Dosage and Administration of Fusion Polypeptides for the Treatment of Sickle Cell Disease - Patent application

Abstract

The present disclosure provides methods of treating a human patient with sickle cell disease. These methods comprise administering a properdin-binding antibody or antigen-binding fragment thereof to the patient. In a first aspect, the present disclosure provides a method of treating a human patient with sickle cell disease, comprising administering to the patient a properdin-binding antibody or antigen-binding fragment thereof, wherein the properdin-binding antibody or antigen-binding fragment thereof comprises the CDR1, CDR2, and CDR3 sequences set forth in SEQ ID NOs: 2, 3, and 4, respectively.

Description

[Background technology]

[0001] Sequence Listing This application contains a Sequence Listing that has been submitted electronically in XML format and is incorporated herein by reference in its entirety. The XML copy, created on August 25, 2023, is named 51196-032WO3_Sequence_Listing_8_25_23 and is 50,329 bytes in size.

[0002] Sickle cell disease (SCD) is the most common monogenic disease worldwide. In some forms, the disease is caused by mutations in the β-globin gene, such as a single nucleotide mutation in the β-globin gene, resulting in a glutamic acid substitution with valine at position 6; this gene also causes beta-thalassemia (BT). Despite widespread recognition of the underlying cause of the disease, few treatment options are available to control SCD symptoms. Anemia and vaso-occlusive crisis (VOC), the two main symptoms of SCD, affect the mortality, morbidity, and quality of life of SCD patients. While there are two approved treatment options for SCD patients, hydroxyurea and L-glutamine, they are generally considered suboptimal in attenuating disease symptoms. Therefore, novel therapies are needed in the art. Summary of the Invention [Means for solving the problem]

[0003] In a first aspect, the disclosure provides a method of treating a human patient with sickle cell disease, comprising administering to the patient a properdin-binding antibody or antigen-binding fragment thereof, wherein the properdin-binding antibody or antigen-binding fragment thereof comprises the CDR1, CDR2, and CDR3 sequences set forth in SEQ ID NOs: 2, 3, and 4, respectively. In some embodiments, the antibody or antigen-binding fragment thereof further comprises a human serum albumin-binding sequence. In some embodiments, the human serum albumin-binding sequence is fused to the C-terminus of the properdin-binding antibody or antigen-binding fragment thereof. In some embodiments, the human serum albumin-binding sequence is fused to the C-terminus of the properdin-binding antibody or antigen-binding fragment thereof via a linker. In some embodiments, the linker comprises the amino acid sequence of SEQ ID NO: 10. In some embodiments, the human serum albumin-binding sequence comprises the CDR1, CDR2, and CDR3 sequences set forth in SEQ ID NOs: 5, 6, and 7. In some embodiments, the antibody or antigen-binding fragment thereof comprises the sequence of SEQ ID NO: 1, or a modification thereof. In some embodiments, the modification comprises converting the N-terminal glutamine of the sequence of SEQ ID NO: 1 to pyroglutamic acid.

[0004] In some embodiments, the antibody or antigen-binding fragment thereof is administered to the patient at a dose of 300 mg. In some embodiments, the antibody or antigen-binding fragment thereof is administered to the patient weekly. In some embodiments, the antibody or antigen-binding fragment thereof is administered to the patient for up to 13 weeks (e.g., 12 weeks). In some embodiments, the antibody or antigen-binding fragment thereof is administered to the patient once every two weeks. In some embodiments, the antibody or antigen-binding fragment thereof is administered up to four times.

[0005] In some embodiments, the antibody or antigen-binding fragment thereof is administered to the patient at a dose of 600 mg. In some embodiments, the antibody or antigen-binding fragment thereof is administered to the patient every four weeks. In some embodiments, the antibody or antigen-binding fragment thereof is administered to the patient up to four times.

