain their physical, functional, and / or chemical stability upon storage over time. Stability can be measured at a selected temperature for a selected period of time. Preferably, the formulation is stable at room temperature (about 30°C) or about 40°C for at least one month, and / or at about 2°C to about 8°C for at least one year, preferably at least two years. For example, the extent of protein degradation or aggregation during storage can be used as an indicator of protein stability. Thus, a "stable" formulation can be one in which less than about 20%, more preferably less than about 10%, and most preferably less than about 5% of the protein component(s) is present in a degraded or aggregated form in the formulation after storage. A "stable" formulation retains essentially the same functional or therapeutic characteristics as a freshly prepared formulation. A variety of analytical techniques for measuring protein stability are available in the art, e.g., Peptide and Protein Drug Delivery, 247-301, Vincent Lee Ed., Marcel Dekker, Inc., New York, NY, Pubs. (1991) and Jones, A. Adv. Drug Delivery Rev. 10:29-90 (1993).

[0021] The terms "prevention" or "reduction," or grammatical equivalents thereof, when used in connection with preventing or alleviating one or more symptoms or physiological consequences of CLN2 disease in a subject, refer to a slower rate of symptom reduction in treated CLN2 subjects than that observed in untreated CLN2 subjects. In this regard, the untreated CLN2 may be the same subjects subsequently treated with a composition of the invention, or may be the average rate of symptom reduction in subjects observed from natural history trial results disclosed herein.

[0022] In jurisdictions that prohibit the patenting of methods performed on the human body, "administering" rhTPP1 or a formulation thereof to a human subject refers to medical uses of rhTPP1 or a formulation thereof, such as, for example, using rhTPP1 or a formulation thereof for the treatment of CLN2 disease as described herein, or using rhTPP1 for the manufacture of a medicament for treating CLN2 disease as described herein. The broadest reasonable interpretation consistent with any statute or regulation defining patentable subject matter is intended. In jurisdictions that do not prohibit the patenting of methods performed on the human body, "administering" rhTPP1 or a formulation thereof includes both the method and the aforementioned activity performed on the human body.

[0023] The present disclosure provides formulations and kits containing rhTPP1, as well as methods of using them to treat CLN2 disease. Administration of rhTPP1 allows for cellular uptake of the protein via the cation-independent mannose-6-phosphate receptor (CI-MPR) and localization to lysosomes in cells throughout the central nervous system. Lysosomal uptake and subsequent activation of the enzyme promotes increased catabolism of storage materials in affected tissues, reducing the progressive accumulation of lysosomal storage materials and preventing disease regression. The formulations and methods of the present disclosure offer therapeutic benefits beyond currently approved treatments.

[0024] formulation For the purposes of the present disclosure, the formulation comprises an amount of rhTPP1, and in exemplary embodiments, the formulation is suitable for intracerebroventricular, intrathecal, and / or intraocular administration. In one embodiment, the rhTPP1 comprises SEQ ID NO: 1 or a fragment thereof. RhTPP1 proteins suitable for use in the formulations and methods described herein, as well as methods for obtaining rhTPP1 proteins, are described in U.S. Patent Nos. 6,302,685 and 8,277,800, which are incorporated herein by reference in their entireties.

[0025] In one embodiment, rhTPP1 comprises the amino acid sequence of SEQ ID NO:1 (amino acids 1-544 of the amino acid sequence shown in Figure 1) or a catalytically active fragment thereof. In another embodiment, rhTPP1 comprises the amino acid sequence of SEQ ID NO:2 (amino acids 177-544 of the amino acid sequence shown in Figure 1) or a catalytically active fragment thereof. In yet another embodiment, rhTPP1 has detectable enzymatic activity or is processed in vivo to a form having detectable enzymatic activity (i.e., "functional") and an enzymatic form having at least about 70% sequence identity to SEQ ID NO:1 or SEQ ID NO:2. For example, functional rhTPP1 is at least about 70% identical, at least about 75% identical, at least about 80% identical, at least about 85% identical, at least about 90% identical, at least about 95% identical, or at least about 97% identical to SEQ ID NO:1 or SEQ ID NO:2. In one embodiment, the formulation is a liquid formulation containing rhTPP1 at a concentration of about 1 mg / mL to about 100 mg / mL, e.g., about 10 mg / mL to about 50 mg / mL, about 25 mg / mL to about 40 mg / mL, or about 30 mg / mL to about 60 mg / mL. In various embodiments, the formulation contains rhTPP1 at a concentration of about 1 mg / mL to about 100 mg / mL, about 5 mg / mL to about 80 mg / mL, about 10 mg / mL to about 50 mg / mL, about 20 mg / mL to about 40 mg / mL, or about 25 mg / mL to about 35 mg / mL, more specifically, about 1 mg / mL, about 10 mg / mL, about 20 mg / mL, about 30 mg / mL, about 40 mg / mL, about 50 mg / mL, about 60 mg / mL, about 70 mg / mL, about 80 mg / mL, about 90 mg / mL, or about 100 mg / mL. In one embodiment, the formulation has a pH of about 5.5 to about 7.5 or about 6.0 to about 7.0, for example, about 5.5, about 6.0, about 6.5, about 7.0, or about 7.5.

[0026] In one embodiment, a formulation comprising rhTPP1 of the present disclosure further comprises one or more excipients that maintain the levels of major electrolytes in cerebrospinal fluid (CSF) or ocular fluid. For example, in one embodiment, in addition to rhTPP1 or a fragment thereof, the formulation further comprises potassium chloride at a concentration of about 0.01 mg / mL to about 1 mg / mL, e.g., about 0.1 mg / mL to about 0.5 mg / mL, about 0.2 mg / mL to about 0.8 mg / mL, about 0.2 mg / mL to about 0.4 mg / mL, about 0.15 mg / mL to about 0.25 mg / mL, or about 0.05 mg / mL to about 0.3 mg / mL. In another embodiment, the formulation further comprises magnesium chloride hexahydrate at a concentration of about 0.01 mg / mL to about 1 mg / mL, e.g., about 0.1 mg / mL to about 0.5 mg / mL, about 0.1 mg / mL to about 0.8 mg / mL, about 0.1 mg / mL to about 0.3 mg / mL, about 0.15 mg / mL to about 0.25 mg / mL, or about 0.05 mg / mL to about 0.3 mg / mL. In another embodiment, the formulation further comprises calcium chloride dihydrate at a concentration of about 0.01 mg / mL to about 1 mg / mL, e.g., about 0.1 mg / mL to about 0.5 mg / mL, about 0.2 mg / mL to about 0.8 mg / mL, about 0.15 mg / mL to about 0.25 mg / mL, about 0.1 mg / mL to about 0.3 mg / mL, or about 0.05 mg / mL to about 0.3 mg / mL. In yet another embodiment, the formulation comprises a combination of all or any of the foregoing.

[0027] In another embodiment, the formulation containing rhTPP1 further comprises one or more buffering agents. For example, in various embodiments, the formulation further comprises disodium hydrogen phosphate heptahydrate at a concentration of about 0.01 mg / mL to about 1 mg / mL, e.g., about 0.1 mg / mL to about 0.5 mg / mL, about 0.05 mg / mL to about 0.4 mg / mL, or about 0.1 mg / mL to about 0.3 mg / mL, and / or monosodium phosphate monohydrate at a concentration of about 0.01 mg / mL to about 1 mg / mL, e.g., about 0.01 mg / mL to about 0.2 mg / mL, about 0.05 mg / mL to about 0.3 mg / mL, or about 0.08 mg / mL to about 0.4 mg / mL.

[0028] In another embodiment, the formulation further comprises an isotonicity agent such as sodium chloride at a concentration of about 1 mg / mL to about 20 mg / mL, e.g., about 1 mg / mL to about 10 mg / mL, about 5 mg / mL to about 15 mg / mL, or about 8 mg / mL to about 20 mg / mL. Other buffers and isotonicity agents known in the art are suitable and routinely available for use in the formulations of the present disclosure.

[0029] In one embodiment, a formulation containing about 30 mg / mL of rhTPP1 further comprises disodium hydrogen phosphate heptahydrate at a concentration of about 0.11 mg / mL, monosodium phosphate monohydrate at a concentration of about 0.08 mg / mL, sodium chloride at a concentration of about 8.77 mg / mL, potassium chloride at a concentration of about 0.22 mg / mL, magnesium chloride hexahydrate at a concentration of about 0.16 mg / mL, calcium chloride dihydrate at a concentration of about 0.21 mg / mL, and a diluent such as water for injection.

[0030] The rhTPP1 formulations of the present disclosure are stable and can be stored for extended periods of time without unacceptable changes in quality, potency, or purity. In one embodiment, the formulation is stable at a temperature of about 5°C (e.g., 2°C to 8°C) for at least 1 month, e.g., at least 1 month, at least 3 months, at least 6 months, at least 12 months, at least 18 months, at least 24 months, or at least 36 months or more. In another embodiment, the formulation is stable at a temperature of about -20°C or less for at least 6 months, e.g., at least 6 months, at least 12 months, at least 18 months, at least 24 months, or at least 36 months or more. In another embodiment, the formulation is stable at a temperature of about -40°C or less for at least 6 months, e.g., at least 6 months, at least 12 months, at least 18 months, at least 24 months, or at least 36 months or more. In another embodiment, the formulation is stable at a temperature of about -60°C or less for at least 6 months, e.g., at least 6 months, at least 12 months, at least 18 months, at least 24 months, or at least 36 months or more.

[0031] In one embodiment, the formulations of the present disclosure do not contain preservatives and / or stabilizers, and therefore do not contain thimerosal, phenylmercury salts, chlorhexidene, phenol, benzoic acid, sorbic acid, parabens, alcohol, or other preservatives commonly found in parenteral or ophthalmic formulations.

[0032] In another embodiment, the preparation of the present invention can comprise one or more preservatives, stabilizers or excipients.In this regard, many well-known and commonly used preservatives, stabilizers and excipients are known in the art, which are useful for the protein-containing preparation for intrathecal or ICV delivery.More specifically, the example of such additives for the enzyme-containing preparation for intrathecal or ICV delivery is described in WO2013 / 096899, which is incorporated herein by reference.

[0033] method The present disclosure provides a method for treating CLN2 disease, comprising administering a therapeutically effective amount of a formulation comprising rhTPP1 described herein to a subject in need thereof. The disclosure also provides compositions comprising rhTPP1 for use in treating CLN2 disease as described herein, and the use of rhTPP1 in the manufacture of a medicament for treating CLN2 disease as described herein. In one embodiment, the severity and progression of CLN2 disease, as well as the therapeutic benefit of administering rhTPP1 in patients, can be measured using the Hamburg or WCMC Clinical Disease Rating Scale. Both the Hamburg and WCMC scales are composed of four disease-related domains scored on a 0- to 3-point subscale scale, with 3 representing normal, 2 representing abnormal but functional, 1 representing abnormal and significantly impaired, and 0 representing no residual function. Two of the four domains, gait / motor and language, are shared in common between the two scales, providing high intrinsic content validity. Each summative scale captures changes that occur as a function of both disease progression and disease management. Gait, speech, and vision scales capture disease progression. Seizure frequency, motor impairment, and feeding influence care decisions, particularly anticonvulsant medication and feeding tube management. Clinical progression is often assessed using the sum of the speech and speech subscales, with a 6-point rating representing normal for age and a 0-point rating representing complete loss of function. Table 1 shows the disease scales for the WCMC and Hamburg CLN2. [Table 1]

[0034] In various aspects, the present disclosure provides a method for treating CLN2 disease or one or more clinical symptoms of CLN2 disease, use of rhTPP1 in the manufacture of a medicament for treating CLN2 disease in a subject, or rhTPP1 for use in treating CLN2 disease in a subject, comprising administering a therapeutically effective amount of a composition comprising rhTPP1 to a subject in need thereof.

[0035] The present disclosure also provides methods for preventing one or more clinical symptoms of CLN2 disease, comprising administering a formulation comprising rhTPP1 described herein to a subject in need thereof, optionally wherein the subject has a family history of CLN2 disease. In various embodiments, the present disclosure provides methods for preventing one or more clinical symptoms of CLN2 disease, comprising administering a therapeutically effective amount of a composition comprising rhTPP1 to a subject in need thereof, use of rhTPP1 in the manufacture of a medicament for preventing one or more clinical symptoms of CLN2 disease in a subject, or comprising rhTPP1 for use to prevent one or more clinical symptoms of CLN2 disease in a subject, or optionally, wherein the subject has a family history of CLN2 disease.

[0036] The present disclosure further provides a method of treating CLN2 disease, comprising administering rhTPP1 to a subject in need thereof at a dose effective to maintain physiological function or slow or reduce deterioration of the subject's physiological function, where the physiological function is language function, motor function, vision, or feeding function. The present disclosure also provides use of rhTPP1 in the manufacture of a medicament for maintaining physiological function or slowing or reducing decline in physiological function in a subject with CLN2 disease, and for use of rhTPP1 for maintaining physiological function or slowing or reducing physiological deterioration in a subject suffering from CLN2 disease, where the physiological function is language function, motor function, vision, or feeding function.

[0037] In one embodiment, a method for treating a subject with CLN2 disease or a family history of CLN2 disease comprises administering a dose of rhTPP1 effective to maintain language function or to slow or reduce the decline of language function to the subject. In one embodiment, the decline in language function is a decrease of at least 1 point compared to a previous rating determined before or during treatment, as measured using the WCMC or Hamburg Disease Rating Scale. On both the WCMC and Hamburg scales, a rating of 3 points indicates normal language; 2 points indicates abnormal (recognizable) language; 1 point indicates slightly / barely intelligible language; and 0 points indicates no intelligible or no language. In one embodiment, the dose of rhTPP1 is effective to maintain the subject's language rating at the same level as a previous rating determined before or during treatment, for example, 3 points, 2 points, or 1 point. In another embodiment, the dose of rhTPP1 is effective to delay or reduce CLN2-related deterioration of a subject's language function, as evidenced by maintaining language ratings at the same level over time or a smaller decrease in language function ratings compared to what would be expected given the natural progression of the disease.

[0038] In another embodiment, a method for treating a subject with CLN2 or a family history of CLN2 comprises administering a dose of rhTPP1 effective to maintain motor function or slow or reduce the deterioration of motor function to the subject. In one embodiment, the decline in motor function is a decrease of at least 1 point compared to a previous rating determined before or during treatment, as measured using the WCMC or Hamburg Disease Rating Scale. Motor function can be assessed using the WCMC gait scale or the Hamburg movement clinical rating scale. In both the WCMC and Hamburg scales, a rating of 3 points indicates normal gait. A rating of 2 points indicates abnormal but independent gait, such as frequent falls or obvious clumsiness. A rating of 1 point indicates abnormal gait requiring assistance, such as crawling without unassisted walking. A rating of 0 points indicates a non-ambulatory / immobile subject, such as being mostly bedridden. In one embodiment, the dose of rhTPP1 is effective to maintain the subject's motor function rating at the same level as the previous rating determined before or during treatment, e.g., 3 points, 2 points, or 1 point. In another embodiment, the dose of rhTPP1 is effective to delay or reduce the CLN2-related deterioration of the subject's motor function, as evidenced by maintaining the motor rating at the same level for a longer period of time or by a smaller decrease in motor function rating compared to what would be expected given the natural progression of the disease.

[0039] In yet another embodiment, a method for treating a subject with CLN2 or a family history of CLN2 comprises administering a dose of rhTPP1 effective to maintain the subject's visual acuity or to slow or reduce visual acuity decline. In one embodiment, the decline in visual acuity is measured using the Hamburg Disease Rating Scale, where the subject's visual acuity decline is at least 1 point lower than the previous score determined before or during treatment. According to the Hamburg Scale, a score of 3 indicates that the subject recognizes and grasps the desired object. A score of 2 indicates that the subject grasps the object clumsily. A score of 1 indicates that the subject responds to light, and a score of 0 indicates that the subject is unresponsive to visual stimuli. In one embodiment, the dose of rhTPP1 is effective to maintain the subject's visual acuity score at the same level as the previous score determined before or during treatment, for example, 3 points, 2 points, or 1 point. In another embodiment, the dose of rhTPP1 is effective to slow or reduce CLN2-related vision loss in a subject, as evidenced by maintaining visual acuity ratings at the same level over time or a smaller decrease in visual acuity ratings compared to what would be expected given the natural progression of the disease.

[0040] In another embodiment, the method for treating a subject with CLN2 or a family history of CLN2 comprises administering rhTPP1 to the subject at a dose effective to maintain feeding function or slow or reduce the deterioration of feeding function.In one embodiment, the decline in feeding function is measured using the WCMC rating scale, and is a decrease of at least 1 point compared to the previous rating determined before or during treatment.According to the WCMC scale, a rating of 3 points indicates no swallowing dysfunction; 2 points indicates mild swallowing dysfunction; 1 point indicates moderate swallowing dysfunction, and 0 points indicates that the subject is dependent on a gastrostomy tube.In one embodiment, the dose of rhTPP1 is effective to maintain the feeding function rating of the subject at the same level as the previous rating determined before or during treatment, for example, 3 points, 2 points, or 1 point. In another aspect, the dose of rhTPP1 is effective in delaying or reducing CLN2-associated deterioration of feeding function in a subject, as evidenced by maintaining feeding function at the same level for a longer period of time or by a smaller decrease in feeding ratings compared to what would be expected given the natural progression of the disease.

[0041] The present disclosure further provides a method for treating CLN2 disease, comprising administering rhTPP1 to a subject in need thereof in an amount effective to improve physiological function, wherein the physiological function is language function, motor function, vision, or feeding function. The present disclosure also provides use of rhTPP1 in the manufacture of a medicament for improving physiological function in a subject with CLN2, or rhTPP1 for use in improving physiological function in a subject with CLN2, wherein the physiological function is language function, motor function, vision, or feeding function. Given the progressive degenerative nature of the disease, improvement in language function, motor function, vision, and / or feeding function, indicating that the subject has regained lost function, is particularly desirable but difficult to achieve with current treatment options.

[0042] In one embodiment, the method for treating a subject with CLN2 disease comprises administering to the subject an effective dose of rhTPP1 to improve language function.In one embodiment, the improvement of language function is measured by using WCMC or Hamburg Disease Rating Scale, and compared with the previous score determined before or during treatment, an increase of at least 1 point.For example, the subject can improve from a score of 1 point or 2 points to a score of 3 points, or from a score of 1 point to a rating of 2 points, which indicates that the subject has returned to normal language.

