Methods for selecting patients for treatment with IL-33 axis antagonists

Abstract

The present disclosure relates to methods for treating a subject suffering from respiratory distress or preventing respiratory distress in a subject at risk of respiratory distress with an IL-33 axis antagonist, methods for determining whether such a subject will respond to treatment with an IL-33 axis antagonist, and methods for selecting a subject for treatment with an IL-33 axis antagonist by determining whether the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a given reference level. Corresponding uses of the methods are also provided.

Description

[Technical Field]

[0001] (CROSS-REFERENCE TO RELATED APPLICATIONS) This application claims the benefit under 35 U.S.C. §119(e) of U.S. Provisional Patent Application No. 63 / 371,936, filed August 19, 2022, which is incorporated herein by reference in its entirety for all purposes.

[0002] Reference to an electronically submitted sequence listing This application incorporates by reference the Sequence Listing submitted with this application in computer readable format (CRF) as a text file entitled "IL33-601-WO-PCT Sequence Listing," created on August 17, 2023, and having a size of 51,179 bytes.

[0003] The present disclosure relates to methods for treating a subject suffering from respiratory distress or preventing respiratory distress in a subject at risk of respiratory distress with an IL-33 axis antagonist, methods for determining whether such a subject will respond to treatment with an IL-33 axis antagonist, and methods for selecting a subject for treatment with an IL-33 axis antagonist by determining whether the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a given reference level. Corresponding uses of the methods are also provided. [Background technology]

[0004] Interleukin-33 (IL-33), also known as IL-1F11, is a member of the IL-1 cytokine family. IL-33 is a 270-amino acid protein consisting of two domains: a homeodomain and a cytokine (IL-1-like) domain. The homeodomain contains a nuclear localization signal (NLS). IL-33 is known to exist in two distinct forms: a reduced form (redIL-33) and an oxidized form (oxIL-33). Previous studies have shown that the reduced form is rapidly oxidized under physiological conditions, forming at least one disulfide bond in the oxidized form, and that these two forms may have distinct biochemical properties and biological functions.

[0005] Furthermore, reduced forms of IL-33 have previously been shown to bind to ST2 and, in fact, are the only known ligand for the ST2 receptor expressed by immune cells, including Th2 cells and mast cells. Reduced IL-33 stimulates target cells by binding to ST2 and subsequently activating the NFκB and MAP kinase pathways, which leads to the production of cytokines and chemokines, such as IL-4, IL-5, and IL-13, promoting inflammation. Soluble ST2 (sST2) is thought to be a decoy receptor that binds to reduced IL-33 and prevents IL-33 signaling by forming an IL-33 / sST2 complex.

[0006] More recently, it has been shown that oxidized IL-33 forms are also biologically active: they do not bind to ST2 but instead bind to the receptor for advanced glycation end products (RAGE), signaling through this alternative pathway to regulate airway epithelial remodeling.

[0007] IL-33 is therefore of great interest as a therapeutic target, primarily due to the ability of what is currently known as the reduced form to stimulate ST2 and exert its potent inflammatory effects, but now also due to the ability of the oxidized form to stimulate RAGE-EGFR signaling, which is involved in a wide range of diseases.

[0008] IL-33 antagonists are being developed as therapeutic agents that target and bind to the various forms of IL-33 present in the IL-33 axis. Currently, several antibody therapeutics that target and inhibit reduced IL-33 are known. Such antibodies include tozolaximab (binding molecule 33_640087-7B, described in WO 2016 / 156440), etoximab (described in WO 2015 / 106080), itepekimab, and tordoximab.

[0009] Although some of these antibody therapies have shown good results in treating subjects suffering from IL-33 mediated diseases, such as inflammatory or respiratory diseases, not all subjects respond equally to the treatment, and some patients may benefit more from treatment with such therapies than others.

[0010] Until now, there has been no reliable, highly sensitive IL-33 assay that can distinguish between different forms of IL-33, making it difficult to track and monitor how subjects respond to such therapies that target the IL-33 axis. Assays have now been developed that can detect these forms of IL-33 and provide users with information about biological pathways that may be inhibited or activated in a given biological sample and their relationship to the patient's condition. Sensitive assays have been developed that can detect not just one of the different forms of IL-33 in a biological sample, but each of the different forms of IL-33, namely, reduced IL33, oxidized IL33, and bound IL33 / sST2.

[0011] Using this assay, the inventors further discovered for the first time that patients suffering from respiratory distress can be stratified into those more likely to experience a beneficial therapeutic effect from treatment with such an IL-33 axis antagonist therapy and those less likely to experience a therapeutic effect. The inventors surprisingly discovered that the level of IL-33 / sST2 complexes in biological samples indicates the therapeutic effect of IL-33 axis antagonist therapy. The inventors believe that measuring IL-33 / sST2 in biological samples can influence the selection of medical treatments and determine the likelihood of response to IL-33 axis antagonist therapy, such as those described above.

[0012] Accordingly, one or more aspects of the present disclosure and further features thereof are defined below. Summary of the Invention

[0013] According to a first aspect of the present disclosure, there is provided a method of treating a subject suffering from respiratory distress or preventing respiratory distress in a subject at risk of respiratory distress, the method comprising administering to the subject an effective amount of an IL-33 axis antagonist, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0014] According to an alternative first aspect of the present disclosure, there is provided an IL-33 axis antagonist for use in treating a subject suffering from respiratory distress or for use in preventing respiratory distress in a subject at risk of respiratory distress, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml. In one example, the subject has a level of IL-33 / sST2 equal to or greater than a reference level of about 25 pg / ml. In one example, the subject has a baseline level of IL-33 / sST2 equal to or greater than a reference level of about 25 pg / ml. In one example, the subject has a baseline serum level of IL-33 / sST2 equal to or greater than a reference level of about 25 pg / ml.

[0015] According to a second aspect of the present disclosure, there is provided a method of treating a subject suffering from respiratory distress or preventing respiratory distress in a subject at risk of respiratory distress, the method comprising measuring the level of IL-33 / sST2 in a sample obtained from the subject, and administering to the subject an effective amount of an IL-33 axis antagonist if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml.

[0016] According to an alternative second aspect of the present disclosure, there is provided an IL-33 axis antagonist for use in a method of treating a subject suffering from respiratory distress or for use in preventing respiratory distress in a subject at risk of respiratory distress, the method comprising measuring the level of IL-33 / sST2 in a sample obtained from the subject, and administering to the subject an effective amount of an IL-33 axis antagonist if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml.

[0017] According to a third aspect of the present disclosure, there is provided a method for preventing acute respiratory failure in a subject at risk of acute respiratory failure, the method comprising administering to the subject an effective amount of an IL-33 axis antagonist, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0018] According to an alternative third aspect of the present invention there is provided an IL-33 axis antagonist for use in preventing acute respiratory failure in a subject at risk of acute respiratory failure, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0019] In one example, the method of the third embodiment may include measuring the level of IL-33 / sST2 in a sample obtained from a subject, and administering to the subject an effective amount of an IL-33 axis antagonist if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml.

[0020] In one example, the subject at risk of acute respiratory failure in the method of the third embodiment is a subject suffering from respiratory distress.

[0021] According to a fourth aspect of the present disclosure, there is provided a method of reducing the likelihood of death and / or acute respiratory failure in a subject suffering from or at risk of suffering from respiratory distress, comprising administering to the subject an effective amount of an IL-33 axis antagonist, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0022] According to an alternative fourth aspect of the present invention there is provided an IL-33 axis antagonist for use in reducing the likelihood of death and / or acute respiratory failure in a subject suffering from or at risk of suffering from respiratory distress, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0023] In one example, the method of the fourth embodiment may include measuring the level of IL-33 / sST2 in a sample obtained from a subject, and administering to the subject an effective amount of an IL-33 axis antagonist if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml.

[0024] In one example, the method of the fourth aspect comprises significantly reducing the likelihood of death and / or respiratory failure, preferably significantly reducing the likelihood of acute respiratory failure, preferably compared to a subject not administered an effective amount of an IL-33 axis antagonist.

[0025] In one example of the method of the fourth aspect, reducing the likelihood may include reducing the rate of mortality and / or respiratory failure in subjects suffering from or at risk of suffering from respiratory distress.

[0026] In one example, the method of the fourth aspect can include treating a subject suffering from respiratory distress by reducing the likelihood of death and / or acute respiratory failure.

[0027] In one example, the method can include selectively treating a subject suffering from respiratory distress or selectively preventing respiratory distress in a subject. Suitably, the method can include selectively administering an effective amount of an IL-33 axis antagonist if the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0028] According to a fifth aspect of the present disclosure, there is provided a method of selecting a subject suffering from or at risk of suffering from respiratory distress for treatment with an IL-33 axis antagonist, the method comprising measuring the level of IL-33 / sST2 in a sample obtained from the subject, and selecting the subject for the treatment if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml.

[0029] In one example, the method can include selecting a subject suffering from or at risk of suffering from respiratory distress who will respond to or benefit from treatment with an IL-33 axis antagonist.

[0030] In another example, the method can include identifying a subject suffering from or at risk of suffering from respiratory distress due to treatment with an IL-33 axis antagonist. In another example, the method can include identifying a subject suffering from or at risk of suffering from respiratory distress that will respond to or benefit from treatment with an IL-33 axis antagonist.

[0031] In one example, the method further comprises administering to the subject an effective amount of an IL-33 axis antagonist.

[0032] In an alternative fifth aspect of the present disclosure, there is provided a method of selecting a subject for treatment with an IL-33 axis antagonist, the method comprising measuring the level of IL-33 / sST2 in a sample obtained from the subject, and selecting the subject for the treatment if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml.

[0033] In one example, the method can include selecting a subject that will respond to or benefit from treatment with an IL-33 axis antagonist.

[0034] In another example, the method can include identifying a subject for treatment with an IL-33 axis antagonist. In another example, the method can include identifying a subject that will respond to or benefit from treatment with an IL-33 axis antagonist.

[0035] In one example, the subject is suffering from a disease, disorder, condition, or infection. In one example, the subject is suffering from or at risk of suffering from respiratory distress, preferably where the respiratory distress is caused by a disease, disorder, condition, or infection.

[0036] In one example, the method further comprises administering to the subject an effective amount of an IL-33 axis antagonist.

[0037] According to a sixth aspect of the present disclosure, there is provided a method for determining whether a subject suffering from or at risk of suffering from respiratory distress is likely to respond to treatment with an IL-33 axis antagonist, the method comprising measuring a level of IL-33 / sST2 in a sample obtained from the subject, and determining that the subject is likely to respond to the treatment if the measured level of IL-33 / sST2 in the sample is equal to or greater than a reference level.

[0038] In one example, the method can include determining whether a subject suffering from or at risk of suffering from respiratory distress will respond to treatment with an IL-33 axis antagonist. In one example, the method can include determining whether a subject suffering from or at risk of suffering from respiratory distress is likely to benefit from treatment with an IL-33 axis antagonist. In one example, the method can include determining whether a subject suffering from or at risk of suffering from respiratory distress will benefit from treatment with an IL-33 axis antagonist.

[0039] In one example, the method further comprises administering to the subject an effective amount of an IL-33 axis antagonist.

[0040] In an alternative sixth aspect of the present disclosure, there is provided a method for determining whether a subject is likely to respond to treatment with an IL-33 axis antagonist, the method comprising measuring the level of IL-33 / sST2 in a sample obtained from the subject, and determining that the subject is likely to respond to the treatment if the measured level of IL-33 / sST2 in the sample is equal to or greater than a reference level.

[0041] In one example, the method can include determining whether the subject will respond to treatment with an IL-33 axis antagonist. In one example, the method can include determining whether the subject is likely to benefit from treatment with an IL-33 axis antagonist. In one example, the method can include determining whether the subject will benefit from treatment with an IL-33 axis antagonist.

[0042] In one example, the subject is suffering from a disease, disorder, condition, or infection. In one example, the subject is suffering from or at risk of suffering from respiratory distress, preferably where the respiratory distress is caused by a disease, disorder, condition, or infection.

[0043] In one example, the method further comprises administering to the subject an effective amount of an IL-33 axis antagonist.

[0044] In one example, the method of the sixth aspect may comprise determining or predicting the likelihood that a subject suffering from or at risk of suffering from respiratory distress will respond to or benefit from treatment with an IL-33 axis antagonist. Preferably, the method comprises determining or predicting that the subject is more likely to respond to or benefit from treatment if the measured level of IL-33 / sST2 in the sample is equal to or greater than a reference level, preferably compared to a reference subject as defined herein.

[0045] In one example of any of the methods, the IL-33 axis antagonist comprises a heavy chain variable region having VHCDRs 1-3 of SEQ ID NO: 37, SEQ ID NO: 38, and SEQ ID NO: 39, respectively, and a light chain variable region having VLCDRs 1-3 of SEQ ID NO: 40, SEQ ID NO: 41, and SEQ ID NO: 42, respectively. In one example of any of the methods, the IL-33 axis antagonist is tozolaximab.

[0046] In one example of any of the methods, the subject is suffering from or at risk of acute respiratory failure.

[0047] In one example, any of the present methods can include comparing the measured level of IL-33 / sST2 in the sample to a reference level of about 25 pg / ml.

[0048] In one example, the measuring step of any of the methods can include assaying a sample obtained from the subject, preferably to measure the level of IL-33 / sST2. In one example, any of the methods can include (a) contacting the sample with one or more binding molecules capable of binding to IL-33 / sST2 under conditions sufficient to form a complex, and (b) detecting the level of IL-33 / sST2 complex in the sample.

[0049] For the avoidance of doubt, each embodiment or example of a "method" of treatment includes a composition for use in that method of treatment, and the use of that composition in the manufacture of a medicament for use in that method of treatment.

[0050] definition As used herein, "IL-33" protein refers to interleukin-33, particularly mammalian interleukin-33 protein, e.g., the human protein deposited under UniProt number 095760. However, the inventors' findings indicate that this entity is not a single species, but exists in reduced and oxidized forms. The terms "IL-33" and "IL-33 polypeptide" are used interchangeably. In certain instances, IL-33 is full-length. In other instances, IL-33 is mature, truncated IL-33 (amino acids 112-270). Recent studies have shown that full-length IL-33 is active (Cayrol and Girard, Proc Natl Acad Sci USA 106(22):9021-6(2009); Hayakawa et al., Biochem Biophys Res Commun. 387(1):218-22(2009); Talabot-Ayer et al., J Biol Chem. 284(29):19420-6(2009)). However, N-terminally processed or truncated IL-33, including but not limited to amino acids 72-270, 79-270, 95-270, 99-270, 107-270, 109-270, 111-270, and 112-270, may have enhanced activity (Lefrancais 2012, 2014). In another example, IL-33 can include full-length IL-33, a fragment thereof, or an IL-33 mutant or variant polypeptide, where a fragment of IL-33 or an IL-33 variant polypeptide retains some or all of the functional properties of active IL-33.