[0006] In some embodiments, the patient has been clinically diagnosed with sickle cell disease. In some embodiments, sickle cell disease is characterized by HbSS or HbSβ 0 In some embodiments, the patient is further administered hydroxyurea. In some embodiments, the patient has been receiving a stable dose of hydroxyurea for at least three months prior to administration of the antibody or antigen-binding fragment thereof. In some embodiments, the patient has not been receiving hydroxyurea for at least 30 days prior to administration of the antibody or antigen-binding fragment thereof.

[0007] In some embodiments, the patient does not experience any treatment-emergent adverse events after 12 weeks of treatment. In some embodiments, the patient does not experience any serious adverse events after 12 weeks of treatment. In some embodiments, the patient does not experience any adverse events after 12 weeks of treatment.

[0008] In some embodiments, the method further comprises measuring a change in serum concentration of the antibody or antigen-binding fragment thereof for up to 30 weeks after initiation of treatment. In some embodiments, the method further comprises measuring a change in blood concentration of an anti-drug antibody for up to 30 weeks after initiation of treatment. In some embodiments, the patient experiences a change from baseline in serum concentrations of total properdin and free properdin after up to 30 weeks of treatment.

[0009] In some embodiments, the patient experiences a change from baseline in serum concentrations of complement component Ba (Ba), complement component C3a (C3a), or soluble complement component C5B-9 (sC5B9) after 12 weeks of treatment. In some embodiments, the patient experiences a change from baseline in blood or serum concentrations of hemopexin, nitric oxide, a marker of inflammation, or a marker of cell adhesion after 12 weeks of treatment. In some embodiments, the marker of inflammation comprises interleukin-1. In some embodiments, the marker of cell adhesion comprises soluble P-selectin.

[0010] In some embodiments, the patient experiences a change from baseline in hemoglobin levels after 12 weeks of treatment. In some embodiments, the patient experiences a change from baseline in serum LDH levels, indirect bilirubin, haptoglobin, or hemopexin after 12 weeks. In some embodiments, the patient experiences a change from baseline in reticulocyte levels after 12 weeks.

[0011] In some embodiments, the patient experiences a decrease in the rate of vascular occlusive events after 12 weeks of treatment compared to baseline, hi some embodiments, the patient experiences an increase in the time to first vascular occlusive event after 12 weeks of treatment compared to baseline.

[0012] In some embodiments, the antibody or antigen-binding fragment thereof is formulated for subcutaneous administration.

[0013] In some embodiments, the antibody or antigen-binding fragment thereof is formulated at a concentration of 150 mg / mL in an aqueous solution containing 20 nM sodium acetate, 250 mM sucrose, and 0.05% polysorbate-80 at a pH of 5.4. In some embodiments, the human patient is aged 18 to 65 years. In some embodiments, the human patient weighs ≧40 kg.

[0014] In another aspect, the disclosure provides an antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease, the use comprising administering to the patient a properdin-binding antibody or antigen-binding fragment thereof, wherein the properdin-binding antibody or antigen-binding fragment thereof comprises the CDR1, CDR2, and CDR3 sequences set forth in SEQ ID NOs: 2, 3, and 4, respectively. In some embodiments, the antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease further comprises a human serum albumin-binding sequence. In some embodiments, the human serum albumin-binding sequence is fused to the C-terminus of the properdin-binding antibody or antigen-binding fragment thereof. In some embodiments, the human serum albumin-binding sequence is fused to the C-terminus of the properdin-binding antibody or antigen-binding fragment thereof via a linker. In some embodiments, the linker comprises the amino acid sequence of SEQ ID NO: 10. In some embodiments, the human serum albumin-binding sequence comprises the CDR1, CDR2, and CDR3 sequences set forth in SEQ ID NOs: 5, 6, and 7. In some embodiments, the antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease comprises the sequence of SEQ ID NO: 1 or a modification thereof. In some embodiments, the modification comprises converting the N-terminal glutamine of the sequence of SEQ ID NO: 1 to pyroglutamic acid.