[0043] In another embodiment, the method for treating the subject with CLN2 disease comprises administering to the subject an effective dose of rhTPP1 to improve motor function.In one embodiment, the improvement of motor function is measured by using WCMC or Hamburg disease rating scale, and compared with the previous score determined before or during treatment, the increase is at least 1 point.For example, the subject can improve from a score of 1 point or 2 points to a score of 3 points, or from a score of 1 point to a score of 2 points, which indicates that the subject has returned to normal walking.

[0044] In one embodiment, the method for treating the subject with CLN2 disease comprises administering rhTPP1 at an effective dose to improve the visual acuity of the subject.In one embodiment, the improvement of visual acuity is measured by using the Hamburg Disease Rating Scale, and compared with the previous score determined before or during treatment, the increase is at least 1 point.For example, the subject can improve from a score of 1 point or 2 points to a score of 3 points, or from a score of 1 point to a score of 2 points.

[0045] In another embodiment, the method for treating the subject with CLN2 disease comprises administering to the subject an effective dose of rhTPP1 to improve feeding function.In one embodiment, the improvement of feeding function is measured by using WCMC disease rating scale, and compared with the previous score determined before or during treatment, an increase of at least 1 point.For example, the subject can improve from a score of 1 or 2 points to a score of 3 points, which indicates that the subject has returned to normal swallowing, or from a score of 1 point to a score of 2 or 3 points.

[0046] The present disclosure further provides a method of treating CLN2 disease, comprising administering rhTPP1 to a subject in need thereof in an amount effective to prevent or treat a neurological symptom of the disease, the neurological symptom being seizures, decreased brain volume, decreased gray matter in the brain, or increased cranial cerebrospinal fluid (CSF). The present disclosure also provides use of rhTPP1 in the manufacture of a medicament for preventing or treating a neurological symptom in a subject with CLN2 or a family history of CLN2, and rhTPP1 for use in preventing or treating a neurological symptom in a subject with CLN2 or a family history of CLN2, wherein the neurological symptom is seizures, decreased brain volume, decreased gray matter in the brain, or increased cranial CSF.

[0047] In one embodiment, a method for treating a subject with CLN2 or a family history of CLN2 comprises administering a dose of rhTPP1 effective to maintain or reduce the number of seizures to the subject. In one embodiment, the dose is effective to reduce the number of seizures experienced by the subject per month. In another embodiment, the dose is effective to increase the seizure score by at least 1 point compared to the previous score determined before or during treatment, as measured using the Hamburg Disease Rating Scale. According to the Hamburg scale, a score of 3 indicates no seizures within 3 months; 2 indicates 1 to 2 seizures in 3 months; 1 indicates 1 seizure per month; and 0 indicates 1 or more seizures per month. In one embodiment, the dose of rhTPP1 is effective to maintain the subject's seizure score at the same level as the previous score determined before or during treatment, e.g., 3, 2, or 1 point. In another embodiment, the dose of rhTPP1 is effective to maintain or reduce the number of seizures in a subject, which can be demonstrated by maintaining the number of seizures per month for a longer period of time or by a small decrease in seizure scores compared to what would be expected given the natural progression of the disease.

[0048] In another embodiment, a method for treating a subject with CLN2 or a family history of CLN2 comprises administering a dose of rhTPP1 effective to maintain the subject's brain volume or to slow or reduce the loss of brain volume. Brain atrophy increases as the disease progresses, resulting in loss of brain volume and an increase in the relative proportion of intracranial CSF volume. Brain volume can be measured using methods known in the art, such as magnetic resonance imaging (MRI), computed tomography (CT / CAT), positron emission tomography (PET), single-photon emission computed tomography (SPECT), electroencephalography (EEG), magnetoencephalography (MEG), and near-infrared spectroscopy (NIRS). In one embodiment, the dose of rhTPP1 is effective in slowing or reducing the CLN2-related loss of brain volume in a subject, which can be demonstrated by maintaining brain volume for a long period of time or by a smaller loss of brain volume compared to what would be expected given the natural progression of the disease.

[0049] In another embodiment, the method for treating a subject with CLN2 or a family history of CLN2 comprises administering to the subject an effective dose of rhTPP1 to maintain gray matter in the brain or slow or reduce the loss of gray matter in the brain.The loss of gray matter due to brain atrophy occurs as the disease progresses, resulting in a decrease in gray matter as a percentage of brain volume.The amount of gray matter in the brain can be evaluated using methods known in the art, for example, imaging techniques such as MRI, CT / CAT, PET, SPECT, EEG, MEG, and NIRS.In one embodiment, the dose of rhTPP1 is effective for slowing or reducing the loss of gray matter in the subject, which can be demonstrated by maintaining the amount of gray matter for a long period of time or by a decrease in gray matter as a percentage of brain volume compared to what is expected given the natural progression of the disease.

[0050] In another embodiment, a method for treating a subject with CLN2 or a family history of CLN2 comprises administering a dose of rhTPP1 effective to maintain the amount of cranial CSF or slow the increase in the amount of cranial CSF in the subject. Cranial CSF increases the amount and proportion of total CSF as a result of brain atrophy. The amount and proportion of cranial CSF can be assessed using methods known in the art, for example, imaging techniques such as MRI and CT / CAT. In one embodiment, the dose of rhTPP1 is effective to slow or reduce the increase in the amount of cranial CSF in the subject, which can be demonstrated by maintaining the amount of cranial CSF for a longer period of time or by a smaller increase in cranial CSF as a percentage of total CSF compared to what would be expected given the natural progression of the disease.

[0051] The aforementioned methods, compositions for use, and uses may further comprise any of the following features, alone and in combination.

[0052] In one embodiment, the method, composition for use, or use of the present disclosure comprises administering to a subject a formulation, composition, or dose containing rhTPP1 continuously or continuously for a period of at least about 1 hour, e.g., at least about 1 hour, at least about 2 hours, at least about 3 hours, at least about 4 hours, at least about 5 hours, at least about 6 hours, or longer. In another embodiment, the method or use of the present disclosure comprises administering to a subject in need thereof a formulation, composition, or dose containing about 20 mg to about 500 mg, about 30 mg to about 500 mg, about 50 mg to about 500 mg, about 100 mg to about 500 mg, about 200 mg to about 400 mg, about 250 mg to about 350 mg, or about 275 mg to about 325 mg of rhTPP1, e.g., about 20 mg, about 30 mg, about 50 mg, about 100 mg, about 200 mg, about 300 mg, or about 400 mg. In one embodiment comprising administering about 500 mg of rhTPP1, the disclosed method or use comprises administering a formulation, composition or dose having a volume of about 20 mL or less, about 15 mL or less, about 10 mL or less, about 7.5 mL or less, or about 5 mL or less per administration or administration event, e.g., about 20 mL, about 15 mL, about 10 mL, about 9 mL, about 8 mL, about 7 mL, about 6 mL, about 5 mL, about 4 mL, about 3 mL, about 2 mL, about 1 mL, or about 0.5 mL.

[0053] In various embodiments, the disclosed methods, compositions for use, or uses comprise administering to a subject a formulation, composition, or dose comprising rhTPP1 at a rate of about 2.5 mL or less per hour of the formulation, composition, or dose, or about 75 mg or less of rhTPP1 per hour, or about 75 mg or less of rhTPP1 per 2.5 mL of the formulation or composition per hour. The formulation, composition, or dose is optionally administered continuously or continuously for a period of at least about 4 hours.

[0054] In one embodiment, the disclosed method, composition for use, or use comprises administering a formulation, composition, or dose comprising rhTPP1 weekly or less frequently, for example, weekly, biweekly, or monthly. More specifically, the disclosed method, composition for use, or use comprises administering a formulation, composition, or dose comprising rhTPP1 once every 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, or 31 days. In one embodiment, the formulation, composition, or dose is administered intracerebroventricularly. In another embodiment, the formulation, composition, or dose is administered intrathecally. In yet another aspect, the formulation, composition, or dose is administered intraocularly. In one embodiment, preparation, composition or dosage is administered intracerebroventricularly or intrathecally and intraocularly.Intracerebroventricular delivery not only allows ventricular delivery to enter the third and fourth ventricles, but also allows CSF to penetrate into the deep gray matter structures of the brain, such as the thalamus, striatum and midbrain, due to the physiology of CSF flow, which penetrates through the neuropil of cerebral hemispheres along the slight pressure gradient from ventricle to subarachnoid space.The intracerebroventricular and intracerebroventricular administration of recombinant enzyme for treating lysosomal storage disease is described in United States Patent No. 7,442,372, the entire contents of which are incorporated herein by reference.

[0055] The rhTPP1 formulations, compositions, or doses of the present disclosure can be administered as a single bolus injection or a series of injections (e.g., into the brain, lumbar region, or eye), or as a continuous or continuous infusion, for example, using an infusion pump or other implanted device. In one embodiment, the rhTPP1 formulations, compositions, or doses are administered using an infusion system comprising tubing, an in-line filter (e.g., about 0.2 μm), a reservoir (e.g., intrathecally or intracerebroventricularly), and a catheter. Often, when a composition is administered intrathecally or intracerebroventricularly, an amount of CSF equivalent to the amount of the composition to be administered is first removed from the subject prior to administration of the composition to prevent adverse side effects resulting from an artificial increase in intracerebral or intrathecal pressure. However, as described in Example 3, it is shown herein that the rhTPP1 formulations, compositions, or doses of the present disclosure can be administered without removing any amount of CSF from the subject immediately prior to administration of the rhTPP1 formulations, compositions, or doses.

[0056] In one embodiment, the method or use of the disclosure comprises administering about 10 mL of the formulation, composition, or dose (comprising about 300 mg of rhTPP1) intracerebroventricularly over about 4 hours every other week to a subject with CLN2.

[0057] The formulations and compositions of the present invention can be administered directly to a subject in need thereof (i.e., non-isovolumic), or can be administered after previously removing a defined amount of CSF from the subject, which defined amount is approximately the same as the amount of composition subsequently administered (i.e., isovulic).

[0058] In one embodiment, the disclosed method, composition for use, or use further comprises administering a flush solution to the subject following administration of rhTPP1. The flush solution is administered via the same route and using the same delivery system (e.g., an infusion system) as rhTPP1 to remove any rhTPP1 remaining in the delivery system and ensure the subject receives the full intended dose of rhTPP1. In one embodiment, the flush solution is administered to the subject (e.g., using the same catheter previously used to administer the rhTPP1-containing composition) in a volume of about 0.5 mL to about 5 mL, e.g., about 0.5 mL, about 1 mL, about 2 mL, about 3 mL, or about 5 mL. In one embodiment, the flush solution contains the same ingredients as a formulation or composition containing rhTPP1, but does not contain rhTPP1. In one embodiment, the flush solution comprises disodium hydrogen phosphate heptahydrate in the concentration of about 0.11 mg / mL, monosodium phosphate monohydrate in the concentration of about 0.08 mg / mL, sodium chloride in the concentration of about 8.77 mg / mL, potassium chloride in the concentration of about 0.22 mg / mL, magnesium chloride hexahydrate in the concentration of about 0.16 mg / mL, calcium chloride dihydrate in the concentration of about 0.21 mg / mL, and a diluent such as water for injection.

[0059] In various embodiments, the maximum concentration of rhTPP1 in the cerebrospinal fluid (T max ) is 4 to 10 hours after the end of the infusion. In various embodiments, the elimination half-life (t 1 / 2 ) is 5 to 20 hours.

[0060] Pediatric Indications The present disclosure is also directed to methods of treating CLN2 disease or one or more symptoms associated with CLN2 disease in a subject, as well as methods of delaying the onset of CLN2 disease or its symptoms in a subject, exemplary subjects being, for example, pediatric subjects under about 18 years of age. In various embodiments, the subject is under 3 years of age. In various embodiments, the subject is under 2 years of age. In various embodiments, the subject is under 1 year of age. In various embodiments, the subject is more than 1 month old, or from about 1 month to about 3 months or older, or more than 1 month old, or from about 1 month to about 6 months or older, or more than 1 month old, or from about 1 month to about 9 months, or more than 1 month old, or from about 1 month to about 12 months of age. In various embodiments, the subject is less than about 12 months old, or about 12 months old, but at least or about 2 weeks old, about 4 weeks old, about 6 weeks old, about 12 weeks old, or about 16 weeks old. In various instances, the subject is less than 12 months old, but is at least or about 5 months old, at least or about 6 months old, at least or about 7 months old, at least or about 8 months old, at least or about 9 months old, at least or about 10 months old, or at least or about 11 months old. In various instances, the subject is at least 12 months old, but is at least or less than about 24 months old, or at least or less than about 23 months old, or at least or less than about 22 months old, or at least or less than about 21 months old, or at least or less than about 20 months old, or at least or less than about 19 months old, or at least or less than about 18 months old, or at least or less than about 17 months old, or at least or less than about 16 months old, or at least or less than about 15 months old, or at least or less than about 14 months old, or at least or less than about 13 months old.In various cases, the subject is less than 24 months old, is at least or about 13 months old, or is at least or about 14 months old, or is at least or about 15 months old, or is at least or about 16 months old, or is at least or about 17 months old, or is at least or about 18 months old, or is at least or about 19 months old, or is at least or about 20 months old, or is at least or about 21 months old, or is at least or about 22 months old, or is at least or about 23 months old. In various examples, the subject is greater than or about 24 months old, less than or about 36 months old, or less than or about 35 months old, or less than or about 35 months old, or less than or about 34 months old, or less than or about 34 months old, or less than or about 33 months old, or less than or about 32 months old, or less than or about 31 months old, or less than or about 31 months old, or less than or about 30 months old, or less than or about 29 months old, or less than or about 28 months old, or less than or about 28 months old, or less than or about 27 months old, or less than or about 27 months old, or less than or about 26 months old, or less than or about 26 months old.

[0061] In exemplary embodiments, the method includes administering to the subject a formulation comprising an amount of recombinant human tripeptidyl peptidase-1 (rhTPP1) effective to achieve a desired result, e.g., treating CLN2 disease or a symptom thereof or delaying the onset of CLN2 disease or a symptom thereof. In various examples of the disclosed methods, a dose of about 300 mg or less of rhTPP1 is administered to the subject. In exemplary embodiments, the subject is greater than or about 2 years old, and optionally, a dose of about 300 mg of rhTPP1 is administered to the subject. In various embodiments, the subject is greater than or about 1 and less than 2 years old, and optionally, a dose of about 200 mg of rhTPP1 is administered to the subject. In exemplary embodiments, the subject is administered multiple doses of rhTPP1. In exemplary embodiments, the method includes administering an initial dose, followed by subsequent doses. In various embodiments, the initial dose is smaller than the subsequent doses. In various embodiments, the initial dose is larger than the subsequent doses. In various embodiments, the first dose is about 200 mg of rhTPP1, and subsequent doses are higher. In exemplary embodiments, the first dose is about 200 mg of rhTPP1, and subsequent doses are at least 50% higher, for example, at least or about 300 mg of rhTPP1. In exemplary embodiments, the first, second, third, and fourth doses administered to a subject (e.g., over 1 year old or about 1 year old and under 2 years old) are each about 200 mg of rhTPP1, and each of the fifth and subsequent doses administered to the subject is greater than about 200 mg of rhTPP1. In an exemplary example, each of the fifth and subsequent doses administered to the subject is about 300 mg of rhTPP1. In various embodiments, the subject is over 6 months old or about 6 months old and under 1 year old, and optionally, a dose of about 150 mg of rhTPP1 is administered to the subject. In various embodiments, the subject is less than 6 months old, and optionally, the subject is administered a dose of about 100 mg of rhTPP1. In various embodiments, the formulation is administered once every two weeks, every other week, every other week, or about once every 14 days (± 3 days). In various embodiments, the formulation is administered by infusion at a rate of about 2.5 mL per hour or lower.

[0062] In an exemplary embodiment, the subject, e.g., a pediatric subject, exhibits reduced TPP1 enzyme activity based on a blood test. In an exemplary example, the subject, e.g., a pediatric subject, is a sibling of an individual diagnosed with CLN2. In an exemplary example, the subject, e.g., a pediatric subject, is not a sibling of an individual diagnosed with CLN2. In an exemplary embodiment, the subject, e.g., a pediatric subject, has a total score of about 3 to about 6 points (e.g., about 3 points, about 4 points, about 5 points, about 6 points) on the motor and language subscales. In an exemplary embodiment, the subject, after administration of rhTPP1, has a score close to that associated with "healthy" or "normal" according to the scores shown in Table 1.

[0063] In exemplary embodiments, the subject, e.g., a pediatric subject, has not undergone prior treatment with stem cell therapy, gene therapy, or enzyme replacement therapy. In exemplary examples, the method includes administering an antihistamine, with or without an antipyretic, to the subject prior to administration of rhTPP1, optionally about 30 to about 60 minutes prior to administration of rhTPP1. In various embodiments, the formulation includes rhTPP1 and at least one pharmaceutically acceptable carrier, diluent, or excipient. In various cases, the formulation includes any of the foregoing, including, but not limited to, disodium hydrogen phosphate pentahydrate, monosodium phosphate monohydrate, sodium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or combinations thereof. In various examples, the method includes administering a flush solution to the subject after administering the formulation. In various embodiments, the flush solution is any one of those described herein. In various embodiments, the flush solution comprises disodium hydrogen phosphate pentahydrate, monosodium phosphate monohydrate, sodium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or a combination thereof. In various embodiments, the treatment period is at least 10 weeks, at least 20 weeks, at least 40 weeks, at least 80 weeks, or at least 96 weeks. In various embodiments, the treatment period is longer than 96 weeks. In various embodiments, the method treats CLN2 disease or delays the onset of CLN2 disease or its symptoms without causing a serious adverse event (SAE). In various embodiments, the subject has an ICV device. In various embodiments, the method includes implanting an ICV device into the subject.