[0051] "Oxidized IL-33" or "oxIL-33" is a protein that appears as a distinct band, for example by Western blot analysis under non-reducing conditions, and in particular has a mass that is 4 Da less than the corresponding reduced form. In particular, it refers to a protein that has one or two disulfide bonds between cysteines independently selected from cysteines 208, 227, 232, and 259. In one example, oxidized IL-33 does not exhibit binding to ST2.

[0052] As used herein, "reduced IL-33" or "redIL-33" refers to a form of IL-33 that binds to ST2 and initiates ST2-mediated signaling. In particular, cysteines 208, 227, 232, and 259 in the reduced form are not disulfide bonded.

[0053] As used herein, "IL-33 / sST2" refers to the reduced form of IL-33 bound to the soluble ST2 receptor. As used herein, "IL-33 / sST2" may also be referred to as the "IL-33 / sST2 complex."

[0054] As used herein, "antigenically distinct forms of IL-33" refers to any form of IL-33 that can act as an antigen and be recognized by an antibody or a binding fragment thereof, and in the context of the present disclosure typically refers to oxidized IL-33, reduced IL-33, and reduced IL-33 / sST2 complex.

[0055] It should be noted that the term "a" or "an" entity refers to one or more of that entity; for example, "an anti-IL-33 antibody" is understood to refer to one or more anti-IL-33 antibodies. Thus, the terms "a" (or "an"), "one or more," and "at least one" can be used interchangeably herein.

[0056] As used herein, the term "treat" or "treatment" refers to both therapeutic treatment and prophylactic or preventative measures, i.e., prevention, where the objective is to prevent or slow (alleviate) an undesirable physiological change or disorder. Beneficial or desired clinical results include, but are not limited to, alleviation of symptoms, diminishment of the extent of the disease, stabilization of the disease state (i.e., not worsening), delay or slowing of disease progression, improvement or palliation of the disease state, and remission (whether partial or total), whether detectable or undetectable. "Treatment" can also mean prolonging survival as compared to expected survival if not receiving treatment. Subjects in need of treatment include those already with the condition or disorder, as well as those susceptible to the condition or disorder, or those in whom the condition or disorder is to be prevented. The term "prevention" is used herein to mean preventing, delaying, or treating, as appropriate, the onset or continuation or worsening of a condition or disorder, or all three.

[0057] "Subject" or "individual" or "animal" or "patient" or "mammal" means any subject, particularly a mammalian subject, for whom diagnosis, prognosis, or treatment is desired, except where the subject is defined as a "healthy subject." Mammalian subjects include humans, domestic animals, farm animals, such as dogs, cats, guinea pigs, rabbits, rats, mice, horses, cattle, dairy cows, etc.

[0058] The term "assaying" is used to refer to the act of identifying, screening, probing, testing, measuring, or determining, and this act can be performed by any conventional means. The term "detecting" (and similar terms) refers to the act of extracting specific information from a given source, which can be direct or indirect. In some examples of the methods disclosed herein, the presence (e.g., level) of IL-33 / sST2 is detected in a biological sample. The terms "assaying" and "determining" contemplate a change in a substance, for example, changing a biological sample (e.g., a serum sample) from one state to another by subjecting the sample to a physical test.

[0059] The term "obtain" means to obtain in some way, e.g., to take possession, for example, by physical intervention (e.g., a biopsy) or non-physical intervention (e.g., transmitting information via a server).

[0060] The term "pharmaceutical composition" is defined herein to refer to a mixture or solution containing at least one therapeutic agent that is administered to a subject, e.g., a mammal or a human, to prevent or treat a particular disease or condition.

[0061] The term "pharmaceutically acceptable" is defined herein to refer to compounds, materials, compositions, and / or dosage forms that are suitable, within the scope of sound medical judgment, for contact with the tissues of a subject, e.g., a mammal or human, without excessive toxicity, irritation, allergic response, and other problem or complication, commensurate with a reasonable benefit / risk ratio.

[0062] As used herein, "selecting" or "identifying" with respect to a subject means that a particular subject is specifically selected from a larger group of subjects based on (or because of) the particular subject having a predetermined criterion, e.g., a reference level of IL-33 / sST2 or higher. Similarly, "selectively treating" refers to providing treatment to a subject specifically selected from a larger group of subjects based on (or because of) the particular subject having a predetermined criterion, e.g., a reference level of IL-33 / sST2 or higher. Similarly, "selectively administering" refers to administering a drug to a subject specifically selected from a larger group of subjects based on (or because) the particular subject has a predetermined criterion, e.g., a particular biological marker, such as a reference level of IL-33 / sST2 or higher. Selecting, identifying, selectively treating, and selectively administering refer to providing a subject with an individualized therapy based on the patient's particular biology, rather than providing a standard treatment regimen based solely on the subject having or being at risk for a particular disease or condition. As used herein, with respect to treatment methods, select refers to the deliberate choice to administer an IL-33 axis antagonist to a subject based on the subject having IL-33 / sST2 at or above the baseline level, rather than to the incidental treatment of a subject who may coincidentally have IL-33 / sST2 at or above the baseline level. Thus, selective treatment differs from standard treatment, which delivers a particular drug to all subjects regardless of this biomarker.

[0063] As used herein, "predicting" or "determining" indicates that the methods described herein provide information that allows a healthcare provider to ascertain the likelihood that an individual with a baseline level of IL-33 / sST2 or higher will respond, or will respond better, to treatment with an IL-33 axis antagonist. This does not refer to the ability to predict response with 100% accuracy. Rather, one of skill in the art will understand that this refers to an increased probability.

[0064] As used herein, "likelihood" and "likely" are measures of the probability that an event will occur. It may be used interchangeably with "probability." Likelihood refers to a probability that is higher than guesswork, but lower than certainty. Thus, an event is likely if a reasonable person, using common sense, training, or experience, would conclude, after considering the circumstances, that the event is likely to occur. The phrase "increased likelihood" refers to an increased probability that an event will occur. For example, some methods herein allow for prediction of whether a subject will exhibit a higher likelihood of responding to treatment with an IL-33 axis antagonist compared to reference subjects who do not have a certain baseline level of IL-33 / sST2 or above.

[0065] Further features of the above-defined aspects are set out in the following heading sections, each of which may be combined in any compatible combination with any of the above-mentioned aspects. DETAILED DESCRIPTION OF THE INVENTION

[0066] subject The methods of the disclosure relate to treating a subject, determining whether a subject will benefit from a treatment, and selecting a treatment for a subject, each of which involves using a sample obtained from the subject, preferably in which the level of IL-33 / sST2 is measured.

[0067] Preferably, the subject may be a human. The subject may be receiving or seeking medical care. Preferably, the subject is male or female. Preferably, the subject is an adult or a child.

[0068] Preferably, the subject is suffering from or is thought to be suffering from respiratory distress. Preferably, the subject may be suffering from or thought to be suffering from a condition, disease, disorder or infection. Preferably, the condition, disease, disorder or infection causes respiratory distress, as further described below.

[0069] Preferably, the subject may have one or more symptoms consistent with respiratory distress, such as higher than normal breathing rate, low blood oxygen levels, labored breathing, shortness of breath, low blood pressure, higher than normal heart rate, chest pain, changes in skin color, sweating, wheezing, confusion, fatigue, etc.

[0070] Thus, preferably, the subject may be a patient.

[0071] Alternatively, the subject may be one who is considered to be at risk of respiratory distress, preferably at risk of developing such a condition, disease, disorder, or infection that causes respiratory distress. For example, a subject at risk may already be suffering from a condition, disease, disorder, or infection that causes respiratory distress, may have come into contact with an individual suffering from such a condition, disease, disorder, or infection that causes respiratory distress, may be suffering from a related condition, disease, disorder, or infection that causes respiratory distress, or may meet risk factors associated with such a condition, disease, disorder, or infection, such as smoking, advanced age, allergies, etc. Further definitions of a subject at risk of respiratory distress are provided below.

[0072] respiratory distress The methods of the present disclosure relate to subjects suffering from or at risk of respiratory distress.

[0073] Preferably, a subject suffering from respiratory distress may be defined as a subject who is unable to ventilate adequately to provide sufficient oxygen to the blood and systemic organs.

[0074] Preferably, a subject suffering from respiratory distress has one or more of the following symptoms: higher than normal breathing rate, low blood oxygen level, labored breathing, shortness of breath, low blood pressure, higher than normal heart rate, chest pain, change in skin color, sweating, wheezing, confusion, and fatigue. Preferably, respiratory distress may be defined as a subject having at least one of the following symptoms: higher than normal breathing rate, low blood oxygen level, labored breathing, shortness of breath, and may further include one or more of the following symptoms: low blood pressure, higher than normal heart rate, chest pain, change in skin color, sweating, wheezing, confusion, and fatigue.

[0075] Preferably, a subject at risk of respiratory distress may exhibit one or more of the following symptoms: higher than normal respiratory rate, low blood oxygen levels, labored breathing, shortness of breath, low blood pressure, higher than normal heart rate, chest pain, changes in skin color, sweating, wheezing, confusion, and fatigue. Preferably, a subject at risk of respiratory distress may have few or no such symptoms, but may be at risk of developing additional symptoms. Preferably, a subject at risk of respiratory distress may have a disease, disorder, condition, or infection identified elsewhere herein that is associated with or may lead to respiratory distress.

[0076] Preferably, a subject suffering from respiratory distress may be a subject requiring oxygen or a subject requiring ventilation. In one example, a subject suffering from respiratory distress requires supplemental oxygen. In one example, a subject requiring supplemental oxygen may have an oxygen saturation (SpO2) of 90% or less. In one example, a subject requiring supplemental oxygen may have an SpO2 of 92% or less and may be suffering from a viral lower respiratory tract infection (or disease - "vLRTD"). In some examples, vRLTD is determined by the presence of a radiographic infiltrate on a chest X-ray / CT scan that is compatible with a viral lung infection. In another example, a subject requiring supplemental oxygen may have an SpO2 of 92% or less and is using accessory respiratory muscles or has a respiratory rate of more than 22 breaths per minute.

[0077] In one example, the subject suffering from respiratory distress is hospitalized, preferably before the method of the present invention is performed. Preferably, the subject is suffering from or at risk of respiratory failure, and preferably, the respiratory failure is acute respiratory failure (ARF) or chronic respiratory failure (CRS). Preferably, the respiratory failure can be type 1 (hypoxemic), type 2 (hypercapnic), type 3 (perioperative), or type 4 (shock-induced).

[0078] In one example, the subject is suffering from or at risk of acute respiratory failure (ARF). In one example, the subject is suffering from or at risk of hypoxemic (type 1) acute respiratory failure. In one example, the subject is suffering from or at risk of hypercapnic (type 2) acute respiratory failure.

[0079] Preferably, a subject at risk for acute or other respiratory failure may be a subject having any one or more of the above symptoms of respiratory distress, such as a higher than normal respiratory rate, low blood oxygen levels, labored breathing, shortness of breath, low blood pressure, a higher than normal heart rate, chest pain, changes in skin color, sweating, wheezing, confusion, and fatigue.

[0080] Preferably, a subject at risk of acute or other respiratory failure is a subject suffering from respiratory distress. Preferably, respiratory distress, if left untreated, can typically lead to respiratory failure. Thus, in one example, a subject is suffering from respiratory distress and may be at risk of developing respiratory failure, preferably acute respiratory failure.

[0081] Preferably, the respiratory distress, such as acute respiratory failure (ARF), may be caused by a condition, disease, disorder or infection. Preferably, the condition, disease, disorder or infection is a respiratory disease. Preferably, the respiratory disease is a disease affecting the trachea, bronchi, bronchioles, alveolar ducts and / or alveoli.

[0082] Preferably, respiratory distress, such as acute respiratory failure (ARF), may be caused by any of the following conditions, diseases, or disorders: acute respiratory distress syndrome (ARDS), chronic obstructive pulmonary disease (COPD), asthma, bronchitis, bronchiectasis, emphysema, heart failure, myocardial ischemia, mitral stenosis, pulmonary edema, pulmonary embolism, thromboembolism, cystic fibrosis, amyotrophic lateral sclerosis, muscular dystrophy, Guillain-Barré syndrome, myasthenia gravis, acute poliomyelitis, polymyositis, botulism, hypokalemia, hypophosphatemia, myxedema, hypothyroidism, sepsis, stroke, acute pancreatitis, blood transfusion, reperfusion, drug or alcohol overdose, chest trauma, viral or bacterial infection, inhalation injury (from inhalation of smoke, fumes, or chemicals), aspiration, or drowning. Thus, preferably, many subjects may have any of these conditions, diseases, or disorders. Preferably, the subject has any of these conditions, diseases or disorders and is at risk of respiratory distress, such as acute respiratory failure (ARF).

[0083] In one example, the subject has asthma. In one example, the subject has COPD.

[0084] Preferably, the respiratory distress such as acute respiratory failure (ARF) is caused by a bacterial or viral infection, preferably a bacterial or viral respiratory infection, preferably a bacterial or viral lower respiratory tract infection. Thus, preferably, the subject may suffer from a bacterial or viral infection, preferably a bacterial or viral lower respiratory tract infection. Preferably, the subject may suffer from a bacterial or viral infection, preferably a bacterial or viral lower respiratory tract infection, and is at risk of respiratory distress such as acute respiratory failure (ARF).

[0085] In one example, the subject suffering from respiratory distress has or is suspected of having a viral lower respiratory tract infection or disease.

[0086] Suitable bacterial or viral respiratory infections may be selected from tonsillitis, scarlet fever, pharyngitis, laryngitis, diphtheria, angina, Lemierre's syndrome, tularemia, plague, enteritis, colds, influenza, mononucleosis, HIV infection, pneumonia, preferably viral pneumonia, bronchitis, psittacosis, SARS, MERS, and COVID-19.

[0087] Preferably, such infections may be caused by the following bacteria or viruses: Streptococcus sp., Arcanobacterium haemolyticum, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Fusobacterium necrophorum, Francisella tulareniss, Yersinia pestis, Yersinia enterocolitica, Adenovirus sp., Herpes simplex virus (HSV), HIV, Coxsackievirus sp., Coronavirus sp., Rhinovirus sp.), influenza A or B virus, parainfluenza virus, Bocaparvovirus sp., Metapneumovirus sp., respiratory syncytial virus (RSV), Epstein-Barr virus, cytomegalovirus sp., Mycoplasma pneumoniae, Chlamydophla pneumoniae, and Chlamydophla psittaci.