[0015] In some embodiments, the antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease is administered to the patient at a dose of 300 mg. In some embodiments, the antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease is administered to the patient weekly. In some embodiments, the antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease is administered to the patient for up to 13 weeks. In some embodiments, the antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease is administered to the patient once every two weeks. In some embodiments, the antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease is administered up to four times. In some embodiments, the antibody or antigen-binding fragment thereof is administered to the patient at a dose of 600 mg. In some embodiments, the antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease is administered to the patient every four weeks. In some embodiments, the antibody or antigen-binding fragment thereof for use in treating a human patient with sickle cell disease is administered up to four times to the patient. In some embodiments, the patient has been clinically diagnosed with sickle cell disease. In some embodiments, sickle cell disease is characterized by HbSS or HbSβ 0The patient has thalassemia. In some embodiments, the patient is further administered hydroxyurea. In some embodiments, the patient has been receiving a stable dose of hydroxyurea for at least 3 months prior to administration of the antibody or antigen-binding fragment thereof. In some embodiments, the patient has not been receiving hydroxyurea for at least 30 days prior to administration of the antibody or antigen-binding fragment thereof. In some embodiments, the patient does not experience a treatment-emergent adverse event after 12 weeks of treatment. In some embodiments, the patient does not experience a serious adverse event after 12 weeks of treatment. In some embodiments, the patient does not experience an adverse event after 12 weeks of treatment. In some embodiments, the method further comprises measuring a change in serum concentration of the antibody or antigen-binding fragment thereof for up to 30 weeks after initiation of treatment. In some embodiments, the method further comprises measuring a change in blood concentration of an anti-drug antibody for up to 30 weeks after initiation of treatment. In some embodiments, the patient experiences a change from baseline in serum concentrations of total properdin and free properdin after up to 30 weeks of treatment. In some embodiments, the patient experiences a change from baseline in serum concentrations of complement component Ba (Ba), complement component C3a (C3a), or soluble complement component C5B-9 (sC5B9) after 12 weeks of treatment. In some embodiments, the patient experiences a change from baseline in blood or serum concentrations of hemopexin, nitric oxide, an inflammation marker, or a cell adhesion marker after 12 weeks of treatment. In some embodiments, the inflammation marker comprises interleukin-1. In some embodiments, the cell adhesion marker comprises soluble P-selectin. In some embodiments, the patient experiences a change from baseline in hemoglobin levels after 12 weeks of treatment. In some embodiments, the patient experiences a change from baseline in serum LDH levels, indirect bilirubin, haptoglobin, or hemopexin after 12 weeks. In some embodiments, the patient experiences a change from baseline in reticulocyte levels after 12 weeks. In some embodiments, the patient experiences a reduction in the rate of vaso-occlusive episodes after 12 weeks of treatment compared to baseline.In some embodiments, the patient experiences an increase in time to first vaso-occlusive event after 12 weeks of treatment compared to baseline. In some embodiments, the antibody or antigen-binding fragment thereof is formulated for subcutaneous administration. In some embodiments, the antibody or antigen-binding fragment thereof is formulated at a concentration of 150 mg / mL in an aqueous solution containing 20 nM sodium acetate, 250 mM sucrose, and 0.05% polysorbate-80 at a pH of 5.4. In some embodiments, the human patient is aged 18 to 65 years. In some embodiments, the human patient weighs ≥ 40 kg.

[0016] All embodiments can be combined unless the context clearly indicates otherwise. All embodiments can be applied to all aspects of the invention unless the context clearly indicates otherwise.

[0017] Specific preferred embodiments of the invention will become apparent from the following more detailed description of certain embodiments and claims. [Brief explanation of the drawings]

[0018] [Figure 1] FIG. 1 is a schematic diagram of the study presented in Example 1. [Figure 2] FIG. 1 is a schematic diagram of the study presented in Example 2. [Figure 3] 1 is a graph showing mean serum complement activity pathways over time for each cohort described in Example 2. DETAILED DESCRIPTION OF THE INVENTION

[0019] definition To facilitate understanding of this disclosure, several terms are defined below. Terms defined herein have meanings commonly understood by one of ordinary skill in the art relevant to this disclosure. Terms such as "a," "an," and "the" are not intended to refer to a singular entity only, but include general classifications for which specific examples may be used for illustration. While terminology herein is used to describe specific embodiments, their use does not limit the disclosure, except as outlined in the claims.