[0064] kit The present disclosure further provides kits containing formulations of rhTPP1 described herein in dosages and forms suitable for administration to patients. In one embodiment, the kit includes a formulation comprising about 30 mg / mL of rhTPP1, disodium hydrogen phosphate heptahydrate at a concentration of about 0.11 mg / mL, monosodium phosphate monohydrate at a concentration of about 0.08 mg / mL, sodium chloride at a concentration of about 8.77 mg / mL, potassium chloride at a concentration of about 0.22 mg / mL, magnesium chloride hexahydrate at a concentration of about 0.16 mg / mL, calcium chloride dihydrate at a concentration of about 0.21 mg / mL, and a diluent such as water for injection. In one embodiment, the kit further includes, in addition to the therapeutic formulation, instructions for intraventricular, intrathecal, and / or intraocular administration of the therapeutic composition of the present invention. In another embodiment, the kit further includes a flush solution described herein. In yet another embodiment, the kit further includes a system for administering the formulation, including any or all of tubing, an in-line filter, an implantable reservoir, and a catheter. In one embodiment, the kit can include a catheter, reservoir, or other device preloaded with a therapeutic formulation of the present disclosure. For example, catheters preloaded with about 100 mg, about 200 mg, about 300 mg, about 400 mg, or about 500 mg of rhTPP1 in a pharmaceutically acceptable formulation are specifically contemplated. Alternatively, the kit can include a refillable catheter, reservoir, or other device and an appropriate amount of enzyme for refilling such a device.

[0065] In certain embodiments, the kits of the invention may include one or more of the following components: an extension line (e.g., product number 536040, Smiths Medical, Dublin OH), an in-line filter (e.g., product number FS116, Smiths Medical), a port needle (e.g., product number 21-2737-24, Smiths Medical), a syringe or two or more syringes (e.g., product number 309604, Becton Dickinson, Franklin Lakes, NJ) or a needle or two or more needles (e.g., product number 305196, Becton Dickinson).

[0066] The present disclosure will be more readily understood by reference to the following examples, which are provided by way of illustration and are not intended to be limiting. [Example]

[0067] The following examples describe formulations containing rhTPP1 for intracerebroventricular (ICV) administration and the results of administering the formulations to human patients compared to matched untreated natural history patients.

[0068] Example 1 Formulation of rhTPP1 for intraventricular administration RhTPP1 was produced in a genetically engineered CHO host cell line and purified by standard chromatographic methods, as described in U.S. Patent No. 6,302,685 and Sleat et al. 1997, Science 277:1802-1805. rhTPP1 was produced as an inactive proenzyme that is autoactivated at acidic pH upon uptake into lysosomes. The proenzyme form of rhTPP1 has a calculated isotopic average molecular weight of approximately 59 kDa. The apparent molecular weight of the mature enzyme is approximately 46 kDa. The amino acid sequence of the rhTPP1 proenzyme is shown in SEQ ID NO: 1 and in Figure 1. The prosegment of the enzyme is the first 176 amino acid residues, and the mature enzyme is 368 amino acids long, beginning at position 177, and is shown in SEQ ID NO: 2.

[0069] The rhTPP1 formulation used in the examples was a sterile solution for ICV infusion. It was a clear, colorless to pale yellow liquid containing rhTPP1 protein formulated at a concentration of 30 mg / mL. The formulation was packaged in a container closure system consisting of a Type 1 clear borosilicate glass vial closed with a fluoropolymer-coated butyl rubber stopper and capped with an aluminum seal. The formulation was stored at a temperature of -40°C ± 10°C and supplied frozen. The target pH value of the formulation was pH 6.5.

[0070] The composition of the rhTPP1 formulation used in the examples is shown in Table 2. [Table 2]

[0071] The rhTPP1 formulation was carefully designed to mimic the properties of human CSF, including concentrations of key electrolytes similar to those found in human CSF in vivo and containing no traditional preservatives or stabilizers as excipients. No previously unforeseen significant safety issues, i.e., serious adverse events, were reported or observed following administration of the rhTPP1 formulation.

[0072] Stability studies were conducted at long-term (≤-60°C) and accelerated conditions (5 ± 3°C) per protocol, following ICH guidelines, to monitor time-temperature stability. Stability samples were stored in small-scale bottles constructed from the same materials as the full-scale packaging. Stability data collected on supportive and clinical batches demonstrated that the rhTPP1 formulation was stable for at least 36 months at ≤-60°C and at least 6 months at 5 ± 3°C, which was surprising given that the formulation lacked preservatives and stabilizers commonly found in pharmaceuticals. Table 3 shows the results of the stability studies. [Table 3]

[0073] Example 2 Natural history trial Quantitative assessment of CLN2 natural history disease progression was analyzed in a cohort of 41 treatment-naive patients with CLN2. The Hamburg Clinical Scale was used to assess age-appropriate neurological and functional domains affected by the disease.

[0074] A quantitative description of the clinical decline of untreated natural history CLN2 subjects is shown in Figure 2. Natural history analysis demonstrated a clear and predictable relationship between age and disease severity. After the onset of motor and language symptoms, there was an essentially rapid linear decline, with children losing approximately two milestone events per year on average (linear decline rate of 2.1 points per year). While there was a largely predictable course, there were several "late-onset" cases, representing less than 20% of the cohort population. These patients tended to have a later onset of symptoms and a longer period of mild disease, but then succumbed to a rapid and vigorous decline, usually 2–3 years later than the typical form.

[0075] Quantitative clinical progression from the Hamburg cohort was corroborated by overlaying clinical scores from an independent (patient and assessor) cohort from WCMC (n=49). While the clinical descriptions of the independent CLN2 cohorts were similar, this was the first confirmation of a strong quantitative relationship in disease progression in separate patient groups. Both cohorts of CLN2 patients showed a majority of classic late infantile onset and progression, exhibiting a "late-onset" phenotype, with a small proportion of children experiencing early onset at age 5 years rather than the usual age of 3 years. Measures using motor (gait) and language function reproducibly captured neurological decline in CLN2 patients. Based on the aforementioned analysis, the natural history cohort was determined to be an appropriate untreated control population, and the mean decline in CLN2 disease symptoms in this untreated natural history population can be used as an efficient and informative comparator for the prevention or reduction of symptom decline in subjects with CLN2 disease caused by the administration of the compositions of the present invention.

[0076] Example 3 Phase 1 / 2 Open-Label Dose-Escalation Study in Patients with CLN2 This trial was an open-label, treatment-based clinical trial to evaluate the safety, tolerability, and efficacy of the disclosed rhTPP1 formulation, in which 300 mg (total volume of 10 mL) was delivered every other week via an ICV catheter to children with CLN2 disease. The trial was designed to evaluate safety and tolerability starting at low doses (30 mg and 100 mg), but all patients were titrated to the higher expected therapeutic dose (300 mg) if the lower dose was deemed safe by an independent data monitoring committee. All enrolled patients were administered 300 mg every other week for the duration of the trial. Treatment consisted of 48 weeks of stable, expected therapeutic doses of ICV. The primary study objectives were to evaluate the safety and tolerability of the disclosed rhTPP1 formulation administered to subjects with CLN2 disease via an implanted ICV reservoir and cannula, and to assess efficacy using CLN2 disease-specific rating scale scores compared with natural history data after 12 months of treatment. A secondary objective of the study was to evaluate the effect of treatment on measures of brain atrophy compared with natural history data of CLN2 disease after 12 months of treatment.

[0077] The main inclusion criteria were a CLN2 diagnosis and an enrollment age of at least 3 years. Patients with a baseline disease rating scale of less than 3 at screening (using the Hamburg Gross Motor / Language Scale, 0 to 6) were excluded from the trial. As indicated by the horizontal line on the progression curve, patients younger than 3 years of age may not have progressed due to their age rather than treatment. Patients with a score of 2 or less at screening were also considered to be less linear, more variable, and more resistant to treatment due to disease stage. Therefore, treatment groups were simply defined by age and score, including those with early, highly predictable decline.

[0078] The mean age at enrollment was 4.0 years, there were slightly more girls than boys, and the participants were predominantly white. Clinical CLN2 scores at screening and baseline are shown in Table 4 below, which shows the Hamburg Motor / Language Score for each study cohort and the combined score at both screening and baseline. [Table 4]

[0079] Overall, pretreatment CLN2 scores were biased toward more advanced disease. A bias toward lower scores was expected given the rapid progression of the disease and the difficulty of ascertainment. Furthermore, there was some decline in scores between screening and the period (up to 2 weeks) leading up to the baseline assessment (just before ICV reservoir placement). Four patients in the screening group who scored 3 lost points at baseline, and two patients in the screening group who scored 4 lost points to 3 at baseline. Two patients who scored 6 (i.e., very normal) were siblings of affected children. The disposition, demographics, and characteristics of the study population are summarized in Table 5 below. [Table 5]

[0080] All enrolled patients received a stable dose of 300 mg ICV every other week. Cohort 1 began with 30 mg ICV every other week for ≥1 month, then increased to 100 mg ICV every other week for ≥4 weeks. Cohort 2 began with 100 mg ICV every other week for ≥4 weeks. Both Cohort 1 and Cohort 2 were increased to 300 mg ICV every other week, and all subsequent patients, including Cohort 3, began on a stable dose regimen of 300 mg ICV every other week and continued for ≥48 weeks. The 300 mg dose was administered via an ICV catheter via a 10 mL infusion over approximately 4 hours. For example, a volume of CSF equivalent to the amount of rhTPP1 formulation administered was not removed immediately before the infusion began, which, although unusual, surprisingly did not cause any adverse effects. Immediately following the 300 mg dose, approximately 2 mL of flush solution was administered to the subject via the same ICV catheter. The flush solution had the same formulation as in Table 2 but did not contain rhTPP1. The 300 mg enzyme bolus dose per administration event was significantly higher than previous intrathecal or ICV-administered enzyme replacement therapies, and therefore, the safety and efficacy profile observed after administration of such a high dose of drug was previously unpredictable. More specifically, administration of a 300 mg bolus dose of rhTPP1 without associated serious and unmanageable adverse events was previously unpredictable.

[0081] result Treatment effects on clinical assessment of gait and speech: The primary assessment tool for quantitative assessment of clinical severity was a 0- to 6-point summary of the gait and speech subscale common to both the Hamburg and WCMC Disease Rating Scales. This scale captured the predictable, rapid, and progressive clinical decline in matched, untreated, natural history patients, who were used as comparators for the primary efficacy analysis.

[0082] The gait / speech disability rating scales for 23 patients with a treatment duration of more than 42 weeks are shown in Figures 3A–3F. Of the 23 patients, three patients (1244-1001, 1244-1002, and 1244-1003) were from Cohort 1 (C1), three patients (1244-1004, 1244-1006, and 1244-1005) were from Cohort 2 (C2), and three patients (1244-1008, 1244-1009, and 1244-1010) were from Cohort 3 (C3). Fourteen patients (0119-1020, 0146-1021, 0146-1022, 0146-1023, 1244-1011, 1244-1012, 1244-1017, 1244-1024, 1323-1013, 1323-1014, 1323-1015, 1323-1016, 1323-1018, and 1323-1019) were in the 300 mg stable dose only (SBO) group. As expected, speech impairment usually progressed more rapidly than gait impairment. Entry scores were not randomly distributed. Twelve patients showed significant disease progression with a total entry score of 3 points, and two patients showed a total entry score of 6 points. Given the rapid progression and disease confirmation, children often present as obvious decliners or as siblings of children who showed obvious decliners.

[0083] After treatment with the disclosed rhTPP1 formulation (shown in Table 2 above), the CLN2 Gait / Speech Rating Scale stabilized, as shown in Figures 3A-3F. Eleven of the 23 patients experienced no irreversible decline during the treatment period. Four patients experienced a one-unit decline early in the treatment period, but no subsequent irreversible declines. Two patients (1244-1008 and 1323-1013) experienced a one-unit decrease from 3 to 2 points between screening and baseline, but no additional loss of scores occurred during treatment. Based on the results, there was a clear treatment benefit for all patients, regardless of cohort (starting dose) or entry score. Many patients experienced a reversal of the decline in scores. For example, patient 1287-1005 (Figure 3B) experienced a two-unit decline in scores during the first month of treatment, representing a loss of both gait and speech function. However, this patient regained one unit on treatment day 60 and subsequently experienced no net change until analysis day 440. The recovered score was language acquisition, highlighting the clinical significance of a one-unit change.

[0084] Neither of the two patients with an entry score of 6 lost a rating unit. Seven of the 12 patients with an entry score of 3 had no irreversible decline, and two stabilized after an initial decline of one unit. Thus, treatment benefit was evident in patients with significant deficits and disease progression.

[0085] As demonstrated in the CLN2 natural history trial, the median rate of decline in the untreated natural history population was estimated to be 2.1 units per year. Thus, all patients in the treatment group had an improvement in their scores compared with the expected outcome of the untreated natural history population.

[0086] To establish a clearer relationship between the disease course between treated and matched untreated natural history patients, each trial patient was matched to untreated natural history patients by baseline CLN2 score, age, and genotype parameters. While there are no clear subgroups or factors predicting CLN2 disease progression, these parameters are most commonly used to define disease severity. As shown in Figures 4A-4I, each treated patient was compared to each member of the natural history cohort who demonstrated similar gait / language assessment measures at baseline. Trial patients were matched for baseline CLN2 score as follows: For a given trial patient with a specific baseline score, all natural history patients who reported 1 or more CLN2 assessments with the same CLN2 score were identified. If the trial patient's baseline CLN2 score was 2, 3, 4, or 5, the CLN2 vs. time profile of each natural history patient was time-shifted left or right to overlay the trial patient's baseline score. If a natural history patient had multiple assessments equal to the trial patient's baseline CLN2 score, the midpoint of the multiple assessments was used for time shifting. If the baseline CLN2 score of the trial patient was 6 points, the last score of 6 points in the natural history patient was used for time shifting. Sensitivity analyses were performed using other matching criteria, and the results of these analyses were consistent with the score-matching analysis.

[0087] Figures 4A-4I show results from subjects treated with the disclosed rhTPP1 formulation plotted against matched, untreated, natural history patients. Treated and untreated natural history patients were matched by disease rating scale, using gait and speech subscales ranging from 0 to 6 units as aggregates. Individual ratings were compared over the 1-year treatment period. Compared to all members of the matched, untreated, natural history patient group, subjects receiving rhTPP1 benefited from treatment. Subject 1244-1001 (Figure 4A) experienced a decline in rating from 3 units to 2 units after 120 days of treatment, but regained 1 unit and experienced no net change thereafter. Subject 1244-1002 (Figure 4B) maintained overall disease rating at the end of the study compared to Day 1, as his rating increased from 3 units to 4 units, decreased from 4 units to 2 units, and increased from 2 units to 3 units. Subjects 1244-1003 (Figure 4C) and 1244-1010 (Figure 4I) maintained a score of 6 units throughout the trial, i.e., normal motor and language function. Subjects 1244-1004 (Figure 4D) and 1244-1009 (Figure 4H) maintained a score of 3 units throughout the trial. Subject 1244-1006 (Figure 4E) initially dropped from 3 units to 2 units, but then regained 1 unit before dropping again from 3 units to 2 units with no net change. Subject 1244-1008 (Figure 4G) initially dropped from 3 units to 2 units with no net change.

[0088] In contrast to all treated subjects, the majority of matched untreated natural history patients showed a non-reversible decline in scores from 3 units to 0 units by the end of the comparison period, indicating progression to complete loss of combined walking and speech function. Matching analyses demonstrate a treatment effect in patients who maintained their disease rating scales and whose initial ratings declined but then stabilized.

[0089] The most complex response (subject 1287-1005) is shown in Figure 4F. This patient experienced a rapid decline of two units from a baseline score of 3 to a trial score of 1 in the first month of the trial. However, the patient regained one unit and stabilized at a score of 2. The interpretation of this progression was clarified by comparison with score-matched untreated natural history patients. Clinical progression worsened in 15 of 18 score-matched untreated natural history patients and was the same in just two score-matched untreated natural history patients (the natural history match for one untreated patient could not be assessed). The untreated patient's clinical course was always worsening, with little time between lost milestones. There was no reestablishment of lost function followed by stabilization. The match with the most complex treatment profile therefore demonstrated a clear treatment effect.

[0090] Figure 5 shows the distribution of clinical change from baseline in matched, untreated, natural history patients over the treatment period compared with the trial subjects. As previously noted, 7 of 9 patients (>75%) had no change in baseline disease rating scales. For these 7 patients, all matched, untreated, natural history patients experienced a decrease of at least 1 unit during the treatment period, but more commonly, losses of multiple units, i.e., 2 to 4 units. As an example, patient 1244-1001 lost 1 point with 1 match, 2 points with 3 matches, and all 3 available speech / gait disease rating points with 14 matches. Thus, over the same period, there was no change in the treated patients, whereas 14 of 18 (>75%) matched, untreated, natural history patients lost all gait and speech function. Although there was a three-point floor effect for baseline entry scores, and many of the matched untreated natural history patients lost all available rating units, two patients with entry scores of six (patients 1244-1003 and 1244-1010) importantly showed that these matches also actively worsened, with some dropping by four and five points over the treatment period. This observation was a clear clinical demonstration of a substantial treatment effect. In the context of the untreated natural history matches, who actively lost language and independent walking over the same period, and many completely lost function, most treated children retained their entry clinical ratings. The remaining two treated patients (subjects 1287-1005 and 1287-1006), who lost one point, still demonstrated better clinical ratings than the majority of their matches over the treatment period. In total, 97% of the score-matched untreated natural history patients demonstrated worse ratings than their treated counterparts.

[0091] When multiple matching criteria (e.g., baseline, age, genotype) were used, nearly 100% of comparisons demonstrated a favorable treatment effect compared with matched untreated natural history patients. The mean treatment difference across all matching criteria for treated patients compared with natural history patients ranged from 1.9 to 2.1 percentage points depending on the matching criteria utilized.

[0092] Figure 9A shows the mean change in motor and speech ratings for treated patients ≥48 weeks (n = 21, dashed line) and the natural history cohort (n = 41, solid line). The mean decline in disease ratings for treated patients was 0.43 (SD 0.839), with a median decline of 0.00 units at 48 weeks. In contrast, the mean decline in disease ratings for the natural history cohort was 2.09 (SD 0.966), with a median decline of 1.87 units at 48 weeks. Overall, there was a significant savings of 79% (p < 0.0001) of expected clinical decline for treated patients. Figure 9B shows the change in motor and speech scores for patients (n = 23) from the last measurement (baseline) before the first 300 mg dose to the final 300 mg dose at ≥48 weeks. Overall, 65% of patients (15 of 23) improved or had no clinical disease progression during treatment, and 87% of patients (20 of 23) performed better during treatment (i.e., score change of -1 or greater) compared with untreated subjects in the natural history study. These analyses uniformly supported the conclusion that there is a dramatic and clinically meaningful stabilization of CLN2 scores in treated patients compared with matched members of the untreated natural history group, who experience a rapid and predictable decline.

