Agent for treatment of diseases associated with intervertebral disc degeneration

Abstract

To employ MMP-7 as an active ingredient in an agent for treatment of diseases associated with intervertebral disc degeneration, even in a case where the subject is a human.SOLUTION: An agent for treatment of a disease associated with intervertebral disc degeneration, the agent containing MMP-7 as an active ingredient, the disease being selected from the group consisting of intervertebral disc hernia, lumbago, disc disease, kyphoscoliosis, and spondylosis deformans, in which a dose of MMP-7 per administration is 100 μg to 700 μg.SELECTED DRAWING: None

Description

[Technical Field]

[0001] The present invention relates to a therapeutic agent for diseases associated with intervertebral disc degeneration, and more specifically to a therapeutic agent for diseases associated with intervertebral disc degeneration selected from the group consisting of herniated disc, low back pain, discopathy, kyphoscoliosis, and spondylosis deformans. [Background technology]

[0002] Lumbar disc herniation occurs most frequently in young and middle-aged people aged 20 to 40 years, and in the acute phase, it is accompanied by severe lower back and leg pain and neurological disorders, significantly restricting socioeconomic activities. However, it has been reported that pain is relieved in approximately 70% of patients with lumbar disc herniation within six weeks of onset (Non-Patent Document 1). Since 60% of symptomatic disc herniations are resorbed within three months of onset, pain and neurological symptoms may improve.

[0003] Conservative therapy is the standard of treatment for lumbar disc herniation. Pharmacotherapy, including analgesics, muscle relaxants, and peripheral neuropathic pain medications, is commonly used around the world. However, the effectiveness of specific medications has not been clearly demonstrated in pharmacotherapy aimed at improving pain and physical function in patients with lumbar disc herniation (Non-Patent Document 1). Furthermore, the effectiveness of physical therapy and alternative therapies, such as exercise therapy, traction therapy, ultrasound therapy, and corsets, has not been fully demonstrated, and their therapeutic effects are considered limited (Non-Patent Document 1). In other words, conservative treatment currently implemented in Japan is symptomatic and not a definitive treatment for the pathology of this disease, in which degenerated discs bulge or prolapse outside the spinal canal or intervertebral foramen, compressing nerve roots and the dural canal and causing inflammation. Meanwhile, evidence for surgical treatment is established, particularly in the short term, and surgery is beneficial when appropriate. However, past evidence has conflicting opinions in the long term, and determining whether surgery is appropriate is crucial (Non-Patent Document 1). Condoliase is available on the market as an intradiscal treatment agent as an alternative to surgery, but because it is a heterologous protein, it carries the risk of serious side effects such as shock and anaphylaxis (Non-Patent Documents 2 to 3). Furthermore, its indication is limited to "lumbar disc herniation under the posterior longitudinal ligament where sufficient improvement cannot be achieved with conservative treatment," and only a single administration into the high intervertebral disc that is the cause of the symptoms is permitted, and it is not permitted to administer the drug again.

[0004] KTP-001 is a novel chemonucleolytic agent containing recombinant human matrix metalloproteinase-7 (MMP-7) (rhMMP-7) as its active ingredient, developed based on the inventor's basic research. MMP-7 enzymatically cleaves proteoglycans, the main component of the extracellular matrix produced by intervertebral disc nucleus pulposus cells. Expression of MMP-7 has been confirmed in the natural regression mechanism of herniated discs, and intradiscal administration of MMP-7 is thought to physiologically promote the natural regression mechanism in a similar manner.

[0005] Patent Document 1 discloses the use of MMP-7 as a therapeutic agent for intervertebral disc degeneration. Patent Document 2 discloses a method for producing MMP-7 that enables mass production in Escherichia coli. Patent Document 3 discloses a method for producing an MMP-7 formulation with improved storage stability in vial formulations, etc. [Prior art documents] [Patent documents]

[0006] [Patent Document 1] Patent No. 4512038 [Patent Document 2] Patent No. 5602635 [Patent Document 3] Patent No. 6755793 [Non-patent literature]

[0007] [Non-Patent Document 1] Nankodo, Lumbar Disc Herniation Treatment Guidelines, Revised 3rd Edition (Published May 2021) [Non-patent document 2] Seikagaku Corporation, Hernicore (registered trademark) for disc disease 1.25 units, Appropriate Use Guide, 1st edition (created June 2018) [Non-patent document 3] Seikagaku Corporation reports on the results of a post-marketing investigation into Hernicore (registered trademark) 1.25 units for disc disease (April 2019) [Non-patent document 4] Haro H, et al. Experimental chemonucleolysis with recombinant human matrix metalloproteinase 7 in human herniated discs and dogs. Spine J. 2014; 14(7): 1280-1290. [Non-Patent Document 5] Ikeda, T. et al. Development of a scoring method for the Japanese version of the EQ-5D-5L. Health and Medical Sciences. 2015; 64(1): 47-55. [Non-patent document 6] Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, et al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005; 113(1-2):9-19. Summary of the Invention [Problem to be solved by the invention]

[0008] Patent Document 1 describes that when MMP-7 is used as a therapeutic agent for treating intervertebral disc degeneration, the dosage per administration is approximately 1 μg to 100 mg, preferably 100 μg to 1 mg. However, the examples in Patent Document 1 only describe the administration of 10 μg / 100 μl or 40 μg / 100 μl of human recombinant MMP-7 to rabbit intervertebral discs (Example 2), the administration of 20 μg / 200 μl or 10 μg / 100 μl of MMP-7 to dog intervertebral discs (Example 3), and the administration of 20 μg / 200 μl of MMP-7 to dog intervertebral discs (Example 4). Therefore, it was unclear whether MMP-7 could be used as a therapeutic agent for intervertebral disc degeneration at dosages other than these. Furthermore, Patent Document 1 does not describe the administration of MMP-7 to human intervertebral discs, and it was unclear whether MMP-7 could be used as a therapeutic agent for human intervertebral disc degeneration.

[0009] In fact, in a clinical trial of the present MMP-7 preparation (KTP-001) conducted by the present inventors in the United States, 5 μg of MMP-7 was administered to humans, but with one exception, no effect of intradiscal injection was observed. Also, when 15 μg of MMP-7 was administered to humans, all cases were herniated discs, which simply progressed naturally, and no clear therapeutic effect was observed. Therefore, it was suspected that MMP-7 cannot be used as a therapeutic agent for intervertebral disc degeneration when used in humans, unlike in rabbits and dogs.

[0010] Therefore, the present invention aims to use MMP-7 as an active ingredient in a therapeutic agent for diseases associated with intervertebral disc degeneration, even when the subject is humans. [Means for solving the problem]

[0011] After extensive research, the present inventors have unexpectedly found that by setting the dose of MMP-7 per administration to a specific amount, MMP-7 can be used as an active ingredient in a treatment for diseases associated with intervertebral disc degeneration, even in humans.

[0012] As mentioned above, in clinical trials of the present MMP-7 preparation (KTP-001) in the United States, when 5 μg of MMP-7 was administered to humans, no effect of intervertebral disc injection therapy was observed, with one exceptional case being the only case; when 15 μg of MMP-7 was administered to humans, all cases developed prolapse herniation, which was merely a natural progression, and no clear therapeutic effect was obtained. In light of these findings, the present inventors' findings are completely unexpected when considering that, in humans, changing the dose of MMP-7 per administration did not make it possible to use MMP-7 as an active ingredient in a treatment for diseases associated with intervertebral disc degeneration.

[0013] That is, the present invention provides the following. [Aspect A-1] A therapeutic agent for a disease associated with intervertebral disc degeneration selected from the group consisting of intervertebral disc herniation, lower back pain, intervertebral disc disease, kyphoscoliosis, and spondylosis degenerativeis, comprising MMP-7 as an active ingredient, wherein the dosage of MMP-7 per administration is 300 μg to 600 μg. [Aspect A-2] The treatment agent according to aspect A-1, wherein the MMP-7 is recombinant human MMP-7. [Aspect A-3] The treatment agent according to Aspect A-1, which is to be administered directly to the affected area of ​​the disease. [Aspect A-4] The treatment according to aspect A-1, for multiple administration to a patient with said disease. [Aspect A-5] The treatment agent according to aspect A-1, for administration to a patient with the disease who is not receiving conservative treatment for the disease. [Aspect A-6] The treatment according to aspect A-1, for administration to a patient with said disease, the patient shortly after a diagnosis confirming said disease. [Aspect A-7] The treatment according to aspect A-6, wherein the diagnosis that confirms the disease is performed using MRI. [Aspect A-8] The treatment agent according to aspect A-1, which is an injection having a single dose of 2 cc or more. [Aspect A-9] The treatment agent according to Aspect A-1, wherein the amount of MMP-7 contained is 300 μg to 600 μg. [Aspect A-10] The treatment of aspect A-1, which is a unit dosage form. [Aspect A-11] The treatment according to aspect A-1, for administration once per day to a patient with said disease. [Aspect B-1] A therapeutic agent for a disease associated with intervertebral disc degeneration selected from the group consisting of intervertebral disc herniation, lower back pain, intervertebral disc disease, kyphoscoliosis, and spondylosis degenerativeis, comprising MMP-7 as an active ingredient, wherein the dosage of MMP-7 per administration is 100 μg to 700 μg. [Aspect B-2] The treatment agent according to aspect B-1, wherein the dose of MMP-7 per administration is 250 μg to 500 μg. [Aspect B-3] The treatment agent according to aspect B-1, wherein the dose of MMP-7 per administration is 300 μg to 450 μg. [Aspect B-4] The treatment agent according to aspect B-1, wherein the MMP-7 is recombinant human MMP-7. [Aspect B-5] The treatment agent according to aspect B-1, which is to be administered directly to the affected area of ​​the disease. [Aspect B-6] The treatment according to aspect B-1, for administration once per day to a patient with said disease. [Aspect B-7] The treatment according to aspect B-1, for multiple administration to a patient with said disease. [Aspect B-8] The treatment agent according to aspect B-1, for administration to a patient with the disease who is not receiving conservative treatment for the disease. [Aspect B-9] The treatment according to aspect B-1, for administration to a patient with said disease, the patient shortly after a diagnosis confirming said disease. [Aspect B-10] The treatment of aspect B-9, wherein the diagnosis that confirms the disease is performed using MRI. [Aspect B-11] The treatment agent according to aspect B-1, which is an injection having a single dose of 2 cc or more. [Aspect B-12] The treatment agent according to aspect B-1, wherein the amount of MMP-7 contained is 100 μg to 700 μg. [Aspect B-13] The treatment agent according to aspect B-1, wherein the amount of MMP-7 contained is 250 μg to 500 μg. [Aspect B-14] The treatment agent according to aspect B-1, wherein the content of MMP-7 is 300 μg to 450 μg. [Aspect B-15] The treatment of aspect B-1, which is a unit dosage form. [Aspect B-16] A pharmaceutical composition for treating a disease associated with intervertebral disc degeneration selected from the group consisting of intervertebral disc herniation, lower back pain, discopathy, kyphoscoliosis, and spondylosis degenerativeis, comprising MMP-7 as an active ingredient, wherein the dosage of MMP-7 per administration is 100 μg to 700 μg. [Aspect B-17] The pharmaceutical composition according to aspect B-16, wherein the dose of MMP-7 per administration is 250 μg to 500 μg. [Aspect B-18] The pharmaceutical composition according to aspect B-16, wherein the dose of MMP-7 per administration is 300 μg to 450 μg. [Aspect B-19] The pharmaceutical composition of aspect B-16, wherein the MMP-7 is recombinant human MMP-7. [Aspect B-20] The pharmaceutical composition according to aspect B-16, for direct administration to the affected area of ​​said disease. [Aspect B-21] The pharmaceutical composition according to aspect B-16, for administration once per day to a patient with said disease. [Aspect B-22] The pharmaceutical composition according to aspect B-16, for multiple administration to a patient with said disease. [Aspect B-23] A pharmaceutical composition according to aspect B-16, for administration to a patient with said disease, who is not receiving conservative treatment for said disease. [Aspect B-24] The pharmaceutical composition according to aspect B-16, for administration to a patient with said disease, shortly after a diagnosis confirming said disease. [Aspect B-25] The pharmaceutical composition of aspect B-24, wherein the diagnosis that confirms the disease is performed using MRI. [Aspect B-26] The pharmaceutical composition according to aspect B-16, which is an injection and has a single dose of 2 cc or more. [Aspect B-27] The pharmaceutical composition according to aspect B-16, wherein the content of MMP-7 is 100 μg to 700 μg. [Aspect B-28] The pharmaceutical composition according to aspect B-16, wherein the content of MMP-7 is 250 μg to 500 μg. [Aspect B-29] The pharmaceutical composition according to aspect B-16, wherein the content of MMP-7 is 300 μg to 450 μg. [Aspect B-30] The pharmaceutical composition according to aspect B-16, which is a unit dosage form. [Effects of the Invention]

[0014] According to the present invention, even in the case of humans, diseases associated with intervertebral disc degeneration selected from the group consisting of herniated disc, low back pain, discopathy, kyphoscoliosis, and degenerative spondylosis can be treated using MMP-7 as an active ingredient.

[0015] Unlike the competing product, condoliase (trade name: HERNICORE (registered trademark)), the present MMP-7 preparation (KTP-001) surprisingly did not cause anaphylaxis, and therefore, in a more specific embodiment, the treatment agent of the present invention can be administered multiple times. Furthermore, while condoliase (trade name: HERNICORE (registered trademark)) is not a treatment target until 6 weeks or more after the start of conservative treatment, the treatment agent of the present invention in a more specific embodiment can be administered immediately after the diagnosis is confirmed, which is useful. [Brief explanation of the drawings]

[0016] [Figure 1] Figure 1 shows the timeline of this trial. [Figure 2] Figure 2 shows the cohort schedule. [Figure 3] Figure 3 shows an overview of the trial procedures. [Figure 4] Figure 4 shows the time course of lower limb pain (NRS: average pain over the past 24 hours) (FAS). The number of subjects at each time point (sham group, 150 μg group, 300 μg group, 600 μg group, and so on) is as follows: Baseline: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 24 hours after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 1 week after administration: 3 subjects, 3 subjects, 10 subjects, 2 subjects; 2 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 4 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 6 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 13 weeks after administration: 3 subjects, 2 subjects, 11 subjects, 2 subjects; 24 weeks after administration / at discontinuation: 3 subjects, 3 subjects, 11 subjects, 2 subjects. [Figure 5]Figure 5 shows the time course of lower limb pain (NRS: worst pain over the past 24 hours) (FAS). The number of subjects at each time point (sham group, 150 μg group, 300 μg group, 600 μg group, and so on) is as follows: Baseline: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 24 hours after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 1 week after administration: 3 subjects, 3 subjects, 10 subjects, 2 subjects; 2 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 4 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 6 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 13 weeks after administration: 3 subjects, 2 subjects, 11 subjects, 2 subjects; 24 weeks after administration / at discontinuation: 3 subjects, 3 subjects, 11 subjects, 2 subjects. [Figure 6] Figure 6 shows the time course of lower back pain (NRS: average pain over the past 24 hours) (FAS). The number of subjects at each time point (sham group, 150 μg group, 300 μg group, 600 μg group, and so on) is as follows: Baseline: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 24 hours after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 1 week after administration: 3 subjects, 3 subjects, 10 subjects, 2 subjects; 2 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 4 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 6 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 13 weeks after administration: 3 subjects, 2 subjects, 11 subjects, 2 subjects; 24 weeks after administration / at discontinuation: 3 subjects, 3 subjects, 11 subjects, 2 subjects. [Figure 7] Figure 7 shows the time course of lower back pain (NRS: worst pain in the past 24 hours) (FAS). The number of subjects at each time point (sham group, 150 μg group, 300 μg group, 600 μg group, and so on) is as follows: Baseline: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 24 hours after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 1 week after administration: 3 subjects, 3 subjects, 10 subjects, 2 subjects; 2 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 4 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 6 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 13 weeks after administration: 3 subjects, 2 subjects, 11 subjects, 2 subjects; 24 weeks after administration / at discontinuation: 3 subjects, 3 subjects, 11 subjects, 2 subjects. [Figure 8] Figure 8 shows the time to additional treatment (Kaplan-Meier plot) (FAS). Number of cases at baseline: 3 in the sham group, 3 in the 150 μg group, 11 in the 300 μg group, and 2 in the 600 μg group. [Figure 9]Figure 9 shows the time course of serum keratan sulfate concentrations (PPS). The number of subjects at each time point (Sham group, 150 μg group, 300 μg group, 600 μg group, and so on) is as follows: Baseline: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 24 hours after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 1 week after administration: 3 subjects, 3 subjects, 10 subjects, 2 subjects; 2 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 1 subject; 6 weeks after administration: 3 subjects, 3 subjects, 10 subjects, 0 subjects. DETAILED DESCRIPTION OF THE INVENTION

[0017] The present invention provides a therapeutic agent for treating a disease associated with intervertebral disc degeneration selected from the group consisting of intervertebral disc herniation, low back pain, intervertebral disc disease, kyphoscoliosis, and spondylosis degenerativeis, which contains MMP-7 as an active ingredient and has a single dose of 100 μg to 700 μg of MMP-7.