[0020] As used herein, the term "about" refers to a value within 10% above or below the stated value.

[0021] As used herein, any value provided in a range of values ​​includes both the upper and lower limits, and any value subsumed within the limits.

[0022] The term "antibody" as referred to herein includes whole antibodies and any antigen-binding fragment (i.e., "antigen-binding portion") or single-chain form thereof. In one preferred embodiment, "antibody" refers to a glycoprotein or antigen-binding portion thereof comprising at least two heavy (H) chains and two light (L) chains inter-connected by disulfide bonds. Each heavy chain comprises a heavy chain variable region (referred to herein as V H Each light chain is composed of a light chain variable region (abbreviated herein as V) and a heavy chain constant region. The heavy chain constant region is composed of three domains: CH1, CH2, and CH3. L The light chain constant region is composed of one domain, CL. H and V L The region can be further subdivided into regions of hypervariability called complementarity-determining regions (CDRs), interspersed with more conserved regions called framework regions (FRs). H and V Lis composed of three CDRs and four FRs, arranged from the amino terminus to the carboxy terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. The variable regions of the heavy and light chains contain binding domains that interact with antigens. The constant region of the antibody can mediate the binding of the immunoglobulin to host tissues or factors, including various cells of the immune system (e.g., effector cells) and the first component (Clq) of the classical complement system.

[0023] As used herein, "effective treatment" refers to treatment that results in a beneficial effect, e.g., an improvement in at least one symptom of a disease or disorder. The beneficial effect can take the form of an improvement over baseline, i.e., an improvement over measurements or observations made before initiation of treatment according to the method. Effective treatment can refer to the alleviation of at least one symptom of sickle cell disease.

[0024] As used herein, the term "fused to" refers to a polypeptide that is made by combining two or more sequences, typically by cloning a coding sequence in frame with one or more second coding sequences into an expression vector, such that the two (or more) coding sequences are transcribed and translated into a single, contiguous polypeptide. In addition to being made by recombinant techniques, portions of a polypeptide can be "fused" to one another by chemical reaction or other means known in the art for making custom polypeptides.

[0025] "Heavy chain antibodies" refer to antibodies that consist of two heavy chains and lack the two light chains found in conventional antibodies. Camelids (members of the biological family Camelidae, the only currently living family in the suborder Tylopoda; extant camelids include dromedaries, Bactrian camels, wild or feral camels, llamas, alpacas, vicuñas, and guanacos) are the only mammals with single-chain VHH antibodies. In camelids, approximately 50% of the antibodies are heavy chain antibodies, and the other 50% are of the usual or conventional mammalian heavy chain / light chain antibody type.

[0026] "VHH domain" refers to the variable domain present in naturally occurring heavy chain antibodies and is distinguished from the heavy chain variable domain present in conventional four-chain antibodies (referred to herein as a "VH domain") and the light chain variable domain present in conventional four-chain antibodies (referred to herein as a "VL domain").