[0093] Effect of Treatment on Clinical Assessment of Vision: In untreated CLN2 patients, vision loss occurs later than speech and gait decline, but once symptoms appear, the progression is predictably rapid, progressing to blindness. Therefore, preservation of vision is an important treatment outcome. Vision loss can be captured on a 0- to 3-point subscale in a similar manner to other subscales, where 3 is normal and 0 is functionally blind. During treatment, the majority of treated patients had no unreversed loss in the vision subscale domain. When treated patients were matched to untreated natural history subjects by score, age, and genotype using a composite scale of gait, speech, and vision subscales (0-9 units), it was clear that untreated matched natural history patients lost additional points compared to the treated group.

[0094] Figures 6A-6I show the results of nine subjects treated with the disclosed rhTPP1 formulation, matched using gait, language, and vision subscales ranging from 0 to 9 as aggregates and plotted against untreated patients with a natural history of matched disease rating scales. Subject 1244-1001 (Figure 6A) experienced a one-unit drop in rating from 6 to 5 points, but then quickly returned to a score of 6, with no net change thereafter. Subject 1244-1002 (Figure 6B) experienced an increase in rating from 5 to 6 points, followed by a decrease from 6 to 4 points, and then an increase from 4 to 5 points, resulting in an overall maintenance of disease rating at the end of the trial compared to Day 1. Subjects 1244-1003 (Figure 6C) and 1244-1010 (Figure 6I) maintained a 9-point rating throughout the trial, demonstrating normal gait, language function, and vision. Subjects 1244-1004 (Figure 6D) and 1244-1009 (Figure 6H) maintained a 6-point rating throughout the trial, and subject 1244-1008 (Figure 6G) maintained a 5-point rating throughout the trial. Subject 1244-1006 (Figure 6E) initially decreased by one unit from 6 to 5, then further decreased to 4, but regained one unit, resulting in a 5-point rating with no net change thereafter. Subject 1287-1005 (Figure 6F) decreased from 6 to 4, then increased from 4 to 5, then decreased to 4, but regained one unit again, resulting in a final rating of 5.

[0095] The addition of the visual acuity subscale did not result in any change in the nine treated patients over the treatment period. However, score-matched untreated natural history patients had a significant contribution of visual acuity loss to the total score. There were multiple untreated natural history matches with a difference of more than three points compared with treated patients, indicating a contribution of visual acuity loss to the total score over the study period. Thus, the addition of the visual acuity subscale increased the difference between treated and matched untreated natural history patients. Because there was no loss of disease score units without reversal in matched untreated natural history patients, the observed effect of treatment with rhTPP1 associated with halting disease progression and stabilizing function can be extended to include vision in motor / gait and speech.

[0096] Effect of treatment on overall disease assessment: Patients were also assessed over the course of the trial using a combined 12-point scale, including the complete Hamburg or WCMC score. The score on the 12-point scale was the sum of the patient's individual scores for (1) movement / gait, (2) language, (3) seizures / myoclonus, and (4) vision / eating. Figures 10A-10L show results from subjects treated with the disclosed rhTPP1 formulation using a combined 0-12 scale of the Hamburg scale (left panel) and the WCMC scale (right panel). Sixteen of the 23 patients had no unreversed decline on at least one scale, and eight had an increase in score on at least one scale at the end of the treatment period compared to baseline, confirming the overall treatment effect for patients receiving rhTPP1.

[0097] Treatment effect on brain volume: MRI was used to assess secondary endpoints in treated patients. The disease process is characterized by atrophy, cell loss, and signal abnormalities. These parameters, individually or as a composite score, correlate with patient age and disease rating scales. Thus, there is general consensus that disease progression correlates with MRI indices of atrophy, and multiple MRI parameters have been shown to correlate with age and disease severity in CLN2 disease (Dyke et al., AJNR Am J Neuroradiol. 2013;34(4):884-9), (Paniagua et al., Clin Neuroradiol. 2013;23(3):189-96). The imaging databases supporting these conclusions are based on cross-sectional correlations of a significant number of patients, but there is no longitudinal acquisition of MRI images within patients. Therefore, there is not the same ability to match MRI analyses obtained from longitudinal trials with similarly obtained natural history databases.

[0098] For analysis of treated patients, MRI acquisition parameters were standardized across the study site's hardware platform. Data were acquired locally, redacted with identifying information, and transmitted to a central imaging core lab. Images were randomized so that independent radiologists were blinded to the patient or their temporal relationship to baseline. Brain volume changes were reconstructed from the randomized, independent central reads. Data were analyzed to compare baseline and longitudinal comparisons across the entire treated population. Figure 7 shows a summary of brain volumes measured on MRI in treated patients. Brain atrophy increases the volume and proportion of intracranial CSF. Increases in these measures of atrophy correlate with age and severity in CLN2 patients. Longitudinal plots of CSF volume and proportion in treated patients also showed that there appeared to be little, if any, change in CSF parameter measurements. All patients had MRI volume measurements that appeared constant, consistent with stabilization of the scoring system.

[0099] Figures 8A–8L show longitudinal MRI assessments of brain volume in treated patients. Active neurodegeneration in CLN2 patients is characterized by a predominant loss of gray matter and a compensatory increase in CSF. However, over the evaluated period, there was very stable brain volume and no evidence of a neurodegenerative process in treated patients. Gray matter volume, shown in Figures 8A–8L as the difference between the CSF and gray matter plots (dashed lines) and the CSF plots (solid lines) in the upper and lower panels, respectively, remained stable throughout the trial in each treated patient. The change in cortical gray matter volume as a percentage of total brain volume from the last measurement (baseline) before the first 300 mg infusion compared to the last observation of treatment (≥48 weeks) is shown in Table 6 below. [Table 6] Longitudinal changes in cortical volume were -1% per year in normal children aged 4-12 years, but -12.5% ​​per year in untreated CLN2 patients. CSF, gray matter, and white matter volumes remained relatively constant during treatment with rhTPP1, which attenuated 89% of disease-associated cortical volume loss.

[0100] Adverse Events: One patient withdrew from the study due to failure to comply with the protocol. The remaining 23 patients continued on the study and tolerated treatment with rhTPP1 medication via the ICV route. There were no deaths, treatment-related discontinuations, or study discontinuations due to safety-related reasons. Consistent with the minimal impact of device implantation, all patients received the medication within one week of surgery. Of the 325 total infusions, only five (1.5%) were discontinued for any reason, and only two (0.6%) were discontinued for reasons related to adverse events. The most frequent non-CLN2 disease-related adverse events observed in this study were fever, hypersensitivity, and upper respiratory tract infection (each occurring in 25% of subjects). Generally, these events were mild, self-limited, and medically managed. Investigator-defined hypersensitivity events were associated with several peripheral symptoms and were medically managed with a combination of antipyretics, antihistamines, and / or steroids. Laboratory data showed no clinically relevant changes in terminal laboratory data. In the CSF, some patients had mild, transient pleocytosis without changes in CSF glucose or protein. In summary, evaluation of safety parameters demonstrated that treatment with the disclosed rhTPP1 formulations via ICV infusion was well tolerated in all patients.

[0101] conclusion Clinical trials have demonstrated that all patients with 36 weeks or more of treatment exposure had a significant clinical benefit characterized by a complete halt in CLN2 disease progression, which constitutes the greatest treatment benefit in patients with moderate progression and active degeneration over a time period in which no gain in function is expected.

[0102] This finding was even more compelling when patients were matched to members of a natural history database based on multiple parameters, including baseline disease assessment, age, and genotype. This match revealed that during the same period in which treated subjects experienced halted disease progression with rhTPP1 medications, matched untreated natural history patients experienced substantial loss of function. Thus, all treated patients demonstrated halted disease progression compared with active disease progression relative to matched untreated natural history patients. The median rate of decline in the untreated natural history population was estimated to be 2.1 points per year based on available natural history data, with each unit of decline representing a significant milestone loss of physiological function. For the majority of patients participating in the trial, a preservation of 2 units translated into continued independent ambulation and meaningful communication.

[0103] Overall, the results demonstrated that the disclosed rhTPP1 formulations and treatment methods have an acceptable safety / tolerability profile. No subjects discontinued the study or treatment due to adverse events. One subject withdrew from the study after one treatment dose due to failure to comply with the protocol. PK and immunogenicity analyses revealed high CNS delivery and no antibody formation in the CSF.

[0104] The foregoing examples demonstrate that the formulations and methods comprising rhTPP1 described herein are effective in preventing or treating CLN2 disease and / or one or more clinical symptoms of CLN2. In a disease whose clinical course is characterized by rapid, relentless, and irreversible neurodegenerative disease progression, halting disease progression, particularly in each patient treated, would be a substantial and unexpected clinical benefit.

[0105] Example 4 This example describes a Phase 2, open-label clinical trial to evaluate the safety, tolerability, and efficacy of a formulation containing rhTPP1 for intraventricular administration in pediatric patients under the age of 18 with CLN2 disease.

[0106] Clinical trial objectives The primary objectives of this trial are: (1) to evaluate the safety and tolerability of TPP1 administered via an intracerebroventricular (ICV) device, and (2) to evaluate the treatment effect as delay of progression of the CLN2 motor speech clinical scale.

[0107] Secondary objectives of this trial are: (1) to assess CSF and serum immunogenicity, (2) to measure MRI parameters of disease progression, and (3) to evaluate the impact of treatment on the overall Hamburg Clinical Rating Scale.

[0108] The exploratory objectives of this trial are: (1) to assess developmental achievement, (2) to evaluate abnormal involuntary movements, (3) to evaluate retinal anatomy using optical coherence tomography (OCT), (4) to determine the onset, type, and frequency of seizures, (5) to assess quality of life metrics, and (6) to analyze putative molecular biomarkers from CSF and plasma.

[0109] Study Design: Overall study design and planning This will be a phase 2, open-label trial in patients with CLN2 disease who have confirmed mutations in the CLN2 gene and reduced TPP1 activity. A formulation containing rhTPP1 (referred to herein as "TPP1") will be administered every 2 weeks via ICV infusion. Practical and ethical concerns will exclude concurrent or untreated control subjects, so findings can be compared with historical data from existing CLN2 disease registries and / or data from siblings, if desired. A summary of events will be provided by visit in Figure 11.

[0110] Study eligibility will be determined in advance (≤21 days) and subjects will be admitted to the hospital for surgical implantation of an ICV access device. A baseline visit to collect clinical scores and laboratory parameters will be completed no later than 2 days before the first infusion.

[0111] The planned enrollment for this trial is a maximum of five subjects. Eligible patients must have a sibling with a confirmed CLN2 diagnosis who was enrolled in a previous trial described in Example 3. All subjects will receive a dose of TPP1 (300 mg) every 14 days for at least 96 weeks from the first infusion date (day +3). Dosing may be adapted at the investigator's discretion for adverse events by reducing to 150 mg and / or by reducing the infusion rate over the course of the trial.

[0112] Patients in this trial will need to have an ICV reservoir surgically implanted for administration of TPP1. An MRI will be performed prior to the procedure to ensure proper planning and placement of the ICV access device. Patients will be closely monitored in a nursing-intensive setting for 48 hours after the procedure. Following placement of the ICV access device, subjects and their caregivers will be given written instructions providing details of signs and symptoms of concern regarding device complications and instructions on when they should return to the facility for device evaluation. An additional follow-up phone call will be made within 48 hours of discharge for inpatients.

[0113] The first infusion will occur at least 14 days after surgery to implant the ICV reservoir and within 28 days of surgery. Thereafter, study visits will occur every 2 weeks ± 3 days from the day of the first infusion (+3 days). Generally, functional and quality of life assessments should precede the MRI and sampling prior to the infusion; sample collection can occur while the subject is sedated for the MRI. If the subject prematurely discontinues the study, an early termination visit should be scheduled within 3 days.

[0114] For all infusions, subjects will be monitored in an inpatient facility for a minimum of 24 hours from the start of the infusion. For the first infusion only, subjects will also return for a follow-up clinic visit 72 hours after the start of the infusion. After all visits, a phone call will be made to the parent or legal guardian within 48 hours to verify their health.

[0115] Vital signs will be measured within 30 (± 5) minutes before the infusion, every 60 (± 5) minutes during the infusion, and every 1 and 4 hours (± 5 minutes) after the infusion. For the first dose, vital signs will be measured within 30 (± 5) minutes before the infusion is started (or restarted), every 30 (± 5) minutes during the infusion, 0.5 and 1 hour (± 5 minutes) after the infusion is completed, and every 4 hours (± 15 minutes) until discharge.

[0116] Efficacy will be measured using the CLN2 Motor-Verbal Clinical Rating Scale. The Hamburg total 0- to 12-point CLN2 scale will be collected. Other secondary efficacy measures include developmental status, seizure frequency, involuntary movements, retinal anatomy, and quality of life metrics. Safety and tolerability of treatment will be assessed by collection of adverse events (AEs), physical examination findings, vital signs, ECG, EEG, and laboratory tests. AEs will be assessed by the investigator for severity, severity, and relationship to the study drug and / or ICV access device.

[0117] Because hypersensitivity reactions may be associated with ERT administration, subjects should be pretreated with an age-appropriate dose of antihistamine (and antipyretic, if appropriate) approximately 30 minutes prior to infusion. Subjects may be pretreated with an age-appropriate sedative approximately 30 minutes prior to TPP1 infusion, at the investigator's discretion and in accordance with the institution's standard practice.

[0118] The temporal relationship to the investigational drug infusion is used to define a TRE, which must be distinguished from the clinical assessment of an infusion reaction. Therefore, an adverse event occurring within 24 hours of initiating or restarting a TPP1 infusion is defined as a TRE.

[0119] Some events occurring within 24 hours of infusion may be hypersensitivity mediated. Hypersensitivity reactions are characterized by localized or generalized adverse reactions due to exposure to an allergen. Symptoms of hypersensitivity reactions may include fever, chills / rigors, skin symptoms (urticaria, angioedema, rash), respiratory symptoms (dyspnea, wheezing, stridor), gastrointestinal symptoms (nausea, vomiting, abdominal pain), and / or cardiovascular changes (hypotension / hypertension).

[0120] In severe cases, anaphylaxis (a systemic hypersensitivity reaction) may also occur. Anaphylaxis is the most serious hypersensitivity reaction, with symptoms that can occur during or within hours of infusion. If anaphylaxis is left untreated, it can be fatal.

[0121] Symptoms of anaphylaxis may include skin and / or mucosal tissue involvement (e.g., generalized urticaria, pruritus or flushing, lip-tongue-uveal swelling), respiratory problems (e.g., dyspnea, wheezing-bronchospasm, stridor, decreased peak expiratory flow, hypoxemia), and decreased blood pressure or end-organ dysfunction (e.g., wheezing, syncope, incontinence).

[0122] To date, there have been no anaphylactic or anaphylactoid reactions in clinical trials with TPP1. However, in the case of suspected anaphylactic reactions, severe hypersensitivity events, or severe hypersensitivity (defined as a grade 3 or higher hypersensitivity event), blood samples are collected within 1 hour of the event to assess C4, serum tryptase, and total IgE, and blood samples are collected within 8 hours after the event (or before the next infusion) to assess drug-specific IgE.

[0123] Another possible AE is infection from the indwelling ICV catheter. If infection is suspected, blood and CSF samples are obtained for evaluation. The subsequent course of treatment may include antibiotic therapy and catheter repositioning or withdrawal. If TPP1 treatment is interrupted, TPP1 may resume if no more than four consecutive missed doses have elapsed since the last dose given.

[0124] The schedule of assessments planned during the study is shown in Figure 11.

[0125] screening Before any study-related procedures are performed, a parent or legal guardian provides informed consent to the study patient. Patients are evaluated to determine whether they meet the study entry criteria (Example 5) and are suitable candidates for ICV access device implantation. A diagnosis of CLN2 disease, as determined by TPP1 enzyme activity (dried blood spot), should be available at screening. Regardless of whether this genotype information is available, blood will be collected for CLN2 genetic analysis at the screening visit. Additionally, blood for TPP1 enzyme activity (dried blood spot) will be collected at the screening visit and centrally analyzed. Screening procedures must be completed ≤21 days before ICV reservoir implant surgery.

[0126] The CLN2 rating scale will be fully implemented for each subject. The rating guidelines provide detailed instructions for rating scale assessment, and the Imaging Charter (see Denver Development Scale II) provides instructions for centralized MRI evaluation. In addition, a complete physical examination will be performed.

[0127] Surgery and initial administration Study subjects will be admitted to the hospital for surgical implantation of an MRI-compatible ICV access device into the right lateral ventricle. Surgery and anesthesia will be performed under the direction of a neurosurgeon (see the Study Pharmacy Manual for compatible ICV reservoirs and cannulas). An MRI will be performed prior to surgery to ensure proper planning and placement of the ICV access device. Generally, surgical and postoperative care will be determined by the study center's standard of care and the subject's specific clinical needs. Subjects will be monitored in a nursing-intensive setting for a minimum of 48 hours after the procedure. Following placement of the ICV access device, subjects and their caregivers will be given written instructions detailing any signs and symptoms of concern regarding device complications and instructions on when they should return to the facility for device evaluation. An additional follow-up phone call will be conducted within 48 hours of inpatient discharge.

[0128] The first injection will occur at least 14 days after surgery to implant the ICV reservoir and within 28 days after surgery. At the time of the first (and each subsequent) study drug administration, the investigator will assess reservoir patency, position, and skin integrity. Access to the device will be performed using strict sterile technique. The skin overlying the reservoir will be inspected for an appropriate needle insertion site. The needle insertion site must be intact, with no evidence of breakdown, wound, infection, or rash. The needle used will be a small-gauge, non-perforating tip. Once the reservoir is accessed, the needle will be secured to minimize the risk of movement or dislodgement. Guidance for assessing reservoir device leaks and replacement is available from Study Pharmacy. The reservoir may be replaced during the clinical trial at the discretion of the investigator and / or neurosurgeon.