[0018] The dose of MMP-7 per administration may be, for example, 100 μg or more, 110 μg or more, 120 μg or more, 130 μg or more, 140 μg or more, 150 μg or more, 160 μg or more, 170 μg or more, 180 μg or more, 190 μg or more, 200 μg or more, 210 μg or more, 220 μg or more, 230 μg or more, 240 μg or more, 250 μg or more, 260 μg or more, 270 μg or more, 280 μg or more, 290 μg or more, 300 μg or more, 310 μg or more, 320 μg or more, 330 μg or more, 340 μg or more, 350 μg or more, 360 μg or more, 370 μg or more, 380 μg or more, 390 μg or more, 400 μg or more, 410 μg or more, 420 μg or more, 430 μg or more, 440 μg or more, 450 μg or more, 460 μg or more, 470 μg or more, 480 μg or more, 490 μg or more, 500 μg or more, 510 μg or more, 520 μg or more, 530 μg or more, 540 μg or more, 550 μg or more, 560 μg or more, 570 μg or more, 580 μg or more, 590 μg or more, 600 μg or more, 610 μg or more, 620 μg or more, 630 μg or more, 640 μg or more, 430 μg or more, 440 μg or more, 450 μg or more, 460 μg or more, 470 μg or more, 480 μg or more, 490 μg or more, 500 μg or more, 510 μg or more, 520 μg or more, 530 μg or more, 540 μg or more, 550 μg or more, 560 μg or more, 570 μg or more, 580 590 μg or more, 600 μg or more, 610 μg or more, 620 μg or more, 630 μg or more, 640 μg or more, 650 μg or more, 660 μg or more, 670 μg or more, 680 μg or more, or 690 μg or more.

[0019] The dosage of MMP-7 used in one session is as follows: 700 μg or less, 690 μg or less, 680 μg or less, 670 μg or less, 660 μg or less, 650 μg or less, 640 μg or less, 630 μg or less, 620 μg or less, 610 μg or less, 600 μg or less, 590 μg or less, 580 μg or less, 570 μg or less, 560 μg or less, 550 μg or less, 540 μg or less, 530 μg or less, 520 μg or less, 510 μg or less, 500 μg or less, 490 μg or less, 480 μg or less, 470 μg or less, 460 μg or less, 450 μg or less, 440 μg or less, 430 μg or less, 420 μg or less, 410 μg or less, 400 μg or less. Below μg, below 390 μg, below 380 μg, below 370 μg, below 360 μg, below 350 μg, below 340 μg, below 330 μg, below 320 μg, below 310 μg, below 300 μg, below 290 μg, below 280 μg, below 270 μg, below 260 μg, below 250 μg, below 240 μg, below 230 μg, below 220 μg, below 210 μg, below 200 μg, below 190 μg, below 180 μg, below 170 μg, below 160 μg, below 150 μg, below 140 μg, below 130 μg, below 120 μg, and below 110 μg.

[0020] Preferably, MMP-7 is recombinant human MMP-7. MMP-7 is an extracellular matrix degrading enzyme. MMP-7 is a matrix metalloproteinase (hereinafter sometimes referred to as "MMP") belonging to the zinc-type metalloproteinase family, which has a zinc molecule at its active site. MMPs are produced as precursors, and upon extracellular secretion, the signal sequence is processed, followed by the prosequence, resulting in their active form. While extracellularly secreted MMPs control the metabolism of the extracellular matrix, MMP-7 is primarily secreted by cancer cells and has been reported to be involved in invasion and metastasis. MMP-7 lacks the hinge and hemopexin-like domains found in many other MMPs. It is the smallest molecular unit among MMPs and utilizes collagen and components of the extracellular matrix (fibronectin, vitronectin, laminin, and aggrecan) as substrates. MMP-7 is presumed to be involved in the spontaneous regression of herniated discs because it utilizes aggrecan, a major component of cartilage tissue, as a substrate; macrophages derived from surgical specimens of herniated discs express MMP-7; and studies using MMP-7-deficient mice have shown no activation of inflammatory cytokines involved in the regression of herniated discs. The MMP-7 contained as an active ingredient in the therapeutic agent of the present invention may be full-length MMP-7 or a portion of MMP-7. For example, full-length MMP-7 may be a known MMP (SEQ ID NO: 2) (https: / / www-ncbi-nlm-nih-gov.translate.goog / protein / NP_002414?_x_tr_sl=en&_x_tr_tl=ja&_x_tr_hl=ja&_x_tr_pto=sc), and the portion of MMP-7 may be that described in the Examples below (SEQ ID NO: 1), including equivalents thereof. The precursor of human matrix metalloproteinase-7 (MMP-7) has a molecular weight of approximately 29 kDa, and the active form of human matrix metalloproteinase-7 (MMP-7) has a molecular weight of approximately 19 kDa (173 amino acids). MMP-7 is activated (cleaved) from the approximately 29 kDa precursor to become the active form of approximately 19 kDa, which exhibits enzymatic activity. The MMP-7 is preferably the active form.

[0021] The therapeutic agent of the present invention is intended for administration, for example, by intrathecal administration, oral administration, intravenous administration, subcutaneous administration, transdermal administration, intramuscular administration, intraarticular administration, nasal administration, intraperitoneal administration, direct injection into target tissue, inhalation administration, enteral administration, enema administration, tube feeding, etc. However, the therapeutic agent of the present invention is preferably intended for administration directly to the affected area of ​​the disease. The affected area may, for example, be a herniated area. More specifically, the affected area may include the intervertebral disc portion, particularly the intervertebral disc portion near the herniation, and the nucleus pulposus portion, particularly the herniated portion of the nucleus pulposus.

[0022] The therapeutic agent of the present invention may be administered, for example, into an intervertebral disc, particularly into an intervertebral disc near a herniation and / or into the nucleus pulposus, particularly into the herniated portion of the nucleus pulposus. For example, during disc puncture, a puncture needle is advanced percutaneously under X-ray fluoroscopy to puncture the intervertebral disc. For example, an inner tube is advanced from there toward the herniated disc, selectively puncturing the herniated disc and injecting the therapeutic agent of the present invention. For example, the affected intervertebral level of the lumbar disc herniation is identified under X-ray fluoroscopy. Then, for example, the patient is positioned in a prone or semi-lateral position under X-ray fluoroscopy so that the target disc space does not overlap with adjacent endplates. Then, for example, the body surface from the lumbar region to the pelvis is disinfected, and a sterilized disc puncture needle is used under X-ray fluoroscopy to puncture the skin and the outer layer of the annulus fibrosus of the disc. During skin puncture, a local anesthetic may be administered subcutaneously. Thereafter, for example, X-ray fluoroscopy is performed from the front, lateral, and oblique positions as appropriate, and the tip of the intervertebral disc puncture needle is positioned centrally within the intervertebral disc. For example, to more accurately administer the therapeutic agent to the herniated disc mass, a device may be used in which the inner barrel of the intervertebral disc puncture needle can be bent toward the herniated orifice where the herniated disc bulges or prolapses. Preferably, the therapeutic agent of the present invention is then injected. Alternatively, to more accurately administer the therapeutic agent to the herniated disc mass, the intervertebral disc puncture needle may be inserted into the intervertebral disc under X-ray fluoroscopy via the intervertebral foramen or interlaminar space, and the therapeutic agent of the present invention may be administered. Alternatively, it is anticipated that insertion of the puncture needle into the intervertebral disc may be difficult due to the subject's anatomical characteristics. In such cases, the therapeutic agent of the present invention may be administered into the epidural space, for example, via the intervertebral foramen or interlaminar space.

[0023] The therapeutic agent of the present invention may be administered, for example, by epidural injection. In some cases, a method of administering the therapeutic agent directly to the herniated disc mass, rather than intradiscal administration, is preferable. For example, a spinal endoscope or surgical microscope is used to reach the vicinity of the herniated disc bulge or prolapse from the anterior part of the disc, the intervertebral foramen, or the intervertebral space, and the herniated disc is punctured using, for example, a disc puncture needle, and the therapeutic agent of the present invention is administered.

[0024] The treatment agent of the present invention may be administered using a device such as the puncture device described in Japanese Patent No. 4181599. The puncture device described in Japanese Patent No. 4181599 is characterized by comprising a lumen-shaped puncture body having a protrusion opening on its side, an acting body housed within the puncture body and having an acting part that acts inside the body, and a guide means for causing the acting part of the acting body to protrude laterally from the protrusion opening. Furthermore, the puncture device described in Japanese Patent No. 4181599 is more specifically a puncture device comprising a lumen-shaped puncture body having an opening on its side, an acting body housed within the puncture body and having an acting part that acts inside the body, and a guide means for causing the acting part of the acting body to protrude laterally from the opening, the guide means comprising a wire housed within the puncture body for guiding the acting body, and a moving means for freely moving the wire from the opening to the side of the puncture body, the tip of the wire being fixed to the puncture body, and the moving means moving the wire in the lengthwise direction relative to the puncture body, thereby bending the wire and causing a part of it to protrude from the opening, and causing the acting part to protrude laterally from the opening.

[0025] By administering the therapeutic agent of the present invention in this manner, the natural regression of hernia can be promoted.

[0026] The therapeutic agent of the present invention may be administered to a patient with the disease once a day, for example, once, twice, three times, four times, five times, six times, seven times, eight times, nine times, or ten times a day.

[0027] The therapeutic agent of the present invention may be administered multiple times to a patient with the disease, for example. The number of times administered to a patient with the disease may be, for example, 1 time, 2 times, 3 times, 4 times, 5 times, 6 times, 7 times, 8 times, 9 times, 10 times, 11 times, 12 times, 13 times, 14 times, 15 times, 16 times, 17 times, 18 times, 19 times, 20 times, 21 times, 22 times, 23 times, 24 times, 25 times, 26 times, 27 times, 28 times, 29 times, 30 times, 31 times, 32 times, 33 times, 34 times, 35 times, 36 times, 37 times, 38 times, 39 times, 40 times, 41 times, 42 times, 43 times, 44 times, 45 times, 46 times, 47 times, 48 ​​times, 49 ... 0, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100 times.

[0028] The treatment agent of the present invention may be, for example, one intended to be administered to a patient with the above-mentioned disease who is not receiving conservative treatment for the disease.

[0029] The therapeutic agent of the present invention may be administered to a patient suffering from the above-mentioned disease immediately after a definitive diagnosis of the disease. Here, the definitive diagnosis may be performed using, for example, MRI. Examples of definitive diagnosis of the disease include confirming the presence of neurological symptoms such as radiculopathy, cauda equina, or myelopathy, and then using magnetic resonance imaging (MRI) to confirm the state of nerve compression and intervertebral disc degeneration, e.g., the location and extent of herniation. Furthermore, the definitive diagnosis of the disease may involve imaging the herniated mass at the site to be treated using a discography to accurately determine the location and extent of the herniated disc. Therefore, the therapeutic agent of the present invention may be administered directly to the herniated area of ​​a patient suspected of having disc degeneration (e.g., herniation) after undergoing MRI and discography and finding that the patient has disc degeneration (e.g., herniation), depending on the pathology. Administration of the therapeutic agent of the present invention in this manner can promote the natural regression of herniated tissue.

[0030] The therapeutic agent of the present invention may be formulated into oral dosage forms such as tablets, capsules, elixirs, and microcapsules, or parenteral dosage forms such as injections, ointments, and patches. That is, the therapeutic agent of the present invention may be, for example, an injection, with a single dose of 2 cc or more. The single dose of the therapeutic agent of the present invention in the form of an injection may be, for example, 2 cc or more, 3 cc or more, 4 cc or more, 5 cc or more, 6 cc or more, 7 cc or more, 8 cc or more, or 9 cc or more. The single dose of the therapeutic agent of the present invention in the form of an injection may be, for example, 10 cc or less, 9 cc or less, 8 cc or less, 7 cc or less, 6 cc or less, 5 cc or less, 4 cc or less, or 3 cc or less. Note that a solution volume of 1 cc was used in the US clinical trial described below. However, in discography, administering 1 cc of contrast agent into the intervertebral disc did not allow complete imaging from the center of the disc to the herniated disc. It is preferable to administer at least 2 cc to 3 cc of contrast agent to visualize the herniated disc mass. Therefore, from the viewpoint of ensuring sufficient distribution of the active ingredient to the affected area, the single dose of the treatment agent of the present invention is preferably 2 cc or more. Another treatment agent for herniated discs, Hernicore (registered trademark), has a dose of 1 cc, but its effectiveness in treating only lumbar disc herniation of subligamentous extrusion type according to the Macnab classification has been confirmed, and pharmaceutical approval has only been obtained for subligamentous extrusion type lumbar disc herniation.In contrast, the present inventors have found that the therapeutic agent of the present invention, administered in an amount of 2 cc or more, is expected to reach the affected area based on findings from intervertebral discography, and is therefore expected to be effective in treating not only subligamentous extrusion, but also protrusion, transligamentous extrusion, and sequestration, preferably subligamentous extrusion, protrusion, and transligamentous extrusion, and more preferably subligamentous extrusion and transligamentous extrusion. In particular, non-clinical studies have confirmed that KTP-001 caused no pathological or physiological abnormalities when administered epidurally or intrathecally, and MMP-7-positive cells have been confirmed in the tissues of herniated discs in surgical specimens, suggesting that it can be safely administered to subligamentous extrusion and transligamentous extrusion. Therefore, from the perspective of achieving a broad therapeutic effect for disc herniation, not limited to subligamentous extrusion, the dosage of the treatment agent of the present invention per administration is preferably 2 cc or more.

[0031] The contents of MMP-7 contained in the disposal regulations and examples of this disclosure are: 100 μg or more, 110 μg or more, 120 μg or more, 130 μg or more, 140 μg or more, 150 μg or more, 160 μg or more, 170 μg or more, 180 μg or more, 190 μg or more, 200 μg or more, 210 μg or more, 220 μg or more, 230 μg or more, 240 μg or more, 250 μg or more, 260 μg or more, 270 μg or more, 280 μg or more, 290 μg or more, 300 μg or more, 310 μg or more, 320 μg or more, 330 μg or more, 340 μg or more, 350 μg or more, 360 μg or more, 370 μg or more, 380 μg or more, 390 μg or more, 400 μg or more, 410 μg or more, 420 μg or more, 430 μg or more, 440 μg or more, 450 μg or more, 460 μg or more, 470 μg or more, 480 μg or more, 490 μg or more, 500 μg or more, 510 μg or more, 520 μg or more, 530 μg or more, 540 μg or more, 550 μg or more, 560 μg or more, 570 μg or more, 580 μg or more, 590 μg or more, 600 μg or more, 610 μg or more, 620 μg or more, 630 μg or more, 640 μg or more, 650 μg or more, 660 μg or more, 670 μg or more, 680 μg or more, and also 690 μg or more.

[0032] The therapeutic agent of the present invention has an MMP-7 content of, for example, 700 μg or less, 690 μg or less, 680 μg or less, 670 μg or less, 660 μg or less, 650 μg or less, 640 μg or less, 630 μg or less, 620 μg or less, 610 μg or less, 600 μg or less, 590 μg or less, 580 μg or less, 570 560 μg or less, 550 μg or less, 540 μg or less, 530 μg or less, 520 μg or less, 510 μg or less, 500 μg or less, 490 μg or less, 480 μg or less, 470 μg or less, 460 μg or less, 450 μg or less, 440 μg or less, 430 μg or less, 420 μg or less, 410 μg or less, 400 μg or less, 390 μg or less, 380 less than μg, less than 370 μg, less than 360 μg, less than 350 μg, less than 340 μg, less than 330 μg, less than 320 μg, less than 310 μg, less than 300 μg, less than 290 μg, less than 280 μg, less than 270 μg, less than 260 μg, less than 250 μg, less than 240 μg, less than 230 μg, 220 Less than 1 μg, 210 μg or less, 200 μg or less, 190 μg or less, 180 μg or less, 170 μg or less, 160 μg or less, 150 μg or less, 140 μg or less, 130 μg or less, 120 μg or less, or 110 μg or less.

[0033] The therapeutic agent of the present invention may be, for example, a unit preparation. A unit preparation is, for example, a preparation corresponding to a single administration. Examples of unit preparations include tablets, capsules, and preparations enclosed in ampoules or syringes.

[0034] As will be shown in the Examples below, by administering the therapeutic agent of the present invention to a subject, it is possible to treat a disease associated with intervertebral disc degeneration in the subject, which is selected from the group consisting of herniated disc, low back pain, discopathy, kyphoscoliosis, and degenerative spondylosis. Here, examples of intervertebral disc herniation include, for example, protrusion, subligamentous extrusion, transligamentous extrusion, and sequestrated disc or sequestration, based on the Macnab classification. The therapeutic agent of the present invention can treat any of these types of intervertebral disc herniation. However, the therapeutic agent of the present invention is preferably capable of treating protrusion, subligamentous extrusion, and transligamentous extrusion, and more preferably subligamentous extrusion and transligamentous extrusion. The term "sequestrated disc" refers to a disc that has migrated from a high disc position to the cranial or caudal side. Disease treatment includes not only treatment but also prevention. Treatment of a disease includes not only complete cure of the disease, but also improvement or alleviation of symptoms of the disease.

[0035] The subject may be, for example, a vertebrate. The vertebrate may be, for example, a mammal such as a mouse, a rat, a rabbit, a pig, a cow, a monkey, or a human. The mammal is preferably a human. The subject may be of any age, including an infant, a juvenile, an adolescent, an adult, or an elderly person.

[0036] The therapeutic agent of the present invention may consist of MMP-7, or may be formulated as a pharmaceutical composition mixed with a pharmaceutically acceptable carrier.