[0088] In one example, the respiratory distress, such as acute respiratory failure (ARF), is caused by a coronavirus infection. Therefore, preferably, the subject may have a coronavirus infection. Preferably, the subject may be suffering from a coronavirus infection and be at risk of respiratory distress, such as acute respiratory failure (ARF). Preferably, the coronavirus infection may be an alphacoronavirus infection or a betacoronavirus infection. Preferably, the alphacoronavirus infection may be an infection with the following viruses: alphacoronavirus 1 (TGEV, feline coronavirus, canine coronavirus), human coronavirus 229E, human coronavirus NL63, Miniopterus bat coronavirus 1, Miniopterus bat coronavirus HKU8, porcine epidemic diarrhea virus, Rhinolophus bat coronavirus HKU2, and Scotophilus bat coronavirus 512. Preferably, the betacoronavirus infection can be an infection with any of the following viruses: betacoronavirus 1 (bovine coronavirus, human coronavirus OC43), hedgehog coronavirus 1, human coronavirus HKU1, Middle East respiratory syndrome-associated coronavirus, murine coronavirus, Pipistrellus bat coronavirus HKU5, Rousettus bat coronavirus HKU9, severe acute respiratory syndrome-associated coronavirus (SARS-CoV, SARS-CoV-2), and Tylonycteris bat coronavirus HKU4.

[0089] In one example, the coronavirus infection is a SARS infection, preferably a SARS-CoV-2 infection. In one example, respiratory distress, such as acute respiratory failure (ARF), is caused by COVID-19 resulting from SARS-CoV-2 infection. In one example, the subject is suffering from respiratory distress or acute respiratory failure caused by COVID-19 or SARS-CoV-2 infection. In one example, the subject is suffering from COVID-19 and is at risk of respiratory distress or acute respiratory failure.

[0090] In one example, the subject is suffering from or has a COVID-19 or SARS-CoV-2 infection. In one example, the subject is at risk for COVID-19 or at risk for a SARS-CoV-2 infection.

[0091] In one example, the respiratory distress, such as acute respiratory failure (ARF), is caused by influenza A or B virus, parainfluenza virus, coronavirus, or respiratory syncytial virus infection. In one example, the respiratory distress, such as acute respiratory failure (ARF), is caused by viral pneumonia resulting from infection with influenza A or B virus, parainfluenza virus, coronavirus, or respiratory syncytial virus. Thus, preferably, the subject may be suffering from influenza A or B virus, parainfluenza virus, coronavirus, or respiratory syncytial virus infection and be at risk of respiratory distress, such as acute respiratory failure (ARF). Thus, preferably, the subject may be suffering from influenza A or B virus, parainfluenza virus, coronavirus, or respiratory syncytial virus infection and be at risk of viral pneumonia.

[0092] In one example, the subject is suffering from respiratory distress or acute respiratory failure caused by pneumonia, preferably viral pneumonia. In one example, the subject is suffering from or has pneumonia, preferably viral pneumonia. In one example, the subject is at risk for pneumonia or viral pneumonia.

[0093] In one example, the viral pneumonia is caused by COVID-19, preferably resulting from an infection with a coronavirus, which may be selected from any of those listed above, preferably SARS-CoV-2. In some examples, the pneumonia is caused by influenza A virus, influenza B virus, respiratory syncytial virus, human parainfluenza virus, adenovirus, metapneumovirus, SARS-CoV, Middle East respiratory syndrome virus (MERS-CoV), hantavirus, herpes simplex virus, varicella-zoster virus, measles virus, rubella virus, cytomegalovirus, smallpox virus, or dengue virus. In some examples, the pneumonia is caused by influenza A virus, influenza B virus, respiratory syncytial virus, or human parainfluenza virus.

[0094] Thus, preferably, in some instances, the subject is suffering from or has both COVID-19 and viral pneumonia. In some instances, the viral pneumonia is caused by COVID-19 or SARS-CoV-2 infection. In some instances, the subject is suffering from COVID-19 and is at risk for viral pneumonia.

[0095] Preferably, in any of the above examples, the subject tests positive for SARS-CoV-2 infection. Preferably, any test available in the art can be used to determine whether a subject has a SARS-CoV-2 infection, such as an antigen test, an antibody test, or a nucleic acid-based test. Preferably, a nucleic acid-based test includes a PCR test. Preferably, any of the methods of the present disclosure may further comprise testing the subject for the presence of SARS-CoV-2 infection or the presence of COVID-19.

[0096] Suitably, any reference herein to a subject suffering from any condition, disease, disorder or infection may also be a reference to a subject at risk of suffering from said condition, disease, disorder or infection. Suitably, the IL-33 axis antagonist may also be used to prevent a condition, disease, disorder or infection in a subject at risk for the condition, disease, disorder or infection, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0097] Accordingly, the present disclosure preferably further provides a method of preventing a condition, disease, disorder or infection in a subject at risk of said condition, disease, disorder or infection, preferably comprising administering to the subject an effective amount of an IL-33 axis antagonist as described elsewhere herein.

[0098] Preferably, as identified above, the subject may be at risk of suffering from respiratory distress or at risk of acute respiratory failure. Accordingly, preferably, the present disclosure provides a method of preventing respiratory distress in a subject at risk of respiratory distress or preventing death and / or acute respiratory failure in a subject at risk of death and / or acute respiratory failure, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0099] In one example, a method for preventing acute respiratory failure in a subject at risk of acute respiratory failure is provided, comprising administering to the subject an effective amount of an anti-IL-33 antibody or antigen-binding fragment thereof, wherein the anti-IL-33 antibody or antigen-binding fragment thereof comprises a heavy chain variable region having VH CDRs1 to 3 of SEQ ID NOs: 37, 38, and 39, respectively, and a light chain variable region having VL CDRs1 to 3 of SEQ ID NOs: 40, 41, and 42, respectively, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0100] In one example, a method for preventing acute respiratory failure in a subject suffering from acute respiratory distress is provided, comprising administering to the subject an effective amount of an anti-IL-33 antibody or antigen-binding fragment thereof, wherein the anti-IL-33 antibody or antigen-binding fragment thereof comprises a heavy chain variable region having VH CDRs 1 to 3 of SEQ ID NOs: 37, 38, and 39, respectively, and a light chain variable region having VL CDRs 1 to 3 of SEQ ID NOs: 40, 41, and 42, respectively, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0101] In one example, a method for preventing acute respiratory failure in a subject suffering from COVID-19, pneumonia, or viral pneumonia is provided, comprising administering to the subject an effective amount of an anti-IL-33 antibody or antigen-binding fragment thereof, wherein the anti-IL-33 antibody or antigen-binding fragment thereof comprises a heavy chain variable region having VH CDRs 1-3 of SEQ ID NOs: 37, 38, and 39, respectively, and a light chain variable region having VL CDRs 1-3 of SEQ ID NOs: 40, 41, and 42, respectively, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0102] Preferably, the present disclosure also provides a method of reducing the likelihood of death and / or acute respiratory failure in a subject at risk of death and / or acute respiratory failure, preferably a subject suffering from respiratory distress. Preferably, the present disclosure also provides a method of reducing the rate of mortality and / or acute respiratory failure in a subject at risk of death and / or acute respiratory failure, preferably a subject suffering from respiratory distress.

[0103] In one example of any of the methods described herein, the subject has or is suspected of having a viral lower respiratory tract infection and may optionally be hospitalized and / or may optionally require supplemental oxygen or ventilatory support. In one example of any of the methods described herein, the subject has a viral lower respiratory tract infection, is hospitalized, and requires supplemental oxygen or ventilatory support.

[0104] sample The present disclosure relies on measuring the level of IL-33 / sST2 in a sample taken from a subject. Suitably, the sample may be a test sample.

[0105] Preferably, the sample is a biological sample. As used herein, the term "biological sample" refers to a sample from a subject that can be used for identification, diagnosis, prognosis, or monitoring. Preferably, the sample is a body fluid sample. Alternatively, a suitable sample may include a tissue sample, such as a biopsy tissue.

[0106] Suitable bodily fluid samples may include a blood sample (e.g., a whole blood sample, a plasma sample, or a serum sample, or a combination thereof), a mucosal lining fluid sample (e.g., mucosal lining fluid derived from epithelium), a lavage sample (e.g., a lung or bronchoalveolar lavage sample), or a supernatant sample (e.g., from a culture of epithelial cells).

[0107] Preferably, the supernatant sample is an epithelial cell supernatant sample, preferably derived from a bronchial epithelial culture, and preferably derived from the cells or the air-liquid interface of the culture.

[0108] Preferably, the mucosal lining fluid sample or lavage sample contains biological cells, and preferably, these samples contain epithelial cells.

[0109] Preferably, IL-33 / sST2 is abundant in serum, and therefore, in one example, the sample is a serum sample.

[0110] Preferably, the method of the present disclosure may further comprise the step of obtaining a sample. Preferably, the sample is obtained from a subject. Preferably, this step is performed before measuring the level of IL-33 / ST2 in the sample. Alternatively, the sample may be obtained in advance before performing the method of the present disclosure.

[0111] Preferably, a sample is obtained and the level of IL-33 / ST2 in the sample is measured prior to any treatment of the subject. Thus, preferably, it is the baseline level of IL-33 / sST2 in the sample that is measured.

[0112] Preferably, the blood sample may be obtained by drawing blood from the subject. Preferably, the serum sample may be obtained from the blood sample by allowing the blood to clot and centrifuging the blood to obtain a serum supernatant.

[0113] Preferably, the mucosal lining fluid sample may be obtained from the subject by nasal swab.

[0114] Preferably, the lavage sample may be obtained by pulmonary lavage from the subject.

[0115] Suitably, the supernatant sample may be obtained by culturing cells from the subject, suitably by culturing epithelial cells isolated from the epithelium of the subject, suitably isolated from the respiratory epithelium of the subject.

[0116] Preferably, the sample represents cytokine levels in a subject on which the method of the present disclosure has been performed. Preferably, the sample represents interleukin levels in a subject on which the method has been performed. Preferably, the sample represents IL-33 levels in a subject on which the method has been performed. Preferably, the sample represents IL-33 / sST2 levels in a subject on which the method has been performed. Preferably, the sample represents baseline IL-33 / sST2 levels in a subject on which the method has been performed.

[0117] The sample may be processed to enrich IL-33 / sST2. Suitable techniques for such enrichment may be determined based on the properties of the sample. Generally, examples of suitable techniques (e.g., techniques for isolating biological molecules from a sample) are well known to those skilled in the art. Preferably, the sample may be filtered, purified, concentrated, etc.

[0118] Measurement of IL-33 / sST2 The methods of the present disclosure may include measuring the level of IL-33 / sST2 in a sample obtained from the subject, or may involve a subject having a certain level of IL-33 / sST2 measured in a sample from the subject.

[0119] Preferably, "level" refers to any suitable quantification of the amount of IL-33 / sST2 in a sample. Preferably, "level" may refer to the mass, volume, or concentration of IL-33 / sST2 in a sample. Preferably, level refers to the concentration of IL-33 / sST2 in a sample. Preferably, the concentration may be measured in suitable units such as international units per milliliter (IU / ml), grams per milliliter (g / ml), % w / v, or moles (M). In one example, the concentration is measured in grams per milliliter (g / ml), preferably in micrograms per milliliter (ug / ml), nanograms per milliliter (ng / ml), picograms per milliliter (pg / ml), or femtograms per milliliter (fg / ml). In one example, the concentration of IL-33 / sST2 is measured in picograms per milliliter (pg / ml).

[0120] Preferably, the level of IL-33 / sST2 is a baseline level of IL-33 / sST2, as described above. Preferably, it is a baseline serum level of IL-33 / sST2. In one example, the subject has a level of IL-33 / sST2 at or above a baseline level of about 25 pg / ml. In one example, the subject has a baseline level of IL-33 / sST2 at or above a baseline level of about 25 pg / ml. In one example, the subject has a baseline serum level of IL-33 / sST2 at or above a baseline level of about 25 pg / ml.

[0121] Preferably, the level of IL-33 / sST2 is measured in a sample obtained from a subject of interest. Preferably, any method for measuring IL-33 / sST2 in a sample can be used. Preferably, any method is capable of determining the level of IL-33 / sST2 in a sample.

[0122] Examples of suitable samples are described elsewhere herein. It will be appreciated, then, that the nature of the sample may determine the nature of the assay techniques that may be used in practicing the methods of the present disclosure.

[0123] IL-33 / sST2 is formed from two proteins bound together in a complex. Thus, preferably, the assay technique is a protein assay technique. Thus, preferably, the method of the present disclosure may include measuring IL-33 / sST2 in a sample obtained from a subject using an assay, preferably, assaying the sample obtained from the subject to determine the level of IL-33 / sST2 in the sample.

[0124] Protein levels can be determined by a variety of assay techniques, such as S-plex, ELISA, radioimmunoassay, immunoprecipitation, Western blot and mass spectrometry, which are known to those skilled in the art.

[0125] Preferably, the level of IL-33 / sST2 in a sample obtained from a subject is determined by immunoassay. Thus, preferably, the method of the present disclosure may comprise the step of measuring the level of IL-33 / sST2 in a sample obtained from a subject using an immunoassay, preferably the step of determining the level of IL-33 / sST2 in the sample by performing an immunoassay on the sample obtained from the subject.

[0126] Immunoassays typically require a capture reagent, such as an antibody, to capture the analyte of interest, and optionally a probe reagent to detect the analyte of interest. Suitable immunoassay techniques include: ELISA (enzyme-linked immunosorbent assay), S-plex, Western blotting, immunocytochemistry, immunoprecipitation, affinity chromatography, Biolayer interferometry, Octet, ForteBio, and biochemical assays such as dissociation-promoted lanthanide fluorescence immunoassays (DELFIA®, Perkin Elmer), Förster resonance energy transfer (FRET) assays (e.g., homogeneous time-resolved fluorescence (HTRF®, Cis Biointernational), and radioimmuno / radioligand binding assays.

[0127] Western blot analysis generally involves preparing a protein sample, electrophoresing the protein sample in a polyacrylamide gel (e.g., 8-20 SDS-PAGE depending on the molecular weight of the antigen), transferring the protein sample from the polyacrylamide gel to a membrane such as nitrocellulose, PVDF, or nylon, blocking the membrane in a blocking solution (e.g., PBS containing 3% BSA or nonfat milk), washing the membrane in a wash buffer (e.g., PBS-Tween 20), blocking the membrane with a primary antibody (antibody of interest) diluted in the blocking buffer, washing the membrane in the wash buffer, blocking the membrane with a secondary antibody (which recognizes the primary antibody, e.g., an anti-human antibody) conjugated to an enzyme substrate (e.g., horseradish peroxidase or alkaline phosphatase) or a radioactive molecule (e.g., 32P or 125I) diluted in the blocking buffer, washing the membrane in the wash buffer, and detecting the presence of the antigen. Those skilled in the art will be familiar with parameters that can be modified to increase the detected signal and reduce background noise. For further discussion of Western blot protocols, see, e.g., Ausubel et al., eds. (1994) Current Protocols in Molecular Biology (John Wiley & Sons, Inc., NY) Vol. 1 at 10.8.1.