[0129] Discussion of clinical trial design, including choice of control group This trial must be conducted in patients with CLN2 disease because neither the implantation of an ICV access device nor the potential development of TPP1 autoimmunity nor their unknown long-term health consequences are acceptable risks in healthy volunteers, but these risks in the patient population are balanced by the almost certain severe disability and death within a few years.

[0130] Diagnosis of CLN2 disease is often based on assays of enzyme activity, which will be required for participation in this clinical trial. Diagnosis of CLN2 disease determined by TPP1 enzyme activity (dried blood spot) should be available at screening. Blood will be collected for CLN2 genetic analysis at the screening visit, regardless of whether genotype information is available.

[0131] Because CLN2 disease is fatal in childhood, the trial population must be children. Given the widespread depletion of cortical neurons, the lack of widespread CLN2 disease progression is required for inclusion in the trial, providing a trial population comparable to that of TPP1 gene therapy trials (Worgall, 2008, Hum. Genet. 2008). Ther.). Safety assessment is also limited in advanced patients who are essentially in a vegetative state. This trial is limited to affected children aged 1 year or older.

[0132] A clinical rating scale, the Hamburg Scale, was developed to document the natural history of CLN2 disease (Steinfeld, 2002, Am. J. Med. Genet.).

[0133] Although all four domains of the Hamburg Rating Scale will be completed (Figure 12), the motor and language domains are most useful for this trial. Because language and motor are the earliest areas of function lost, the CLN2 Motor Language Scale total is an appropriate indicator of efficacy. Efficacy endpoints will compare the motor and language subscale scores of treated trial subjects with scores from untreated patients obtained from natural history data from the CLN2 Disease Registry and / or data from siblings, as appropriate.

[0134] The remaining two domains of the rating scale (Figure 12) are less likely to be useful for this study. To gain a more detailed understanding of the seizure and movement disorder symptoms of CLN2 disease, the adapted domain of the Unified Batten Disease Rating Scale (UBDRS) was incorporated into the protocol. The UBDRS domain records involuntary movements and seizures according to type, frequency, and severity (Kwon, 2011, Neurology).

[0135] Due to practical (limited number of available patients) and ethical (pediatric neurosurgery with a life-threatening neurological disease) concerns, this study design cannot include concurrent, matched, randomized, blinded, or untreated control subjects (Arkin, 2005, Hum. Gene Ther.), (Crystal, 2004, Hum. Gene Ther.). Motor and language subscales and total scores of the Hamburg CLN2 Disease Scale will be compared with historical natural history data and / or data from siblings, as appropriate, from the registry of the University Medical Center in Hamburg, Germany.

[0136] Example 5 This example describes the selection of a study population for the Phase 2 open-label study described in Example 4.

[0137] Study design: Selection of study population Patients with confirmed CLN2 disease progression may be eligible to participate in this trial. Additional criteria for participation in this trial are detailed below. Subjects must meet the following criteria to enroll in the trial (Table 7): [Table 7]

[0138] Example 6 This example describes the duration of subject participation in the clinical trial described in Examples 4 and 5.

[0139] Subject participation includes surgical implantation of an ICV access device followed by 14-28 days of postoperative recovery, with treatment continuing for at least 96 weeks for all subjects. Treatment will continue until all procedures are completed, the subject withdraws consent and discontinues the study, the study is discontinued by the investigator, or the study is terminated. A safety follow-up visit will be conducted 6 months after the last TPP1 infusion, but is not required if the subject is in an extension study, enrolled, or continues to access TPP1 within 6 months of the last infusion (see Section 10.2.1 for AE / SAE reporting procedures).

[0140] Example 7 This example describes the treatments administered in the clinical trials described in Examples 4-6.

[0141] All study subjects will receive TPP1 via ICV infusion every two weeks, preferably in the morning after a minimum of two hours of fasting. If a feeding tube is used, the tube must be turned off two hours before the infusion. All subjects will receive a 300 mg TPP1 infusion, although a dose reduction to 150 mg will be permitted if necessary for safety reasons.

[0142] Management Instructions Surgical implantation of the ICV reservoir occurs prior to study drug administration. The investigator assesses reservoir patency, position, and skin integrity at the time of each study drug administration (see Study Pharmacy Manual). At each administration, the investigator aspirates 1-2 ml of CSF into the device cannula to confirm patency before administering the study drug. Access to the device is performed using strict sterile technique. The skin overlying the reservoir is inspected for an appropriate needle insertion site. The needle insertion site must be intact, with no evidence of breakdown, wound, infection, or rash. The needle used is a small-gauge, non-perforating tip. Once the reservoir is accessed, the needle is secured to minimize the risk of movement or dislodgement. Reservoirs may be replaced during the clinical trial at the discretion of the investigator and / or neurosurgeon.

[0143] All study subjects will receive TPP1 by ICV infusion every 2 weeks, preferably in the morning after a minimum of 2 hours of fasting. If a feeding tube is used, the tube must be turned off 2 hours before the infusion. Unless otherwise specified, study procedures at each study visit should be performed before the infusion of study medication. The date, time, amount, and concentration of each dose of study medication administered to each subject will be recorded in the dispensing log and appropriate CRF provided for the study. The Study Pharmacy Manual contains detailed instructions for the preparation and administration of study medication.

[0144] Subjects will be admitted to the hospital for each TPP1 infusion. For all infusions, subjects will be monitored in an inpatient facility for a minimum of 24 hours from the start of the infusion. For the first infusion only, subjects will also return for a follow-up visit to the clinic 72 hours after the start of the infusion. After all visits, a phone call will be made to a parent or legal guardian within 48 hours to verify their health.

[0145] Because hypersensitivity reactions may be associated with ERT administration, subjects should be pretreated with an age-appropriate dose of antihistamine (and antipyretic, if appropriate) approximately 30 minutes prior to TPP1 infusion. Subjects may be pretreated with age-appropriate sedatives approximately 30 minutes prior to TPP1 infusion, at the investigator's discretion and according to the institution's standard practice. Clinical, developmental, and quality of life assessments should be performed prior to infusion premedication.

[0146] When administered at 300 mg, TPP1 should be infused ICV at 2.5 mL / hour to deliver the entire dose over approximately 4 (±1) hours. A consistent infusion rate should be ensured by using a syringe pump with adequate delivery range, delivery rate accuracy, and alarms for incorrect delivery or occlusion. If administration must be stopped for safety or other reasons, it can be resumed and completed at the same rate, as long as the total dose is administered within 10 hours of preparation of the dosing syringe.

[0147] The usual infusion is 300 mg administered over 4 (± 1) hours. If the subject experiences an AE, the investigator may reduce the dose or infusion rate for future infusions, taking into account medical monitoring. Changes in infusion should be performed in the following order: (I) Slow the infusion rate and administer the drug over a total of 6 hours. (II) Reduce the dose to 150 mg administered over a standard time period of 4 (±1) hours. (III) Reduce the infusion rate to 150 mg over a total of 6 hours.

[0148] safety monitoring Following placement of the ICV access device, subjects and their caregivers will be given written instructions providing details of any signs and symptoms of concern regarding device complications and instructions on when they should return to the facility for device evaluation. Subjects will be admitted to the hospital for each TPP1 infusion. For all infusions, subjects will be monitored in the inpatient facility for a minimum of 24 hours from the start of the infusion. For the first infusion only, subjects will also return for a follow-up visit to the clinic 72 hours after the start of the infusion. After all visits, a phone call will be made to the parent or legal guardian within 48 hours to verify their health.

[0149] During the first infusion, vital signs (see Vital Signs) are measured within 30 (± 5) minutes before starting or restarting the infusion, every 30 (± 5) minutes during the infusion, 0.5 and 1 hour (± 5 minutes) after the end of the infusion, and every 4 hours (± 15 minutes) until discharge.

[0150] For each subsequent infusion, vital signs will be measured within 30 (±5) minutes before the start of the infusion, every 60 (±5) minutes during the infusion, and 1 and 4 hours (±5 minutes) after the end of the infusion.

[0151] Subjects will require regular monitoring for adverse events and seizures by appropriately trained personnel throughout the duration of the infusion. If a seizure occurs, the infusion may be interrupted at the investigator's discretion. Due to the potential for hypersensitivity reactions (anaphylaxis or general allergies), appropriately trained personnel and equipment for emergency resuscitation (including epinephrine) must be available near the bedside during the infusion of the study drug. All subjects should have an intravenous line during the infusion if emergency treatment is required.

[0152] Symptoms of a hypersensitivity reaction include fever, chills / rigors, skin symptoms (hives, angioedema, rash), respiratory symptoms (dyspnea, wheezing, stridor), gastrointestinal symptoms (nausea, vomiting, abdominal pain), and / or cardiovascular changes (hypotension / hypertension). If more severe symptoms such as angioedema (swelling of the tongue or throat) or wheezing occur, the infusion should be discontinued.

[0153] To date, there have been no anaphylactic or anaphylactoid reactions in clinical trials with TPP1. However, if anaphylaxis is suspected, local guidelines should be followed. In cases of suspected anaphylactic reaction, severe TRE, or severe TRE (defined as grade 3 or higher TRE), blood samples should be collected within 1 hour of the event to assess C4, serum tryptase, and total IgE, and within 8 hours after the event (or before the next infusion) to assess drug-specific IgE.

[0154] Safety assessments will be conducted during and after each infusion. Subjects may need to remain for a longer observation period at the investigator's discretion. If an AE consistent with a TRE (Section 7.4.1) is observed, appropriate interventions may include interrupting the infusion, slowing the infusion rate, or administering antihistamines, oxygen, fluids, or steroids. When resuming the infusion after an interruption, the initial rate should be approximately half the rate at which the reaction occurred. Details regarding infusion changes are provided in the Study Pharmacy Manual.

[0155] The parent or legal guardian will be instructed to contact the investigator to discuss any AEs after discharge.

[0156] Use of ICV access devices can lead to infection, intracerebral hemorrhage due to chronic reservoir use, reservoir leaks, and seizures (Karavelis, 1996, Neurosurgery) (Kronenberg, 1998, Pain). Additional surgery may be required to repair or replace the device. Patients will be monitored throughout the trial for signs of potential infection (high temperature, cough, rash, headache, swelling or drainage at the incision site) and ICV reservoir leak or failure (see Study Pharmacy Manual).

[0157] Due to the inherent safety considerations surrounding implanted devices, Arrangements must be made for subjects to have their ICV access device removed within 4 weeks of either the study completion visit or early termination visit. If subjects continue to receive TPP1 after participation in this study (e.g., commercial product, use in a registry, or another TPP1 trial), device removal is not required. After device removal, subjects should return to the site 4 weeks (± 3 days) later for a safety follow-up visit.

[0158] How subjects are assigned to treatment groups Subjects will be enrolled as they become available without regard to inclusion criteria or other patient characteristics.

[0159] Dose selection The planned dose is 300 mg.

[0160] The proposed dose levels were derived from those used in the TPP1-null dachshund clinical trial (Vuillemenot, 2011, Mol. Genet. Metab.). Pharmacological effects, such as improved function and increased lifespan, have been robustly demonstrated in TPP1-null dachshunds at dose levels of 4 mg and 16 mg. Because TPP1 activity in brain tissue is closely related to CNS lysosomal storage material, brain mass scaling was determined to predict the human therapeutic dose. The human equivalent dose was calculated using brain mass scaling. On average, the human brain reaches approximately 75% of its adult mass by age 2 and 100% by age 5 (Giedd, 1996, Cereb. Cortex). Given that an adult brain mass is 1400 g, the range for a healthy child aged 2–7 years is 1050–1400 g. Given the progressive brain atrophy in patients with CLN2 disease, a mean mass of 1000 g was assumed, resulting in a scaling factor of 20 based on the mean dachshund brain mass of 50 g.

[0161] The no-observed-adverse-effect level (NOAEL) that also produced clinical benefit in non-clinical trials in dachshunds was 48 mg, which is equivalent to 960 mg in humans.

[0162] Preliminary analyses performed on the trial of Example 3 demonstrated a positive benefit-risk profile in all children enrolled in the trial who received 300 mg every two weeks via an intracerebroventricular (ICV) device. Furthermore, children receiving TPP1 for 36 weeks or more had stable clinical scores, in contrast to matched, untreated controls, whose decline was rapid and severe in the majority of matches.

[0163] Selection of timing of administration for each subject The average CNS half-life of approximately 2 weeks suggests that biweekly dosing may maintain therapeutic TPP1 levels in the CNS. TPP1 concentrations in the CSF remained above lysosomal uptake for approximately 48 hours after a single ICV or intravenous injection in species with CSF kinetics similar to humans (Vuillemenot, 2014, Toxicol. Appl. Pharmacol.), (Vuillemenot, 2011, Mol. Genet. Metab; 0190-09-071). In these same species (dogs and monkeys), the CNS distribution of TPP1 was widespread in many brain regions.

[0164] Selection of injection volume and injection rate Nonclinical studies in dachshunds and cynomolgus monkeys utilized an infusion rate of approximately 5% of the total CSF volume per hour. This was expected to represent a safe infusion rate that minimized changes in total CSF volume and intracranial pressure. Dachshunds received ICV infusions at a rate of 0.6 mL / hour for 2–4 hours, while monkeys received ICV infusions at 0.88 mL / hour for 3.6 hours. No effects of infusion rate indicating safety concerns were observed in these studies. In the CLN2 patient population, the estimated CSF volume is approximately 100 mL. In the proposed clinical trial, a volume of 10 mL infused over 4 hours represents an infusion rate of 2.5% of the total CSF volume per hour, approximately half the rate that did not impact safety in nonclinical studies. Therefore, in CLN2 patients, a 10 mL infusion over 4 hours is expected to be safe.

[0165] Blinding This is a single-arm, open-label study. Site assessments of safety and clinical severity will be performed without blinding to treatment, and subjects will be enrolled as they become eligible.

[0166] As defined by the Imaging Charter, oversight of MRI evaluations will be performed by independent radiologists at the central imaging facility. Interpreting radiologists and software analysis will be blinded to the study subjects and timeframe. All subject identifying information will be redacted before endpoints are assessed.

[0167] Prior and concomitant medications Medications (prescription, over-the-counter, and herbal) and dietary supplements taken in the 30 days prior to informed consent will be recorded on the CRF at screening. At each subsequent visit (or within 1 week of the early termination visit), any changes in medications (dose, frequency, new medications, or discontinuation) since the previous visit will be recorded on the CRF.

[0168] Concomitant medications added or discontinued during the study must be recorded on the CRF (or within 1 week of the early termination visit).

[0169] Subjects may be taking anticonvulsants or medications for myoclonus, tremors, agitation, and pain. Subjects will be asked to keep these regimens constant throughout the study unless a change is required due to lack of efficacy or toxicity.

[0170] Treatment compliance Investigational medication will be administered to subjects at the investigational site by qualified professionals. The date, time, amount, and strength of each dose should be recorded in the dispensing log as well as the appropriate CRF. If a dose of investigational medication is missing or incomplete, the investigator should record the reason and any other relevant information on the CRF, as appropriate.

[0171] dietary or other protocol restrictions There are no dietary or other protocol restrictions in this study. Subjects who require a PEG (percutaneous endoscopic gastrostomy) tube as standard of care during the course of the study will be allowed to continue in the study. If a feeding tube is used, the tube must be turned off two hours before infusion.

[0172] Example 8 This example describes the efficacy and safety variables of the clinical trials in Examples 4-7.

[0173] Efficacy variables The trial is primarily designed to evaluate safety and tolerability, while efficacy will be measured using the CLN2 Motor Verbal Clinical Rating Scale. The Hamburg 0-12 point CLN2 scale combined with MRI measures of disease progression will be collected as secondary endpoints. Other exploratory efficacy measures will include developmental status, seizure frequency, involuntary movements, retinal anatomy, and quality of life metrics.

[0174] CLN2 clinical rating scale Disease severity is assessed by the CLN2 Clinical Rating Scale (Steinfeld, 2002, Am. J. Med. Genet.); (Worgall, 2008, Hum. Genet. Ther.). This scale consists of four domains with intrinsic content validity. Within each domain, a score ranging from 0 to 3 is assigned, and an overall score is calculated by summing the four domain scores for a final rating ranging from 0 (severe impairment) to 12 (normal).

[0175] Motor and language domains are most relevant to CLN2 disease progression (Section 9.2) and therefore will be used to assess efficacy (Appendix 1).

[0176] Raters will be identified as qualified practitioners trained in the definition and administration of the CLN2 Disease Rating Scale. All raters at all sites must pass a training session designed to standardize definitions and scale anchor points across studies before study ratings are administered. Whenever possible, one rater should assess each enrolled patient throughout the treatment period. Furthermore, patient assessments should be conducted simultaneously with study visits, preferably the morning before the procedure and / or infusion. CLN2 scale assessments should be conducted prior to pretreatment TPP1 infusions.

[0177] Denver Developmental Scales II The Denver II is a revised and updated version of the Denver Developmental Screening Test.

[0178] Both tests were designed to monitor the development of infants and preschool children. The tests cover four general functions: social personality (e.g., smiling), fine motor adaptation (e.g., grasping and drawing), language (e.g., word combination), and gross motor skills (e.g., walking). The age range covered by the tests ranges from birth to six years of age.

[0179] Modified Unified Batten Disease Rating Scale Involuntary Movement Table The modified Unified Batten Disease Rating Scale (mUBDRS) Involuntary Movements is a rating scale that measures the type, frequency, and severity of common involuntary movements associated with CLN2 disorders, such as myoclonus and dystonia.

[0180] magnetic resonance imaging All imaging data will be acquired on a 1.5 Tesla MRI platform. Investigational MRI will include localizer, 3D T1-weighted sagittal, T2-weighted gradient echo, diffusion-weighted axial, and FLAIR axial acquisitions as specified in the Imaging Charter. Total scanner time will be less than 60 minutes, which is expected to be achievable in the majority of sedated subjects.

[0181] Volumetric analysis of the images is performed by estimating both the total cortical gray matter volume and the proportion of intracranial CSF.

[0182] All patients will undergo a non-contrast MRI prior to implantation of the ICV access device to ensure proper planning and placement. No MRI-related study evaluations will be performed at the time of this MRI, and readings obtained during this MRI will not be included in the analysis of study data.

[0183] Whenever infection or shunt dysfunction is suspected by the investigator, an MRI scan should also be performed. In this case, according to the Imaging Charter, the MRI should be at least T1-weighted, axial and sagittal, with or without intravenous contrast. If meningitis is suspected, an MRI of the brain should be performed with or without contrast, according to the Imaging Manual.