[0037] Examples of pharmaceutically acceptable carriers include solvents such as sterilized water and physiological saline; binders such as gelatin, corn starch, tragacanth gum, and gum arabic; excipients such as crystalline cellulose; and leavening agents such as corn starch, gelatin, and alginic acid.

[0038] Pharmaceutically acceptable carriers include additives such as lubricants such as magnesium stearate, sweeteners such as sucrose, lactose, and saccharin, flavorings such as peppermint and rhododendron oil, stabilizers such as benzyl alcohol and phenol, buffers such as phosphates and sodium acetate, solubilizers such as benzyl benzoate and benzyl alcohol, antioxidants, preservatives, surfactants, and emulsifiers.

[0039] Pharmaceutical compositions can be formulated, for example, by combining the above-mentioned carriers appropriately and mixing them in unit dosage forms required for generally accepted pharmaceutical practice.

[0040] When the pharmaceutical composition is an injection, examples of the solvent for the injection include isotonic solutions containing adjuvants such as physiological saline, glucose, D-sorbitol, D-mannose, D-mannitol, sodium chloride, etc. The solvent for the injection may contain alcohol such as ethanol, polyalcohol such as propylene glycol, polyethylene glycol, nonionic surfactants such as Polysorbate 80 (trademark), HCO-50, etc.

[0041] The therapeutic agent of the present invention may be accompanied by an instruction manual. The instruction manual may include, for example, information about the active ingredient contained, the single dose of the active ingredient MMP-7, the number of doses per day, the administration method, the total number of doses, and the amount per dose. The instruction manual does not necessarily need to be physically present in writing, and may be provided via an electronic communication line such as the Internet.

[0042] The present invention provides a method for treating a disease associated with intervertebral disc degeneration in a subject, the disease being selected from the group consisting of herniated disc, low back pain, discopathy, kyphoscoliosis, and spondylosis degenerativeis, which comprises administering MMP-7 to the subject, wherein the amount of MMP-7 administered to the subject per administration is 100 μg to 700 μg.

[0043] The present invention provides a pharmaceutical composition containing MMP-7 as an active ingredient for use in treating a disease associated with intervertebral disc degeneration selected from the group consisting of herniated disc, low back pain, discopathy, kyphoscoliosis, and spondylosis degenerativeis, wherein the dosage of MMP-7 per administration is 100 μg to 700 μg.

[0044] The present invention provides use of MMP-7 in the manufacture of a pharmaceutical composition for use in treating a disease associated with intervertebral disc degeneration selected from the group consisting of herniated disc, low back pain, discopathy, kyphoscoliosis, and degenerative spondylosis, wherein the MMP-7 is used in a single dose of 100 μg to 700 μg. [Example]

[0045] List of abbreviations [Table 1]

[0046] Introduction Nonclinical studies have shown that rhMMP-7 has the ability to degrade human herniated disc specimens and beagle dog intervertebral discs, without affecting neural tissue, ligaments, or epidural tissue. Furthermore, rhMMP-7 has high degrading activity for aggrecan but very low degrading activity for type I and II collagen, suggesting that it has strong tissue or degradation specificity (Non-Patent Document 4). In toxicity studies using single and two-week intravenous administration in rats and dogs, hemorrhagic and inflammatory changes were observed at doses significantly higher than the exposure levels expected in humans if all intradiscally administered KTP-001 had been transferred to the bloodstream. These hemorrhagic and inflammatory changes are thought to be due to the enzymatic effects of excessive intravenously administered KTP-001 on blood vessels. Reproductive and developmental toxicity studies in rats and rabbits showed no effects on female reproductive function, early embryonic development, or embryo-fetal development. No evidence of fetal teratogenicity was found.

[0047] In the United States, a Phase I / II clinical trial began in 2013 with the primary objective of confirming the safety and tolerability of a single intradiscal injection of KTP-001 in patients with lumbar disc herniation. Six patients were administered doses of 5 μg, 15 μg, 50 μg, and 150 μg. No serious complications were observed in any of the patients, and blood KTP-001 concentrations and antibodies were not detected. Administration of doses up to 150 μg in patients with disc herniation was reported to be safe. The most common adverse events were injection site pain, bronchitis, procedural pain, back pain, pain in extremities, musculoskeletal pain, muscle spasms, and disc bulge. The distribution of adverse events was similar across all doses, and no deaths occurred during the trial. Four patients experienced serious adverse events (appendicitis, diverticulitis, urinary tract infection, and menorrhagia), but none of these adverse events were determined to be causally related to the study drug. Furthermore, no significant changes were observed in serum keratan sulfate concentrations, except in the 150 μg group. In the 150 μg group, mean serum keratan sulfate concentrations increased 24 hours after administration, peaked 1 week after administration, and gradually decreased until 4 weeks after administration. In conclusion, KTP-001 was safe and well-tolerated at the dose studied. All serum KTP-001 concentrations were below the limit of quantitation, and anti-KTP-001 antibodies were negative in all patients. Regarding efficacy, leg pain (worst pain and average pain over the past 24 hours) assessed using the Numeric Rating Scale (NRS) showed a significant decrease from baseline in the 15 μg and 50 μg groups compared with the 5 μg group. Furthermore, in both treatment groups, leg elevation test results changed from positive at baseline to negative at Week 6 and Week 13 in more than half of the subjects. The femoral nerve extension test changed from positive at baseline to negative at Week 6 in one patient and from positive at baseline to negative at Week 13 in three patients.

[0048] The primary objective of this investigator-initiated clinical trial is to confirm the safety and tolerability of a single intradiscal injection of KTP-001 in patients with lumbar disc herniation. A secondary objective is to confirm efficacy in patients with subposterior longitudinal ligament prolapse, which is less susceptible to early spontaneous regression. In a Phase I / II clinical trial conducted in the United States, elevated serum keratan sulfate levels were observed only after the KTP-001 dose was gradually increased to 150 μg. Because elevated serum keratan sulfate levels are a marker of the resolution of prolapsed disc nucleus pulposus, increasing the KTP-001 dose to 150 μg or higher is expected to enhance the efficacy of this agent in resolving herniated discs. Therefore, in this clinical trial, patients with lumbar disc herniation were administered KTP-001 at doses ranging from 150 μg to 600 μg, and the tolerability, safety, and secondary efficacy were evaluated at each dose.

[0049] Clinical trial objectives The purpose of this clinical trial was to confirm the safety and tolerability of a single intradiscal administration of this drug in patients with lumbar disc herniation. Based on the results of this trial, we will also consider the recommended dose in the next phase and the optimal endpoints for efficacy evaluation. Furthermore, we will examine the transfer of KTP-001 and keratan sulfate from the intervertebral disc to serum over time, and investigate the presence of anti-KTP-001 antibodies in serum.

[0050] 1. Clinical trial planning

[0051] 1.1 Overall design and planning of the clinical trial

[0052] 1.1.1 Types of clinical trials Phase I / IIa clinical trial

[0053] 1.1.2 Clinical trial design Multicenter, single-blind, dose-escalation, single-dose study

[0054] 1.1.3 Treatments considered The following doses of study drug were administered to each cohort: * Cohort 1: KTP-001 150 μg or Sham * Cohort 2: KTP-001 300 μg * Cohort 3: KTP-001 600 μg

[0055] 1.1.4 Patient population studied and planned sample size Target number of cases: 18 cases + additional cases (maximum 5 cases) For the KTP-001 administration group, the following number of subjects was set as subjects eligible for safety evaluation up to 6 weeks after administration of the investigational drug. * Cohort 1: 3 cases in the sham group, 3 cases in the KTP-001 150 μg group * Cohort 2: 6 patients in the KTP-001 300 μg group * Cohort 3: 6 cases in the KTP-001 600 μg group In addition, if any of the three patients in the 150 μg group in Cohort 1 discontinued treatment within six weeks and safety could not be evaluated up to six weeks, additional cases would be added as appropriate. In addition, we decided to add cases (up to 5 cases) to the cohort of doses for which safety was confirmed and efficacy in secondary endpoints was suggested.

[0056] 1.1.5 Level and method of blinding This clinical trial was conducted as a single-blind study. In all cohorts, subjects were not informed of which cohort they were in and whether they were in the KTP-001 or sham group.

[0057] 1.1.6 Type of Control and Study Configuration This clinical trial consisted of three cohorts, with subjects enrolled starting with Cohort 1, followed by Cohort 2 and Cohort 3. Cohort 1 included a sham group. * Cohort 1: KTP-001 150 μg group or sham group * Cohort 2: KTP-001 300 μg group * Cohort 3: KTP-001 600 μg group

[0058] 1.1.7 Clinical trial allocation method The principal investigator (subinvestigator) or clinical trial collaborator used the electronic data capture system (EDC) to randomly assign the registered subjects. Cohort 1 was randomly assigned to the sham group (3 cases) and the 150 μg group (3 cases). Cohorts 2, 3, and additional cases were not assigned.

[0059] 1.1.8 Sequence and length of clinical trial periods This clinical trial consisted of a single dose in both cohorts. The administration schedule is shown in Figure 1. Each cohort received an intradiscal injection of 150 μg or sham, 300 μg, or 600 μg of KTP-001. Local anesthetics were allowed at the discretion of the investigator. All cohorts were single-blind, and subjects were unaware of which cohort they were in. The items to be performed at each visit are described in detail in "1.5.1.2 Observation and test items and their timing."

[0060] 1.1.9 Committees established and their roles An efficacy and safety evaluation committee was established for this clinical trial. The committee reviewed and evaluated the occurrence of serious adverse events of concern, and provided advice and recommendations to the coordinating investigator regarding the addition of cases to the highest dose cohort that were deemed safe. This was stipulated in a separate procedure manual for the efficacy and safety evaluation committee.

[0061] 1.1.10 Interim Analysis No interim analyses were performed in this trial.

[0062] 1.2 Clinical trial design considerations, including choice of control group This clinical trial is a multicenter, single-blind, dose-escalation, single-dose study consisting of three cohorts. Cohort 1 will receive a single dose of KTP-001 150 μg or sham, Cohort 2 will receive a single dose of KTP-001 300 μg, and Cohort 3 will receive a single dose of KTP-001 600 μg (only puncture in the sham group). The tolerability, safety, and secondary efficacy endpoints of each dose will be confirmed. In a Phase I / II clinical trial conducted in the United States, six patients were administered doses of 5, 15, 50, and 150 μg each. No adverse events were reported, and serum levels of KTP-001 and anti-KTP-001 antibodies were not detected. Furthermore, administration of up to 150 μg for herniated discs was not associated with safety. Therefore, the purpose of this clinical trial was to confirm the safety of doses of 300 μg and 600 μg, which are two and four times the 150 μg dose.

[0063] 1.3 Selection of the study population

[0064] 1.3.1 Inclusion criteria

[0065] 1.3.1.1 Target diseases Lumbar disc herniation under the posterior longitudinal ligament

[0066] 1.3.1.2 Selection Criteria The subjects were patients who met all the following criteria. Diagnosis and evaluation were in accordance with the diagnostic criteria proposed by the Committee for the Development of Guidelines for the Treatment of Lumbar Disc Herniation (Non-Patent Document 1). 1) Patients diagnosed with lumbar disc herniation of the type under the posterior longitudinal ligament at L3-L4, L4-L5, or L5-S1 level based on clinical symptoms, neurological findings, and MRI (patients diagnosed with lumbar disc herniation of the type under the posterior longitudinal ligament at L3-L4, L4-S1 level in the case of sacralization, and L4-L5, L5-L6, or L6-S1 level in the case of lumbarization) 2) Patients with a positive leg-raising test or femoral nerve extension test, neurologically consistent with a high-disc level lumbar disc herniation 3) Patients with an average leg pain score / day of 4 or higher for at least 3 of the 5 days immediately prior to administration and an average leg pain score / day of 2 or higher for all 5 days immediately prior to administration (using an 11-point NRS ranging from "0: no pain" to "10: worst pain ever experienced"). 4) Patients with a leg pain score of 4 or higher immediately before administration (Day 1) 5) Adult males or females between the ages of 20 and 60 (at the time of consent) 6) Body mass index (BMI) of 18-35 kg / m 2 7) The investigator (subinvestigator) has confirmed that there are no clinical problems based on medical history, electrocardiogram, and physical examination findings. 8) Oswestry Disability Index (ODI) of 30% or more 9) Patients whose preoperative X-ray findings showed vertebral endplate closure and no growth plate was observed 10) Patients who have received a sufficient explanation using an information sheet, understood the contents, and have given written consent to participate in the clinical trial based on their own free will. [Basis for setting selection criteria] The main ones are listed below. The type of lumbar disc herniation targeted was prolapse of the posterior longitudinal ligament, which is thought to allow for appropriate evaluation of drug efficacy with little influence from natural regression. Regarding the target age, the lower age limit was set at 20 years, taking into account the age at which lumbar disc herniation most commonly occurs (20-40 years). While the vertebral endplates are generally considered closed in adults, the target patients were those whose pre-administration X-rays confirmed that the vertebral endplates were closed and no growth plate was visible. Considering the involvement of spinal canal stenosis, the upper age limit was set at 60 years.

[0067] 1.3.1.3 Exclusion criteria Patients who met the following criteria were excluded. If any of the following exclusion criteria were met during the clinical trial period, the clinical trial would be discontinued at the discretion of the principal investigator (subinvestigator). 1) Patients diagnosed with bulging disc herniation (protrusion), posterior longitudinal ligament perforation disc herniation (transligamentous extrusion), lumbar disc sequestration, or intradural herniation based on clinical symptoms, neurological findings, and MRI. 2) Patients diagnosed with intraforaminal or extraforaminal herniation by MRI 3) Patients who have significant disc herniation in two or more places on MRI, and whose clinical symptoms and physical findings do not identify the intervertebral space involved in the clinical symptoms, or who are judged to have the possibility of herniation at multiple intervertebral spaces. 4) Patients who have previously undergone intradiscal intervention* or back surgery for the herniated disc that is the subject of this clinical trial *Interventional treatment: Refers to the treatments listed in "Exclusion Criteria 5)" (chemonucleolysis or clinical trials using drugs targeting the intervertebral disc). 5) Patients who have previously undergone chemonucleolysis or participated in clinical trials using drugs targeting the intervertebral disc, regardless of disc height 6) Patients with the following lumbar diseases or deformities other than lumbar disc herniation i) Lumbar spinal canal stenosis without underlying lumbar spondylolisthesis, spondylolysis, scoliosis, or lumbar disc herniation ii) Lumbar vertebral fracture, ankylosing spondylitis, inflammatory bone disease, inflammatory disc disease, primary or metastatic malignant tumor, or other diseases related to the vertebral body 7) Patients with cauda equina syndrome or progressive lower limb motor paralysis 8) Patients who wish to become pregnant. Female patients who are pregnant, breastfeeding, or who may be pregnant as determined by a pregnancy test. 9) Patients whose vital signs and laboratory test values ​​at screening correspond to Grade 2 or higher according to the Common Terminology Criteria for Adverse Events (CTCAE) ver. 5.0 Japanese translation. 10) Patients who are deemed inappropriate for participation in the clinical trial according to the clinical trial protocol [Rationale for setting exclusion criteria] 1)-4), 10): To target eligible subjects for this clinical trial. 5)~7), 9): This was due to consideration of the possibility of affecting the safety of the subjects and the evaluation of the safety and efficacy of the investigational drug. 8): The effects on pregnancy and the fetus cannot be completely ruled out.

[0068] 1.3.2 Censoring of Patient Treatment or Evaluation In this clinical trial, subjects who met the discontinuation criteria were considered to have been discontinued. In addition, the trial was considered to have been completed when the prescribed observations and tests at 24 weeks after administration as specified in the clinical trial protocol were completed.

[0069] 1.3.2.1 Pre-administration Discontinuation Criteria If any of the following conditions apply, the subject will not be administered the investigational drug. 1) Ineligible at screening: If the inclusion criteria are not met or if the exclusion criteria are found to be violated. 2) Subject's request: If the subject refuses or withdraws consent 3) Investigator's (subinvestigator's) judgment: If the investigator determines that administering the investigational drug is difficult

[0070] 1.3.2.2 Discontinuation Criteria After Study Drug Administration If any of the following conditions occurred after administration of the study drug, the subject's participation in the study was to be discontinued. 1) Adverse events: When a doctor determines that a subject's continuation in the clinical trial is difficult due to the occurrence of an adverse event, when a subject requests discontinuation due to the occurrence of an adverse event, or when a subject dies as a result of an adverse event and the clinical trial cannot be continued. 2) Insufficient effect: When the effect of the investigational drug is insufficient and it is necessary to switch to another therapeutic drug. 3) Unable to follow up: When the subject does not come to the hospital, and the prescribed visits, examinations, and observations (including follow-up by telephone, etc.) are not possible. 4) Serious deviations from the protocol: Serious deviations from the protocol (GCP violations, deviations from inclusion criteria or violations of exclusion criteria, registration violations, duplicate registrations, etc.) are recognized. 5) Ineligibility after study drug administration: If it is found that the inclusion criteria are not met after study drug administration, or if it is found that the exclusion criteria are violated. However, if it is found that the exclusion criteria 8) are violated after study drug administration, and it is determined that tests other than X-ray images can be continued, the clinical trial may be continued after ensuring the safety of the subject. 6) Subject's request: If the subject refuses or withdraws consent 7) Implementation of restricted concomitant medications, restricted concomitant therapies, and prohibited concomitant therapies: When restricted concomitant medications, restricted concomitant therapies, or prohibited concomitant therapies are newly implemented. However, examinations and observations will continue even after discontinuation. 8) Investigator's (sub-investigator's) judgment: If the investigator determines that it is difficult to continue the clinical trial for other reasons

[0071] 1.3.2.3 Treatment of subjects who discontinue or drop out The investigator (sub-investigator) decided to discontinue the clinical trial if the subject declined to participate in the trial or withdrew consent, or if it was determined that the trial could not be continued for any reason. In such cases, the investigator will record the date and time of discontinuation / withdrawal, the reason for discontinuation / withdrawal, and progress in the patient's medical record and electronic case report form (eCRF), and will also perform any necessary tests at the time of discontinuation / withdrawal and evaluate safety. If the study was discontinued due to the occurrence of an adverse event, appropriate measures and treatment were immediately implemented, and follow-up investigations were conducted as appropriate until the adverse event returned to or improved to the state before the event occurred, or until the principal investigator (subinvestigator) determined that further investigations were unnecessary. Responses after discontinuation were recorded in source documents such as medical records. If consent was withdrawn after the start of administration of the investigational drug, we made it clear as much as possible whether the withdrawal was due to an adverse event or some other accidental event (such as relocation), and recorded this in the patient's medical record and eCRF to serve as a reference for determining whether the patient should be included in the safety evaluation.