[0128] ELISA involves preparing an antigen, coating the wells of a 96-well microtiter plate with the antigen, adding an antibody of interest conjugated to a detectable compound such as an enzyme substrate (e.g., horseradish peroxidase or alkaline phosphatase) to the wells, incubating for a certain period of time, and detecting the presence of the antigen. In ELISA, the antibody of interest does not need to be conjugated to a detectable compound; instead, a second antibody (that recognizes the antibody of interest) conjugated to a detectable compound may be added to the well. Furthermore, instead of coating the wells with the antigen, an antibody may be coated to the well. In this case, the second antibody conjugated to a detectable compound may be added after the antigen of interest has been added to the coated well. Those skilled in the art will be familiar with parameters that can be modified to increase the signal detected, as well as other variations of ELISA known in the art. For further discussion of ELISA, see, e.g., Ausubel et al., eds. (1994) Current Protocols in Molecular Biology (John Wiley & Sons, Inc., NY) Vol. 1 at 13.2.1.

[0129] Preferably, the level of IL-33 / sST2 in the sample is determined by immunoassay, preferably by using a modified ELISA called the S-plex assay, which is available from Meso Scale Diagnostics LLC with suitable instructions for use.

[0130] Immunoassays typically involve incubating a sample in the presence of one or more binding molecules capable of specifically binding to a protein of interest, and detecting the bound molecules by any of several techniques well known in the art. The assays described herein follow this general format.

[0131] Preferably, the level of IL-33 / sST2 in the sample is measured by an assay, preferably an immunoassay, which comprises the following steps: (a) contacting the sample with one or more binding molecules capable of binding to IL-33 / sST2 under conditions sufficient to form a complex; (b) detecting the level of IL-33 / sST2 complex in the sample. may include:

[0132] Optionally, the method may include step (c) of contacting the complexes with one or more reporter molecules capable of binding to one or more of the complexes, in such a case detecting step (b) includes detecting the level of bound reporter molecule in the sample.

[0133] Therefore, suitably, any of the methods of the present disclosure may further comprise the above steps (a) and (b), as well as optional step (c).

[0134] Thus, suitably, in one example, a method for treating a subject suffering from respiratory distress or preventing respiratory distress in a subject at risk of respiratory distress may comprise: (a) measuring the level of IL-33 / sST2 in a sample obtained from the subject by (i) contacting the sample with one or more binding molecules capable of binding to IL-33 / sST2 under conditions sufficient to form complexes; and (ii) detecting the level of IL-33 / sST2 complexes in the sample; and (b) administering to the subject an effective amount of an IL-33 axis binding antagonist if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml.

[0135] Thus, suitably, in one example, a method for selecting a subject suffering from or at risk of suffering from respiratory distress for treatment with an IL-33 axis antagonist may comprise: (a) measuring the level of IL-33 / sST2 in a sample obtained from the subject by (i) contacting the sample with one or more binding molecules capable of binding to IL-33 / sST2 under conditions sufficient to form a complex; and (ii) detecting the level of IL-33 / sST2 complexes in the sample; and (b) selecting the subject for the treatment if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml.

[0136] Thus, suitably, in one example, a method for determining whether a subject suffering from or at risk of suffering from respiratory distress is likely to respond to treatment with an IL-33 axis binding antagonist may comprise: (a) measuring the level of IL-33 / sST2 in a sample obtained from the subject by (i) contacting the sample with one or more binding molecules capable of binding to IL-33 / sST2 under conditions sufficient to form complexes; and (ii) detecting the level of IL-33 / sST2 complexes in the sample; and (b) determining that the subject is likely to respond to the treatment if the measured level of IL-33 / sST2 in the sample is equal to or greater than a reference level.

[0137] Any binding molecule that specifically binds to IL-33 / sST2 can be used. Any reporter molecule that specifically binds to the IL-33 / sST2-binding molecule complex can be used.

[0138] Alternatively, the reporter molecule and the binding molecule are the same entity. In such cases, the binding molecule can directly bind to IL-33 / sST2 and indicate this. Therefore, the binding molecule can preferably be labeled. Preferably, the binding molecule can be detectably labeled.

[0139] Preferably, the one or more reporter molecules, when present, are capable of indicating their presence and / or binding. Preferably, the one or more reporter molecules are labelled. Preferably, the one or more reporter molecules are detectably labelled.

[0140] Preferably, the binding molecule is contacted with the biological sample for a time sufficient to form complexes. Preferably, the reporter molecule is contacted with the biological sample for a time sufficient to bind to one or more complexes, if present.

[0141] Preferably, this time may be referred to as the incubation time. Preferably, the incubation time varies depending on the binding molecule and optional reporter molecule used, and the biological sample.

[0142] Preferably, a sufficient incubation time may be from 5 minutes to 180 minutes, preferably from 10 minutes to 150 minutes, preferably from 20 minutes to 120 minutes, preferably from 30 minutes to 100 minutes, preferably from 45 minutes to 90 minutes, preferably about 60 minutes.

[0143] Preferably, the one or more binding molecules are contacted with the biological sample for about 120 minutes.

[0144] Preferably, the one or more reporter molecules, if present, are contacted with the complex / biological sample for about 120 minutes.

[0145] Suitably, contacting the biological sample with the binding molecule or reporter molecule (if present) comprises bringing the binding molecule or reporter molecule and the biological sample together such that binding can occur.

[0146] Suitably, the biological sample may be contacted with the binding molecule or reporter molecule (if present) in any suitable manner using known assay techniques.

[0147] The sample may be contacted with one or more binding molecules by use of a solid phase support or carrier. Suitably, either the sample or the binding molecules may be immobilized on the support or carrier.

[0148] Preferably, the support may then be washed. Preferably, the support is washed with a suitable buffer. Preferably, the method of the present disclosure may include one or more washing steps. Preferably, washing is performed after the addition of one or more binding molecules and before the addition of one or more reporter molecules (if present). Preferably, washing is performed after the addition of one or more reporter molecules (if present) and before the measurement step.

[0149] Preferably, at least one washing step is carried out after step (a) and preferably before step (b).

[0150] Preferably, the support may be contacted with one or more reporter molecules after step (a). Thus, preferably, the step of contacting the complex with one or more reporter molecules capable of binding to the one or more complexes may comprise contacting the complex immobilized on the support with one or more reporter molecules capable of binding to the one or more complexes. Preferably, the support may then be washed a second time to remove unbound reporter molecules. Thus, preferably, a second washing step may be performed after contacting the complex with one or more reporter molecules.

[0151] Optionally, the binding molecule or reporter molecule (if present) may comprise or be subsequently labeled with a detectable label. Suitable labels are discussed elsewhere herein. The amount of bound label that may be bound on the solid support may then be detected by conventional means, preferably as described in step (b).

[0152] "Solid support or carrier" is intended to mean any support capable of binding an antigen or antibody. Well-known supports or carriers include glass, polystyrene, polypropylene, polyethylene, dextran, nylon, nitrocellulose, amylase, natural and modified celluloses, polyacrylamide, and magnetite. The nature of the support, for purposes of this disclosure, can be soluble to some extent or insoluble. The support material can have virtually any possible structural configuration so long as the coupled molecule is capable of binding to an antigen or antibody. Thus, the shape of the support can be spherical, such as a bead, or cylindrical, such as the interior surface of a test tube or the exterior surface of a rod. Alternatively, the surface can be flat, such as a sheet, test strip, etc. Preferred supports include polystyrene beads. Those of skill in the art will know of many other suitable carriers for binding antibodies or antigens, or will be able to identify them by routine experimentation.

[0153] Preferably, reporter molecules (if present) are detected by detecting a detectable label associated with each reporter molecule. Preferably, the detectable label may be part of the reporter molecule or may be added separately, preferably after the reporter molecule has bound to one or more IL-33 / sST2 complexes in the sample.

[0154] Alternatively, detecting one or more IL-33 / sST2 complexes in a sample can include detecting the level of one or more bound binding molecules in the sample. In such cases, preferably, the binding molecules are detected directly by detecting a detectable label associated with each binding molecule. Preferably, in such cases, a reporter molecule is not required. Preferably, the detectable label may be part of the binding molecule, or may be added separately, preferably after the binding molecule has bound to IL-33 / sST2 in the sample.

[0155] Suitable detectable labels may be radioactive labels, fluorescent labels, enzymes, or chromophores. Preferably, the label may be detectable only upon stimulation. Suitable stimulation sources vary depending on the label used; for example, when using an enzyme label, the stimulation source may be a substrate, and when using a chromophore label, the stimulation source may be radiation of a specific wavelength. Such stimulation sources may be considered as stimulating agents.

[0156] Suitable fluorescent labels may include rhodamine, fluorescein, Cy5, ruthenium diimine complexes, and phosphorescent porphyrin dyes.

[0157] Suitable enzyme labels may include peroxidase, glucose oxidase, alkaline phosphatase (AP), β-galactosidase, catalase, or luciferase. Substrates used with particular enzymes are generally selected to produce a detectable color change upon hydrolysis by the corresponding enzyme. For example, p-nitrophenyl phosphate is suitable for use with alkaline phosphatase conjugates. For peroxidase conjugates, 1,2-phenylenediamine or toluidine are commonly used. Preferably, fluorogenic substrates that produce a fluorescent product may be used.

[0158] Alternatively, the binding molecule or reporter molecule (if present) may be unlabeled. In such instances, the binding molecule or reporter molecule may be attached by a label, preferably a detectable label. Preferably, the detectable label is capable of binding to and indicating the binding molecule or reporter molecule. Preferably, the detectable label is specific for the corresponding binding molecule or reporter molecule.

[0159] Therefore, the assay method may preferably further comprise the step of adding a detectable label to the sample. Preferably, step (b) may comprise detecting the detectable label associated with one or more binding molecules.

[0160] Alternatively, step (b) may involve detecting a detectable label associated with one or more reporter molecules (if present).

[0161] In one example, the reporter molecule includes a detectable label conjugated thereto, in which case the reporter molecule is detected by detection of the conjugated detectable label.

[0162] In one example, one or more reporter molecules are detectably labeled. In one example, one or more reporter molecules include a detectable label conjugated thereto. In one example, one or more reporter molecules are sulfo-tagged.

[0163] In one example, the binding molecule includes a detectable label conjugated thereto, in which case the binding molecule is detected by detection of the conjugated detectable label.

[0164] Preferably, the assay used is highly sensitive. Preferably, the assay can detect IL-33 / sST2 in a sample at submicrogram / ml, subnanogram / ml, subpicogram / ml, or subfemtogram / ml concentrations. In one example, the assay can detect IL-33 / sST2 in a sample at picogram / ml concentrations.

[0165] Preferably, the detection limit is a concentration of microgram / ml or less, nanogram / ml or less, picogram / ml or less, or femtogram / ml or less. Preferably, the detection limit is a concentration of femtogram / ml.

[0166] Binding molecules and reporter molecules Preferably, the level of IL-33 / sST2 may be measured in a sample obtained from a subject by performing an assay, preferably an immunoassay, comprising the steps described herein above.

[0167] Preferably, the binding molecules and reporter molecules for use in the assay are selected from an antibody, an antigen-binding fragment thereof, an aptamer, at least one heavy chain or light chain CDR of a reference antibody molecule, and at least six CDRs from one or more reference antibody molecules.

[0168] In one example, the binding molecule and reporter molecule are antibodies or antigen-binding fragments thereof.

[0169] Preferably, the binding molecule is an anti-IL-33 / sST2 antibody or a binding fragment thereof. Preferably, the reporter molecule is an anti-IL-33 / sST2-binding molecule complex antibody or a binding fragment thereof.

[0170] As used herein, "antibody" refers to immunoglobulin molecules, as discussed in more detail below, particularly full length antibodies or molecules comprising full length antibodies, such as DVD-Ig molecules.

[0171] "Binding fragment thereof" is interchangeable with "antigen-binding fragment thereof" and refers to an epitope / antigen-binding fragment of an antibody fragment, e.g., comprising the binding region, in particular comprising six CDRs, e.g., three CDRs of the heavy chain variable region and three CDRs of the light chain variable region.

[0172] Preferably, the antibody or binding fragment thereof is selected from natural, polyclonal, monoclonal, multispecific, murine, human, humanized, primatized, or chimeric. Preferably, the antibody or binding fragment thereof is an epitope-binding fragment, such as Fab' and F(ab')2, Fd, Fv, single-chain Fv (scFv), disulfide-linked Fv (sdFv), fragments containing either the VL or VH domain, or fragments produced by a Fab expression library. Preferably, the antibody or binding fragment thereof is a minibody, diabody, triabody, tetrabody, or single-chain antibody. Preferably, the antibody or binding fragment thereof is a monoclonal antibody. scFv molecules are known in the art and are described, for example, in U.S. Patent No. 5,892,019.

[0173] Immunoglobulin or antibody molecules of the present disclosure can be of any type (e.g., IgG, IgE, IgM, IgD, IgA, and IgY), class (e.g., IgG1, IgG2, IgG3, IgG4, IgA1, IgA2, etc.), or subclass of immunoglobulin molecule.

[0174] Preferably, the antibody or binding fragment thereof used as the binding molecule is a capture antibody.

[0175] Preferably, the antibody or binding fragment thereof used as a reporter molecule is a probe antibody.

[0176] Preferably, the binding molecules and reporter molecules are paired together so that each capture antibody has a corresponding probe antibody. Preferably, a capture antibody is paired with a probe antibody.

[0177] Suitable binding molecules and reporter molecules with such capabilities, eg antibodies, are available in the art or can be ordered from reagent companies such as R&D systems.

[0178] Preferably, however, the binding molecules and / or reporter molecules used in the assay comprise the following sequences:

[0179] IL33 / sST2 binding molecule-AB1070008 Suitably, a binding molecule that binds to IL-33 / sST2 may comprise three CDRs, for example, three CDRs in a heavy chain variable region (VH) set forth in SEQ ID NO: 43 and / or three CDRs in a light chain variable region (VL) set forth in SEQ ID NO: 44.

[0180] Suitably, a binding molecule that binds to IL-33 / sST2 comprises a heavy chain variable region comprising three CDRs in the VH having an amino acid sequence at least 90%, e.g., 91, 92, 93, 94, 95, 96, 97, 98, 99 or 100%, identical to the VH set forth in SEQ ID NO: 43, and / or a light chain variable region comprising three CDRs in the VL having an amino acid sequence at least 90%, e.g., 91, 92, 93, 94, 95, 96, 97, 98, 99 or 100%, identical to the VL set forth in SEQ ID NO: 44.

[0181] Preferably, a binding molecule that binds to IL-33 / sST2 may comprise a variable heavy domain (VH) and a variable light domain (VL) having VHCDRs 1-3 of SEQ ID NOs: 45, 46, and 47, wherein one or more VHCDRs have no more than three single amino acid substitutions, deletions, or insertions.

[0182] Preferably, it has three, two, one or none single amino acid substitutions, deletions or insertions.

[0183] Preferably, a binding molecule that binds to IL-33 / sST2 may comprise a variable heavy domain (VH) and a variable light domain (VL) having VLCDRs 1-3 of SEQ ID NOs: 48, 49, and 50, wherein one or more VLCDRs have no more than three single amino acid substitutions, deletions, or insertions.