[0027] VHH domains have several unique structural and functional properties that make them highly advantageous for use as isolated VHH domains (and sdAbs, which are based on VHH domains and share these structural and functional properties with naturally occurring VHH domains) and proteins containing VHH domains as functional antigen-binding domains or proteins. For example, VHH domains and sdAbs that bind antigen without the presence of a VL can function as a single, relatively small, functional antigen-binding structural unit, domain, or protein. The small size of these molecules distinguishes VHH domains from the VH and VL domains of conventional four-chain antibodies. The use of VHH domains and sdAbs as single antigen-binding proteins or antigen-binding domains (e.g., as part of a larger protein or polypeptide) offers a number of important advantages over the use of conventional VH and VL domains and scFvs or conventional antibody fragments (such as Fab or F(ab')2 fragments). For example, only a single domain is required to bind to an antigen with high affinity and high selectivity, thereby eliminating the need for two separate domains and ensuring that these two domains exist in a specific spatial conformation and configuration (e.g., through the use of a specific linker, as with scFvs). VHH domains and sdAbs can also be expressed from a single gene and do not require post-translational folding or modification. VHH domains and sdAbs can be easily engineered into multivalent and multispecific formats. VHH domains and sdAbs are also highly soluble and do not tend to aggregate (Ward, E. et al., Nature, 341:544-6, 1989), and they are highly stable against heat, pH, proteases, and other denaturing agents or conditions (Ewert, S. et al., Biochemistry, 41:3628-36, 2002). VHH domains and sdAbs are relatively easy and inexpensive to prepare, even on the scale required for manufacturing. For example, VHH domains, sdAbs and polypeptides containing VHH domains or sdAbs can be produced using microbial fermentation using methods known in the art and do not require the use of mammalian expression systems as, for example, conventional antibody fragments.VHH domains and sdAbs are relatively small (approximately 15 kDa, or 10 times smaller than conventional IgG) compared to conventional four-chain antibodies and their antigen-binding fragments, and therefore exhibit greater tissue penetration (including, but not limited to, solid tumors and other dense tissues) than conventional four-chain antibodies and their antigen-binding fragments. VHH domains and sdAbs can exhibit so-called "cavity binding" properties (e.g., due to their extended CDR3 loops), allowing them to access targets and epitopes that are inaccessible to conventional four-chain antibodies and their antigen-binding fragments. For example, it has been shown that VHH domains and sdAbs can inhibit enzymes (WO 97 / 49805; Transue, T. et al., Proteins, 32:515-22, 1998; Lauwereys, M. et al., EMBO J., 17:3512-20, 1998).

[0028] The term "single domain antibody" or "sdAb," as used herein, refers to an antibody or fragment thereof consisting of a single monomeric variable antibody domain. It is not limited to a particular biological source or a particular method of preparation. sdAbs can be obtained, for example, by (1) isolating the VHH domain of a naturally occurring heavy chain antibody; (2) expressing a nucleotide sequence encoding a naturally occurring VHH domain; (3) "humanizing" a naturally occurring VHH domain or expressing a nucleic acid encoding such a humanized VHH domain; (4) "camelizing" a naturally occurring VH domain from any animal species, particularly a mammal such as a human, or expressing a nucleic acid encoding such a camelized VH domain; (5) "camelizing" a "domain antibody" ("Dab") or expressing a nucleic acid encoding such a camelized VH domain; (6) using synthetic or semi-synthetic techniques to prepare engineered polypeptides or fusion proteins; (7) using nucleic acid synthesis techniques to prepare nucleic acids encoding the sdAb, followed by expression of the nucleic acid thus obtained; and / or (8) any combination of the above.

[0029] The fusion polypeptides or fusion proteins described herein may comprise the amino acid sequence of a naturally occurring VHH domain that has been "humanized", for example, by substituting one or more amino acid residues in the amino acid sequence of the naturally occurring VHH sequence with one or more amino acid residues present at the corresponding position in a VH domain of human origin.

[0030] The fusion polypeptides or fusion proteins described herein may, for example, be "camelized," i.e., comprise the amino acid sequence of a naturally occurring VH domain by substituting one or more amino acid residues therein with, for example, one or more amino acid residues present at the corresponding positions in a VHH domain of a camelid antibody. This can be performed by methods known in the art. Such camelization may occur preferentially at amino acid positions present in the VH-VL interface, so-called "Camelidae hallmark residues" (WO 94 / 04678). VH domains or sequences used as parent sequences or starting materials for generating or designing camelized sequences may, for example, be VH sequences of mammalian origin, and in particular embodiments, human VH sequences. However, it should be noted that such camelized sequences can be obtained by any suitable method known in the art and are therefore not strictly limited to polypeptides obtained using a polypeptide comprising a naturally occurring parent VH domain.