[0072] 1.4 Treatment

[0073] 1.4.1 Treatment

[0074] 1.4.1.1 Dosage and administration Each cohort received a single dose of the study drug at the following doses: * Cohort 1: KTP-001 150 μg or Sham * Cohort 2: KTP-001 300 μg * Cohort 3: KTP-001 600 μg KTP-001 treatment group: The injection site was visualized under X-ray fluoroscopy, and 2.0 mL of the KTP-001 injection prepared to the administration dose was injected into the intervertebral disc. Sham group: As in the drug administration group, the needle was inserted from the posterior oblique position in the direction of the intervertebral disc, reaching the muscle group just before the intervertebral disc, but the needle was only inserted and no injection was administered.

[0075] 1.4.1.2 Transition to the next cohort

[0076] 1.4.1.2.1 Procedures for moving to the next cohort and decisions on adding cases The cohort schedule is shown in Figure 2. [Transition from Cohort 1 to Cohort 2] Random enrollment began in Cohort 1 (150 μg of this drug group, sham group), and safety data obtained up to 6 weeks after administration in this cohort was used to determine whether or not to move on to Cohort 2. * If no events corresponding to "1.4.1.2.2 Safety Assessment, 1)2)" were observed among the three patients in the 150 μg group, the coordinating investigator would consult with the principal investigator and clinical trial advisor via email or web conference, etc., and if they unanimously determined that there were no safety issues in accordance with the criteria in "1.4.1.2.2 Safety Assessment," the patient would be transferred to Cohort 2. *If any of the three patients in the 150 μg group experienced an event corresponding to "1.4.1.2.2 Safety Assessment, 1)2)," the coordinating investigator would consult with the Efficacy and Safety Assessment Committee regarding whether or not to continue the clinical trial. *If the Efficacy and Safety Evaluation Committee determines that there are no problems with continuing the clinical trial, the trial will be able to move on to Cohort 2. *If the Efficacy and Safety Evaluation Committee determines that there are safety issues that would make it difficult to continue the clinical trial, the coordinating investigator will decide whether to discontinue the clinical trial in accordance with the recommendations of the Efficacy and Safety Evaluation Committee. In addition, if any of the three patients in the 150 μg group in Cohort 1 discontinued treatment within six weeks and safety could not be evaluated up to six weeks, additional patients would be added as appropriate.

[0077] [Transition from Cohort 2 to Cohort 3, decision on adding cases] * If no events corresponding to "1.4.1.2.2 Safety Assessment, 1)2)" were observed among the 6 patients in the 300 μg group, the coordinating investigator would consult with the principal investigator and clinical trial advisor via email or web conference, etc., and if they unanimously determined that there were no safety issues in accordance with the criteria in "1.4.1.2.2 Safety Assessment," the patient would be transferred to Cohort 3. * If any of the six patients in the 300 μg group experienced an event corresponding to "1.4.1.2.2 Safety Assessment, 1)2)," the coordinating investigator would consult the Efficacy and Safety Assessment Committee regarding whether or not to continue the clinical trial, following the procedure in "1.4.1.2.2 Safety Assessment." *If the Efficacy and Safety Evaluation Committee determines that there are no problems with continuing the clinical trial, the trial will be able to move on to Cohort 3. *If the Efficacy and Safety Evaluation Committee determines that there are safety issues, the committee will advise and recommend to the coordinating investigator regarding the addition of cases administered 150 μg in Cohort 1. The coordinating investigator will follow the advice and recommendation of the Efficacy and Safety Evaluation Committee and add cases to the highest dose cohort (150 μg group) that is determined to have no safety issues, in order to further examine the safety and efficacy of this drug (the number of additional cases will be limited to a maximum of five, and will be added to the extent feasible within the clinical trial period).

[0078] [Decision on adding cases in Cohort 3] * If no events corresponding to "1.4.1.2.2 Safety Assessment, 1) 2)" were observed among the six patients in the 600 μg group, the coordinating investigator decided to consult the Efficacy and Safety Evaluation Committee on safety data obtained up to six weeks after administration in Cohort 1 (3 patients), Cohort 2 (6 patients), and Cohort 3 (6 patients). The Efficacy and Safety Evaluation Committee will review and evaluate the obtained data to determine whether to continue the clinical trial and will provide advice and recommendations to the coordinating investigator regarding the addition of additional patients. In accordance with the advice and recommendations of the Efficacy and Safety Evaluation Committee, the coordinating investigator decided to add additional patients to the highest dose cohort that was determined to have no safety issues, in order to further evaluate the safety and efficacy of the drug (a maximum of five additional patients were to be added, as many as feasible within the clinical trial period). *If any of the six patients in the 600 μg group experienced an event corresponding to "1.4.1.2.2 Safety Assessment, 1)2)," the coordinating investigator would consult the Efficacy and Safety Assessment Committee regarding whether or not to continue the clinical trial, following the procedure in "1.4.1.2.2 Safety Assessment." *If the Efficacy and Safety Evaluation Committee determines that there are no problems with continuing the clinical trial, cases will be added to the highest dose cohort that is determined to have no safety issues, and the safety and efficacy of this drug will be further examined. *If the Efficacy and Safety Evaluation Committee determines that there are safety issues, the committee will advise and recommend to the coordinating investigator regarding the addition of 300 μg dose cases to Cohort 2. The coordinating investigator will follow the advice and recommendation of the Efficacy and Safety Evaluation Committee and add cases to the highest dose cohort (here, the 300 μg group) that is determined to have no safety issues, to further examine the safety and efficacy of this drug (the number of additional cases will be limited to a maximum of five, and will be added to the extent possible within the clinical trial period).

[0079] 1.4.1.2.2 Safety Determination If any of the following adverse events were observed during the clinical trial period, the principal investigator (subinvestigator) was to report the event to the coordinating investigator (clinical trial coordinating office) and the investigators at other medical institutions jointly conducting the clinical trial within 24 hours of becoming aware of the event. The coordinating investigator was then to consult with the Efficacy and Safety Evaluation Committee. If the Efficacy and Safety Evaluation Committee determined that the reported event posed a problem for continuing the clinical trial, it was to make a recommendation to the coordinating investigator. The coordinating investigator was to make the final decision on whether there was a tolerability problem, taking into account the recommendation of the Efficacy and Safety Committee. In addition, new subject enrollment will be suspended until the Efficacy and Safety Evaluation Committee evaluates adverse events and makes recommendations regarding the continuation of the clinical trial or an increase in dosage. 1) If a serious adverse event (see "1.5.1.2.18.1.1 Definition of a serious adverse event") was observed, it was to be reported using the format in the clinical trial protocol. 2) If any of the following events i) to v) indicating a worsening of the primary disease are observed, they will be reported using the format of the clinical trial protocol. i) Neurological disorders equivalent to cauda equina ii) Newly observed worsening of radicular symptoms associated with bilateral or unilateral lower limb motor impairment after administration of the study drug iii) Changes in MRI intensity corresponding to significant endplate edema or sclerosis compared to before administration of the study drug iv) A 30% or greater reduction in intervertebral disc height (evaluated by X-ray images: mean of anterior and posterior heights) compared to before administration of the study drug v) The following lumbar instability confirmed by radiography in the area to be treated: * The posterior edge of the upper vertebral body relative to the posterior edge of the lower vertebral body has moved forward by 3 mm or more compared to the starting point. * When the range of motion increases by 5 degrees or more compared to the range of motion measured by images of maximum flexion and extension before administration * Changes in endplate destruction confirmed by X-ray after administration Details of the evaluation methods used by the Efficacy and Safety Evaluation Committee are specified in the Procedures for the Efficacy and Safety Evaluation Committee.

[0080] 1.4.2 Investigational Product Identification The investigator provided the investigational drug manager with a procedure manual for the investigational drug and its management. Details of packaging, labeling, and management of the investigational drug, as well as procedures for maintaining blinding, were in accordance with the procedure manual for the management of the investigational drug.

[0081] 1.4.2.1 Investigational Medications KTP-001 is rhMMP-7, and each 2.0 mL vial contains 1.0 mg of KTP-001. drug substance Properties: KTP-001 is a recombinant human MMP-7 protein that degrades proteoglycans. No animal-derived raw materials are used in the manufacture of the active pharmaceutical ingredients used in clinical trials. International Nonproprietary Name: At this stage of development, KTP-001 does not have a nonproprietary name. Code name: KTP-001 Structural formula: The amino acid sequence (SEQ ID NO: 1) of the protein expressed by the gene sequence encoding KTP-001 is shown below. [Table 2] Molecular formula:C 860 H 1299 N 239 O 251 S4 Molecular weight: 19130.23 (theoretical value) Formulation: A lyophilized powder for injection. The KTP-001 formulation was dissolved in 0.5 mL of sterile water for injection, and then diluted with KTP-001 diluent to the required dosage. KTP-001 is composed of 173 amino acids, has no disulfide bonds, forms a complex with two zinc ions, and is approximately 19 kDa. Histidines 69, 84, and 97 and aspartic acid 71 are involved in structural zinc ion binding. Histidines 120, 124, and 130 are involved in the binding of other catalytic zinc ions. [Physical, chemical, and biological properties of KTP-001] Appearance: Colorless, transparent liquid UV spectrum: Absorption maximum at approximately 280 nm and shoulder at approximately 290 nm. Biological properties: Digestes both the synthetic substrate of matrix metalloprotease (MOCAc-Pro-Leu-Gly-Leu-A2pr (Dnp)-Ala-Arg-NH2) and the natural substrate aggrecan.

[0082] 1.4.2.2 Packaging and labelling The individual packaging box was labeled with the content, storage method, serial number, expiration date, and the name, affiliation, job title, and address of the clinical trial coordinating physician, and was also labeled as being for clinical trial use. The affiliation and job title of the clinical trial coordinating physician displayed on the individual packaging will be those at the start of the clinical trial, and the labeling on the individual packaging will not be changed even if changes occur during the clinical trial.

[0083] 1.4.2.3 Serial number and expiry date The serial numbers and expiration dates of the investigational drugs used in this study are shown in Table 3 (Serial numbers and expiration dates of investigational drugs). [Table 3]

[0084] 1.4.2.4 Investigational Drug Management Distribution and collection of investigational drugs 1) The investigational drug provider delivered the investigational drug to the medical institution conducting the study. 2) After the administration of the investigational drug was completed or discontinued, the principal investigator or a designated investigational drug manager collected the investigational drug in accordance with the procedure for the management of investigational drugs. Investigational drug management procedures 1) The investigational drug manager managed the investigational drug in accordance with the investigational drug management procedures and recorded the receipt and disbursement status in the investigational drug management chart. 2) The principal investigator and investigational drug manager will check the consistency of the information entered on the investigational drug management sheet, remaining medication, and eCRF, and if any inconsistencies are found, they will immediately investigate the cause and keep a record of the findings.

[0085] 1.4.3 Method of patient allocation to treatment groups This is described in "1.1.7 Clinical trial allocation method."

[0086] 1.4.4 Dose Selection in Clinical Trials The selection of the investigational drug dose is described in "1.4.1 Treatment Methods." The basis for the setting is described in "1.2 Considerations regarding clinical trial design, including the selection of a control group."

[0087] 1.4.5 Dose Selection and Timing for Each Patient The dose selection and timing of administration for each patient are described in "1.4.1 Treatment Methods." The basis for the setting is described in "1.2 Considerations regarding clinical trial design, including the selection of a control group."

[0088] 1.4.6 Blinding This is described in "1.1.5 Blinded Levels and Methods".

[0089] 1.4.7 Concomitant medications and therapies

[0090] 1.4.7.1 Compatible medications If pain persisted after administration of the study drug, the following adjunctive medications (analgesics) were permitted, except that use of adjunctive medications (analgesics) was prohibited for 6 hours before pain assessment. * Non-steroidal anti-inflammatory drugs (such as loxoprofen sodium and celecoxib) * Acetaminophen * Tramadol hydrochloride

[0091] 1.4.7.2 Restricted Concomitant Drugs and Therapies Regarding the restricted concomitant medications and therapies listed below, if the medication or treatment has been ongoing prior to obtaining consent, it may be continued during the clinical trial period, but changes to the treatment (increased dosage or increased frequency of medication or treatment) are not permitted after consent is obtained. Reductions in dosage and frequency of medication or treatment are permitted. [Restricted concomitant use of drugs] *Medications for peripheral neuropathic pain (pregabalin, mirogabalin) * Antiepileptic drugs (such as gabapentin) * Antidepressants (duloxetine, amitriptyline) * N-methyl-D-aspartate receptor antagonists (ketamine hydrochloride, etc.) * Corticosteroids (excluding topical medications, eye drops, and inhaled medications) * Muscle relaxants, herbal medicines, extracts from inflamed rabbit skin inoculated with vaccinia virus [Combined therapy] Trigger point block, heat therapy, bracing therapy, traction therapy, acupuncture therapy, chiropractic, etc.

[0092] 1.4.7.3 Concomitant Therapies From the time of obtaining consent until the end of observation 24 weeks after administration, nerve block therapy such as nerve root block or epidural block, and surgical treatment (including nucleolysis therapy using condoliase) were prohibited.

[0093] 1.4.8 Treatment Compliance Compliance with the treatment method was monitored through the subjects' medical records, etc. For observation and testing methods, see "1.5.1 Efficacy and safety evaluation items and flowchart."

[0094] 1.5 Efficacy and Safety

[0095] 1.5.1 Efficacy and Safety Endpoints and Flowchart

[0096] 1.5.1.1 Overview of Clinical Trial Procedures An outline of the trial procedure is shown in Figure 3. The principal investigator (sub-investigator) obtained consent after explaining the purpose and content of the clinical trial to the patient in accordance with the provisions for obtaining consent and the method of obtaining consent. The principal investigator (sub-investigator) registered the subject in EDC and assigned a subject identification code. The principal investigator (subinvestigator) confirmed that the subject met "1.3.1.1 Target disease" and "1.3.1.2 Inclusion criteria" and did not fall under "1.3.1.3 Exclusion criteria." Before the start of administration, the subjects underwent the observations and tests specified in the clinical trial protocol. The principal investigator (sub-investigator) enrolled the subject in this clinical trial after final confirmation that the subject met the inclusion criteria and did not violate the exclusion criteria based on the pre-treatment examination. The principal investigator (sub-investigator) or clinical trial collaborator assigned the subject to the EDC. The principal investigator (subinvestigator) initiated administration or treatment of the KTP-001 group or the sham group (Cohort 1 only) according to the group to which the subject was assigned. Observations and tests were performed as specified in the clinical trial protocol until 24 weeks after administration. However, the trial was discontinued if any of the criteria in "1.3.2.2 Discontinuation criteria after administration of the study drug" was met. If the adverse events had not resolved or improved at the time of observation and testing at 24 weeks after administration or at the time of discontinuation, follow-up surveys were to be conducted as appropriate until the adverse events had resolved or improved to the state before the onset of the adverse events, or until the investigator (subinvestigator) determined that further investigation was unnecessary. Even if the patient had not visited the clinic at the time of follow-up surveys, follow-up surveys were to be conducted by appropriate means, such as by telephone.

[0097] 1.5.1.2 Observation and inspection items and their implementation time The observation and examination schedules are shown in Tables 4 and 5 (Observation and Examination Schedules). [Table 4] [Table 5] a The patient was hospitalized for 24 hours after intradiscal injection. If there were no safety issues based on test data up to 24 hours, the patient was discharged. Note that hospitalization solely for the purpose of testing or an extension of hospitalization due to social hospitalization was not treated as an adverse event (see "1.5.1.2.18.1 Definition of an Adverse Event"). b MRI scans were performed using the same method throughout the trial, and the same model was used at each participating medical institution and at laboratories designated by each medical institution, whenever possible. MRI scans at screening were performed within 14 days prior to administration of the study drug. c If any significant abnormalities were detected by electrocardiography after administration of the study drug, additional testing was to be performed and the clinical significance and diagnosis recorded. d Hematology, blood chemistry, coagulation, and urinalysis. e Pregnancy tests were performed only on female subjects and were not required for male subjects. The results of the pre-dose urine pregnancy test at 0 hours were obtained before administration of the study drug. A urine pregnancy test was performed whenever a regular menstrual cycle was not observed during the study (if pregnancy was suspected) and at the end of the study to confirm that the subject was not pregnant during the study. f The study drug was administered by intradiscal injection under fluoroscopic guidance. g If there were X-ray images taken within 14 days prior to obtaining consent, those images were to be used with the subject's consent. hPerformed at the time of visit only.