[0184] Preferably, it has three, two, one or none single amino acid substitutions, deletions or insertions.

[0185] Suitably, a binding molecule that binds to IL-33 / sST2 may comprise a VH having VHCDRs 1-3 of SEQ ID NOs: 45, 46, and 47, and a VL having VLCDRs of SEQ ID NOs: 48, 49, and 50.

[0186] Suitably, a binding molecule that binds to IL-33 / sST2 may comprise a VHCDR1 having the sequence of SEQ ID NO: 45, a VHCDR2 having the sequence of SEQ ID NO: 46, a VHCDR3 having the sequence of SEQ ID NO: 47, a VLCDR1 having the sequence of SEQ ID NO: 48, a VLCDR2 having the sequence of SEQ ID NO: 49, and a VLCDR3 having the sequence of SEQ ID NO: 50.

[0187] Thus, preferably, the binding molecule that binds to IL-33 / sST2 is an antibody or a binding fragment thereof comprising a VH and a VL, wherein the VH has an amino acid sequence at least 90%, for example 91, 92, 93, 94, 95, 96, 97, 98, 99 or 100%, identical to the VH set forth in SEQ ID NO: 43.

[0188] Thus, preferably, the binding molecule that binds to IL-33 / sST2 is an antibody or binding fragment thereof comprising a VH and a VL, wherein the VL has an amino acid sequence at least 90%, for example 91, 92, 93, 94, 95, 96, 97, 98, 99 or 100%, identical to the VL set forth in SEQ ID NO: 44.

[0189] Therefore, preferably, the binding molecule that binds to IL-33 / sST2 is an antibody or a binding fragment thereof comprising a VH and a VL, wherein the VH has the amino acid sequence of SEQ ID NO: 43 and the VL has the amino acid sequence of SEQ ID NO: 44.

[0190] sST2 reporter molecule Preferably, the reporter molecule that binds to sST2 can be obtained from any suitable supplier. For example, the reporter molecule that binds to sST2 is preferably MAB5232 manufactured by R&D Systems. Other examples of sST2-binding molecules that may be useful in the assays disclosed herein include MAB523, AF523, and MAB5231 manufactured by R&D Systems.

[0191] Reference Level The disclosed methods are based on comparing the measured level of IL-33 / sST2 in a sample from a subject with a reference level of IL-33 / sST2. Preferably, the reference level is a determinant level. Preferably, the reference level determines whether the subject is likely to respond to or benefit from treatment with an IL-33 axis antagonist.

[0192] The inventors recognized that a certain baseline level of IL-33 / sST2 in a sample from a subject may indicate the likelihood of successful treatment of the subject with an IL-33 axis antagonist, such as those described herein. The inventors found that subjects with a level of IL-33 / sST2 that is equal to or greater than the baseline level of IL-33 / sST2 in a sample obtained from the subject are more likely to benefit from and respond to treatment with an IL-33 axis antagonist. Therefore, the baseline level can suitably be considered a threshold level. More specifically, the present disclosure shows that the numerical reduction in death and / or respiratory failure upon treatment with tozolaximab compared to standard of care was greater in hospitalized subjects with respiratory distress diagnosed with COVID-19 who had higher levels of the IL-33 / sST2 complex.

[0193] Therefore, the method of the present disclosure may preferably include a step of comparing the measured level of IL-33 / sST2 with a reference level. Preferably, such a step may be automated.

[0194] Therefore, the method of the present disclosure may preferably include a step of determining whether the measured level of IL-33 / sST2 is equal to or greater than a reference level. Preferably, such a step may be automated.

[0195] Preferably, the measured level of IL-33 / sST2 is the baseline level of IL-33 / sST2. Preferably, it is the baseline serum level of IL-33 / sST2.

[0196] Preferably, the comparing and / or determining steps are performed after any measuring step in the methods of the present disclosure.

[0197] Preferably, if the sample has an IL-33 / sST2 level at or above the reference level, this indicates that the subject is likely to respond to or benefit from treatment with an IL-33 axis antagonist. Preferably, if the sample has an IL-33 / sST2 level at or above the reference level, this indicates that the subject should be selected for treatment with an IL-33 axis antagonist. Thus, preferably, the method of the present disclosure may further comprise the step of selecting the subject for treatment with an IL-33 axis antagonist, preferably if the sample has an IL-33 / sST2 level at or above the reference level. Preferably, if the sample has an IL-33 / sST2 level at or above the reference level, this indicates that the subject should be treated with an IL-33 axis antagonist.

[0198] Thus, the methods of the present invention may preferably further comprise treating the subject with an IL-33 axis antagonist, preferably if the sample has an IL-33 / sST2 level equal to or greater than the reference level. Preferably, treating the subject may comprise administering to the subject an effective amount of an IL-33 axis antagonist as described elsewhere herein.

[0199] Preferably, if the sample has an IL-33 / sST2 level below the reference level, this indicates that the subject is unlikely to respond to or benefit from treatment with an IL-33 axis antagonist. Preferably, if the sample has an IL-33 / sST2 level below the reference level, this indicates that the subject should not be selected for treatment with an IL-33 axis antagonist. Preferably, if the sample has an IL-33 / sST2 level below the reference level, this indicates that the subject should not be treated with an IL-33 axis antagonist. Preferably, if the sample has an IL-33 / sST2 level below the reference level, this indicates that the subject is unlikely to respond to or benefit from the treatment, preferably less likely than a subject having an IL-33 / sST2 level that is at or above the reference level.

[0200] Preferably, a subject having a reference level or higher of IL-33 / sST2 in a sample obtained from the subject may be more likely to respond to or benefit from treatment with an IL-33 axis antagonist than a subject having a reference level or lower of IL-33 / sST2 in a sample obtained from the subject. Preferably, a subject having a reference level or higher of IL-33 / sST2 in a sample obtained from the subject may be more likely to respond to or benefit from treatment with an IL-33 axis antagonist than a subject having a reference level or lower of IL-33 / sST2 in a sample obtained from the subject. Preferably, a subject having a reference level or lower of IL-33 / sST2 in a sample obtained from the subject may be referred to as a "reference subject." Accordingly, preferably, a subject having a reference level or higher of IL-33 / sST2 in a sample obtained from the subject may be more likely to respond to or benefit from treatment with an IL-33 axis antagonist than a reference subject.

[0201] Preferably, the measured level must be equal to or greater than the reference level to indicate treatment, selection of a subject for treatment, or determination of likelihood of responding to or benefiting from treatment. Preferably, the measured level must be greater than the reference level to indicate treatment, selection of a subject for treatment, or determination of likelihood of responding to or benefiting from treatment.

[0202] Preferably, "likely to respond" to a treatment can mean that the subject will respond to the treatment. Preferably, "likely to benefit" from a treatment can mean that the subject will benefit from the treatment. Thus, preferably, if the sample has an IL-33 / sST2 level at or above the reference level, this indicates that the subject will respond to or benefit from treatment with an IL-33 axis antagonist.

[0203] Preferably, the reference level is about 25 picograms per milliliter (pg / ml). Preferably, the reference level is about 26 pg / ml, about 27 pg / ml, about 28 pg / ml, about 29 pg / ml, or about 30 pg / ml. In one example, the reference level is about 30 pg / ml. More specifically, in one example, the reference level is 30.15 pg / ml, and preferably, the subject is more likely to be treated, selected for treatment, or respond to treatment if the level of IL-33 / sST2 in a sample obtained from the subject is 30.15 pg / ml or greater. In one example, the subject is more likely to be treated, selected for treatment, or respond to treatment if the level of IL-33 / sST2 in a sample obtained from the subject is greater than 30.15 pg / ml.

[0204] Preferably, "about" means that the measurement may vary + / - 10% from the stated value. Preferably, "about" means that the measurement may vary + / - 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9% or 10% from the stated value.

[0205] Preferably, treatment with or response to an IL-33 axis antagonist may include any improvement in the subject's physiological function. Preferably, any improvement in the subject's condition, disease, disorder, or infection, preferably any improvement in the subject's respiratory distress. Preferably, treatment with or response to an IL-33 axis antagonist may include alleviation of the subject's respiratory distress. Preferably, alleviation of respiratory distress may include any of the following: decreased respiratory rate, increased blood oxygen levels, decreased shortness of breath, increased blood pressure, decreased heart rate, decreased chest pain, normal skin color, decreased sweating, decreased wheezing, decreased confusion, and decreased fatigue.

[0206] Suitably, treatment with or response to an IL-33 axis antagonist may include removal of oxygen or ventilatory support from the subject, or a reduction in the number of days the subject requires oxygen or ventilation.

[0207] Suitably, treatment or response to treatment with an IL-33 axis antagonist may comprise a clinical improvement of at least 2 points on a 9-point ordinal scale. Suitably, response to treatment with an IL-33 axis antagonist may comprise achieving a score of 0, 1, or 2 on the ordinal scale.

[0208] Suitably, treatment with or response to the IL-33 axis antagonist may comprise a reduced likelihood of death and / or acute respiratory failure, or may comprise prevention of respiratory failure and / or death. Suitably, the reduced likelihood of death and / or acute respiratory failure may be compared to a subject not treated with the IL-33 axis antagonist. Suitably, such that the subject is less likely to experience death and / or acute respiratory failure compared to a subject not treated with the IL-33 axis antagonist. Suitably, the reduced likelihood of death and / or acute respiratory failure may be compared to a subject having below the reference level of IL-33 / sST2 in a sample obtained from the subject (which may be referred to as a "reference subject"). Suitably, such that the subject is less likely to experience death and / or acute respiratory failure compared to a subject having below the reference level of IL-33 / sST2 in a sample obtained from the subject.

[0209] Suitably, treatment with or response to an IL-33 axis antagonist may comprise reducing the rate of mortality and / or acute respiratory failure. Suitably, the rate of mortality and / or acute respiratory failure may be reduced in subjects at risk of death and / or acute respiratory failure. Suitably, the reduction in the rate of mortality and / or acute respiratory failure may be in a subject population. Suitably, the rate of mortality and / or acute respiratory failure may be defined as the number of subjects experiencing death and / or acute respiratory failure in a population, suitably a population at risk of death and / or acute respiratory failure, suitably a population suffering from respiratory distress. Suitably, the reduction in the rate of mortality and / or acute respiratory failure may be compared to subjects not receiving treatment with the IL-33 axis antagonist. Suitably, this results in a lower rate of mortality and / or acute respiratory failure in subjects receiving treatment with the IL-33 axis antagonist compared to subjects not receiving treatment with the IL-33 axis antagonist. Preferably, the reduced mortality and / or acute respiratory failure rate may be compared to a subject having a below-reference level of IL-33 / sST2 in a sample obtained from the subject (which may be referred to as a "reference subject"). Preferably, such that the mortality and / or acute respiratory failure rate in the subject is lower than in subjects having a below-reference level of IL-33 / sST2 in a sample obtained from the subject.

[0210] Preferably, in the context of a method for preventing respiratory distress in a subject, responding to or benefiting from treatment with an IL-33 axis antagonist may be considered to be preventing respiratory distress from occurring in the subject, preferably such that the subject does not experience respiratory distress. Preferably, in such cases, responding to or benefiting from treatment with an IL-33 axis antagonist may be considered to be preventing any one of the symptoms associated with respiratory distress from occurring, as defined hereinabove. Preferably, in such cases, responding to or benefiting from treatment with an IL-33 axis antagonist may be considered to be preventing all of the symptoms associated with respiratory distress from occurring, as defined hereinabove. In some examples of a method for preventing respiratory distress in a subject, responding to or benefiting from treatment with an IL-33 axis antagonist may be considered to be preventing acute respiratory failure from occurring in the subject, preferably such that the subject does not experience acute respiratory failure. Preferably, in the context of a method of preventing acute respiratory failure in a subject, responding to or benefiting from treatment with an IL-33 axis antagonist may be considered as preventing the need for ventilation or oxygenation in the subject, preferably preventing the subject from needing ventilation or oxygen. Preferably, in such cases, responding to or benefiting from treatment may be considered as preventing the subject from needing assistance with breathing, preferably preventing the subject from needing assistance with breathing.

[0211] Preferably, the response to treatment with the IL-33 axis antagonist occurs within 2 months of the first treatment, preferably within about 6 weeks of the first treatment, preferably within about 1 month of the first treatment, preferably within 29 days of the first treatment.

[0212] In one example, responding to treatment with an IL-33 axis antagonist can include preventing respiratory failure or death within 29 days of initial treatment.

[0213] Suitably, the phrases "responsive to" or "benefit from" may be used interchangeably herein and may refer to the same response in the subjects identified above.

[0214] IL-33 axis antagonist The methods of the disclosure include treating a subject with an IL-33 axis antagonist or preventing the onset of a condition, disease, or disorder in a subject with an IL-33 axis antagonist.

[0215] As used herein, an "IL-33 axis antagonist" refers to any agent that directly or indirectly attenuates IL-33 activity. The antagonist may attenuate the activity of reduced IL-33, oxidized IL-33, or both. Alternatively, the antagonist may attenuate the activity of other molecules in the IL-33 signaling pathway or "axis," such as ST2, IL1-RaP, MyD88, IRAK1, IRAK4, TRAF6, MAPK, AP-1, NFkB, p38, Foxp3, GATA3, and IRF1. Preferably, the IL-33 axis antagonist may attenuate the activity of reduced IL-33, oxidized IL-33, ST2, and / or IL1-RaP.

[0216] Suitably, the IL-33 axis antagonist is specific for reduced IL-33 and / or oxidized IL-33 and suitably attenuates the activity of reduced IL-33 and / or oxidized IL-33. Suitably, in such cases, the IL-33 axis antagonist may be known simply as an "IL-33 antagonist".

[0217] Preferably, the IL-33 axis antagonist is specific for ST2 and preferably attenuates the activity of ST2. Preferably, in such cases, the IL-33 axis antagonist may be known as an "ST2 antagonist." An example of a suitable ST2 antagonist is the anti-ST2 antibody astegolimab, also known as MSTT1041A, AMG282, and RG6149.

[0218] Preferably, the IL-33 axis antagonist is specific for IL1-RaP and preferably attenuates the activity of IL1-RaP. Preferably, in such cases, the IL-33 axis antagonist may be known as an "IL1-RaP antagonist."

[0219] Preferably, the attenuation is by binding of reduced or oxidized IL-33, or by binding to ST2, or by binding to IL1-RaP. Preferably, where the antagonist attenuates reduced and oxidized IL-33 activity, the attenuation is by binding to reduced IL-33 (i.e. by binding to reduced IL-33).

[0220] Preferably, the IL-33 axis antagonist is a binding molecule or a fragment thereof, and therefore may be preferably referred to as an IL-33 axis binding antagonist.

[0221] As used herein, the term "binding molecule" or "antigen-binding molecule" refers in its broadest sense to a molecule that specifically binds to an antigenic determinant. Preferably, the binding molecule specifically binds to IL-33, particularly reduced IL-33 or oxidized IL-33, to ST2, or to IL1 RaP. In one example, the binding molecule specifically binds to reduced IL-33.