[0031] Both "humanized" and "camelized" refer to naturally occurring VHH domains or VHHs. HThis can be achieved by providing a nucleotide sequence encoding each of the domains and then altering one or more codons in the nucleotide sequence in a manner known to those skilled in the art so that the new nucleotide sequence encodes the humanized or camelized sequence, respectively. Based on the amino acid or nucleotide sequence of a naturally occurring VHH domain or VH domain, a nucleotide sequence encoding the desired humanized or camelized sequence can also be designed and synthesized de novo using nucleic acid synthesis techniques known in the art, and the nucleotide sequence thus obtained can then be expressed by a method known in the art.

[0032] The term "antigen" or "antigen target," as used herein, refers to a molecule or portion of a molecule that can be bound by an antibody, one or more Ig binding domains, or other immunological binding moieties (including, for example, the engineered polypeptides or fusion polypeptides disclosed herein). An antigen can be used to generate antibodies in an animal that can bind to an epitope of that antigen. An antigen can have one or more epitopes.

[0033] The term "antigen-binding fragment" of an antibody (or simply "antibody fragment"), as used herein, refers to one or more fragments or portions of an antibody that retain the ability to specifically bind to an antigen. Such "fragments" are, for example, about 8 to about 1500 amino acids in length, preferably about 8 to about 745 amino acids in length, preferably about 8 to about 300, e.g., about 8 to about 200 amino acids in length, or about 10 to about 50 or 100 amino acids in length. It has been shown that the antigen-binding function of an antibody can be exerted by fragments of a full-length antibody. Examples of binding fragments encompassed by the term "antigen-binding fragment" of an antibody include (i) Fab fragments, V L , V H (ii) a F(ab')2 fragment, a bivalent fragment containing two Fab fragments linked by a disulfide bridge at the hinge region; (iii) a V H and an Fd fragment consisting of the CH1 domain; (iv) a V of a single arm of an antibody L and V HFv fragment consisting of domains, (v) V H and (vi) an isolated complementarity-determining region (CDR) or (vii) a combination of two or more isolated CDRs, which may optionally be linked by a synthetic linker. Additionally, the two domains of the Fv fragment, V, are also included. L and V H Although the V and V proteins are encoded by separate genes, they can be joined by a synthetic linker that allows them to be produced as a single protein chain using recombinant methods. L and V H The domains pair to form a monovalent molecule known as a single-chain Fv (sFv) (see, e.g., Bird et al. (1988) Science 242:423-426; and Huston et al. (1988) Proc Natl. Acad. Sci. USA 85:5879-5883). Such single-chain antibodies are also intended to be encompassed by the term "antigen-binding fragment" of an antibody. These antibody fragments are obtained using conventional techniques known to those skilled in the art, and the fragments are screened for utility in the same manner as intact antibodies. Antigen-binding portions can be produced by recombinant DNA techniques or by enzymatic or chemical cleavage of intact immunoglobulins.

[0034] As used herein, the term "binding domain" refers to the portion of a protein or antibody that contains the amino acid residues that interact with an antigen. Binding domains include, but are not limited to, antibodies (e.g., full-length antibodies) and antigen-binding portions thereof. A binding domain confers specificity and affinity for an antigen to a binder. The term also encompasses any protein having a binding domain that is homologous or primarily homologous to an immunoglobulin binding domain.

[0035] The term "epitope" or "antigenic determinant" refers to a site on an antigen to which an immunoglobulin or antibody specifically binds. Epitopes can be formed from both contiguous amino acids or non-contiguous amino acids that become aligned by tertiary folding of a protein. Epitopes formed from contiguous amino acids are typically retained upon exposure to denaturing solvents, while epitopes formed by tertiary folding are typically lost upon treatment with denaturing solvents. An epitope usually contains at least 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or 15 amino acids in a unique spatial conformation. Methods for determining which epitope a given antibody binds to (i.e., epitope mapping) are well known in the art and include, for example, immunoblotting and immunoprecipitation assays, in which overlapping or contiguous peptides from an antigen are tested for reactivity with a given peptide. Methods of determining spatial conformation of epitopes include techniques in the art and described herein, such as x-ray crystallography and 2-dimensional nuclear magnetic resonance (e.g., Epitope Mapping Protocols in Methods in Molecular Biology, Vol. 66, GE Morris, Ed. (1996)).