[0098] 1.5.1.2.1 Clinical trial schedule 1) Screening Screening was conducted on subjects who provided written consent. The screening period from obtaining consent to administering the investigational drug (Day 1) was a maximum of 28 days. If there were X-ray images taken within 14 days prior to obtaining consent, those images could be used with the subject's consent. Based on the inclusion and exclusion criteria for subjects, the principal investigator (subinvestigator) made a comprehensive judgment of the subjects' eligibility and selected them. In this clinical trial, patients who dropped out during the screening period and were not enrolled were allowed to re-enroll. In the case of re-enrollment, new consent was to be obtained from the patient in consultation with the coordinating investigator.

[0099] 2) Administration of the study drug (Day 1) Subjects were hospitalized for 24 hours after the intradiscal injection of the investigational drug and were discharged when all procedures were completed and the investigator deemed it safe for them to be discharged. Note that hospitalizations solely for the purpose of examinations and prolonged hospitalization due to social reasons were not considered adverse events (see "1.5.1.2.18.1 Definition of Adverse Events").

[0100] 3) Observation and examination at the time of discontinuation For subjects who were discontinued in accordance with "1.3.2.2 Criteria for Discontinuation after Study Drug Administration," the observation and examination items specified in Tables 4 and 5 (Observation and Examination Schedule) at 24 weeks after administration were immediately conducted after discontinuation. Among the examples of restricted concomitant drugs and restricted concomitant therapies shown in "1.4.7.2 Restricted Concomitant Drugs and Restricted Concomitant Therapies," cases in which changes to treatment were made after consent was obtained (increased dosage, increased medication / treatment frequency) and examples of prohibited concomitant therapies shown in "1.4.7.3 Prohibited Concomitant Therapies" were considered discontinued cases, but observation and testing were continued even after discontinuation. When continuing observation after discontinuation, evaluation items, etc. were specified at the visit after discontinuation. Analysis of safety and MRI image evaluation after discontinuation was to be conducted.

[0101] 1.5.1.2.2 Obtaining consent Prior to conducting this clinical trial, the principal investigator (sub-investigator) provided the patient with a thorough explanation using an IRB-approved informed consent form, and then obtained written consent from the patient to voluntarily participate in the clinical trial.

[0102] 1.5.1.2.3 Subject demographics At screening, the following data on the subjects' clinical characteristics were collected: Age, sex, race*, medical history, complications, concomitant medications / previous medications, disc herniation level (L3-L4, L4-L5, L5-S1, L3-L4, L4-S1 for sacralization, L4-L5, L5-L6, L6-S1 for lumbarization) *If racial information is not recorded in source documents such as medical records, the principal investigator (sub-investigator) or clinical trial collaborator will collect the information from the subject themselves at the time of screening.

[0103] 1.5.1.2.4 Physical examination A physical examination, including height and weight, was performed at screening. A physical examination, including weight, was performed before dosing. A physical examination, including weight, was performed again 2 hours after dosing to confirm there were no abnormal findings. A physical examination, including weight, was performed 24 hours after dosing and at scheduled visits throughout the study (weeks 1, 2, 4, 6, 13, and 24 after dosing).

[0104] 1.5.1.2.5 MRI images MRI images were taken at screening, and 6 and 13 weeks after the intradiscal injection of the investigational drug. MRI images at screening were taken within 14 days before administration of the investigational drug. The morphology and brightness changes of the endplate adjacent to the administered disc, as well as the size of the disc herniation, were evaluated by two members of an image evaluation committee consisting of third-party radiologists. Images were taken using the same method throughout the clinical trial, and the same model was used as much as possible at each participating medical institution and at the testing facilities designated by each medical institution.

[0105] 1.5.1.2.6 X-ray images Photographs were taken at screening and 6, 13, and 24 weeks after administration to evaluate the disc height (average of anterior and posterior disc height) and lumbar instability (vertebral slippage, intervertebral range of motion, and endplate changes) of the treated discs. Regarding X-ray images taken at screening, if images were taken within 14 days prior to obtaining consent, those images could be used with the subject's consent. At the time of administration, the puncture needle was inserted into the center of the intervertebral disc under X-ray fluoroscopy, and the injection site was photographed.

[0106] 1.5.1.2.7 Neurological examination Examinations were conducted at screening, before administration, 2 and 24 hours after administration, and on the scheduled visit day. Neurological examinations included pain provocation tests such as the leg elevation test and femoral nerve extension test, and neurological findings such as manual muscle testing of both lower limb muscles, sensory (tactile) testing, and lower limb deep tendon reflexes. The results of the neurological examinations were recorded individually on the eCRF. Each neurological finding was recorded, and an overall assessment (worsening, no change, improvement, normalization) compared to baseline was also recorded.

[0107] 1) Pain induction test a) Leg raising test The leg-raising test involved subjects lying supine and raising their legs at three different angles (0-30 degrees, 30-70 degrees, and over 70 degrees), and assessing pain. The angle at which pain appeared (0-30 degrees, 30-70 degrees, or over 70 degrees) was recorded on the eCRF. b) Femoral nerve extension test For the femoral nerve extension test, subjects were asked to lie face down, flex their knees, and extend their hips, and pain was assessed. The results were recorded as "negative" or "positive" on the eCRF.

[0108] 2) Neurological findings a) Manual muscle testing The principal investigator (sub-investigator) or clinical trial collaborator evaluated the degree of force exerted by the subjects' lower limb muscles (iliopsoas, quadriceps, hamstrings, tibialis anterior, gastrocnemius, flexor and extensor muscles of the toes) on a 6-point scale ranging from 0 (no muscle contraction observed) to 5 (the muscles can move across the entire range of motion even with strong resistance). b) Sensory testing The evaluation was performed by touch. The subjects' lower limbs were lightly touched with a soft brush or cotton wool. The principal investigator (subinvestigator) scored the abnormal areas on the doll diagram on the questionnaire. c) Deep tendon reflexes The principal investigator (sub-investigator) or clinical trial collaborator evaluated whether the reflexes were functioning normally at the subject's sites (patellar tendon, Achilles tendon).

[0109] 1.5.1.2.8 Vital signs Heart rate, systolic and diastolic blood pressure, respiratory rate, and body temperature were measured at screening, before administration, and 2, 4, 6, and 24 hours after administration, and on scheduled visits.

[0110] 1.5.1.2.9 12-lead electrocardiogram Electrocardiograms were performed at screening and 24 hours after administration. If any significant abnormalities were detected by electrocardiogram after administration of the study drug, additional tests were performed, and the clinical significance and diagnosis were recorded.

[0111] 1.5.1.2.10 Clinical tests, pregnancy tests, and viral infection tests 1) Clinical testing Hematological tests, blood biochemistry tests, coagulation tests, and urinalysis were performed (see Table 6 (Clinical Test Items) for details). Tests were performed at screening, 24 hours after administration, and at visits 1, 2, and 6 weeks after administration (see Tables 4 and 5 (Observation and Test Schedule)). Laboratory tests were performed in the laboratories of each clinical trial medical institution or at clinical testing institutions contracted by each medical institution. The sample collection date was recorded on the eCRF. Subjects were in a sitting or recumbent position to have blood drawn. Blood collection for clinical tests followed the procedures of the clinical testing institution. Screening clinical test results were defined as the final measurement value before administration of the study drug. Clinical test reference values ​​were used for clinical evaluation. [Table 6] The amount of blood collected in this clinical trial is shown in Table 7 (Amount of blood collected in this clinical trial). [Table 7]

[0112] 2) Pregnancy test Pregnancy testing was performed only on female subjects; it was not required for male subjects. Serum human chorionic gonadotropin beta subunit (βHCG) tests were performed at screening and at the 13-week post-treatment visit. Urinary βHCG tests were performed at least 0 hours before administration and at the 24-week post-treatment visit, or at the time of study discontinuation if the study was discontinued midway. Urine pregnancy tests were performed at appropriate times, also referring to note e in Tables 4 and 5 (observation and testing schedule). If pregnancy was discovered after study drug administration, the study could be continued after ensuring the subject's safety. However, if the study was continued, X-ray imaging was not permitted. Furthermore, efforts were made to collect information in accordance with the "Pregnancy during the Clinical Trial Period" section of the clinical trial protocol.

[0113] 3) Viral infection testing During screening, the presence or absence of hepatitis B virus surface (HBs) antigen, anti-hepatitis C virus (HCV) antibody, and anti-human immunodeficiency virus (HIV) antibody was confirmed.

[0114] 1.5.1.2.11 Anti-KTP-001 antibody measurement Blood samples for measuring serum anti-KTP-001 antibodies were collected before administration and at a visit 13 weeks after administration.

[0115] 1.5.1.2.12 Pharmacokinetic (PK) Measurements Serum KTP-001 concentrations were measured before administration and 2, 4, 6, and 24 hours after administration. The following PK parameters were measured using serum KTP-001 concentration data. * Maximum serum concentration (C max ) (unit: μg / mL) * Time to reach maximum serum concentration (T max ) (unit: h) * Area under the serum concentration-time curve (AUC) from 0 to 24 hours after administration 0-24h )(Unit:h*μg / mL)

[0116] 1.5.1.2.13 Pharmacodynamic (PD) measurements Blood samples for keratan sulfate concentrations were collected before administration, 24 hours after administration, and 1, 2, and 6 weeks after administration. Serum keratan sulfate concentrations were measured using an enzyme-linked immunosorbent assay.

[0117] 1.5.1.2.14 Pain assessment 1) Low back pain and leg pain (NRS) The survey was conducted at screening, before administration, and 2, 4, 6, and 24 hours after administration, as well as on designated visit days. Subjects' lower back pain and leg pain (worst pain and average pain in the past 24 hours, and current pain at 2, 4, and 6 hours after administration) were assessed using an 11-point numerical rating scale of the NRS.

[0118] 2) Use of auxiliary medications (analgesics) This was checked at screening, before administration, 24 hours after administration, and on scheduled visits.

[0119] 3) Pain Detect The survey was conducted at screening, before administration, 24 hours after administration, and on the scheduled visit. Subjects rated their own pain using the Japanese version of Pain Detect. Nine questions were scored (0 to 38 points).

[0120] 1.5.1.2.15 Physical function assessment The ODI (version 2.0) was used to measure the degree to which lower back or leg pain interfered with the subject's ability to manage daily tasks. Improvement, no change, or deterioration in functional level was assessed by the change in score from baseline. The ODI measures daily functioning in nine domains: pain intensity, self-care, lifting, walking, sitting, standing, sleep, social life, and transportation. The question about sexual activity was omitted from this study. Items were scored from 0 to 5, with 0 representing the best level of function and 5 representing the worst level of function. A percentage was then calculated from these responses (subject score / maximum total score: 45 points x 100) and recorded as the ODI for that day. Scores were then categorized into disability levels, as shown in Table 8 below. [Table 8]

[0121] 1.5.1.2.16 Quality of Life (QOL) Assessment The survey was conducted at screening, before administration, 24 hours after administration, and on the scheduled visit. Subjects evaluated their health status using the EuroQol 5 Dimensions 5 Level (EQ-5D-5L) developed by the EuroQol Group. Five overall health utility scales (mobility, personal care, usual activities, pain / discomfort, and anxiety / depression) were each rated on a 5-point scale. The QOL score developed by Ikeda et al. (Non-Patent Document 5) was also used.

[0122] 1.5.1.2.17 Provision, collection, and confirmation of patient diary At the time of screening, the principal investigator (sub-investigator) or clinical trial collaborator handed the patient diary to the subject and instructed them to fill out "12) Pain Assessment" with "i) Lower back pain and leg pain (NRS)" and "ii) Use of adjunctive medications (analgesics)." The principal investigator (sub-investigator) collected and checked the patient diary according to the prescribed schedule, and then recorded the information in the eCRF.

[0123] 1.5.1.2.18 Adverse Events

[0124] 1.5.1.2.18.1 Definition of Adverse Events In this clinical trial, an adverse event is any undesirable or unintended sign (including abnormal laboratory test values), symptom, or disease that occurs in a subject after administration of the investigational drug or procedure for the administration of the investigational drug, but before the end of the clinical trial, regardless of whether or not there is a causal relationship with the investigational drug or clinical trial procedure. The following events are not considered adverse events: * Procedures for diagnostic purposes only (endoscopy, etc.) * Fluctuations in the disease or condition that were present before the start of the clinical trial are within the expected daily range of fluctuation or have not worsened. * If no adverse medical events have occurred (social hospitalization, visits / hospitalization for tests / medication, etc.)

[0125] 1.5.1.2.18.1.1 Definition of a Serious Adverse Event Serious adverse events are defined as follows among the adverse events defined in "1.5.1.2.18.1 Definition of Adverse Events": 1) death 2) Anything that may lead to death 3) Treatment requires hospitalization or an extended hospital stay. 4) Disability 5) Anything that may cause injury 6) Cases that are serious in nature, similar to those listed in 1) to 5). 7) Congenital diseases or abnormalities in future generations

[0126] 1.5.1.2.18.1.2 Side effects If the investigator (sub-investigator) cannot deny the causal relationship between an adverse event that occurred after administration of the investigational drug and the investigational drug, the adverse event will be defined as an adverse reaction.

[0127] 1.5.1.2.18.2 Evaluation of Adverse Events

[0128] 1.5.1.2.18.2.1 Assessment of the severity of adverse events The severity was determined using CTCAE ver. 5.0 on a 5-point scale (Grades 1 to 5). Adverse events not defined in CTCAE ver. 5.0 were determined according to the severity shown in Table 9 below. [Table 9]

[0129] 1.5.1.2.18.2.2 Assessment of causality of adverse events The causal relationship to the administration of the investigational drug was determined according to one of the categories shown in Table 10 below. [Table 10] The causal relationship with the administration of the investigational drug was determined by taking into consideration the subject's general condition, complications, concomitant medications and therapies, and the temporal relationship. The causal relationship was determined by the principal investigator (subinvestigator).

[0130] 1.5.1.2.18.2.3 Adverse Event Outcome The outcome of an adverse event will be classified into one of the categories shown in Table 11 below. [Table 11]

[0131] 1.5.1.2.18.3 Adverse Events of Interest The following adverse events were considered to be of interest and were to be reported to the coordinating investigator (clinical trial coordinating office) and the investigators of other medical institutions jointly conducting the clinical trial within 24 hours of the principal investigator (sub-investigator) becoming aware of the occurrence of the event. 1) MRI or X-ray findings show the appearance of modic changes, a decrease in intervertebral disc height of 30% or more compared to before administration, or the appearance of intervertebral instability 2) When worsening of leg pain is observed. In other words, when the average daily leg pain score on the NRS increases by 2 points or more from before administration and this condition continues for 3 or more consecutive days. 3) Objective changes in neurological examination (progression of muscle weakness, worsening of sensory disturbances, changes in deep tendon reflexes) regardless of changes in pain 4) When emergency MRI, epidural steroid injection, selective nerve root block, or surgical intervention is performed at the discretion of the investigator (subinvestigator).

[0132] 1.5.1.2.18.4 Anticipated adverse events Adverse events that the investigator (subinvestigator) judged to be "expected" were defined as "expected adverse events."

[0133] 1.5.1.2.18.5 Pregnancy during the clinical trial If the principal investigator (subinvestigator) finds out that a female subject is pregnant after the administration of the investigational drug, he / she will immediately consider discontinuing some tests such as X-rays, monitor the progress, and report this to the coordinating investigator. Furthermore, if the pregnancy of a male subject's partner is found to be a pregnancy problem, the principal investigator (subinvestigator) will endeavor to obtain information on the subsequent progress with the consent of the subject or partner. If the pregnancy of the subject or the male subject's partner results in a serious adverse event (e.g., postpartum complications, spontaneous abortion, stillbirth, neonatal death, congenital anomaly, etc.), the principal investigator (subinvestigator) will promptly report this in accordance with "1.5.1.2.18.1 Definition of Adverse Events."

[0134] 1.5.1.3 Evaluation Contents

[0135] 1.5.1.3.1 Primary endpoint (safety) *Adverse events * Vital signs * 12-lead electrocardiogram * Clinical testing *MRI images * X-ray image * Anti-KTP-001 antibody

[0136] 1.5.1.3.2 Secondary endpoints 1) Pain assessment (pain intensity) *NRS* assessment of leg pain *NRS* assessment of low back pain *Worst pain and average pain over the past 24 hours 2) Neurological examination * Leg raising test * Femoral nerve extension test 3) PK and PD *PK: Serum KTP-001 concentration, PK parameters (C max , T max , AUC 0-24h ) *PD: Serum keratan sulfate concentration

[0137] 1.5.1.3.3 Exploratory Endpoints 1) Pain assessment i) Pain intensity *ODI * Use of auxiliary medications (analgesics) ii) Type of pain * Pain Detect 2) Physical function assessment * EQ-5D-5L 3) Neurological examination * Overall neurological assessment 4) Presence or absence of restricted concomitant medications, their contents (including dose reduction and reduction in administration frequency), and duration 5) Presence or absence of additional treatment*, its contents, and the period until its initiation *Additional treatment: When new restricted drugs, permitted drugs, or prohibited therapies are used during the clinical trial period, or when restricted drugs or restricted therapies are added or treatment content is changed. 6) MRI images (changes in size of herniated disc)

[0138] 1.5.2 Appropriateness of Measurements

[0139] 1.5.2.1 Primary Safety Endpoint The safety endpoints selected for this clinical trial were typical for the patient population with herniated discs and were widely used both domestically and internationally.