[0184] Optical coherence tomography Optical coherence tomography (OCT) is a non-invasive imaging test that uses light waves to take cross-sectional pictures of retinal layers to measure their thickness. These measurements aid in the early detection and treatment of retinal disease. OCT is performed locally and should be performed before injection.

[0185] Modified Unified Batten Disease Rating Scale Seizure Table The mUBDRS Seizure Inventory measures the type and frequency of seizures in CLN2 patients over the past three months. The inventory is completed with the help of caregiver / family member recall between study visits.

[0186] PedsQL The PedsQLTM Generic Core Scales are designed to measure quality of life in children and adolescents. The assessment is brief, practical, and developmentally appropriate. The instrument is responsive to clinical change over time (Msall, 2005, Ment. Retard. Dev. Disabil. Res. Rev). Four parent-report measures are targeted to ages 1-12 months, 13-24 months, 2-4 years, and 5-7 years and include questions about physical, emotional, and social functioning, and, if applicable, school functioning. Patients age 7 years or older during the trial are no longer assessed using this tool.

[0187] EQ-5D-5L The EQ-5D-5L instrument is a self-report questionnaire designed to measure general health status (The EuroQol Group, 1990, Health Policy), (Brooks, 1996, Health Policy). The EQ-5D-5L consists of two parts: a descriptive system that rates five levels of perceived problems in five dimensions (mobility, self-care, usual activities, pain / discomfort, anxiety / depression) and the EQ Visual Analog Scale (EQ VAS) for the assessment of overall health.

[0188] CLN2-specific QoL questionnaire The CLN2-specific QoL questionnaire is a disease-specific supplement to PedsQL using the same format and quantification. The questionnaire is a new instrument designed in collaboration with patient families and advocacy groups to capture elemental care and quality of life issues in CLN2 disease in late infancy.

[0189] Infant Quality of Life Questionnaire The Infant Quality of Life Questionnaire (ITQOL) is designed to assess the health and well-being of children aged 2 months to 5 years. This tool asks parents of preschool-aged children to reflect on physical and psychosocial domains such as development, pain, mood, and the impact of their child's health on the parents.

[0190] immunogenicity Immunogenicity testing will be performed at a central clinical trial site using validated immunogenicity assays on serum and CSF samples. Blood (serum) samples will be collected for TAb testing, and CSF samples will be collected for TAb and NAb testing before the first infusion (baseline or week 1 pre-infusion), every 12 weeks thereafter, and at safety follow-up (or within 1 week of the early termination visit). Collection must occur before infusion. NAb will be tested in CSF at baseline and then only at times when TAb is positive in CSF.

[0191] The baseline sample is used to obtain baseline total and drug-specific IgE levels in case of a later hypersensitivity reaction requiring additional laboratory work.

[0192] To date, there have been no anaphylactic or anaphylactoid reactions in clinical trials with TPP1. However, in the case of suspected anaphylactic reactions, severe hypersensitivity events, or severe hypersensitivity (defined as a grade 3 or higher hypersensitivity event), blood samples are collected within 1 hour of the event to assess C4, serum tryptase, and total IgE, and blood samples are collected within 8 hours after the event (or before the next infusion) to assess drug-specific IgE.

[0193] Clinical laboratory evaluation Blood and urine samples will be collected for routine clinical laboratory evaluation (blood chemistry, hematology, urinalysis) and analyzed centrally. Collection should occur prior to infusion.

[0194] Abnormal test results that the investigator determines to be clinically significant must be repeated until the cause is identified, the value returns to baseline or within the normal range, or the investigator determines that the abnormal value is no longer clinically significant.

[0195] All abnormal laboratory findings should be initiated and dated by the investigator, along with a comment regarding clinical significance. Each clinically significant laboratory finding will be recorded as a medical history at screening and subsequently as an AE.

[0196] If known, diagnoses associated with laboratory abnormalities deemed clinically significant by the investigator should be recorded on the AE CRF.

[0197] A table of the laboratory tests performed as described here is as follows (Table 8): [Table 8]

[0198] Cerebrospinal fluid monitoring Standard laboratory CSF samples for routine monitoring (differential cell count, protein, and glucose) will be collected within 30 (± 5) minutes prior to every infusion. A small amount of CSF will be collected from the ICV reservoir and analyzed locally. Collection should occur prior to the infusion of the study drug.

[0199] Biomarkers Plasma and CSF samples will be collected to assay putative molecular / biochemical biomarkers. Collection should occur prior to investigational drug infusion. Samples will be tested centrally.

[0200] Other Laboratory Evaluations Subjects experiencing an SAE potentially related to TPP1 or other AEs of concern may have additional blood samples taken to assess immunogenicity or safety parameters.

[0201] Vital signs, physical examination, and other observational vital signs During the first infusion, vital signs (SBP, DBP, heart rate, respiratory rate, and temperature) will be measured within 30 (±5) minutes before starting or restarting the infusion, every 30 (±5) minutes during the infusion, 0.5 and 1 (±5 minutes) after the end of the infusion, and every 4 hours (±15 minutes) until discharge.

[0202] For each subsequent infusion, vital signs will be measured within 30 (±5) minutes before the start of the infusion, every 60 (±5) minutes during the infusion, and 1 and 4 hours (±5 minutes) after the end of the infusion.

[0203] Physical examination A complete physical examination will include general appearance (head, eyes, ears, nose, and throat), cardiovascular, dermatological, lymphatic, respiratory, gastrointestinal, genitourinary, musculoskeletal, and weight and height.

[0204] A brief physical examination will include general appearance, cardiovascular, respiratory, neurological, and gastrointestinal evaluation.

[0205] Use of an ICV reservoir device for intraventricular drug administration requires monitoring patients throughout the trial for signs of possible infection (high fever, cough, rash, headache, altered mental status, swelling or drainage at the incision site) and ICV reservoir leakage or failure (skin swelling around the reservoir site, difficulty extracting CSF, scalp erythema, bulging of the reservoir device, or extravasation of fluid during injection).

[0206] The investigator will assess reservoir patency, position, and skin integrity at the time of each study drug administration. The investigator will check the scalp for edema, erythema, or skin breakdown at the reservoir site before infusion. Patency will be assessed during pre-infusion sampling and again at the time of infusion. Difficulty obtaining the required volume of CSF needed for the pre-infusion sample or signs of an ICV reservoir leak (skin swelling around the reservoir site, scalp erythema, reservoir device bulging, or fluid extravasation) will prompt further evaluation of the reservoir for failure before proceeding with the infusion. Additional surgical consultation, including surgery, may be required to repair or replace the device.

[0207] Clinically significant abnormalities will be recorded as medical history at screening or as subsequent AEs.

[0208] Neurological examination A complete neurological examination will include level of consciousness, speech, language, cranial nerves, motor strength, motor tone, abnormal movements, reflexes, upper extremity sensation, lower extremity sensation, gait, Romberg's, nystagmus, and coordination.

[0209] electro-cardiogram Standard 12-lead ECG, including rate, rhythm, interval, axis, conduction disorders, and anatomic abnormalities. The ECG will be performed within 15 (± 5) minutes after the end of the infusion.

[0210] If a clinically significant abnormality is observed, the investigator or designee will assess whether enrollment or continuation in the study is appropriate. Clinically significant abnormalities will be recorded in the medical history as AEs during screening and thereafter.

[0211] EEG A standard awake EEG will be recorded. If clinically significant abnormalities are observed, the investigator or designee will assess whether enrollment or continuation in the study is appropriate. Clinically significant abnormalities will be recorded in the medical history during screening.

[0212] Pregnancy test At screening and any time during the study, female subjects determined by the investigator to be of childbearing potential (defined by the onset of menstruation) will be tested for pregnancy with a urine pregnancy test. Whenever pregnancy is suspected, an additional urine test will be performed. If the urine test result is positive or equivocal, a serum pregnancy test will be performed.

[0213] Example 9 In this example, the investigation procedures for the investigations of Examples 4 to 8 will be described.

[0214] After the nature of the trial has been explained, written informed consent by a parent or authorized legal guardian must be obtained prior to any trial-related procedures. The following procedures will be performed within 21 days of admission for ICV access device implantation: Informed consent Confirm the diagnosis of CLN2 disease as determined by TPP1 enzyme activity (dried blood spot) Blood for CLN2 gene analysis Hamburg CLN2 Disease Rating Scale (Figure 12) and videotaping · Check the criteria for clinical trial entry Cranial MRI Complete physical examination including medical history CLN2-specific QoL questionnaire Pregnancy tests (women of childbearing potential) After informed consent, assessment of SAEs related to protocol interventions and seizure history Concomitant medications

[0215] Surgery visit Eligible trial candidates will be admitted to the hospital for surgical implantation of an ICV access device into the right lateral ventricle. An MRI will be performed prior to surgery to ensure proper planning and placement of the ICV access device. At a minimum, subjects will be observed in a nursing-intensive setting for 48 hours postoperatively. The following procedures will also be performed: AE assessment, including ongoing seizure history Concomitant medications

[0216] Following placement of the ICV access device, subjects and their caregivers will be given written instructions providing details of signs and symptoms of concern regarding complications from the device, as well as instructions on when they should return to the facility for device evaluation. An additional follow-up phone call will be made within 48 hours of discharge for inpatients.

[0217] Baseline visit and first infusion Baseline visit The following baseline values ​​will be recorded within 2 days prior to the first infusion (which will occur at least 14 days and within 28 days after surgery): Hamburg CLN2 Disease Rating Scale (Appendix 1) and videotaping ECG (12 leads) (heart rate, rhythm, interval, axis, conduction disorders, anatomical abnormalities) EEG (standard awake) Cranial MRI CSF (TAb and NAb in all subjects) and serum (TAb and drug-specific IgE in all subjects) for immunogenicity Complete physical examination Neurological examination Clinical testing (hematology, blood chemistry, urinalysis) Modified Unified Batten Disease Rating Scale-Involuntary Movement Scale (mUBDRS-Movement) Modified Unified Batten Disease Rating Scale Seizure Inventory (mUBDRS-Seizures) Optical coherence tomography Infant QOL Survey PedsQL EQ-5D-5L Denver II Developmental Scale CLN2-specific QoL questionnaire Ophthalmological evaluation AE assessment, including ongoing seizure history Concomitant medications

[0218] First injection Generally, for all infusions, functional and quality of life assessments should be completed prior to MRI and blood sampling. Blood samples may be collected when the subject is sedated for the MRI.

[0219] First Infusion - Day 1 The following procedure is performed on day 1 of the first injection. CSF monitoring (cell count, protein, glucose) Device patency / infection Injection of investigational drugs CSF and plasma for biomarkers Vital signs within 30 (±5) minutes before the start of the infusion, every 30 (±5) minutes during the infusion, every 0.5 and 1 hour (±5) after the end of the infusion, and every 4 hours (±15 minutes) until discharge - Simple physical examination AE assessment (the investigator may collect additional blood samples for safety or immunogenicity testing of AEs of concern) and ongoing seizure history -Evaluation of concomitant medications Post-infusion monitoring for at least 24 hours in an inpatient facility

[0220] First infusion - Days 2-6 The following procedures are performed 2–6 days after the initial injection. Vital signs (Day 2) (every 4 hours until 20 hours after the end of the infusion) Clinical tests (hematology, blood chemistry, urinalysis) (Day 2) CSF surveillance (cell count, protein, glucose) (day 6) Simple health check (Day 6) Device patency / infection (day 6) AE assessment (the investigator may collect additional blood samples for safety or immunogenicity testing for AEs of concern) (daily) and ongoing seizure history Concomitant medication assessment (daily)

[0221] A follow-up phone call will be made to the parent / guardian within 48 hours after inpatient discharge from the initial infusion.

[0222] Every two weeks The following assessments and procedures should be performed every 2 weeks for the duration of the trial. All study visits should occur every 2 weeks from the day of the first infusion (± 3 days). Unless otherwise specified, all assessments and procedures should be completed prior to the study drug infusion. In general, functional and quality of life assessments should be completed prior to MRI and blood draws. Blood samples may be collected when the subject is sedated for the MRI.

[0223] If no safety issues are observed at all visits, the subject may be discharged after 24 hours if medically stable. A follow-up call to the parent or legal guardian will be made approximately 48 hours after discharge to determine their health status. - Simple physical examination CSF surveillance (differential cell count, protein, glucose) Device patency / infectivity assessment Administration of investigational drugs Vital signs within 30 (±5) minutes before the start of the infusion, every 60 (±5) minutes during the infusion, and 1 hour and 4 hours (±5 minutes) after the end of the infusion AE assessment (the investigator may collect additional blood samples for safety or immunogenicity testing of AEs of concern) and ongoing seizure history -Evaluation of concomitant medications · A phone call to the parent / guardian within 48 hours of the visit

[0224] Every 4 weeks The following assessments and procedures must be performed every 4 weeks for the duration of the study: Blood may be drawn during sedation for MRI, if applicable.

[0225] Routine laboratory tests (hematology, blood chemistry, and urinalysis) Every 12 weeks The following assessments and procedures must be performed every 12 weeks for the duration of the trial. Unless otherwise specified, all assessments and procedures must be completed prior to study drug infusion. In general, functional and quality of life assessments must be completed prior to MRI and blood draws. Blood samples may be collected when the subject is sedated for the MRI. Videotaped Hamburg CLN2 Disease Rating Scale (Figure 12) Neurological examination CSF and serum sampling for immunogenicity ·mUBDRS-Movement mUBDRS-seizures Optical coherence tomography Infant Quality of Life Survey PedsQL Denver II Development Scale CLN2-specific QoL questionnaire EQ-5D-5L

[0226] Every 24 weeks The following assessments and procedures should be performed every 24 weeks during the study. ECG (12 leads) within 15 (±5) minutes after the end of the infusion (heart rate, rhythm, interval, axis, conduction disorders, anatomical abnormalities) EEG (standard awake) Cranial MRI CSF and plasma for biomarker assays Complete physical examination

[0227] Every 48 weeks The following assessments and procedures must be performed every 48 weeks during the study. Ophthalmological evaluation

[0228] Study completion or early termination visit Upon completion or early termination of the study, subjects will return to the study site within 3 days. The following procedures will be completed: Videotaped Hamburg CLN2 Disease Rating Scale (Appendix 1) ECG (12 leads) (heart rate, rhythm, interval, axis, conduction disorders, anatomical abnormalities) [in the case of injection, within 15 (± 5) minutes after the end of injection] Cranial MRI CSF monitoring (cell count, protein, glucose) CSF and plasma for biomarker assays CSF and serum sampling for immunogenicity Vital signs (SBP, DBP, heart rate, oral temperature, respiratory rate) Complete physical examination Neurological examination Regular laboratory tests (hematology, blood chemistry, urinalysis) Denver II Development Scale CLN2-specific QoL questionnaire Ophthalmological evaluation AE assessment (the investigator may collect additional blood samples for safety or immunogenicity testing of AEs of concern) and ongoing seizure history -Evaluation of concomitant medications

[0229] Following the Study Completion Visit or Early Termination Visit, subjects who do not continue to receive TPP1 in another setting (e.g., commercial use, participation in a registry, participation in another TPP1 clinical trial, etc.) must have their ICV access device removed. Device removal must occur within 4 weeks of the Study Completion Visit or ETV.

[0230] Equipment and Safety Follow-Up Subjects will return to the investigational site 4 weeks (± 3 days) after removal of the ICV access device and the following procedures will be completed: Vital signs (SBP, DBP, heart rate, oral temperature, respiratory rate) A brief physical examination (including a thorough inspection of the previous facility for signs of infection) Serum sampling for immunogenicity Neurological examination Regular laboratory tests (hematology, blood chemistry, urinalysis) AE assessment (the investigator may collect additional blood samples for safety or immunogenicity testing of AEs of concern) -Evaluation of concomitant medications

[0231] The 4-week device safety follow-up visit will be waived for subjects who do not undergo device removal because they continue to receive TPP1 at another institution (e.g., commercial use, registry participation, participation in another TPP1 clinical trial, etc.).

[0232] Safety Follow-Up If subjects enroll in an extension study or registry, or continue to access TPP1 within 6 months of their last infusion, a safety follow-up visit is not required. If needed, subjects will return to the study site 6 months after their last study treatment and the following procedures will be completed: ECG (12 leads) (heart rate, rhythm, interval, axis, conduction disorders, anatomical abnormalities) [if injected, within 15 (± 5) minutes after the end of injection] Serum sampling for immunogenicity Vital signs (SBP, DBP, heart rate, oral temperature, respiratory rate) Complete physical examination Regular laboratory tests (hematology, blood chemistry, urinalysis) AE assessment (investigators may collect additional blood samples for safety or immunogenicity testing of AEs of concern) and an ongoing history of seizures -Evaluation of concomitant medications

[0233] End of clinical trial A clinical trial will end after the last subject completes their final safety follow-up visit. BioMarin reserves the right to discontinue a clinical trial at any time for clinical or administrative reasons and to discontinue the participation of any individual investigator or site for clinical or administrative reasons, including, but not limited to, failure to enroll or violations of the protocol or GCP procedures. Additionally, a clinical trial may be terminated if, in BioMarin's opinion, the safety of the trial subjects may be compromised.

[0234] Example 10 This example describes the results, modifications, and explanations of the clinical trials described in Examples 4-9.

[0235] Medications and Flush Solutions, Ingredients and Formulation Development The investigational drug product described in Examples 4-9 is a lyophilized injectable formulation containing 150 mg of cerliponase alfa per 5 mL of solution in a single 10 mL glass vial. The formulation contains the following excipients: disodium hydrogen phosphate pentahydrate, monosodium phosphate monohydrate, sodium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, and water for injection. A flush solution is provided for the purpose of fully administering any remaining drug in the administration line to maintain line patency after intraventricular administration of the drug product. The composition of the flush solution is the same as the drug product, except that the flush solution does not contain the active substance. The flush solution is provided in a single 10 mL glass vial containing 5 mL of solution.