[0222] Suitably, the binding molecule may be selected from an antibody, an antigen-binding fragment thereof, an aptamer, at least one heavy chain or light chain CDR of a reference antibody molecule, and at least six CDRs from one or more reference antibody molecules.

[0223] Preferably, the IL-33 axis antagonist is an antibody or a binding fragment thereof. Preferably, the IL-33 axis antagonist is an anti-IL-33 antibody or a binding fragment thereof, an anti-ST2 antibody or a binding fragment thereof, or an anti-IL1 RaP antibody or a binding fragment thereof. Preferably, the anti-IL-33 antibody or a binding fragment thereof specifically binds to IL-33, particularly reduced IL-33 or oxidized IL-33.

[0224] In one example, the IL-33 axis antagonist is an anti-IL-33 antibody or a binding fragment thereof.

[0225] As used herein, "antibody" refers to immunoglobulin molecules, as discussed in more detail below, particularly full length antibodies or molecules comprising full length antibodies, such as DVD-Ig molecules.

[0226] "Binding fragment thereof" is interchangeable with "antigen-binding fragment thereof" and refers to an epitope / antigen-binding fragment of an antibody fragment, e.g., comprising the binding region, in particular comprising six CDRs, e.g., three CDRs of the heavy chain variable region and three CDRs of the light chain variable region.

[0227] Preferably, the antibody or binding fragment thereof is selected from natural, polyclonal, monoclonal, multispecific, murine, human, humanized, primatized, or chimeric. Preferably, the antibody or binding fragment thereof is an epitope-binding fragment, such as Fab' and F(ab')2, Fd, Fv, single-chain Fv (scFv), disulfide-linked Fv (sdFv), fragments containing either the VL or VH domain, or fragments produced by a Fab expression library. Preferably, the antibody or binding fragment thereof is a minibody, diabody, triabody, tetrabody, or single-chain antibody. Preferably, the antibody or binding fragment thereof is a monoclonal antibody. scFv molecules are known in the art and are described, for example, in U.S. Patent No. 5,892,019.

[0228] Immunoglobulin or antibody molecules of the present disclosure can be of any type (e.g., IgG, IgE, IgM, IgD, IgA, and IgY), class (e.g., IgG1, IgG2, IgG3, IgG4, IgA1, IgA2, etc.), or subclass of immunoglobulin molecule.

[0229] Preferably, the IL-33 axis antagonist is a reduced IL-33 antagonist. In other words, the IL-33 axis antagonist attenuates the activity of reduced IL-33. Preferably, the attenuation is due to binding to reduced IL-33.

[0230] Preferably, the binding molecule or fragment thereof is 5×10 -2 M, 10 -2 M, 5 x 10 -3 M, 10 -3 M, 5 x 10 -4 M, 10 -4 M, 5 x 10 -5 M, 10 -5 M, 5 x 10 -6 M, 10 -6 M, 5 x 10 -7 M, 10 -7 M, 5 x 10 -8 M, 10 -8 M, 5 x 10 -9 M, 10 -9 M, 5 x 10 -10 M, 10 -10 M, 5 x 10 -11 M, 10 -11 M, 5 x 10 -12 M, 10 -12 M, 5 x 10 -13 M, 10 -13 M, 5 x 10 -14 M, 10 -14 M, 5 x 10 -15 M or 10 -15 Specifically binds to reduced IL-33 with a binding affinity (Kd) of less than 5×10 M. Preferably, the binding affinity for reduced IL-33 is less than 5×10 -14 M (i.e., less than 0.05 pM). Preferably, the binding affinity is measured using an equilibrium exclusion assay (KinExA) or BIACORE™, preferably using KinExA, using a protocol such as that described in WO 2016 / 156440 (see, e.g., Example 11), which is incorporated herein by reference in its entirety. Binding molecules that bind reduced IL-33 with this binding affinity likely bind reduced IL-33 strongly enough to prevent dissociation of the binding molecule / reduced IL-33 complex within a biologically relevant timescale. Without being bound by theory, it is believed that this binding strength prevents release of the antigen prior to degradation of the antibody / antigen complex in vivo, such that reduced IL-33 is not released.

[0231] Preferably, the binding molecule or fragment thereof is 10 3 M -1 sec -1 , 5×10 3 M -1 sec-1, 104M -1 sec-1 or 5 x 10 4 M -1 sec -1 For example, the binding molecules of the present disclosure may specifically bind reduced IL-33 or a fragment or variant thereof with an on-rate (k(on)) of 10 or greater. 5 M -1 sec -1 , 5×10 5 M -1 sec -1 , 10 6 M -1 sec -1 or 5 x 10 6 M -1 sec -1 or 10 7 M -1 sec -1 The coupling can be performed with an on-rate (k(on)) of 10 or more. Preferably, the k(on) rate is 10 7 M -1 sec -1 That's all.

[0232] Preferably, the binding molecule or fragment thereof has a binding affinity of 5×10 sec, 10 sec, 5×10 sec, 10 -2 sec -1 , 5×10 -3 sec -1 or 10 -3 sec -1 For example, a binding molecule of the present disclosure may specifically bind reduced IL-33 with an off rate (k(off)) of 5×10 -4 sec -1 , 10 -4 sec -1 , 5×10 -5 sec -1 , 10 -5 sec -1 , 5×10 -6 sec -1 , 10 -6 sec-1 , 5×10 -7 sec -1 or 10 -7 sec -1 It can be said that the reduced IL-33 or a fragment or variant thereof binds with an off rate (k(off)) of 10 or less. Preferably, the k(off) rate is 10 -3 sec -1 IL-33 is an alarmin cytokine that is released rapidly and in high concentrations in response to inflammatory stimuli.

[0233] Preferably, the IL-33 binding molecule is capable of competitively inhibiting the binding of IL-33 to tozorakimab and the binding molecule 33_640087-7B (described in WO 2016 / 156440), also known as MEDI3506. Preferably, WO 2016 / 156440 describes that 33_640087-7B binds to reduced IL-33 with particularly high affinity. The light chain of tozorakimab has the amino acid sequence set forth in SEQ ID NO: 52, and the heavy chain of tozorakimab has the amino acid sequence set forth in SEQ ID NO: 51.

[0234] Tozolaximab is a fully human IgG1 monoclonal antibody being developed specifically for the treatment of chronic obstructive pulmonary disease (COPD). It binds to human reduced IL-33 (IL-33red) and prevents IL33red from binding to its receptor ST2. It binds to human IL-33 with exceptionally high affinity (approximately 30 fM) and completely neutralizes endogenous full-length and all mature forms of IL-33red (Scott et al., ERS International Congress 2022, Barcelona (ES), Abstract OA2254). By binding to IL33red, tozolaximab potently inhibits ST2-dependent inflammatory responses in several primary human cells and in an allergen-driven in vivo model of lung epithelial injury. Oxidized IL-33 (IL33ox) is unable to engage ST2 signaling via the RAGE / EGFR pathway. Although tozolaximab cannot bind to IL-33ox, it prevents IL-33 oxidation and IL-33ox-dependent signaling via the RAGE / EGFR complex, mimicking the mechanism of action of ST2 (Scott et al., supra). Inhibition of IL-33ox signaling by tozolaximab can improve airway epithelial repair function and reverse airway epithelial dysfunction in respiratory diseases, including mucus hypersecretion (Scott et al., supra). Therefore, binding molecules that competitively inhibit IL-33 binding to the binding molecule 33_640087-7B are likely to inhibit both reduced and oxidized IL-33 signaling.

[0235] A binding molecule or fragment thereof is said to competitively inhibit the binding of a reference antibody to a given epitope if it specifically binds to that epitope to the extent that it blocks the binding of the reference antibody to that epitope to some extent. Competitive inhibition can be determined by any method known in the art, for example, solid-phase assays such as competitive ELISA assays, dissociation-promoting lanthanide fluorescence immunoassays (DELFIA®, Perkin Elmer), and radioligand binding assays. For example, one skilled in the art can determine whether a binding molecule or fragment thereof competes for binding to redIL-33 by using an in vitro competitive binding assay, such as a derivative of the HTRF assay described in Example 1 of WO 2016 / 156440 (incorporated herein by reference). For example, one skilled in the art can label a recombinant antibody of Table 1 with a donor fluorophore and mix multiple concentrations with a fixed concentration sample of acceptor fluorophore-labeled redIL-33. Fluorescence resonance energy transfer between the donor and acceptor fluorophores in each sample can then be measured to confirm binding characteristics. To identify competitive binding molecules, one skilled in the art can first mix various concentrations of a test binding molecule with a fixed concentration of a labeled antibody from Table 1. A decrease in FRET signal when the mixture is incubated with labeled IL-33, compared to a positive control of labeled antibody alone, indicates competitive binding to IL-33. A binding molecule or fragment thereof can be said to competitively inhibit binding of a reference antibody to a given epitope by at least 90%, at least 80%, at least 70%, at least 60%, or at least 50%.

[0236] In some examples, the IL-33 axis binding antagonist is selected from the group consisting of the following anti-IL-33 antibodies: 33_640087-7B, also known as tozolaximab (described in WO 2016 / 156440), ANB020, also known as etoximab (described in WO 2015 / 106080), 9675P or itepekimab (described in U.S. Patent Application Publication No. 2014 / 0271658), A25-3H04 (described in U.S. Patent Application Publication No. 2017 / 0283494), Ab43 (described in WO 2018 / 081075), IL33-158 (described in U.S. Patent Application Publication No. 2018 / 0037644), 10C12.38.H6.87Y.581 IgG4 (described in WO 2016 / 077381) or a binding fragment thereof, each of which is incorporated herein by reference. All of these antibodies are referenced in Table 1.

[0237] Preferably, the IL-33 axis-binding antagonist is an antibody or antigen-binding fragment comprising the complementarity-determining regions (CDRs) of a heavy chain variable region (HCVR or VH) and a light chain variable region pair (LCVR or VL) selected from Table 1. Pair 1 corresponds to the HCVR and LCVR sequences of tozolaximab (33_640087-7B) described in WO 2016 / 156440. Pairs 2-7 correspond to the HCVR and LCVR sequences of antibodies described in U.S. Patent Application Publication No. 2014 / 0271658. Pairs 8-12 correspond to the HCVR and LCVR sequences of antibodies described in U.S. Patent Application Publication No. 2017 / 0283494. Pair 13 corresponds to the HCVR and LCVR sequences of ANB020 described in WO 2015 / 106080. Pairs 14 to 16 correspond to the HCVR and LCVR sequences of antibodies described in WO 2018 / 081075, Pair 17 corresponds to the HCVR and LCVR sequences of IL33-158 described in U.S. Patent Application Publication No. 2018 / 0037644, and Pair 18 corresponds to the HCVR and LCVR sequences of 10C12.38.H6.87Y.581 IgG4 described in WO 2016 / 077381.

[0238] [Table 1-1]

[0239] [Table 1-2]

[0240] [Table 1-3]

[0241] Preferably, those skilled in the art are aware of methods available in the art for identifying CDRs within the heavy and light chain variable regions of an antibody or its antigen-binding fragment. Preferably, those skilled in the art can perform, for example, sequence-based annotation. The regions between CDRs are generally highly conserved, and therefore, logical rules can be used to determine the locations of CDRs. Those skilled in the art can use a set of sequence-based rules for conventional antibodies (Pantazes and Maranas, Protein Engineering, Design and Selection, 2010), or alternatively, or in addition, refine the rules based on multiple sequence alignments. Alternatively, those skilled in the art can compare antibody sequences with publicly available databases operating on the Kabat, Chothia, or IMGT methods using the BLASTP command in BLAST+ to identify the most similar annotated sequences. Each of these methods devise a unique residue numbering scheme according to which hypervariable region residues are numbered, and then the start and end of each of the six CDRs are determined according to certain key positions. For example, alignment with the most similar annotated sequence allows for extrapolation of the CDRs from the annotated sequence to the unannotated sequence, thereby identifying the CDRs. Suitable tools / databases include, for example, the Kabat database, Kabatman, Scalinger, IMGT, and Abnum.

[0242] Preferably, the IL-33 axis antagonist is an anti-IL-33 antibody or antigen-binding fragment comprising a heavy chain variable region (HCVR or VH) and a light chain variable region (LCVR or VL) pair selected from Table 1.

[0243] Thus, preferably, in one example, there is provided a method for treating a subject suffering from respiratory distress or preventing respiratory distress in a subject at risk of respiratory distress, the method comprising administering to the subject an effective amount of an anti-IL-33 antibody or antigen-binding fragment thereof, the anti-IL-33 antibody or antigen-binding fragment comprising a pair of heavy chain variable regions and light chain variable regions selected from Table 1, preferably 33_640087-7B / tozolaximab, wherein the level of IL-33 / sST2 in a sample obtained from the subject is equal to or greater than a reference level of about 25 pg / ml.

[0244] Thus, preferably, in one example, there is provided a method of treating a subject suffering from respiratory distress or preventing respiratory distress in a subject at risk of respiratory distress, the method comprising: measuring the level of IL-33 / sST2 in a sample obtained from the subject; and, if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml, administering to the subject an effective amount of an anti-IL-33 antibody or antigen-binding fragment thereof, wherein the anti-IL-33 antibody or antigen-binding fragment comprises a pair of heavy chain and light chain variable regions selected from Table 1, and preferably 33_640087-7B / tozolaximab.

[0245] Accordingly, suitably, in one example, there is provided a method of selecting a subject suffering from or at risk of suffering from respiratory distress for treatment with an anti-IL-33 antibody or antigen-binding fragment comprising a pair of heavy and light chain variable regions selected from Table 1, preferably 33_640087-7B / tozolaximab, the method comprising measuring the level of IL-33 / sST2 in a sample obtained from the subject, and selecting the subject for the treatment if the level of IL-33 / sST2 in the sample is equal to or greater than a reference level of about 25 pg / ml.

[0246] Thus, in one example, there is preferably provided a method for determining whether a subject suffering from or at risk of suffering from respiratory distress is likely to respond to treatment with an anti-IL-33 antibody or antigen-binding fragment, the anti-IL-33 antibody or antigen-binding fragment comprising a pair of heavy chain variable region and light chain variable region selected from Table 1, preferably 33_640087-7B / tozolaximab, the method comprising measuring the level of IL-33 / sST2 in a sample obtained from the subject, and determining that the subject is likely to respond to the treatment if the measured level of IL-33 / sST2 in the sample is equal to or greater than a reference level.

[0247] Preferably, the anti-IL33 antibody or antigen-binding fragment thereof comprises a HCVR / VH of the sequence of SEQ ID NO: 1 and a LCVR / VL of the sequence of SEQ ID NO: 19.

[0248] Suitably, the anti-IL33 antibody or antigen-binding fragment thereof comprises a HCVR / VH of the sequence of SEQ ID NO: 7 and a LCVR / VL of the sequence of SEQ ID NO: 25.