[0140] 1.5.2.2 Secondary and Exploratory Efficacy Endpoints The efficacy endpoints selected in this trial were those previously selected in domestic and international patient populations with disc herniation. The NRS is considered a robust and reliable method for measuring pain in patients with chronic pain (Non-Patent Document 6).

[0141] 1.5.3 Primary Safety Endpoint The primary safety endpoint and the rationale for its establishment are described in "1.5.1.3.1 Primary Endpoint (Safety)" and "1.5.2 Appropriateness of Measurement Items."

[0142] 1.5.4 Measurement of drug concentrations Serum KTP-001 concentration and its PK parameters (C max , T max , AUC 0-24h ) were set as other secondary endpoints.

[0143] 1.6 Data Quality Assurance

[0144] 1.6.1 Quality Control and Quality Assurance of Clinical Trials The coordinating investigator set quality goals, prepared a quality management plan that outlined the plan for achieving the quality goals, and disseminated it to all personnel involved in the clinical trial. No risks anticipated in the quality management plan were observed in this clinical trial, and no new risks were observed during the conduct of the trial. In order to ensure the proper implementation of the following quality control and quality assurance activities, the principal investigator and the head of the participating medical institution will ensure that monitors, auditors, and regulatory authorities have direct access to source documents, and will be present at and respond to monitoring, audits, and inspections as necessary.

[0145] 1.6.2 Quality control The accuracy, consistency, completeness, and reliability of the data in this study were ensured by: 1) The monitor appointed by the coordinating investigator conducted monitoring and confirmed that the clinical trial was being conducted appropriately in compliance with the clinical trial protocol and GCP, etc. 2) A monitor appointed by the coordinating investigator personally reviewed the source documents and confirmed the accuracy of the eCRF. 3) The principal investigator ensured that the clinical trial was being properly monitored by monitors appointed by the coordinating investigator, who visited the medical institution and other facilities involved in the conduct of the clinical trial and directly inspected the source documents.

[0146] 1.6.3 Quality Assurance 1) The auditor evaluated whether the clinical trial system at the medical institution conducting the clinical trial and other facilities involved in the conduct of the clinical trial was properly established and functioning appropriately. 2) The auditors conducted on-site audits at the participating medical institutions as necessary and confirmed that the clinical trial was being conducted appropriately and that the reliability of the data was being maintained by directly inspecting the source documents, etc. 3) The coordinating investigator prepared a procedure manual for conducting the audit of this clinical trial and ensured that the audit was conducted in accordance with said procedure manual and the audit plan based on said procedure manual. Regarding clinical testing, standardization and quality assurance were carried out between facilities.

[0147] 1.7 Determining the Statistical Methods and Sample Size Planned in the Clinical Trial Protocol

[0148] 1.7.1 Statistical and Analytical Plan The statistician prepared a statistical analysis plan before the first subject enrolled in this clinical trial. After data fixation, the statistician performed the analysis in accordance with the statistical analysis plan. In addition, if the analysis plan was changed, the statistician revised the statistical analysis plan in accordance with standard operating procedures, and recorded the timing, content, reason, and person who made the revision. The main analysis items and analysis methods were as follows: 1) Treatment of subjects found to be non-compliant with GCP Subjects found to be non-compliant with GCP were excluded from all analysis populations. 2) Significance and confidence levels When conducting tests, the significance level was set at 5% on both sides. Confidence intervals were calculated using two-sided confidence intervals with a 95% confidence level. Confidence intervals were calculated using the Clopper-Pearson method for analyses of adverse events and side effects, and the Kaplan-Meier method for analyses of the time to additional treatment. 3) Summary statistics Quantitative characteristics were summarized using number of cases, mean, standard deviation, minimum, median, and maximum. Qualitative characteristics were summarized using number of cases and percentage of cases in categories. 4) Baseline value The most recent measurement value obtained between -24 hr and 0 hr on Day 1 (or at screening for items not measured between -24 hr and 0 hr on Day 1) before administration of the study drug was used as the baseline value. 5) Handling of missing and rejected data Missing and unaccepted data were not imputed.

[0149] 1.7.1.1 Statistical Analysis Plan

[0150] 1.7.1.1.1 Analysis Set 1) Full Analysis Set (FAS) The group included those who were enrolled in this clinical trial and received the investigational drug at least once. 2) Per Protocol Analysis Set (PPS) This group was selected from the FAS, excluding subjects who met the inclusion criteria and were judged to have an impact on the efficacy evaluation, as follows: i) Those that violate the exclusion criteria ii) Violation of restricted concomitant medications, restricted concomitant therapies, and prohibited concomitant therapies iii) Subjects who met the discontinuation criteria for the clinical trial but did not discontinue the trial iv) Violation of the dosage, administration period, and administration method 3) Safety Analysis Set (SAF) The group consisted of subjects who received the investigational drug at least once and were followed up.

[0151] 1.7.1.1.2 Demographics and other baseline characteristics Summary statistics were calculated for demographics and other baseline characteristics by group.

[0152] 1.7.1.1.3 Safety Analysis

[0153] 1.7.1.1.3.1 Analyzed metrics The following indicators were analyzed for each group. 1) Adverse events The number of adverse events and side effects, the number of cases, the incidence rate, and their 95% confidence intervals were calculated using the Clopper-Pearson method. Similar analyses were also performed by severity and seriousness. 2) Clinical test values, vital signs, 12-lead electrocardiogram, MRI, X-ray, anti-KTP-001 antibody Summary statistics of measured values ​​were calculated by measurement time point, and summary statistics of changes from baseline were calculated by time point after the start of administration.

[0154] 1.7.1.1.3.2 Handling of adverse events and side effects

[0155] 1.7.1.1.3.2.1 Adverse events and side effects The study included adverse events and side effects that occurred from the start of administration of the study drug to the end of the post-administration observation period (24 weeks / discontinuation).

[0156] 1.7.1.1.3.2.2 Count If multiple adverse events (adverse reactions in the adverse reaction count, SOCs in the system organ class [SOC] count, and PTs in the preferred term [PT] count) occurred in the same subject, each was counted as one event and not combined.

[0157] 1.7.1.1.3.2.3 Number of cases If the same subject experienced multiple adverse events (side effects in the side effect tabulation, SOC in the SOC tabulation, and PT in the PT tabulation), they were counted as one case and processed together. In addition, if the same subject experienced multiple occurrences of the same SOC (PT when counting by PT) with different severity / severity, the worst severity / severity was counted as one case.

[0158] 1.7.1.1.4 Efficacy Analysis The following statistics were calculated for each efficacy endpoint by group:

[0159] 1.7.1.1.4.1 Secondary endpoints 1) Pain assessment (pain intensity) *NRS* assessment of leg pain, NRS* assessment of lower back pain Summary statistics were calculated for the results observed at each time point from baseline to 24 weeks after administration. Summary statistics were also calculated for the change from baseline at each time point. *Worst pain and average pain over the past 24 hours 2) Neurological examination * Leg raising test For each measurement period from baseline to 24 weeks after administration, the number and percentage of patients with each diagnostic result (0 to less than 30 degrees, 30 to less than 70 degrees, 70 degrees or more) were calculated. In addition, a shift table for each measurement point relative to the baseline results was created. * Femoral nerve extension test The number and percentage of patients with each diagnostic result (negative, positive) were calculated for each measurement period from baseline to 24 weeks after administration. A shift table was also created for each measurement point relative to the baseline results.

[0160] 1.7.1.1.4.2 Exploratory Endpoints 1) Pain assessment (pain intensity) *ODI Summary statistics were calculated for the results observed at each time point from baseline to 24 weeks after administration. Summary statistics were also calculated for the change from baseline at each time point. * Use of auxiliary medications (analgesics) The number and percentage of subjects who used adjunctive medications (analgesics) were calculated for each measurement period from Day 1 0 hours to 24 weeks after administration and for the entire period. 2) Pain assessment (type of pain) * Pain Detect Summary statistics were calculated for the scores of nine questions, with results observed from baseline to 24 weeks after administration. Summary statistics were also calculated for the change from baseline at each time point. 3) Physical function assessment * EQ-5D-5L For the results observed at each evaluation point from baseline to 24 weeks after administration, summary statistics of the QOL scores and their changes based on the EQ-5D-5L questionnaire were calculated. 4) Neurological examination * Neurological findings The evaluations of manual muscle testing, sensory testing, and deep tendon reflexes and their findings were comprehensively judged, and the evaluation of neurological findings from baseline to 24 weeks after administration was compared with baseline to calculate the number and percentage of cases corresponding to each diagnostic result (0: worsening, 1: no change, 2: improvement, 3: normalization). 5) Presence or absence of additional treatment, its contents, and the period until its initiation The occurrence of additional treatment was referred to as an "event," and the number of days until the event was compared between groups using the log-rank test. The Kaplan-Meier method was used to calculate the event rate and its 95% confidence interval for each group, and a Kaplan-Meier plot of the event rate was also created. For subjects who were lost to follow-up and discontinued treatment due to adverse events, these were treated as competing risks, and the cumulative incidence function method was used to calculate the event rate and its 95% confidence interval as a supplementary analysis. 6) MRI images (changes in size of herniated disc) The MRI evaluators evaluated the MRI images in the following order (a) to (c). (a) For each case number (Y-001, etc.), a table containing the following information was prepared and submitted to the secretariat. * Presence and extent of changes in the endplates (modic changes, etc.) and intervertebral discs on MRI (whether there are any inconsistencies with the natural course of herniation, etc.). * MRI-based herniated disc volume was evaluated for each case using two methods: with and without a tendency toward shrinkage. (b) The secretariat then disclosed to the MRI evaluator which group the case number belonged to (allocation list). (c) After evaluation, group information was obtained. Changes in each case were observed while ensuring blinding using the above flow. Finally, the MRI evaluators conferred and qualitatively evaluated each group in comparison with the other groups.

[0161] 1.7.1.1.5 Pharmacokinetic Analysis Summary statistics (number of subjects, mean, standard deviation, minimum, median, maximum, and coefficient of variation) were calculated for serum KTP-001 concentrations at each blood sampling time point. max , T max , AUC 0-24h ) summary statistics were to be calculated. If PK parameters other than these were to be calculated, they were to be described in the analysis plan. PK parameters were calculated from serum KTP-001 concentration data and actual sample collection times by non-compartmental analysis using Phoenix WinNonlin (Certara LP, Princeton, NJ, USA, version 8.0 or higher). AUC 0-24h The linear trapezoidal method was used to calculate the lower limit of quantitation. The lower limit of quantitation was set at 0.1 (μg / mL), and any values ​​observed below the lower limit of quantitation were treated as 0 (μg / mL) and used in the analysis.

[0162] 1.7.1.1.6 Pharmacodynamic analysis Summary statistics (number of subjects, mean, standard deviation, minimum, median, maximum) were calculated for serum keratan sulfate concentrations and changes from baseline at each blood sampling time point.

[0163] 1.7.2 Determining the number of cases Target number of cases: 18 cases + additional cases (maximum 5 cases) For the KTP-001 administration group, the following number of subjects was set as subjects eligible for safety evaluation up to 6 weeks after administration of the investigational drug. * Cohort 1: 3 cases in the sham group, 3 cases in the KTP-001 150 μg group * Cohort 2: 6 patients in the KTP-001 300 μg group * Cohort 3: 6 cases in the KTP-001 600 μg group In addition, if any of the three patients in the 150 μg group in Cohort 1 discontinued treatment within six weeks and safety could not be evaluated up to six weeks, additional cases would be added as appropriate. In addition, we decided to add cases (up to 5 cases) to the cohort of doses for which safety was confirmed and efficacy in secondary endpoints was suggested.

[0164] <Basis for setting the number of cases in the cohort> The dose used in Cohort 1 has been confirmed to be safe and tolerable in US trials, and no specific adverse events are anticipated, but to observe at least one case of an adverse event with an incidence rate of 70% or more with 90% detection power, three subjects are required. Because this clinical trial will be conducted at two centers with due consideration given to safety, the target number of cases for Cohort 1 was set at three, taking feasibility into account. Similarly, six subjects were required for Cohort 2 and Cohort 3 to observe at least one case of an adverse event with an incidence rate of 40% or higher with 90% detection power. Because this clinical trial would be conducted at two centers with careful consideration given to safety, the target number of cases for Cohort 2 and Cohort 3 was set at six, taking feasibility into consideration. It was decided to add up to five cases to the cohort of the dose for which safety was confirmed and efficacy in the secondary endpoint was suggested, and to explore efficacy in addition to confirming safety in that cohort. By adding five cases to the cohort, for a total of 11 cases, it was possible to secure the number of cases necessary to observe at least one case of an adverse event with an incidence rate of 20% or higher with 90% detection power.

[0165] 2. Patients eligible for the clinical trial Subjects enrolled in Cohort 1 received a single intradiscal injection of 150 μg or sham, subjects enrolled in Cohort 2 received 300 μg, and subjects enrolled in Cohort 3 received 600 μg (puncture only in the sham group).

[0166] 2.1 Subject breakdown The breakdown of subjects in consented cases is shown in Table 12 (Breakdown of subjects (consented cases)), and a summary of reasons for discontinuation is shown in Table 13 (Summary of reasons for discontinuation (consented cases)). A list of discontinued cases is attached in Appendix 16.2.1. [Table 12] [Table 13] Of the 24 patients who provided consent, 19 received the study drug, and 5 discontinued the study before administration. Of the 19 patients who received the study drug, 5 discontinued the study after administration. Reasons for discontinuation before administration of the study drug included ineligibility at screening in 3 cases, subject request (refusal or withdrawal of consent) and investigator's decision in 1 case each. Reasons for discontinuation after administration of the study drug included restricted concomitant medications and restricted concomitant therapy in 4 cases, and insufficient efficacy in 1 case.

[0167] 2.2 Protocol Deviations The breakdown of protocol deviations in consented cases is shown in Table 14 (Protocol deviations (consented cases)). [Table 14] Of the 24 consented cases, no significant deviations from the clinical trial protocol were noted, but non-significant deviations were noted in 8. The breakdown of non-significant deviations was as follows: "MRI imaging was performed using the wrong imaging procedure manual" in 6 cases, "due to an EDC error, the treatment group was assigned the day before administration," "administration of restricted concomitant medications," and "missing future visits and tests on the scheduled visit date due to COVID-19 infection" in 1 case each. There were no deviations from the protocol that could have affected the study results.

[0168] 3. Evaluation of efficacy

[0169] 3.1 Analyzed dataset The datasets analyzed in this trial are shown in Table 15 (Datasets Analyzed). [Table 15] Of the 24 subjects who provided consent, 3 subjects were ineligible at screening, 1 subject requested treatment, and 1 subject was deemed by the investigator (sub-investigator) to be difficult to administer the investigational drug. The remaining 19 subjects were included in the SAF, FAS, and PPS. The number of subjects included in the FAS and PPS was the same, but the analysis period differed depending on the subject.

[0170] 3.2 Demographic and other baseline characteristics

[0171] 3.2.1 Subject background The subject background of the SAF is shown in Tables 16 and 17 (Subject Background (SAF)). [Table 16] [Table 17] The demographic and other baseline characteristics of the SAF are summarized below. The gender distribution was male: 33.3% (1 / 3 cases) in the sham group, 100% (3 / 3 cases) in the 150 μg group, 81.8% (9 / 11 cases) in the 300 μg group, and 100.0% (2 / 2 cases) in the 600 μg group. Age (mean ± standard deviation [minimum, maximum]) was 46.3 ± 15.9 years (28, 57 years) in the sham group, 49.7 ± 7.4 years (44, 58 years) in the 150 μg group, 37.5 ± 7.4 years (27, 51 years) in the 300 μg group, and 33.0 ± 7.1 years (28, 38 years) in the 600 μg group. The main locations of disc herniation were L4-L5 in 66.7% (2 / 3 cases) of the sham group, 33.3% (1 / 3 cases) of the 150 μg group, 54.5% (6 / 11 cases) of the 300 μg group, and 0% (0 / 2 cases) of the 600 μg group, and L5-S1 in 33.3% (1 / 3 cases) of the sham group, 66.7% (2 / 3 cases) of the 150 μg group, 36.4% (4 / 11 cases) of the 300 μg group, and 100.0% (2 / 2 cases) of the 600 μg group.

[0172] 3.2.2 Medical history, complications The percentage of subjects with a medical history was 66.7% (2 / 3 subjects) in the sham group, 100% (3 / 3 subjects) in the 150 μg group, 36.4% (4 / 11 subjects) in the 300 μg group, and 0% (0 / 2 subjects) in the 600 μg group (Tables 16 and 17). The only medical history observed in two or more subjects in each group was appendicitis (3 subjects in the 150 μg group), and each of the other medical histories was observed in one subject each. The percentage of subjects with complications was 66.7% (2 / 3 subjects) in the sham group, 66.7% (2 / 3 subjects) in the 150 μg group, 54.5% (6 / 11 subjects) in the 300 μg group, and 100.0% (2 / 2 subjects) in the 600 μg group. The only complication observed in two or more subjects in each group was seasonal allergy (2 subjects in the 300 μg group), and each of the other complications was observed in one subject each.