[0236] Mechanism of action of seriponase alfa Seriponase alfa is a recombinant human TPP1 precursor consisting of 544 amino acids. The amino acid sequence is identical to that of the in vivo hTPP1 precursor. N-linked oligosaccharides, such as bisphosphorylated high-mannose glycans, are bound to five aspartic acid residues (Asn191, Asn203, Asn267, Asn294, and Asn424) of the N-linked oligosaccharide profile, and are taken up into target cells or lysosomes via CI-M6PR (J Biol Chem 2001;276:2249-55). The propeptide fragment is then cleaved by in vivo proteases in an acidic environment to generate the active enzyme (e.g., J Biol Chem 2004;279,31058-67; J Bio Chem 2009;284:3985-97), which cleaves the tripeptide from the polypeptide, which accumulates in lysosomes, preventing the buildup of storage material and thereby preventing CLN2 disease progression.

[0237] Pharmacokinetics In this trial, non-Japanese CLN2 patients (target sample size: 5) were administered Brineura. The following table (Table 9) shows the CSF and plasma pharmacokinetic parameters of individual patients who received an intracerebroventricular dose of 200 or 300 mg. [Table 9]

[0238] Discussion of this clinical trial The main inclusion criteria for this trial were reduced TPP1 enzyme activity based on blood tests, age 1 year or older, siblings enrolled in the trial in Case 3, and a total score of 3 to 6 points on the motor and language subscales. 19 No prior treatment with stem cell therapy, gene therapy, or enzyme replacement therapy.

[0239] The trial consisted of a 14-28 day post-operative recovery period following the intraventricular device implantation procedure and a 96-week treatment period with the study drug.

[0240] The dose and administration were intracerebroventricular doses of 300 mg of TPP1 (Brineura) administered over approximately 4 hours (infusion rate: 2.5 mL / h) once every 2 weeks. The treatment period was 96 weeks. 20

[0241] Furthermore, the trial protocol was later amended after the data cutoff so that participation in the trial was no longer limited to siblings of CLN2 patients enrolled in the trial in Example 3. The eligibility age for trial participation was changed to birth to <18 years, and the dosage and administration for patients <2 years was modified as follows: 100 mg for patients aged ≥0.5 years, 150 mg for patients ≥0.5 years and <1 year, and 200 mg for the first four doses, followed by 300 mg every 2 weeks for patients ≥1 year and <2 years. All doses were administered intracerebroventricularly at an infusion rate of 2.5 mL / h.

[0242] Four treated patients (baseline age: 2-5 years) were included in both the safety and efficacy analysis sets. For efficacy, see Table 10, and the CLN2 clinical rating scale. 21 Baseline motor and language subscale scores and their total (ML score) are shown. Also included are the changes from baseline to the last assessment. No decline from baseline was observed on any of the clinical rating scales. All remained unchanged. [Table 10]

[0243] As far as safety is concerned, 22 AEs were reported in all four patients (upper respiratory tract infection, upper respiratory tract infection, discomfort, seizure, seizure, partial seizure, partial seizure, constipation, and abdominal pain; fever, sleep disturbance, and fever; influenza, fever, and gastroenteritis; vomiting, hypersensitivity, drop attacks, bronchitis, generalized tonic-clonic seizure, upper respiratory tract infection, upper respiratory tract infection, generalized tonic-clonic seizure, generalized tonic-clonic seizure, and gastroenteritis). Of these events, three (pyrexia in two patients and hypersensitivity in one patient) were considered ADRs.

[0244] No deaths were reported. Serious AEs were reported in three patients (pyrexia in two patients and hypersensitivity in one patient), and all of these events were considered ADRs. No AEs leading to treatment discontinuation were reported.

[0245] All four patients tested positive for anti-serliponase alfa antibodies in serum by 13 weeks after initiation of treatment. Anti-serliponase alfa antibodies were not detected in the CSF of any patient by 37 weeks after initiation of treatment.

[0246] No clinically significant changes in vital signs or 12-lead ECG findings were reported.

[0247] efficacy Regarding the efficacy of Brineura in CLN2 patients younger than 3 years, the trial protocol was amended after the data cutoff to include eligible patients aged from birth to less than 18 years. 27 Brineura was administered to 11 patients, five of whom were under 3 years of age (three were 2 years of age and two were 1 year of age). Table 11 shows the ML scores by age at baseline. From baseline to the last evaluation, the ML scores remained unchanged in eight patients (four patients maintained a score of 6, three patients maintained a score of 4, and one patient maintained a score of 2). Two patients' scores improved (one patient's score improved from 5 to 6, one patient's score improved from 1 to 2), and one patient's score decreased by one point (one patient's score decreased from 4 to 3). Of the three patients aged 2 years, two patients maintained a ML score of 6, and the other patient's score improved by one point (from 5 to 6). Both patients under 2 years of age maintained a ML score of 6. [Table 11]

[0248] Regarding efficacy in patients under 3 years of age, the results confirmed that there was no worsening of symptoms during Brineura therapy.

[0249] Based on these findings, it is believed that the use of Brineura may be effective in preventing disease progression in young patients with CLN2.

[0250] Safety and serious adverse events Safety in CLN2 Patients Under 3 Years of Age: Based on the most recent data, Brineura was administered to 11 patients in this clinical trial (six patients aged 3 years or older, three patients aged 2 years, and two patients aged 1 year). All 11 patients reported adverse events (AEs). Among these, events in three patients aged 3 years or older (one to three fevers per patient) and three patients under 3 years of age (fever and hypersensitivity in two 2-year-old patients; drug hypersensitivity and drug hypersensitivity in one 1-year-old patient) were evaluated as ADRs, and all of these events resulted in "recovery." SAEs were reported in six patients aged 3 years or older (escherichia urinary tract infection, gastrointestinal fistula, and pneumonia; positive propionibacterium test; fever, adenoid hyperplasia, and rhinitis; device insertion complications; periorbital hematoma; and fever, dental caries, and fever) and three patients under 3 years of age (status epilepticus and infection; fever, influenza, influenza, and hypersensitivity; and device site hematoma in a 2-year-old patient). Among them, events in two patients aged 3 years or older (pyrexia and fever; and fever) and events in two patients under 3 years old (pyrexia and hypersensitivity in a 2-year-old patient) were evaluated as ADRs, and the outcomes of all these events were "recovered." Based on the above, no new clinically significant AEs were observed in patients under 3 years old in this trial.

[0251] Based on the incidence of AEs in clinical trials and overseas port-marketing experience, the safety of Brineura Injection is considered acceptable.

[0252] In conclusion, Brineura appears to have a promising level of efficacy and an acceptable safety profile when administered intracerebroventricularly based on previous trials in CLN2 patients ≥3 years of age and this trial in CLN2 patients <3 years of age.

[0253] Dosage and Administration The intraventricular route was determined for the administration of Brineura by using a surgically placed, implantable intraventricular device to bypass the blood-brain barrier and deliver the enzyme directly and widely to the central nervous system, thereby achieving efficacy against neurological symptoms.

[0254] In a primary pharmacodynamic study in TPP1-deficient dogs (dachshunds), 16 mg of seriponase alfa was administered intracerebroventricularly every 2 weeks. 3) This tended to prolong the time to onset of neurological symptoms and survival. Based on the fact that TPP1 activity in brain tissue is more closely associated with lysosomal material accumulated in the central nervous system, clinical doses were investigated based on a scaling factor for human dose by brain weight. Considering that the human brain reaches 75% of its adult brain weight by age 2 and nearly 100% by age 5 (Cereb Cortex 1996;6:551-60), brain weights for children aged 2 to 7 years are estimated to be in the range of 1050–1400 g, based on the average adult brain weight of 1400 g. Considering the possibility of progressive brain atrophy in CLN2 patients, the applicant assumed that the brain weight of CLN2 patients in this age group may be approximately 1000 g. Because the average brain weight of dachshunds was estimated to be 50 g (Peptide Drug Delivery to the Brain, Raven Press, 1991:112), a scaling factor of 20 was used to determine the human dose. Based on the brain weight ratio between species, a dose of 16 mg of seriponase alfa was administered to TPP1-deficient dogs (dachshunds), which was considered to be 320 mg for ages 2 years and older. Next, a clinical trial described in Example 3 was initiated in CLN2 patients aged 3 years and older, with cohorts starting at 30 mg and gradually increasing to 300 mg for safety reasons. After confirming tolerability, a fixed-dose period was included to evaluate the efficacy and safety of 300 mg. In this trial, the protocol was revised (after the data cutoff). The dose was selected based on brain weight in patients under 2 years of age to investigate the efficacy and safety of Brineura. 39The doses are: <100 mg for patients aged 0.5 years to 1 year, 150 mg for patients aged 0.5 to <1 year, 200 mg for patients aged 1 to <2 years for the first four doses, and 300 mg for subsequent doses. For patients aged 1 to <2 years, the dose is estimated to be 300 mg based on brain weight. However, an intermediate dose of 200 mg was set as the initial dose for patients aged 0.5 to <1 year who initiated Brineura treatment, and the dose was increased to 150 mg to 300 mg depending on age for safety reasons. Regarding the dosing interval, Brineura was administered every 2 weeks in clinical trials because tissue distribution results from nonclinical pharmacokinetic studies and other studies indicated that CNS exposure to the active drug substance was expected to be maintained at a dosing interval of once every 2 weeks.

[0255] For children under 2 years of age, reduce the dose according to the following table (Table 12). [Table 12]

[0256] This medication is typically infused using an infusion pump at a rate of 2.5 mL / hour, although the infusion rate may be reduced depending on the patient's condition.

[0257] Hypersensitivity reactions, including anaphylaxis, may occur when this drug is administered. To alleviate symptoms, consider pretreating the patient with an antihistamine, with or without an antipyretic, 30 to 60 minutes before the start of the infusion.

[0258] Regarding the infusion rate in clinical trials, Brineura was administered intracerebroventricularly at an infusion rate of 2.5 mL / h for all ages. The infusion rate was estimated to be approximately 100 mL of CSF for patients aged 2 to 7 years and approximately 50 mL of CSF for patients under 1 year of age (Peptide Drug Delivery to the Brain, Raven Press 1991:112), the proportion of infused Brineura was estimated to be less than 10% of CSF. The CSF production rate in humans is typically about 20 mL / h (Am J Physiol 1962;203:763-74), which is about 12% of the Brineura infusion rate (2.5 mL / h), and the CSF production rate at 0.5 years of age is estimated to be about 2.5-4.7 mL / h. 40 is also assumed to be greater than the infusion rate of Brineura (2.5 mL / h). Based on these data, the intraventricular infusion rate of Brineura does not appear to significantly affect CSF or the rate of CSF production in humans.

[0259] Considering the above, Brineura was demonstrated to be effective in inhibiting disease progression and did not raise any major safety concerns based on the results of a previous clinical trial in which 300 mg was administered intracerebroventricularly to CLN2 patients ≥3 years of age once every 2 weeks, and this trial in which ≤300 mg was administered intracerebroventricularly to CLN2 patients <3 years of age once every 2 weeks.

[0260] References cited in Examples 4-9 The following references are cited herein and / or incorporated by reference according to the following numbering: Arkin, LM, Sondhi, D, Worgall, S, Suh, LH et. al. Confronting the issues of therapeutic misconception,enrollment decisions,and personal motives in genetic medicine-based clinical research studies for fatal disorders.Hum Gene Ther 16[9],1028-1036.2005. Awano, T, Katz, ML, O'Brien, DP, Sohar, I et. al. A frame shift mutation in canine TPP1 (the ortholog of human CLN2)in a juvenile Dachshund with neuronal ceroid lipofuscinosis.Mol Genet Metab 89[3],254-260.2006. Brooks R. EuroQol:the current state of play.Health Policy 37[1],53-72.1996. Chang,M. CLN2.The Nueronal Ceroid Lipofuscinoses.New York:Oxford Univ Press,2011:80￢109. Crystal,RG,Sondhi,D,Hackett,NR,Kaminsky,SM et. al. Clinical protocol.Administration of a replication-deficient adeno-associated virus gene transfer vector expressing the human CLN2 cDNA to the brain of children with late infantile neuronal ceroid lipofuscinosis.Hum Gene Ther 15

[11] ,1131-1154.2004. Dierenfeld,AD,McEntee,MF,Vogler,CA,Vite,CH et. al. Replacing the enzyme alpha-L-iduronidase at birth ameliorates symptoms in the brain and periphery of dogs with mucopolysaccharidosis type I. Sci Transl Med 2

[60] ,60ra89.2010. Dyke,JP,Sondhi,D,Voss,HU,Shungu,DC et. al. Assessment of Disease Severity in Late Infantile Neuronal Ceroid Lipofuscinosis Using Multiparametric MR Imaging.AJNR Am J Neuroradiol .2012. EuroQol Group.EuroQol - a new facility for the measurement of health-related quality of life.Health Policy 16[3],199-208.1990. Giedd,JN,Snell,JW,Lange,N,Rajapakse,JC et. al. Quantitative magnetic resonance imaging of human brain development:ages 4-18.Cereb Cortex 6[4],551-560.1996. Karavelis A,Foroglou G,Selviaridis P et al.Intraventricular administration of morphine for control for intractable cancer pain in 90 patients.Neurosurgery 39[1],57-62.1996. Kronenberg MF,Laimer I,Rifici C et al.Epileptic seizure associated with intracerebroventricular and intrathecal morphine bolus.Pain 75[2],383-387.1998. Kurachi,Y,Oka,A,Mizuguchi,M,Ohkoshi,Y et. al. Rapid immunologic diagnosis of classic late infantile neuronal ceroid lipofuscinosis.Neurology 54[8],1676-1680.2000. Kwon JM,Adams H,Rothberg PG,et al.Quantifying physical decline in juvenile neuronal ceroid lipofuscinosis (Batten disease).Neurology 77

[20] 、1801-1807.2011。 Lishner M,Perrin RG,Feld R et al.Complications Associated with Ommaya Reservoirs in Patients with Cancer:The Princess Margaret Hospital Experience and a Review of the Literature.Arch Intern Med 150[1],173-176.1990. Msall ME.Measuring functional skills in preschool children at risk for neurodevelopmental disabilities.Ment.Retard.Dev.Disabil.Res.Rev.11,263-273.2005. Seitz,D,Grodd,W,Schwab,A,Seeger,U et. al. MR imaging and localized proton MR spectroscopy in late infantile neuronal ceroid lipofuscinosis.AJNR Am J Neuroradiol 19[7],1373-1377.1998. Sleat,DE,El-Banna,M,Sohar,I,Kim,KH et. al. Residual levels of tripeptidyl-peptidase I activity dramatically ameliorate disease in late-infantile neuronal ceroid lipofuscinosis.Mol Genet Metab.94,222-233.2008. Sleat,DE,Wiseman,JA,El-Banna,M,Kim,KH et. al. A mouse model of classical late-infantile neuronal ceroid lipofuscinosis based on targeted disruption of the CLN2 gene results in a loss of tripeptidyl-peptidase I activity and progressive neurodegeneration.J Neurosci 24

[41] ,9117-9126.2004. Steinfeld,R,Heim,P,von Gregory,H,Meyer,K et. al. Late infantile neuronal ceroid lipofuscinosis:quantitative description of the clinical course in patients with CLN2 mutations.Am J Med Genet 112[4],347-354.2002. Vuillemenot,BR,Katz,ML,Coates,JR,Kennedy,D et. al. Intrathecal tripeptidyl-peptidase 1 reduces lysosomal storage in a canine model of late infantile neuronal ceroid lipofuscinosis.Mol Genet Metab 104[3],325-337.2011. Vuillemenot,BR,Kennedy,D,Reed,RP,Boyd,RB,et. al. Recombinant human tripeptidyl peptidase-1 infusion to the monkey CNS:safety,pharmacokinetics,and distribution.Toxicol Appl Pharmacol 277[1],49-57.2014.Worgall,S,Kekatpure,MV,Heier,L,Ballon,D et. al. Neurological deterioration in late infantile neuronal ceroid lipofuscinosis.Neurology 69[6],521-535.2007. Worgall, S., Sondhi, D., Hackett, NR., Kosofsky, B. et. al. Treatment of late infantile neuronal ceroid lipofuscinosis by CNS administration of a serotype 2 adeno-associated virus expressing CLN2 cDNA.Hum Gene Ther 19[5],463-474.2008. Xu,S,Wang,L,El-Banna,M,Sohar,I et. al. Large-volume intrathecal enzyme delivery increases survival of a mouse model of late infantile neuronal ceroid lipofuscinosis.Mol Ther 19

[10] ,1842￢1848.2011.

[0261] Example 11 This example describes additional pharmacokinetic and pharmacodynamic analyses performed on patient samples from the Phase 1 / 2 study of Example 3.

[0262] Pharmacokinetic Analysis: CSF and blood (plasma) samples for pharmacokinetic analysis were collected after the initial dose, the first dose at each new dose level during the dose-escalation phase, and weeks 5 and 13 of the stable dose phase. Samples were collected pre-dose (within 0.25 hours before the start of the infusion) and 0.25, 4, 8, 20, 72, and 120 hours after the end of the infusion. Additional CSF and blood (plasma) samples were collected pre-dose at the start and every 4 weeks during the stable dose phase if serial samples were not collected. CSF samples were obtained from the lateral ventricles of the brain using an ICV port.

[0263] CSF and plasma samples were assayed for seriponase alfa concentrations by a validated electrochemiluminescence immunoassay (ECLA) method (BioMarin Pharmaceutical Inc., Novato, CA, US). The lower limit of quantitation (LLOQ) was 20 ng / mL for CSF and 16 ng / mL for plasma. Both the inter-assay precision (absolute % relative error) and accuracy (% coefficient of variation) of the quality control were ≤13.2% for CSF and ≤17.2% for plasma across sample testing runs.

[0264] PK parameters were estimated based on concentration-time data in CSF and plasma by non-compartmental analysis (NCA) using Phoenix WinNonlin 6.4 (Pharsight Corporation, Cary, NC, USA). max ) and time to maximum concentration (T max ) was recorded directly from the observational data. Other PK parameters estimated were the elimination half-life (t 1 / 2 ), the area under the curve from time 0 to the last measurable concentration (AUC 0-t ), the area under the concentration-time curve extrapolated to infinity (AUC 0-∞ ), clearance of the absorbed fraction (CL), and volume of distribution based on the terminal phase (V z ), steady-state volume of distribution (V ss ) was.