[0249] Suitably, the anti-IL33 antibody or antigen-binding fragment thereof comprises a HCVR / VH of the sequence of SEQ ID NO: 11 and a LCVR / VL of the sequence of SEQ ID NO: 29.

[0250] Preferably, the anti-IL33 antibody or antigen-binding fragment thereof comprises a HCVR / VH of the sequence of SEQ ID NO: 13 and a LCVR / VL of the sequence of SEQ ID NO: 31.

[0251] Preferably, the anti-IL33 antibody or antigen-binding fragment thereof comprises a HCVR / VH of the sequence of SEQ ID NO: 16 and a LCVR / VL of the sequence of SEQ ID NO: 34.

[0252] Suitably, the anti-IL33 antibody or antigen-binding fragment thereof comprises a HCVR / VH of the sequence of SEQ ID NO: 17 and a LCVR / VL of the sequence of SEQ ID NO: 35.

[0253] Suitably, the anti-IL33 antibody or antigen-binding fragment thereof comprises a HCVR / VH of the sequence of SEQ ID NO: 18 and a LCVR / VL of the sequence of SEQ ID NO: 36.

[0254] Thus, suitably, the IL-33 axis antagonist is a binding molecule that may comprise three CDRs in the heavy chain variable region independently selected from, for example, SEQ ID NOs: 1, 7, 11, 13, 16, 17, and 18.

[0255] Suitably, the IL-33 axis antagonist is a binding molecule comprising three CDRs in the heavy chain variable region set forth in SEQ ID NO:1.

[0256] Suitably, the IL-33 axis antagonist is a binding molecule that may comprise three CDRs in the light chain variable region independently selected from SEQ ID NOs: 19, 25, 29, 31, 34, 35, and 36.

[0257] Suitably, the IL-33 axis antagonist is a binding molecule comprising three CDRs in the light chain variable region set forth in SEQ ID NO:19.

[0258] Thus, suitably, the IL-33 axis antagonist is a binding molecule that may comprise, for example, three CDRs in a heavy chain variable region independently selected from SEQ ID NOs: 1, 7, 11, 13, 16, 17, and 18, and three CDRs in a light chain variable region independently selected from SEQ ID NOs: 19, 25, 29, 31, 34, 35, and 36.

[0259] Thus, suitably, the IL-33 axis antagonist is a binding molecule comprising three CDRs from a heavy chain variable region set forth in SEQ ID NO:1 and three CDRs from a light chain variable region set forth in SEQ ID NO:19.

[0260] Thus, suitably, the IL-33 axis antagonist is a binding molecule that may comprise a variable heavy domain (VH) and a variable light domain (VL) having VHCDRs 1-3 with the sequences of SEQ ID NOs: 37, 38, and 39, respectively, wherein one or more VHCDRs have no more than three single amino acid substitutions, insertions, and / or deletions.

[0261] Thus, suitably, the IL-33 axis antagonist is a binding molecule comprising a VH domain comprising VHCDRs 1-3 of SEQ ID NO: 37, SEQ ID NO: 38, and SEQ ID NO: 39, respectively.

[0262] Thus, preferably, the IL-33 axis antagonist is a binding molecule comprising a VH domain comprising VHCDR1-3 consisting of SEQ ID NO:37, SEQ ID NO:38, and SEQ ID NO:39, respectively.

[0263] Thus, preferably, the IL-33 antagonist is a binding molecule that may comprise a variable heavy domain (VH) and a variable light domain (VL) having VLCDRs 1-3 with the sequences of SEQ ID NOs: 40, 41, and 42, respectively, wherein one or more VLCDRs have no more than three single amino acid substitutions, insertions, and / or deletions.

[0264] Thus, suitably, the IL-33 axis antagonist is a binding molecule comprising a VL domain comprising VLCDR1-3 of SEQ ID NO: 40, SEQ ID NO: 41, and SEQ ID NO: 42, respectively.

[0265] Thus, preferably, the IL-33 axis antagonist is a binding molecule comprising a VL domain comprising VLCDR1-3 consisting of SEQ ID NO: 40, SEQ ID NO: 41, and SEQ ID NO: 42, respectively.

[0266] Thus, suitably, the IL-33 axis antagonist is a binding molecule that may comprise a VHCDR1 having the sequence of SEQ ID NO: 37, a VHCDR2 having the sequence of SEQ ID NO: 38, a VHCDR3 having the sequence of SEQ ID NO: 39, a VLCDR1 having the sequence of SEQ ID NO: 40, a VLCDR2 having the sequence of SEQ ID NO: 41, and a VLCDR3 having the sequence of SEQ ID NO: 42.

[0267] Thus, preferably, the IL-33 axis antagonist is an antibody or binding fragment thereof comprising a VH and a VL, wherein the HCVR / VH has an amino acid sequence at least 90%, e.g., 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100%, identical to the HCVR / VH set forth in SEQ ID NOs: 1, 7, 11, 13, 16, 17, and 18.

[0268] Thus, preferably, the IL-33 axis antagonist is an antibody or binding fragment thereof comprising a VH and a VL, wherein the HCVR / VH has an amino acid sequence that is at least 90%, e.g., 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100%, identical to the HCVR / VH set forth in SEQ ID NO:1.

[0269] Thus, preferably, the IL-33 axis antagonist is an antibody or binding fragment thereof comprising a VH and a VL, wherein the HCVR / VH has a sequence as disclosed above in which 1, 2, 3, or 4 amino acids in the framework have been deleted, inserted, and / or independently replaced with different amino acids.

[0270] Thus, preferably, the IL-33 axis antagonist is an antibody or binding fragment thereof comprising a VH and a VL, wherein the LCVR / VL has an amino acid sequence at least 90%, e.g., 91, 92, 93, 94, 95, 96, 97, 98, 99 or 100%, identical to the LCVR / VL set forth in SEQ ID NOs: 19, 25, 29, 31, 34, 35, and 36.

[0271] Thus, preferably, the IL-33 axis antagonist is an antibody or binding fragment thereof comprising a VH and a VL, wherein the LCVR / VL has an amino acid sequence that is at least 90%, e.g., 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100%, identical to the LCVR / VL set forth in SEQ ID NO: 19.

[0272] Thus, preferably, the IL-33 axis antagonist is an antibody or binding fragment thereof comprising a VH and a VL, wherein the LCVR / VL has a sequence as disclosed above in which 1, 2, 3 or 4 amino acids in the framework have been independently deleted, inserted and / or replaced with different amino acids.

[0273] Thus, preferably, the IL-33 axis antagonist is an anti-IL-33 antibody or binding fragment thereof comprising a VH and a VL, wherein the VH has an amino acid sequence at least 90%, e.g., 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100%, identical to the HCVR / VH set forth in SEQ ID NOs: 1, 7, 11, 13, 16, 17, and 18, and the VL has an amino acid sequence at least 90%, e.g., 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100% identical to the LCVR / VL set forth in SEQ ID NOs: 19, 25, 29, 31, 34, 35, and 36, or a binding fragment thereof.

[0274] Thus, preferably, the IL-33 axis antagonist is an anti-IL-33 antibody or binding fragment thereof comprising a VH and a VL, wherein the HCVR / VH has the amino acid sequence of SEQ ID NOs: 1, 7, 11, 13, 16, 17, and 18, and the LCVR / VL has the amino acid sequence of SEQ ID NOs: 19, 25, 29, 31, 34, 35, and 36.

[0275] Thus, preferably, the IL-33 axis antagonist is an anti-IL-33 antibody or binding fragment thereof comprising a VH and a VL, wherein the HCVR / VH has the amino acid sequence of SEQ ID NO: 1 and the LCVR / VL has the amino acid sequence of SEQ ID NO: 19. Preferably, in such a case, the IL-33 axis antagonist is 33_640087-7B, also known as tozolaximab.

[0276] Effective Amounts and Administration The IL-33 axis antagonist in the medical uses and methods described herein may be administered to a subject in the form of a pharmaceutical composition.

[0277] Suitably, any reference herein to an "IL-33 axis antagonist" may refer to a pharmaceutical composition comprising an IL-33 axis antagonist. Suitably, the pharmaceutical composition may comprise one or more IL-33 axis antagonists in combination.

[0278] Suitably, the IL-33 axis antagonist may be administered in a pharmaceutically effective amount for the in vivo treatment of respiratory distress as defined in the medical use and method of treatment aspects herein.

[0279] Suitably, a "pharmaceutically effective amount" or "therapeutically effective amount" of an IL-33 axis antagonist shall mean an amount sufficient to achieve effective binding to a target molecule within the IL-33 axis and achieve a benefit, e.g., amelioration of the symptoms of a disease or condition such as respiratory distress as described in the medical uses / methods herein.

[0280] Suitably, the IL-33 axis antagonist or pharmaceutical composition thereof may be administered to humans or other animals in accordance with the aforementioned methods of treatment / medical use in an amount sufficient to produce a therapeutic effect.

[0281] A suitable dose of an IL-33 axis antagonist or pharmaceutical composition thereof, which may constitute a "pharmaceutically effective amount" or a "therapeutically effective amount," can be calculated by one of skill in the art using known techniques. In one example, a suitable dose may be about 300 mg.

[0282] Suitably, the IL-33 axis antagonist or pharmaceutical composition thereof may be administered to such humans or other animals in conventional dosage forms prepared by combining the IL-33 axis antagonist with one or more conventional pharmaceutically acceptable carriers or diluents in accordance with known techniques.

[0283] Those skilled in the art will recognize that the form and character of the pharmaceutically acceptable carrier or diluent will be dictated by the amounts of active ingredients with which it is to be combined, the route of administration, and other well-known variables. Those skilled in the art will further appreciate that cocktails comprising more than one type of IL-33 axis antagonist may prove particularly effective.

[0284] The amount of IL-33 axis antagonist that can be combined with carrier materials to produce a single dosage form will vary depending on the subject being treated and the particular mode of administration. Preferably, the IL-33 axis antagonist can be administered as a single dose, multiple doses, or as an infusion over an established period of time. Preferably, the dosing regimen can also be adjusted to provide the optimum desired response (e.g., a therapeutic or prophylactic response).

[0285] Preferably, the IL-33 axis antagonist is formulated to facilitate ease of administration and promote stability of the active IL-33 axis antagonist.

[0286] Preferably, the pharmaceutical compositions are formulated to contain pharmaceutically acceptable, non-toxic, sterile carriers such as physiological saline, non-toxic buffers, preservatives, and the like.

[0287] Suitable formulations for use in the therapeutic methods disclosed herein are described in Remington's Pharmaceutical Sciences (Mack Publishing Co.), 16th ed. (1980).

[0288] In some examples, the IL-33 axis antagonist is formulated as a liquid. In some examples, the liquid formulation includes the following: 20 mM L-histidine / L-histidine hydrochloride, 220 mM L-arginine hydrochloride, 0.03% (w / v) polysorbate 80, pH 5.5. In some examples, the formulation includes 150 mg / ml of the IL-33 axis antagonist.

[0289] Methods for administering an IL-33 axis antagonist or a pharmaceutical composition thereof to a subject in need thereof are well known or readily determined by one of ordinary skill in the art.

[0290] Suitably, the route of administration of the IL-33 axis antagonist or pharmaceutical composition thereof may be, for example, oral, parenteral, inhalation or topical. Suitably, the term parenteral as used herein includes, for example, intravenous, intraarterial, intraperitoneal, intramuscular, subcutaneous, rectal or vaginal administration.

[0291] Suitably, the IL-33 axis antagonist or pharmaceutical composition thereof may be administered orally in an acceptable dosage form including, for example, a capsule, a tablet, an aqueous suspension or solution.

[0292] Suitably, the IL-33 axis antagonist or pharmaceutical composition thereof may be administered by nasal aerosol or inhalation.

[0293] In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered intravenously.

[0294] In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered at a dose of 300 mg to 600 mg, for example, 350 mg, 400 mg, 450 mg, 500 mg, 550 mg, or 600 mg. In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered intravenously, preferably at a dose of 300 mg to 600 mg (i.e., a fixed dose is used rather than a weight-dependent dose). In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered intravenously at a dose of 300 mg.

[0295] In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered after the subject is hospitalized. In one example, within 12, 24, 48, or 36 hours of the subject's hospitalization. In one example, within 36 hours of the subject's hospitalization. Preferably, the subject's hospitalization can be considered admission to a hospital.

[0296] In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered for up to about 14 days after the onset of symptoms of a respiratory viral infection.

[0297] The dosing regimens utilized in the present disclosure may include administration of only a single dose of an IL-33 axis antagonist or pharmaceutical composition thereof, or may include multiple doses (particularly two doses). In certain examples, the treatments of the present disclosure include administration of a single dose of an IL-33 axis antagonist or pharmaceutical composition thereof to a subject. That is, the treatment methods disclosed herein include administering a single dose of an IL-33 axis antagonist or pharmaceutical composition thereof over a treatment period.

[0298] When multiple doses of antibody are administered, the administrations are suitably spaced, i.e., an appropriate interval is provided between the administrations. In one example, the IL-33 axis antagonist or pharmaceutical composition thereof may be administered approximately once a week, once every two weeks, once every four weeks, once every six weeks, or once every eight weeks, preferably after the first administration. Preferably, the first administration may be administered within 36 hours of the subject's admission to hospital. Generally, when multiple doses are administered in the present disclosure, each dose is the same amount of antibody. In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered in a first dose and, optionally, a second dose, the second dose being approximately two weeks after the first dose. In some examples, the administration regimen includes administration of a first dose followed by administration of a second dose, optionally two weeks later, depending on the subject's clinical condition / progression. Preferably, the first dose may be administered within 36 hours of the subject's admission to hospital. Preferably, the first dose may be administered up to about 14 days after the onset of respiratory viral infection symptoms. In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered in a single dose.

[0299] In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered intravenously at a dose of 300 mg within 36 hours of the subject's admission to hospital. Preferably, it can be a single dose.

[0300] In one example, the IL-33 axis antagonist or pharmaceutical composition thereof is administered intravenously at a dose of 300 mg for up to about 14 days after the onset of respiratory viral infection symptoms in the subject. Preferably, it can be administered as a single dose. [Brief explanation of the drawings]

[0301] Certain elements of the present disclosure will now be described, by way of example, with reference to the following drawings: [Figure 1] Figure 1 shows patient recruitment for the ACCORD Phase 2a trial during two periods. [Figure 2]1 shows measurements of IL-33 / sST2 in patients during the ACCORD Phase 2a trial. The number of patients treated with SoC and with SoC in combination with tozolaximab who died or experienced respiratory failure on Day 29 of the trial is shown for (a) overall, (b) those with low baseline IL-33 / sST2 levels below baseline, or (c) those with high baseline IL-33 / sST2 levels at or above baseline.

[0302] The present disclosure will now be described with reference to the following non-limiting examples. [Example]

[0303] High baseline IL-33 / sST2 levels are a predictive biomarker for identifying IL-33 axis antagonist responders.