[0173] 3.3 Measuring treatment adherence The administration status of the investigational drug in the FAS is shown in Table 18 (Administration Status of Investigational Drug (FAS)). [Table 18] The mean total dose of the investigational drug was 150 μg in the 150 μg group, 300 μg in the 300 μg group, and 600 μg in the 600 μg group, and all doses were administered as planned. All patients in the FAS (3 in the sham group, 3 in the 150 μg group, 11 in the 300 μg group, and 2 in the 600 μg group) received a single intradiscal injection of the investigational drug (only puncture in the sham group).

[0174] 3.4 Efficacy Results and Individual Patient Data Tables

[0175] 3.4.1 Efficacy Analysis

[0176] 3.4.1.1 Secondary endpoints

[0177] 3.4.1.1.1 Pain assessment (pain intensity)

[0178] 3.4.1.1.1.1 Assessment of leg pain The progression of lower limb pain in the FAS is shown in Figure 4 (average pain over the past 24 hours) and Figure 5 (worst pain over the past 24 hours). The mean values ​​of leg pain (average pain over the past 24 hours and worst pain) in the FAS decreased over time from baseline in all groups. A similar trend was observed in the PPS.

[0179] 3.4.1.1.1.2 Assessment of low back pain The changes in lower back pain in the FAS are shown in Figure 6 (average pain over the past 24 hours) and Figure 7 (worst pain over the past 24 hours). The mean values ​​of low back pain (average pain over the past 24 hours and worst pain) on the FAS decreased over time from baseline in all groups. A similar trend was observed in PPS.

[0180] 3.4.1.1.2 Neurological examination

[0181] 3.4.1.1.2.1 Leg Raise Test The shift tables for the leg raising test in PPS are shown in Tables 19 and 20 (Leg Raising Test Shift Tables (PPS)). [Table 19] [Table 20] In the PPS, the sham group showed a 90% or greater improvement in the leg-raising test after 24 weeks of treatment or at discontinuation, while the 150 μg group showed a 90% or greater improvement as early as 6 weeks after treatment, and the 300 μg group showed a 90% or greater improvement as early as 4 weeks after treatment. Furthermore, the groups administered this drug showed a tendency for improvement 2 hours after treatment. In particular, the 300 μg group showed a significant improvement compared to baseline 2 hours after treatment, with an 80% improvement 1 week after treatment. Similar results were observed in FAS. *Improvement rate: The percentage of cases in which the temperature at baseline was "0 to less than 30 degrees" and changed to "30 to less than 70 degrees" or "70 degrees or more," or the percentage of cases in which the temperature at baseline was "30 to less than 70 degrees" and changed to "70 degrees or more."

[0182] 3.4.1.1.2.2 Femoral nerve extension test The shift table for the femoral nerve extension test in FAS is shown in Table 21 (Shift Table for Femoral Nerve Extension Test (FAS)). [Table 21] The results of the femoral nerve extension test at baseline in the FAS were negative in all subjects. In the 150 μg group, one case changed from "negative" to "positive" 24 hours after administration and one case changed to "positive" one week after administration, but no cases changed to "positive" two weeks or later after administration. In the 300 μg group, one case was observed in which the test result changed from "negative" to "positive" two hours after administration, but no cases changed to "positive" after 24 hours after administration. In the sham group and the 600 μg group, there were no cases in which the test result changed from "negative" to "positive." Similar results were observed in PPS.

[0183] 3.4.1.2 Exploratory Endpoints

[0184] 3.4.1.2.1 Pain assessment

[0185] 3.4.1.2.1.1 Pain intensity

[0186] 3.4.1.2.1.1.1 Oswestry Disability Index(ODI) The change in ODI over time in FAS is shown in Tables 22A and 22B (Change in ODI (FAS)), and the change in ODI over time in PPS is shown in Tables 23A and 23B (Change in ODI (PPS)). [Table 22A] [Table 22B] [Table 23A] [Table 23B] The mean ODI values ​​in the FAS decreased over time in the sham group, starting 24 hours after skin puncture. On the other hand, in the 150-600 μg group, the mean ODI values ​​were maintained for 1-4 weeks after administration and then decreased. At 24 hours after administration, the 300 μg group showed a significant improvement compared to baseline. Similar results were observed in PPS.

[0187] 3.4.1.2.1.1.2 Adjunctive medication (analgesic) use status The use of adjunctive medications (analgesics) in the FAS is shown in Table 24 (Use of adjunctive medications (analgesics) (FAS)). [Table 24] In the 300 μg group of the FAS, the proportion of subjects who used adjunctive medications (analgesics) was 54.5% (6 / 11 cases) at baseline, and 90.0% (9 / 10 cases) and 81.8% (9 / 11 cases) at 1 and 2 weeks after administration of the drug, respectively, which was higher than baseline, but then remained at the same level as baseline. The number of cases in the sham group and the 150 and 600 μg groups was small, and no consistent trend was observed in the use of adjunctive medications (analgesics). Similar results were observed in PPS.

[0188] 3.4.1.2.1.2 Pain Detect Summaries of Pain Detect in the FAS are shown in Tables 25 and 26 (Summary of Pain Detect (FAS)). [Table 25] [Table 26] The mean Pain Detect scores on the FAS decreased over time from baseline in all groups. Similar results were observed in PPS.

[0189] 3.4.1.2.2 Physical Function Assessment (EQ-5D-5L) The changes in EQ-5D-5L scores in the FAS are shown in Tables 27 and 28 (Changes in EQ-5D-5L scores (FAS)). [Table 27] [Table 28] The mean EQ-5D-5L scores in the FAS increased over time from baseline in all groups except the 600 μg group, in which the scores decreased from baseline until one week after administration and then increased over time. Similar results were observed in the PPS.

[0190] 3.4.1.2.3 Neurological examination The changes in the overall assessment of neurological findings in the FAS compared to baseline are shown in Tables 29A to 29B (Changes in the overall assessment of neurological findings compared to baseline (FAS)), and the changes in the overall assessment of neurological findings in the PPS compared to baseline are shown in Table 29C (Changes in the overall assessment of neurological findings compared to baseline (PPS)). [Table 29A] [Table 29B] [Table 29C] In the sham group of the FAS, improvement in neurological findings was observed as early as two weeks after administration, whereas in the 150-600 μg group, improvement in neurological findings was observed as early as two hours after administration. Significant improvement in neurological findings was observed 24 hours after administration in the 300 μg group compared to the sham group. Similar results were observed in the PPS.

[0191] 3.4.1.2.4 Presence or absence of restricted concomitant medications, their contents (including dose reduction and reduction in administration frequency), and duration Of the 19 patients who received the investigational drug, 17 used restricted concomitant medications during the clinical trial period. The breakdown of the purpose of use was "primary disease" in 15 cases and "adverse events" in 4 cases (some overlapping). Of the 15 cases in which the purpose of use was "primary disease," 10 cases discontinued administration of restricted concomitant medications after administration of this drug (2 of which discontinued administration after reducing the dosage), and 5 cases continued administration of restricted concomitant medications. The four patients whose intended use was for "adverse events" experienced hypoesthesia, hypoesthesia and pain in the limbs, joint pain and pain in the limbs, and intervertebral disc protrusion, and therefore used restricted concomitant medications. However, all of the events resolved or improved, and the use of restricted concomitant medications was discontinued.

[0192] 3.4.1.2.5 Presence or absence of additional treatment, its contents, and the period until its initiation A Kaplan-Meier plot of time to additional treatment in the FAS is shown in Figure 8 . The time until additional treatment occurred in 50% of subjects in the FAS was approximately 14 weeks in the sham group (3 cases), approximately 2 weeks in the 150 μg group (3 cases), approximately 6 weeks in the 300 μg group (11 cases), and approximately 1.5 weeks in the 600 μg group (2 cases), and the time until additional treatment occurred was longer in the sham group than in the other groups. The number of subjects was small, and no specific trends were observed between groups and the time to additional treatment. Similar results were observed in PPS.

[0193] 3.4.1.2.6 MRI images (changes in size of herniated disc)

[0194] 3.4.1.2.6.1 Presence and degree of changes in the intervertebral disc and endplate The presence and extent of changes in the intervertebral disc and endplate were evaluated using FAS and PPS. MRI of one patient in the 300 μg group (subject number: Y-010) revealed Type 1 Modic changes that progressed both 6 and 13 weeks after administration, a finding consistent with those occurring in the natural course of herniation. Three patients in the 300 μg group (subject numbers: Y-018, K-004, K-006) showed Type 3 Modic changes from the initial MRI, but no tendency for these changes to increase or decrease was observed during follow-up. Based on the above, no changes in the intervertebral disc or endplate were observed that were strongly suspected to be caused by administration of this drug.

[0195] 3.4.1.2.6.2 Assessment of disc herniation volume The evaluation results of the disc herniation volume by MRI are shown in Table 30 (Evaluation results of disc herniation volume). In this clinical trial, some cases in the sham group showed a reduction in hernia size over time (33.3% at 6 weeks and 66.7% at 13 weeks after administration), but this was considered reasonable as a natural reduction in hernia size. It is also worth noting that although this clinical trial was not designed to test for significant differences and therefore did not result in a significant difference, at 13 weeks after administration, a trend toward a reduction of 81.8% in the 300 μg group and 100% in the 600 μg group was observed, which may represent a certain effect of this drug. [Table 30] *Three pairwise comparisons were performed between the Sham group and the other three groups using Fisher's exact test, and no significant differences were found.

[0196] 3.4.2 Pharmacodynamics

[0197] 3.4.2.1 Serum keratan sulfate concentration The time course of serum keratan sulfate concentrations in PPS is shown in FIG. Serum keratan sulfate concentrations increased dose-dependently at each time point. No clear changes over time were observed in serum keratan sulfate concentrations in the sham group or the 150 μg group. In the 300 μg group, serum keratan sulfate concentrations began to increase 24 hours after administration, peaked at 1 week after administration (mean change from baseline in serum keratan sulfate concentrations: 265,300 ng / mL), and then decreased. In the 600 μg group, serum keratan sulfate concentrations began to increase 24 hours after administration, peaking at 2 weeks after administration (mean change from baseline in serum keratan sulfate concentrations: 710,000 ng / mL).

[0198] 3.4.3 Statistical and analytical issues Details of the statistical methods used for analysis in this clinical trial were summarized in the Statistical Analysis Plan (Version 3.0).

[0199] 3.4.3.1 Adjustment for covariates No adjustment for covariates was performed in this study.

[0200] 3.4.3.2 Handling of Dropouts or Missing Values Missing data were not imputed in this study.

[0201] 3.4.3.3 Interim Analysis and Data Monitoring No interim analysis was performed in this clinical trial. Regarding data monitoring, an efficacy and safety evaluation committee was established to consider and evaluate the occurrence of serious adverse events of concern, and to provide advice and recommendations to the coordinating investigator regarding the addition of cases to the highest dose cohort that was deemed safe, and the clinical trial was conducted based on the committee's deliberations.

[0202] 3.4.3.4 Multicenter Clinical Trials Although this clinical trial was a multicenter study, no analysis by center was performed.

[0203] 3.4.3.5 Multiple comparisons / multiplicity The primary analysis item in this study was the safety of the investigational drug in the analysis population. Other analysis items were treated as secondary, so no adjustment for multiplicity was performed.

[0204] 3.4.3.6 Use of Efficacy Subpopulations of Patients Not applicable

[0205] 3.4.3.7 Active Control Studies Intended to Show Equivalence Not applicable

[0206] 3.4.3.8 Subgroup Considerations Not applicable

[0207] 3.4.4 Tabulation of individual response data Individual efficacy response data were generated for each subject.

[0208] 3.4.5 Drug Dose, Drug Concentration, and Their Relationship to Response This was not planned or carried out in this clinical trial.

[0209] 3.4.6 Drug-drug and drug-disease interactions This was not planned or carried out in this clinical trial.

[0210] 3.4.7 Patient-specific display A list of each data item was prepared for each subject.

[0211] 3.4.8 Efficacy and Pharmacodynamic Conclusions * Mean leg pain and low back pain (average pain over the past 24 hours and worst pain) decreased over time from baseline in all groups. * In the leg-raising test, PPS showed a 90% or greater improvement in the sham group after 24 weeks of administration or at discontinuation, while the 150 μg group showed a 90% or greater improvement as early as 6 weeks after administration, and the 300 μg group showed a 90% or greater improvement as early as 4 weeks after administration. The leg-raising test showed a tendency for improvement two hours after administration. In particular, the 300 μg group showed a significant improvement compared to baseline two hours after administration, with an 80% improvement one week after administration. *In the ODI, the 300 μg group showed significant improvement compared to baseline 24 hours after administration. * In terms of neurological findings, in the FAS, improvement was observed in cases in the sham group as early as two weeks after administration, while in the 150-600 μg group, improvement was observed as early as two hours after administration. In terms of neurological findings, significant improvement was observed in the 300 μg group 24 hours after administration compared to the sham group. * Serum keratan sulfate concentrations increased dose-dependently at each time point. No clear changes over time were observed in serum keratan sulfate concentrations in the sham group and the 150 μg group. In the 300 μg and 600 μg groups, serum keratan sulfate concentrations began to increase 24 hours after administration, reaching their peaks at 1 and 2 weeks after administration, respectively.

[0212] 4. Safety Assessment

[0213] 4.1 Number of patients treated with the investigational drug, duration, and dose Of the 19 subjects, a single intradiscal injection was administered to 3 subjects in the sham group, 3 subjects in the 150 μg group, 11 subjects in the 300 μg group, and 2 subjects in the 600 μg group (the sham group received only puncture).

[0214] 4.2 Adverse events To compile adverse events in this clinical trial, the names of symptoms and events listed on the eCRF were translated using the ICH International Medical Dictionary, Japanese version (MedDRA / J) Ver. 26.1.

[0215] 4.2.1 Brief summary of adverse events A summary of adverse events is shown in Table 31 (Summary of Adverse Events (SAF)). [Table 31] Seven adverse events occurred in 2 of 3 patients (66.7%) in the sham group, one event in 1 of 3 patients (33.3%) in the 150 μg group, 18 events in 7 of 11 patients (63.6%) in the 300 μg group, and eight events in 2 of 2 patients (100.0%) in the 600 μg group. Three adverse reactions were observed in 3 of 11 patients (27.3%) in the 300 μg group and four in 2 of 2 patients (100.0%) in the 600 μg group, but none were observed in the sham group or the 150 μg group. A serious adverse event occurred in one of 11 patients (9.1%) in the 300 μg group, and no serious adverse events were observed in the other groups. There were no adverse events leading to death or treatment discontinuation. Two adverse events and side effects of concern were observed in two of two patients (100.0%) in the 600 μg group, but none were observed in the other groups. Four expected adverse events were observed in 3 of 11 patients (27.3%) in the 300 μg group and 4 in 2 of 2 patients (100.0%) in the 600 μg group, but none were observed in the other groups. The occurrence of expected side effects was identical to the occurrence of side effects.

[0216] 4.2.2 Display of Adverse Events The occurrence of adverse events by symptom is shown in Tables 32 and 33 (occurrence of adverse events by symptom (SAF)). [Table 32] [Table 33] The SOC for adverse events observed in three or more patients in either group was "musculoskeletal and connective tissue disorders" (7 cases in 5 of 11 patients (45.5%) in the 300 μg group), "infections and infestations" (4 cases in 4 of 11 patients (36.4%) in the 300 μg group), and "nervous system disorders" (3 cases in 3 of 11 patients (27.3%) in the 300 μg group). Adverse events (by PT) observed in two or more patients in either group were pain in the extremities (4 cases in 3 of 11 patients (27.3%) in the 300 μg group), back pain (3 cases in 3 of 11 patients (27.3%) in the 300 μg group), nasopharyngitis, COVID-19, and hypoesthesia (2 cases each in 2 of 11 patients (18.2%) in the 300 μg group), and all other adverse events were observed in only one patient each.

[0217] 4.2.3 Analysis of adverse events

[0218] 4.2.3.1 Occurrence of adverse reactions The side effects observed in SAF were as follows: Arthralgia: 1 case in 1 / 2 patients (50.0%) in the 600 μg group ·Back pain: 2 / 11 cases (18.2%) in the 300 μg group, 1 case in 1 / 2 cases (50.0%) in the 600 μg group · Limb pain: 1 / 11 cases (9.1%) in the 300 μg group, 1 case in 1 / 2 cases (50.0%) in the 600 μg group ·Intervertebral disc protrusion: 1 / 2 cases (50.0%) in this drug 600 μg group, 1 case

[0219] 4.2.3.2 Occurrence of adverse events by severity No adverse events of CTCAE Grade 3 or higher were observed.

[0220] 4.2.4 Listing of Adverse Events by Patient Adverse events were listed for each patient.

[0221] 4.3 Deaths, other serious adverse events, and other significant adverse events

[0222] 4.3.1 Listing of Deaths, Other Serious Adverse Events, and Other Significant Adverse Events A list of adverse events leading to death and adverse events leading to discontinuation of study drug administration was prepared.

[0223] 4.3.1.1 Death No deaths were observed in this study.