[0265] Immunogenicity Analysis: CSF and blood (serum) samples for immunogenicity were collected at baseline, every 4 weeks during the dose-escalation phase, and at the start of the stable dose phase and every 4 weeks thereafter. CSF and serum samples were tested for total anti-drug antibodies (TAb) specific for seriponase alfa by a validated bridging electrochemiluminescence assay (BioMarin Pharmaceutical Inc., Novato, CA, US). TAb-positive samples in CSF were further characterized for neutralizing antibodies (NAb) that block seriponase alfa uptake into lysosomes using a validated cell-based flow cytometry assay (BioMarin Pharmaceutical Inc., Novato, CA, US). Because the target site of action is the CNS, NAb testing was performed only on CSF samples, and TAb-positive samples were tested for NAb responses. The complete immunogenicity methodology and results of this study have been reported previously [Cherukuri-2018].

[0266] Statistical Analysis: Demographic characteristics were summarized for the PK population. PK parameters were summarized descriptively by biological matrix, dose group, and study visit. The relationship between PK parameters and demographic characteristics, immunogenicity, safety, and efficacy parameters was assessed graphically, as the PK population was not analyzed extensively to assess statistical significance. In analyses without time as a covariate, the mean PK parameters for each patient were used as a representative measure of individual patient exposure during treatment with 300 mg QOW. Mean PK parameters were calculated based on C across study visits using 300 mg QOW dosing and intensive PK sampling (i.e., initial dose at 300 mg, and weeks 5 and 13 of the stable dose phase). max and AUC 0-t was derived by calculating the average of the values.

[0267] result PK parameters were estimated in all patients across dose levels and study visits. At 300 mg QOW, there were 24 patients with evaluable PK data in CSF and 15 patients with evaluable PK data in plasma.

[0268] Single-dose PK data were available from patients who received an initial dose of 30 (n = 3), 100 (n = 3), or 300 mg (n = 17) of seriponase alfa, 4 / 4 from the dose-escalation phase, and 13 / 14 enrolled directly into the stable dose phase ( Figure 13 ).

[0269] In the CSF, peak concentrations were observed at the first sampling time point after the end of the 4-hour infusion and appeared to decline biphasically. CSF exposure increased with a median C max The dose-dependent increase was less than that of the original dose, resulting in an approximately 5- to 7-fold increase in AUC and C. One patient in the 100 mg group had high exposure after the first dose; therefore, exposure parameters at the 100 mg dose level varied widely due to the small sample size. max and AUC (represented by the maximum reported in the 100 mg group) were higher than the median for the 300 mg group. Although no definitive findings have been identified to explain this outlier exposure, this patient's CSF exposure after subsequent 300 mg infusions was less than that after the initial 100 mg dose.

[0270] During the early stages of trial conduct, plasma PK samples were stored outside the stability range, so no data were available for the 30 mg group and only one patient in the 100 mg group. Based primarily on the 300 mg dose level, plasma concentrations appeared to peak 8 to 20 hours after the end of the 4-hour ICV infusion, declined biphasically, and remain above the lower limit of quantitation (LLOQ) for up to 72 hours.

[0271] Multiple-dose PK data were evaluated from patients (n=14) directly enrolled in the stable dosing phase and administered 300 mg ceriponase alfa QOW throughout the trial ( Figures 14-15 ).

[0272] CSF PK parameters were similar between visits at Day 1, Week 5, and Week 13. Although there was variability, plasma T max , C max , and AUC 0-t The plasma C max The median AUC in plasma was approximately 1000-fold lower than in CSF. 0-t The median CSF and plasma C were approximately 300-1000 times lower than those in CSF. max or AUC 0-t There was no clear correlation between the magnitude of C based on patient-matched and visit-matched PK (Figure 16). max and AUC 0-t The interindividual variability of C across visits was 54-89% and 59-103% for plasma compared with 26-73% and 31-49% for CSF, respectively. max and AUC 0-t The intraindividual variability of was 33% and 24% in CSF, compared with 69% and 80% in plasma.

[0273] Pharmacokinetics and Patient Characteristics: The potential influence of baseline patient characteristics on cerliponase alfa PK was evaluated in the 300 mg QOW regimen. max and AUC 0-t Mean estimates of α were used to represent individual patient exposure during treatment and were deemed appropriate due to the lack of drug accumulation or time-dependent PK at 300 mg QOW. There was no apparent effect of baseline sex, age, weight, or CLN2 score on CSF or plasma serponase alfa exposure (Figures 17A-17D). Plasma α decreased with decreasing age. max There was a slight tendency for plasma AUC 0-t was not shown.

[0274] Pharmacokinetics and Immunogenicity: Total antibodies (TAb) to serponase alfa were detected in the CSF of 5 / 24 (21%) patients and in the serum of 19 / 24 (79%) patients throughout the study. CSF TAb responses were first detected at week 13 of the stable dose phase, whereas serum TAb responses were detected at week 5 of the dose-escalation phase, the earliest time point sampled. Neutralizing antibodies (NAb) were not detected in the CSF of any of the five patients with positive CSF TAb and are therefore unavailable for further analysis.

[0275] To determine whether seriponase alfa PK is affected by the development of anti-drug antibodies (ADA), we compared C between visits with a positive TAb response and those with a negative TAb response. max and AUC 0-t Matched visit exposure parameters and ADA status (i.e., Day 1, Week 5 of stable dose, and Week 13 of stable dose) were assessed for all patients who initiated treatment at 300 mg and had evaluable PK and ADA data. Eighteen patients with CSF data (4 / 4 from the dose-escalation phase and 14 / 14 enrolled directly into the stable dose phase) and 14 patients with plasma / serum data (1 / 4 from the dose-escalation phase and 13 / 14 from the stable dose phase) were included in the analysis.

[0276] As shown in Figure 18A, CSF C by CSF ADA status across patients. max and AUC 0-t There was no discernible trend in CSF C at visits with a positive ADA reaction. max and AUC 0-t The values ​​were within the range of the distribution of exposure values ​​for ADA-negative responses. In two patients with PK and CSF ADA-positive outcomes who were matched for the visit, the CSF AUC 0-t was 17-27% lower in ADA-positive visits compared with ADA-negative visits. Overall and within patients, plasma C max , AUC 0-t No association was observed between serum ADA status and plasma exposure at serum ADA-positive visits (Figure 18b). Plasma exposure at serum ADA-positive visits spanned the range of exposure at ADA-negative visits within individual patients.

[0277] The relationship between cerliponase alfa PK and efficacy outcomes was assessed using the change in motor and speech scores from the start of 300 mg QOW to the end of the study. Of the 23 patients in this analysis, 2 gained 1 point, 13 remained unchanged, 5 lost 1 point, and 3 lost 2 points after 48 weeks of treatment, for an overall responder rate of 87% (20 / 23). Change in patients' motor and speech scores at 48 weeks was measured by their individual mean CSF CSF levels. max and AUC 0-t (Figure 19). Patients who experienced a decrease in score had CSF exposure parameters within the distribution of patients with no change or increase in score. Similarly, no correlation was demonstrated when assessed by the maximum decrease in a patient's score during 48 weeks of treatment.

[0278] The relationship between PK and adverse events was also analyzed. As noted above, study drug-related events occurring in at least 10% of the study population were included in the analysis: fever 46% (11 / 24), hypersensitivity 33% (8 / 24), seizures 33% (8 / 24), epilepsy 17% (4 / 24), headache 13% (3 / 24), and vomiting 13% (3 / 24). There was a significant difference in CSF or plasma C between patients with and without fever, hypersensitivity, seizures, or epilepsy. max and AUC 0-t There were no significant differences in CSF exposures. There was a slight trend for higher CSF exposures in patients with headache compared with those without headache, and for higher exposures in both CSF and plasma in patients with vomiting compared with those without vomiting. Exposures in patients with headache or vomiting generally did not exceed the highest exposure observed in patients without either event.

[0279] The above results show that seriponase alfa demonstrated a less than dose-proportional increase in CSF exposure following initial ICV infusion of 30, 100, and 300 mg. The single-dose range (2.08 x 10, respectively) 5 , 6.65×10 5 , and 1.42 × 10 6 CSF C in ng / mL maxwere roughly consistent with the expected values ​​for an ICV dose administered to approximately 100 mL of CSF in the human brain (3.00 × 10 5、 1.00×10 6 , and 3.00 × 10 6 ng / mL) (Pardridge et al., J. Cereb. Blood Flow Metab. 17, 713-731, 1997). At 300 mg QOW, similar C max , AUC, CL, and V ss Based on the data, there was no apparent accumulation or time dependency in CSF or plasma PK. This is consistent with a CSF half-life of 6.2-7.7 hours across patients and a calculable plasma half-life of 11.8 hours in one patient, given the biweekly dosing frequency. As a rationale for therapeutic biweekly dosing, it must be emphasized that the CSF half-life does not directly reflect target site, and that CNS tissue half-life (from evaluation in monkeys) and lysosomal half-life (from ex vivo human fibroblasts) are most relevant, ranging from days to weeks. In patients, CSF concentrations were approximately 4 days, with lysosomal PK levels remaining. 取り込み This suggests widespread distribution of the enzyme into CNS tissues, based on animal data. This is supported by estimates of the volume of distribution in CSF, which exceeds the normal CSF volume of approximately 100 mL. Direct administration of seriponase alfa into the internal CSF space of the brain results in approximately three orders of magnitude greater exposure than peripherally, resulting in a significant increase in the C between CSF and plasma. max There was no correlation between the magnitude of AUC and plasma PK, indicating that plasma PK is not a good surrogate for CSF PK. max is the CSF T that occurred immediately after the end of the infusion. max Compared with 8 hours after completion of a 4-hour ICV infusion, the blood-CSF barrier is leaky compared to the BBB, so ICV-administered drugs are transported from the brain via the CSF channels and absorbed across the arachnoid villi into the peripheral bloodstream (Pardridge et al., Fluids Barriers CNS. 8:7, 2011).

[0280] Because intrinsic factors did not appear to correlate with seriponase alfa exposure, CSF and plasma PK variability among patients was not explained by patient demographics. Because the ICV dose of seriponase alfa was designed according to brain mass, CSF exposure is not expected to vary significantly across age (3-8 years) and body weight (14.5-26.0 kg) ranges in this trial. On average, the human brain achieves approximately 75% of its adult size by age 2 years and 100% by age 5 years, with a gradual decline in brain-to-body weight ratio during development (Giedd et al., Cereb. Cortex. 6:551-560, 1996). Between the ages of 3 and 8-9 years, brain weights in unaffected humans average 1.09-1.18 kg for females and 1.27-1.37 kg for males, compared with 14.1-26.0 kg and 15.6-27.5 kg, respectively (Dekaban et al., Ann. Neurol. 4, 345-356, 1978). Thus, brain weight changes by only 8% across the age range in this study, compared with an 80% change in body weight. Notably, plasma C levels decreased with decreasing age. max The slight trend toward increased CI may be due to disproportionate changes in body weight and brain weight during infancy: while age-matched by brain weight, the ICV dose is absorbed into a significantly smaller body weight and correspondingly smaller blood volume, resulting in a more concentrated systemic exposure.

[0281] The inter-patient variability of CSF exposure was significantly smaller than the intra-patient variability (CSF C max 33%, CSF AUC 0-t 24% in ICV administration, which may be due to differences in disease severity rather than inherent variability in the enzyme administered ICV. Although an association between CSF exposure and baseline CLN2 score was demonstrated, there may be pathological effects on the CNS that are reflected in CSF PK but do not translate to changes on clinical rating scales. Because of subsequent systemic absorption, both inter- and intrapatient variability in plasma PK was significantly higher than in CSF, partly due to insufficient numbers of plasma samples with quantifiable concentrations.

[0282] Based on a matched patient-visit analysis of the 300 mg QOW dose, the presence of ADAs in CSF and serum did not appear to affect the PK of these drugs in CSF and plasma, respectively. The majority of treated patients expressed ADAs in serum, suggesting that plasma exposure to seriponase alfa likely leads to ADA positivity in serum, consistent with other ERTs, due to patients lacking the endogenous protein (Long et al., Clin. Ther. 39:118-129, 2017). It has previously been demonstrated that the development of ADA responses in this trial does not predict a worse safety profile or poor treatment outcome (Cherukuri et al., Clin. Immunol. 197:68-76, 2018). Regarding the most common adverse events associated with seriponase alfa, there was no clear correlation between CSF or plasma exposure and the incidence of fever, hypersensitivity, seizures, or epilepsy. The slight trends of increasing exposure with incidence of headache and vomiting are of limited interpretation given the low frequency in the small sample size of both events (3 / 24 patients).

[0283] Treatment response, as measured by change in CLN2 score after 48 weeks of 300 mg QOW, did not appear to correlate with the magnitude of CSF exposure, indicating that maximum benefit was achieved across the entire exposure range of 300 mg QOW. Notably, CSF exposure in CLN2 patients exceeded that associated with the effective 16 mg dose of TPP1-null mice, suggesting that these exposures were within the plateau of the exposure-response relationship (Katz et al., J. Neurosci. Res. 92, 1591-1598, 2014; Vuillemenot et al., Mol. Genet. Metab. 114, 281-293, 2015). Despite inter- and intra-patient PK variability, the clinical 300 mg dose provided a reportable CSF AUC 0-t 91% (62 / 68) of visits were significantly lower than the mean CSF AUC 0-t The value exceeded 6.45 × 10 6ng-hr / mL) (Vuillemenot 2015, supra). Low-level TPP1 expression has been shown to dramatically reduce disease in studies of CLN2 mutant mice. Only 6% of normal TPP1 activity in the brain increased lifespan to nearly that of wild-type mice (Sleat 2008, supra). Collectively, these nonclinical and clinical data demonstrate that serponase alfa delivered ICV at 300 mg QOW provides sufficient TPP1 exposure to the CNS for meaningful therapeutic efficacy. This is the first characterization of clinical CSF and plasma pharmacokinetics of an ICV-administered protein.

[0284] All publications, patents, and patent applications mentioned in this specification are herein incorporated by reference to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference. Although the foregoing invention has been described in some detail by way of illustration and example for clarity of understanding, it will be readily apparent to those skilled in the art that certain changes and modifications thereto can be made in light of the teachings of the present disclosure without departing from the spirit or scope of the appended claims. The present invention provides, for example, the following items. (Item 1) A method for treating neuronal ceroid lipofuscinosis (CLN2) disease in a subject under the age of 3, comprising administering to the subject a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) in an amount effective to treat the CLN2 disease in the subject. (Item 2) A method for delaying the onset of neuronal ceroid lipofuscinosis (CLN2) disease or its symptoms in a subject under the age of 3, comprising administering to the subject a formulation comprising recombinant human tripeptidyl peptidase-1 (rhTPP1) for intracerebroventricular, intrathecal, or intraocular administration. (Item 3) 3. The method of item 1 or 2, wherein the formulation is administered to the subject via intracerebroventricular, intrathecal, or intraocular administration. (Item 4) The method of any one of the preceding items, wherein the formulation is administered once every two weeks. (Item 5) The method of any one of the preceding items, wherein the formulation is administered by infusion at a rate of about 2.5 mL per hour. (Item 6) The method of any one of the preceding items, wherein a dose of about 300 mg or less is administered to the subject. (Item 7) 7. The method of item 6, wherein the subject is greater than or about 2 years old. (Item 8) Item 9. The method according to Item 7, wherein a dose of about 300 mg of rhTPP1 is administered to the subject. 7. The method of item 6, wherein the subject is greater than about 1 year old or about 1 year old and less than 2 years old. (Item 10) Item 11. The method of item 9, wherein a dose of about 200 mg of rhTPP1 is administered to the subject. 11. The method of claim 10, wherein each of the first, second, third, and fourth doses administered to the subject is about 200 mg of rhTPP1, and each of the fifth and subsequent doses administered to the subject is greater than about 200 mg of rhTPP1. (Item 12) 12. The method of claim 11, wherein each of the fifth and subsequent doses administered to the subject is about 300 mg of rhTPP1. (Item 13) 7. The method of item 6, wherein the subject is more than 6 months old or about 6 months old and less than 1 year old. (Item 14) 14. The method of claim 13, wherein a dose of about 150 mg of rhTPP1 is administered to the subject. (Item 15) Item 7. The method of item 6, wherein the subject is under 6 months of age. (Item 16) 16. The method of item 15, wherein a dose of about 100 mg of rhTPP1 is administered to the subject. (Item 17) The method of any one of the preceding items, wherein the subject exhibits reduced TPP1 enzyme activity based on a blood test. (Item 18) The method of any one of the preceding items, wherein the subject is a sibling of an individual diagnosed with CLN2. (Item 19) The method of any one of the preceding items, wherein the subject has a total score of about 3 to about 6 points on the Motor and Language subscales. (Item 20) The method of any one of the preceding items, wherein the subject has not been previously treated with stem cell therapy, gene therapy, or enzyme replacement therapy. (Item 21) The method of any one of the preceding items, comprising administering to the subject an antihistamine, with or without an antipyretic, prior to administration of the rhTPP1, optionally about 30 to about 60 minutes prior to administration of the rhTPP1. (Item 22) The method of any one of the preceding items, wherein the formulation comprises the rhTPP1 and at least one pharmaceutically acceptable carrier, diluent, or excipient. (Item 23) 23. The method of claim 22, wherein the formulation comprises disodium hydrogen phosphate pentahydrate, monosodium phosphate monohydrate, sodium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or a combination thereof. (Item 24) The method of any one of the preceding items, comprising administering a flush solution to the subject after administering the formulation. (Item 25) 25. The method of claim 24, wherein the flush solution comprises disodium hydrogen phosphate pentahydrate, monosodium phosphate monohydrate, sodium chloride, potassium chloride, magnesium chloride, calcium chloride hydrate, water for injection, or a combination thereof. (Item 26) 27. The method of any one of the preceding claims, wherein the treatment period is at least 10 weeks, at least 20 weeks, at least 40 weeks, at least 80 weeks, or at least 96 weeks. A composition comprising a formulation containing recombinant human tripeptidyl peptidase-1 (rhTPP1) for intracerebroventricular, intrathecal, or intraocular administration for use in treating neuronal ceroid lipofuscinosis (CLN2) disease in subjects under the age of 3. (Item 28) Use of a formulation containing recombinant human tripeptidyl peptidase-1 (rhTPP1) for intracerebroventricular, intrathecal, or intraocular administration for the manufacture of a medicament for treating neuronal ceroid lipofuscinosis (CLN2) disease in subjects under the age of 3.

Claims

[Claim 1] The invention described in the present specification.

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