[0304] Serum samples from patients infected with SARS-CoV-2 were obtained from patients enrolled in the Phase 2a ACCORD trial (EudracT number: 2020-001736-95, Wilkinson et al., 2020). Patients were recruited over two time periods during the pandemic, as shown in Figure 1.

[0305] Patients were randomized to receive either standard of care (SoC) alone or in combination with anti-IL-33 antibody (tozolaximab) treatment (300 mg intravenously (IV) with an optional second dose if invasively ventilated on day 15) for 29 days. The 300 mg IV dose was administered by the following procedure: 2 ml of tozolaximab was diluted with 8 ml of saline to a total volume of 10 ml and administered to the patient via IV push over 1-2 minutes using an IV line filter, followed by an IV flush with 5 ml of saline.

[0306] The SoC changed over the two periods of the ACCORD trial as our understanding of the SARS-CoV-2 virus evolved. The SoC used during each period is shown in Table 2 below. The SoC treatment in the second period of the ACCORD trial more accurately reflects current best practices.

[0307] [Table 2]

[0308] Sera from patients receiving tozolaximab plus standard of care (n=46 at baseline, n=37 at day 5, n=10 at day 10) and patients receiving SoC alone (n=37 at baseline, n=23 at day 5, n=10 at day 10) were measured for IL-33 / sST2 at a 1:4 dilution.

[0309] All serum samples were stored in aliquots at -80°C after collection.

[0310] To measure levels of IL-33 / sST2 in serum, the MSD S-PLEX assay was performed on serum samples obtained from patients at MSD (Gaithersburg, USA) using S-PLEX technology with the antibody pairs listed in Table 3.

[0311] It should be noted that, as explained hereinabove, any other assay method available in the art could be used to measure the levels of IL-33 / sST2 in serum samples.

[0312] [Table 3]

[0313] [Table 4]

[0314] The estimated LLOD is calculated as the concentration from the standard curve that produces a signal 2.5 standard deviations above the diluent alone (buffer only).

[0315] The custom MSD S-PLEX IL-33 / sST2 complex assay was prepared and validated by Mesoscale Discovery (MSD) and performed according to the manufacturer's instructions. All incubations required plate shaking at room temperature (RT) unless otherwise noted. Plates were washed three times with wash buffer (phosphate-buffered saline (PBS) / 0.05% Tween-20) as described. Biotin-coated capture mAb (Table 5) was diluted in Diluent 100 (MSD) containing the S-Plex coating reagent (Table 5). Assay plates (MSD) were coated with 50 μl / well of the coating solution and incubated for 1 hour. Blocking reagent (1x final concentration) was prepared by diluting S-Plex Blocker reagent (MSD) in Diluent 101 (MSD). A standard curve for recombinant IL-33 / sST2 complex was generated by diluting the stock to the highest standard concentration (Table 5) in Diluent 100 and performing four-fold serial dilutions. 25 μl of blocking reagent was added to all wells, and 25 μl of standards and samples were added to the wells and incubated for 1.5 hours. TURBO-boost solution was prepared by diluting TURBO-boost-labeled detection mAb stock (Table 5) to the working concentration in Diluent 3 (MSD). The plate was washed, and 50 μl of TURBO-boost detection mAb solution was added per well and incubated for 1 hour. The plate was washed, and 50 μl of enhancement solution (MSD) was added per well and incubated for 30 minutes. The plate was washed, and 50 μl of detection solution (MSD) was added per well and incubated for 1 hour at 26°C. The plate was washed, and 150 μl of 1× read buffer A (MSD) was added to each well. Plates were read on an MSD MESO SECTOR S600 instrument.

[0316] [Table 5] * Data are expressed in units / ml for IL-33 / sST2 complex, which can approximate pg / ml if assuming 100% complex formation for the IL-33 / sST2 standard.

[0317] The MSD S-PLEX assay was sensitive enough to determine pg / ml levels of IL-33 / sST2 in patient serum.

[0318] Subgroup analysis of the endpoint "death or respiratory failure on day 29" was performed based on the median baseline IL-33 / sST2 level. The median baseline level was 30.15 U / ml, and subgroups were defined as low IL-33: baseline IL-33 / sST2 < 30.15 U / ml; high IL-33: baseline IL-33 / sST2 ≥ 30.15 U / ml.

[0319] Within each subgroup, the proportion of subjects who died by day 29 or experienced respiratory failure at day 29 was calculated for each treatment, and the relative risk (tozolaximab:placebo) was calculated for each subgroup, along with its 80% confidence interval. Additionally, a logistic regression model was applied to each subgroup, adjusting for age (continuous variable) and baseline severity (WHO score of 3 or 4 vs. 5). From this logistic regression model, the odds ratio (tozolaximab:placebo) of experiencing death or respiratory failure at day 29, along with its 80% confidence interval, was calculated for each subgroup.

[0320] Using this assay, it was determined that patients with elevated baseline serum IL-33 / sST2 levels of 30.15 pg / ml or greater were significantly less likely to die or experience respiratory failure after 29 days when treated with tozolaximab, as shown in Table 6 and Figure 2.

[0321] Such patients form a subgroup that may respond favorably to IL-33 axis antagonist treatment, providing a method for stratifying and selecting patients in respiratory distress for treatment with IL-33 axis antagonists. Treatment may be particularly applicable to subjects in respiratory distress who are hospitalized with viral lower respiratory tract infections requiring supplemental oxygen. These subjects are particularly at risk of death and / or transition to invasive mechanical ventilation (IMV) or ECMO.

[0322] [Table 6]

[0323] Additional sequences to those in Table 1 IL-33 axis antagonist binding molecule (tozorakimab): VH CDRs 1-3: VH CDR1 SEQ ID NO: 37: SYAMS VH CDR2 SEQ ID NO: 38: GISAIDQSTYYADSVKG VH CDR3 SEQ ID NO: 39: QKFMQLWGGGLRYPFGY VL CDR 1~3: VL CDR1 SEQ ID NO: 40:SGEGMGDKYAA VL CDR2 SEQ ID NO: 41: RDTKRPS VL CDR3 SEQ ID NO: 42: GVIQDNTGV

[0324] Anti-IL-33 / sST2 antibody (AB1070008): AB1070008 VH according to SEQ ID NO: 43 QVQLQQSGPELVKPGASVKTSCKASGYSFTSYYIHWVKQRPGQGLEWIGWIYPGSGNTKYNEKFKGKATLTADTSSSTAFMQLSSLTSEDSAVYYCASGFHYYGRMDYWGQGTTLTVSS AB1070008 VL according to SEQ ID NO: 44 DIQMTQSPSSLSASLGERVSLTCRASQEISGYLSWLQQKPDGTIKRLIYSTSTLDSGVPKSFSGSRSGSDYSLTISSLESEDFADYYCLQYASSPWTFGGGTKLEIK

[0325] AB1070008 VHCDR 1~3: VH CDR1 SEQ ID NO: 45:SYYIH VH CDR2 SEQ ID NO: 46 WIYPGSGNTKYNEKFK VH CDR3 SEQ ID NO: 47 GFHYYGRMDY

[0326] AB1070008 VLCDR 1~3: VL CDR1 SEQ ID NO: 48: RASQEISGYLS VL CDR2 SEQ ID NO: 49: STSTLDS VL CDR3 SEQ ID NO: 50: LQYASSPWT

[0327] Tozorakimab heavy chain sequence (SEQ ID NO: 51): EVQLLESGGGLVQPGGSLRLSCAASGFTFSSYAMSWVRQAPGKGLEWVSGISAIDQSTYYADSVKGRFTISRDNSKNTLYLQMNSLRAEDTAVYYCARQKFMQLWGGGLRYPFG YWGQGTMVTVSSASTKGPSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKS CDKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIE KTISKAKGQPREPQVYTLPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

[0328] Tozorakimab light chain sequence (SEQ ID NO: 52): SYVLTQPPSVSVSPGQTASITCSGEGMGDKYAAWYQQKPGQSPVLVIYRDTKRPSGIPERFSGSNSGNTATLTISGTQAMDEADYYCGVIQDNTGVFGGGTKLTVL GQPKAAPSVTLFPPSSEELQANKATLVCLISDFYPGAVTVAWKADSSPVKAGVETTTPSKQSNNKYAASSYLSLTPEQWKSHRSYSCQVTHEGSTVEKTVAPTECS

Claims

1. A pharmaceutical composition for treating a subject suffering from respiratory distress or for preventing respiratory distress in a subject at risk of respiratory distress, comprising an anti-IL-33 antibody or its antigen-binding fragment, wherein the treatment or prevention comprises administering an effective amount of the anti-IL-33 antibody or its antigen-binding fragment to the subject, wherein the level of IL-33 / sST2 in a sample obtained from the subject is determined to be at or above a reference level of 25 pg / ml, and the anti-IL-33 antibody or its antigen-binding fragment comprises a heavy chain variable region (VH) having VHCDR1-3 of SEQ ID NO: 37, SEQ ID NO: 38, and SEQ ID NO: 39, and a light chain variable region (VL) having VLCDR1-3 of SEQ ID NO: 40, SEQ ID NO: 41, and SEQ ID NO: 42, respectively.

2. The pharmaceutical composition according to claim 1, further comprising the steps of: measuring the level of IL-33 / sST2 in a sample obtained from the subject; and administering an effective amount of anti-IL-33 antibody or its antigen-binding fragment to the subject if the level of IL-33 / sST2 in the sample obtained from the subject is equal to or greater than a reference level of 25 pg / ml.

3. The pharmaceutical composition according to claim 1 or 2, wherein the reference level is 26 pg / ml, 27 pg / ml, 28 pg / ml, 29 pg / ml, or 30 pg / ml, preferably 30.15 pg / ml.

4. The pharmaceutical composition according to claim 1 or 2, wherein the sample is a whole blood sample, a serum sample, a plasma sample, or a combination thereof.

5. The pharmaceutical composition according to claim 1 or 2, wherein the respiratory distress is acute respiratory failure.

6. The pharmaceutical composition according to claim 5, wherein the acute respiratory failure is type 1 or type 2 acute respiratory failure.

7. The pharmaceutical composition according to claim 5, wherein the acute respiratory failure is caused by a disease, disorder, condition or infection selected from pneumonia, acute respiratory distress syndrome (ARDS), chronic obstructive pulmonary disease (COPD), asthma, bronchitis, bronchiectasis, emphysema, heart failure, myocardial ischemia, mitral stenosis, pulmonary edema, pulmonary embolism, thromboembolism, cystic fibrosis, amyotrophic lateral sclerosis, muscular dystrophy, Guillain-Barré syndrome, myasthenia gravis, poliomyelitis, polymyositis, botulism, hypokalemia, hypophosphatemia, myxedema, hypothyroidism, sepsis, stroke, acute pancreatitis, blood transfusion, reperfusion, drug or alcohol overdose, acute lung injury, chest trauma, viral or bacterial infection, inhalation injury (by inhalation of smoke, fumes or chemicals), aspiration, and drowning.

8. The pharmaceutical composition according to claim 5, wherein the acute respiratory failure is caused by a bacterial infection, a fungal infection, or a viral infection, preferably a viral respiratory infection, more preferably a SARS-CoV-2 infection.

9. The pharmaceutical composition according to claim 1 or 2, wherein the subject is suffering from COVID-19.

10. The pharmaceutical composition according to claim 1 or 2, wherein the subject is suffering from pneumonia or is suspected of suffering from pneumonia.

11. The pharmaceutical composition according to claim 1 or 2, wherein the subject is suffering from viral pneumonia or is suspected of suffering from viral pneumonia.

12. The pharmaceutical composition according to claim 11, wherein the viral pneumonia is caused by influenza A virus, influenza B virus, respiratory syncytial virus, human parainfluenza virus, adenovirus, metapneumovirus, SARS-CoV, Middle East respiratory syndrome virus (MERS-CoV), hantavirus, herpes simplex virus, varicella-zoster virus, measles virus, rubella virus, cytomegalovirus, smallpox virus, or dengue virus.

13. The pharmaceutical composition according to claim 1 or 2, wherein the subject is suffering from or at risk of acute respiratory failure caused by COVID-19 and / or viral pneumonia.

14. The pharmaceutical composition according to claim 1 or 2, wherein the subject is suffering from or at risk of type 1 or type 2 acute respiratory failure caused by COVID-19 and / or viral pneumonia.

15. The pharmaceutical composition according to claim 1 or 2, wherein the subject is positive in a test for SARS-CoV-2 infection.

16. The pharmaceutical composition according to claim 1 or 2, wherein the subject is suffering from a viral lower respiratory tract infection or disease.

17. The pharmaceutical composition according to claim 1 or 2, wherein the anti-IL-33 antibody or its antigen-binding fragment comprises the heavy chain variable region (VH) described in SEQ ID NO: 1 and the light chain variable region (VL) described in SEQ ID NO:

19.

18. The pharmaceutical composition according to claim 1 or 2, wherein the IL-33 axis antagonist is tozolakimab.

19. The aforementioned subject is, (a) requiring oxygen supplementation or ventilatory support, (b) hospitalized, and / or (c) The pharmaceutical composition according to claim 1 or 2, for a person suffering from a viral lower respiratory tract infection or disease, hospitalized, and requiring oxygen supplementation or ventilatory support.

20. The pharmaceutical composition according to claim 2, wherein measuring the level of IL-33 / sST2 in a sample obtained from the subject is equivalent to determining the level of IL-33 / sST2 by performing an assay on the sample obtained from the subject.

21. The pharmaceutical composition according to claim 2, wherein measuring the level of IL-33 / sST2 in a sample obtained from the subject comprises (i) contacting the sample with one or more binding molecules capable of binding to IL-33 / sST2 under conditions sufficient to form a complex, and (ii) detecting the level of the IL-33 / sST2 complex in the sample.

22. The pharmaceutical composition according to claim 21, further comprising the step (iii) of contacting the complex with one or more reporter molecules that can bind to one or more of the complexes.

23. The pharmaceutical composition according to claim 21, wherein the one or more binding molecules and the one or more reporter molecules are antibodies or antigen-binding fragments thereof.

24. The pharmaceutical composition according to claim 23, wherein the one or more binding molecules are an anti-IL-33 / sST2 antibody or an antigen-binding fragment thereof, and the one or more reporter molecules are an anti-IL-33 / sST2-binding molecule complex antibody or an antigen-binding fragment thereof.

25. The pharmaceutical composition according to claim 24, wherein the anti-IL-33 / sST2 antibody or its antigen-binding fragment comprises a heavy chain variable region having VHCDR1-3 of SEQ ID NO: 45, SEQ ID NO: 46, and SEQ ID NO: 47, and a light chain variable region having VLCDR1-3 of SEQ ID NO: 48, SEQ ID NO: 49, and SEQ ID NO: 50, respectively.

26. The pharmaceutical composition according to claim 25, wherein the anti-IL-33 / sST2 antibody or its antigen-binding fragment comprises the heavy chain variable region (VH) described in SEQ ID NO: 43 and the light chain variable region (VL) described in SEQ ID NO: 44.

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