[0224] 4.3.1.2 Other serious adverse events In this clinical trial, a serious adverse event, hypoesthesia, was observed in one of 11 patients (9.1%) in the 300 μg group. Details of this case are described in Section 4.3.2.

[0225] 4.3.1.3 Other significant adverse events In this clinical trial, "other important adverse events" were examined, including "adverse events that led to discontinuation of the clinical trial," "adverse events of interest," and "anticipated adverse events."

[0226] 4.3.1.3.1 Adverse events leading to discontinuation In this study, no adverse events leading to discontinuation of the study drug were observed.

[0227] 4.3.1.3.2 Adverse Events of Interest Adverse events of interest included back pain and disc protrusion, which occurred in one of two patients (50.0%) in the 600 μg group, and it was determined that a causal relationship to the administration of the investigational drug could not be ruled out for either.

[0228] 4.3.1.3.3 Anticipated adverse events The expected adverse events observed in SAF were as follows: Arthralgia: 1 case in 1 / 2 patients (50.0%) in the 600 μg group ·Back pain: 2 / 11 cases (18.2%) in the 300 μg group, 1 case in 1 / 2 cases (50.0%) in the 600 μg group · Limb pain: 1 / 11 cases (9.1%) in the 300 μg group, 2 cases in the 600 μg group, 1 case in 1 / 2 cases (50.0%) in the 600 μg group ·Intervertebral disc protrusion: 1 / 2 cases (50.0%) in this drug 600 μg group, 1 case The occurrence of expected side effects was identical to the occurrence of adverse reactions (see section 4.2.3.1).

[0229] 4.3.2 Description of Deaths, Other Serious Adverse Events, and Selected Other Significant Adverse Events Hypoesthesia (Subject number: Y-007) The subject was a male, aged 30 years at the time of consent, with a herniated disc at L4-L5. His medical history included surgery for a deviated septum, bilateral maxillary and mandibular wisdom tooth extractions, and complications such as contact dermatitis and tinea pedis. Twelve days after administration of 300 μg of KTP-001, the patient developed severe hypoesthesia and non-severe back pain. Both events were Grade 2 and resolved 79 days after onset. Detailed examinations, including MRI, computed tomography (CT), and X-rays, revealed no test findings that could be attributed to intradiscal administration of KTP-001 (such as changes in MRI brightness of the treated disc and adjacent endplate, or morphological changes such as narrowing of the disc space on CT or X-ray). Therefore, it was determined that the primary influence of COVID-19 infection, which developed six days after administration, was the primary cause. A causal relationship to the administration of the investigational drug was ruled out.

[0230] 4.3.3 Analysis and Discussion of Deaths, Other Serious Adverse Events, and Other Significant Adverse Events No deaths were reported in this study. Serious adverse events, including hypoesthesia (CTCAE Grade 2), were reported in one of 11 patients (9.1%) in the 300 μg group, but the event resolved, and a causal relationship to the study drug was ruled out. The severity of all adverse events that occurred in this clinical trial was Grade 2 or less, and none of the events led to serious outcomes, so the trial was considered to be well tolerated overall.

[0231] 4.4 Laboratory evaluation

[0232] 4.4.1 Listing of individual laboratory values ​​for each patient Individual laboratory values ​​were listed.

[0233] 4.4.2 Evaluation of each clinical test item

[0234] 4.4.2.1 Laboratory Test Values ​​throughout the Study The trends in clinical test values ​​(hematological tests, blood biochemistry tests, coagulation tests) and the trends in urine test results were examined.

[0235] 4.4.2.1.1 Hematological tests No clear or clinically significant differences were observed in the mean and median values ​​of hematological test items between the groups. In addition, no clinically significant changes were observed in the mean and median values ​​of any test items over time.

[0236] 4.4.2.1.2 Blood chemistry tests

[0237] 4.4.2.1.2.1 Aspartate aminotransferase Baseline aspartate aminotransferase (AST) levels (mean ± standard deviation) were 18.7 ± 9.8 U / L in the sham group, 32.7 ± 1.5 U / L in the 150 μg group, 20.8 ± 7.7 U / L in the 300 μg group, and 31.5 ± 13.4 U / L in the 600 μg group, with variation between groups due to the small number of subjects. AST (mean ± standard deviation) at 6 weeks after administration was 23.0 ± 19.9 U / L in the sham group, 31.3 ± 5.8 U / L in the 150 μg group, 22.1 ± 3.4 U / L in the 300 μg group, and 49.5 ± 21.9 U / L in the 600 μg group, with the mean value being higher in the 600 μg group than in the other groups. There were only two subjects in the 600 μg group, and in one of these subjects, the AST value exceeded the upper limit of normal from two weeks after administration, which was thought to have affected the overall values ​​in the 600 μg group (see Section 4.4.2.3).

[0238] 4.4.2.1.2.2 Alanine aminotransferase Baseline alanine aminotransferase (ALT) levels (mean ± standard deviation) were 22.3 ± 23.3 U / L in the sham group, 53.0 ± 6.6 U / L in the 150 μg group, 28.0 ± 26.3 U / L in the 300 μg group, and 37.5 ± 19.1 U / L in the 600 μg group, with variation between groups due to the small number of subjects. The ALT (mean ± standard deviation) at 6 weeks after administration was 28.3 ± 37.0 U / L in the sham group, 44.3 ± 14.7 U / L in the 150 μg group, 28.9 ± 13.0 U / L in the 300 μg group, and 95.5 ± 78.5 U / L in the 600 μg group, with the mean value in the 600 μg group being higher than in the other groups. There were only two subjects in the 600 μg group, and in one of these subjects the ALT value exceeded the upper limit of normal from two weeks after administration, which was thought to have affected the overall values ​​in the 600 μg group (see section 4.4.2.3).

[0239] 4.4.2.1.3 Coagulation tests No clear or clinically significant differences were observed in the mean and median values ​​of coagulation test items (prothrombin time, activated partial thromboplastin time) between the groups. Furthermore, no clinically significant changes were observed in the mean and median values ​​of any test items over time.

[0240] 4.4.2.1.4 Urinalysis Among the urine test items, no clear or clinically significant differences were observed between the groups in the shift tables for urine glucose, urine protein, ketone bodies, and occult blood. Furthermore, no clinically important changes over time were observed in these items. No clear or clinically meaningful differences were observed between groups in the mean and median values ​​for pH and specific gravity, and no clinically significant changes were observed over time in the mean and median values ​​for either test item.

[0241] 4.4.2.2 Individual patient changes Individual laboratory values ​​were listed.

[0242] 4.4.2.3 Individual clinically significant abnormalities Blood biochemistry tests revealed abnormal changes corresponding to increased ALT, increased AST, and increased gamma-glutamyltransferase (gamma-GTP) in one patient in the 600 μg group (all Grade 1 in severity), but all of these symptoms improved after an appropriate examination by a gastroenterologist. Both events were thought to be due to the effects of concomitant medications, and a causal relationship to the administration of the investigational drug was ruled out.

[0243] 4.5 Vital Signs, Physical Observations, and Other Safety-Related Observations

[0244] 4.5.1 Vital signs Throughout the study period, no clinically significant changes were observed in the mean and median values ​​for systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, and body temperature in any group.

[0245] 4.5.2 12-lead electrocardiogram A list of 12-lead electrocardiograms and a summary of positive and negative results of 12-lead electrocardiograms were created. Results of 12-lead electrocardiograms 24 hours after administration showed no clinically significant findings in any group. No clinically significant changes from baseline were observed in the 12-lead electrocardiograms 24 hours after administration in any group.

[0246] 4.5.3 MRI images A trend in MRI imaging results was created. The baseline MRI imaging results were "no findings" (100.0%) in all groups. The MRI results at 6 weeks after administration showed "no findings" (100.0%) in the sham group, the 150 μg group, and the 600 μg group. In the 300 μg group, "no abnormal findings" were found in 10 / 11 cases (90.9%), and "abnormal findings were found (type of abnormal findings: other) but not clinically significant" in 1 / 11 cases (9.1%). The results of MRI examination 13 weeks after administration were "no findings" (100.0%) in all groups. At both 6 and 13 weeks after administration, MRI scan results showed no findings in most subjects.

[0247] 4.5.4 X-ray images A trend in X-ray imaging results was created. No clinically significant radiographic findings were observed in any group throughout the trial.

[0248] 4.5.5 Anti-KTP-001 antibody and serum KTP-001 concentrations, PK parameters (C max 、T max , AUC 0-24h )(PK analysis) The shift table for the anti-KTP-001 antibody results is shown in Table 34. [Table 34] Anti-KTP-001 antibodies were negative in all treatment groups at both baseline and 13 weeks after treatment. Serum KTP-001 concentrations were below the lower limit of quantitation in all subjects throughout the trial. Because serum KTP-001 concentrations were below the lower limit of quantitation in all subjects, PK parameters for serum KTP-001 concentrations, a secondary endpoint, were not calculated.

[0249] 4.6 Safety Conclusions * Overall, the drug was found to be safe and well tolerated when administered as a single intradiscal injection of up to 600 μg in patients with lumbar disc herniation. * Seven adverse events occurred in 2 of 3 patients (66.7%) in the sham group, one in 1 of 3 patients (33.3%) in the 150 μg group, 18 in 7 of 11 patients (63.6%) in the 300 μg group, and eight in 2 of 2 patients (100.0%) in the 600 μg group. Adverse events occurring in two or more patients in any group included pain in extremity (4 cases) in 3 of 11 patients (27.3%) in the 300 μg group, back pain (3 cases) in 3 of 11 patients (27.3%) in the 300 μg group, and nasopharyngitis, COVID-19, and hypoesthesia (2 cases each) in 2 of 11 patients (18.2%) in the 300 μg group. * No adverse events leading to death or discontinuation of treatment were observed, and one serious adverse event, hypoesthesia, was observed in one of 11 patients (9.1%) in the 300 μg group. No serious side effects or adverse events leading to discontinuation of the trial were observed. Adverse events of interest included back pain and disc protrusion, which were observed in one of two patients (50.0%) in the 600 μg group, and it was determined that a causal relationship to the administration of the study drug could not be ruled out for either event. * In hematological tests, coagulation tests, and urinalysis, no clear, clinically meaningful differences, or clinically important changes over time were observed between groups in the mean and median values ​​or shift tables. In blood biochemistry tests, the mean AST and ALT values ​​at 6 weeks after administration were higher in the 600 μg group compared to the other groups. There were only two subjects in the 600 μg group, and in one of these subjects, AST and ALT values ​​exceeded the upper limit of normal from two weeks after administration, which was thought to have affected the values ​​for the entire 600 μg group. In this subject, abnormal fluctuations corresponding to increased ALT, increased AST, and increased γ-GTP were observed (all severity: Grade 1). * No clinically significant changes were observed in vital signs, 12-lead electrocardiograms, or X-ray images throughout the study period. * Anti-KTP-001 antibody results were negative in all subjects throughout the clinical trial, and serum KTP-001 concentrations were below the lower limit of quantification.

[0250] 5. Discussion and general conclusions

[0251] 5.1 Discussion This clinical trial was a multicenter, single-blind, dose-escalation, single-dose study designed to confirm the safety and tolerability of a single intradiscal administration of KTP-001 in patients with lumbar disc herniation. In this clinical trial, 19 of the 24 consented subjects were enrolled in the SAF, FAS, and PPS. Of the 19 subjects, a single intradiscal injection was administered to 3 in the sham group, 3 in the 150 μg group, 11 in the 300 μg group, and 2 in the 600 μg group (puncture only was administered in the sham group). Seven adverse events were observed in 2 of 3 subjects (66.7%) in the sham group, one in 1 of 3 subjects (33.3%) in the 150 μg group, 18 in 7 of 11 subjects (63.6%) in the 300 μg group, and eight in 2 of 2 subjects (100.0%) in the 600 μg group. Adverse events occurring in two or more patients in either group included four cases of pain in the extremities in three of 11 patients (27.3%) in the 300 μg group, three cases of back pain in three of 11 patients (27.3%) in the 300 μg group, and two cases of nasopharyngitis, COVID-19, and hypoesthesia each in two of 11 patients (18.2%) in the 300 μg group. There were no adverse events leading to death or discontinuation of treatment, and one serious adverse event, hypoesthesia, was observed in one of 11 patients (9.1%) in the 300 μg group. No serious side effects or adverse events leading to discontinuation of the study were observed. Adverse events of interest included back pain and disc protrusion, both of which occurred in one of two patients (50.0%) in the 600 μg group, and it was determined that a causal relationship to the administration of the study drug could not be ruled out for either event. Hematological, coagulation, and urinalysis showed no significant, clinically meaningful, or clinically significant intergroup differences in mean and median values ​​or shift tables. Blood biochemistry tests showed higher mean AST and ALT values ​​at 6 weeks post-treatment in the 600 μg group compared with the other groups. Only two subjects in the 600 μg group experienced AST and ALT values ​​exceeding the upper limit of normal starting 2 weeks after administration, which was thought to have affected the overall values ​​in the 600 μg group. This subject experienced abnormal changes corresponding to increased ALT, AST, and γ-GTP (all Grade 1 in severity), but underwent appropriate consultation with a gastroenterologist and all symptoms resolved. No clinically significant changes were observed in vital signs, 12-lead electrocardiograms, MRI images, or X-ray images throughout the study period. Anti-KTP-001 antibodies were negative in all subjects throughout the study period, and serum KTP-001 concentrations were below the lower limit of quantitation. Overall, the drug was found to be safe and well tolerated when administered intradiscally in a single dose of up to 600 μg in patients with lumbar disc herniation. Mean values ​​for leg pain and lumbar back pain (average pain over the past 24 hours and worst pain) decreased over time from baseline in all groups. In the leg-raising test, the 150 μg group showed a 90% or greater improvement as early as 6 weeks after administration, and the 300 μg group showed a 90% or greater improvement as early as 4 weeks after administration compared with the sham group. A trend toward improvement was observed in the leg-raising test 2 hours after administration. In particular, the 300 μg group showed a significant improvement compared to baseline 2 hours after administration, with an 80% improvement at 1 week after administration. In the ODI, the 300 μg group showed a significant improvement compared to baseline 24 hours after administration. Neurological findings showed improvement as early as 2 hours after administration in the 150-600 μg groups compared with the sham group. Neurological findings showed significant improvement in the 300 μg group compared with the sham group 24 hours after administration. Evaluation of herniated disc volume using MRI images showed a tendency for reduction of 81.8% in the 300 μg group and 100% in the 600 μg group at 13 weeks after administration, a result that can represent a certain degree of efficacy of this drug. Serum keratan sulfate concentrations increased dose-dependently at each time point. No clear changes over time were observed in serum keratan sulfate concentrations in the sham group and the 150 μg group. In the 300 μg and 600 μg groups, serum keratan sulfate concentrations began to increase 24 hours after administration, reaching a maximum at 1 and 2 weeks after administration, respectively. Since serum KTP-001 concentrations were below the lower limit of quantitation in all subjects, PK parameters of serum KTP-001 concentrations, a secondary endpoint, were not calculated. Based on the above, this clinical trial, in which KTP-001 was administered intradiscally in a single dose of up to 600 μg to patients with lumbar disc herniation caused by prolapse of the posterior longitudinal ligament, demonstrated a certain level of safety and efficacy. Serum keratan sulfate concentrations, a marker indicating the resolution of the prolapsed disc nucleus pulposus, increased over time in the 300 and 600 μg groups. Based on the results of serum keratan sulfate concentrations, the recommended dose for the next phase is 150 to 600 μg, more preferably 300 to 600 μg, and even more preferably 300 to 450 μg.

[0252] 5.2 General conclusions KTP-001 was safe and well tolerated when administered intradiscally at doses up to 600 μg in patients with lumbar disc herniation. Serum KTP-001 concentrations were below the lower limit of quantification in all subjects throughout the trial, and anti-KTP-001 antibodies were negative. Efficacy evaluation showed a reduction in lower limb pain and low back pain from baseline in all groups. Early improvement was observed in the leg raising test and neurological findings in the drug group. Serum keratan sulfate concentrations increased dose-dependently. These results demonstrate that KTP-001 has a favorable safety and tolerability profile, improves neurological findings due to disc herniation early after administration, and alleviates lower back pain and leg pain over time.

Claims

1. A therapeutic agent for a disease associated with intervertebral disc degeneration selected from the group consisting of intervertebral disc herniation, low back pain, intervertebral disc disease, kyphoscoliosis, and spondylosis deformans, comprising MMP-7 as an active ingredient, wherein the dosage of MMP-7 per administration is 300 μg to 600 μg.

2. The treatment according to claim 1, wherein the MMP-7 is recombinant human MMP-7.

3. The treatment agent according to claim 1, which is to be administered directly to the affected area of ​​the disease.

4. The treatment agent according to claim 1, which is to be administered multiple times to a patient with the disease.

5. The treatment agent according to claim 1, which is to be administered to a patient with the disease who is not receiving conservative treatment for the disease.

6. The treatment agent according to claim 1, which is to be administered to a patient with the disease immediately after a diagnosis that confirms the disease.

7. The method of claim 6, wherein the diagnosis to confirm the disease is performed using MRI.

8. 2. The treatment according to claim 1, which is an injection having a single dose of 2 cc or more.

9. The treatment according to claim 1, wherein the content of MMP-7 is 300 μg to 600 μg.

10. The treatment of claim 1, which is a unit dosage form.

11. The treatment agent according to claim 1, which is to be administered once a day to a patient with the disease.

Images