[0036] The term "bispecific" refers to a fusion polypeptide of the present disclosure that is capable of binding to two antigens.

[0037] The term "effective amount" refers to an amount of an agent that provides a desired biological, therapeutic, and / or prophylactic result. That result can be reduction, amelioration, alleviation, reduction, delay, and / or alleviation of one or more of the signs, symptoms, or causes of a disease, or any other desired alteration of a biological system. In one example, an "effective amount" is an amount of a fusion polypeptide or fragment thereof that has been clinically proven to alleviate at least one symptom of sickle cell disease. An effective amount can be administered in one or more administrations.

[0038] As used herein, "effective treatment" refers to treatment that results in a beneficial effect, e.g., an improvement in at least one symptom of a disease or disorder. The beneficial effect can take the form of an improvement over baseline, i.e., an improvement over measurements or observations made before initiation of treatment according to the method. Effective treatment can refer to the alleviation of at least one symptom of sickle cell disease.

[0039] As used herein, the term "fused to" refers to a polypeptide that is made by combining two or more sequences, typically by cloning a coding sequence in frame with one or more second coding sequences into an expression vector, such that the two (or more) coding sequences are transcribed and translated into a single, contiguous polypeptide. In addition to being made by recombinant techniques, portions of a polypeptide can be "fused" to one another by chemical reaction or other means known in the art for making custom polypeptides.

[0040] As used herein, the term "peptide linker" refers to one or more amino acid residues inserted or included between the engineered polypeptides of a fusion polypeptide. The peptide linker may be inserted or included, for example, at the transition between the engineered polypeptides of the fusion polypeptide at the sequence level.

[0041] As used herein, the term "pharmaceutical composition" or "therapeutic composition" refers to a compound or composition capable of inducing a desired therapeutic effect when administered to a patient.

[0042] The term "pharmaceutically acceptable carrier" or "physiologically acceptable carrier," as used herein, refers to one or more formulation materials suitable for achieving or enhancing delivery of an engineered polypeptide or fusion polypeptide of the present disclosure.

[0043] An antibody, immunoglobulin or immunologically functional immunoglobulin fragment, or engineered polypeptide or fusion polypeptide disclosed herein is said to "specifically" bind to an antigen when the molecule preferentially recognizes its antigen target in a complex mixture of proteins and / or macromolecules. The term "specifically binds," as used herein, refers to a specific binding of at least about 10% of an antibody, immunoglobulin or immunologically functional immunoglobulin fragment, or engineered polypeptide or fusion protein of the disclosure. -6 M, 10 -7 M, 10 -8 M, 10 -9 M, 10 -10 M, 10 -11 M, 10 -12 M or K exceeding it D "Ability to bind to an antigen-containing epitope with an affinity at least two-fold higher than its affinity for a non-specific antigen" refers to the ability to bind to an antigen-containing epitope with an affinity at least two-fold higher than its affinity for a non-specific antigen.

[0044] As used herein, the term "subject" or "patient" refers to a human patient (e.g., a patient with sickle cell disease). As used herein, the terms "subject" and "patient" are interchangeable.

[0045] As used herein, the terms "treatment" or "treating" refer to both therapeutic treatment and prophylactic or preventative measures. Those in need of treatment include those already with the disorder as well as those at risk of having the disorder or those in whom the disorder is to be prevented.

[0046] The present disclosure provides methods for treating sickle cell disease (SCD) in a subject in need thereof by administering, via a peptide linker, a fusion polypeptide comprising an engineered polypeptide that specifically binds human properdin fused to a polypeptide that specifically binds human serum albumin.

[0047] Fusion polypeptide that specifically binds to albumin and properdin Fusion proteins and formulations thereof are described herein. In some embodiments, the fusion protein is a bispecific antibody in which two antigen-binding polypeptides are linked (e.g., by a linker, such as a linker). Such bispecific constructs may include an anti-properdin-binding polypeptide (e.g., a monovalent VHH antibody or a VHH variable domain) linked by a linker to a second polypeptide (e.g., a second monovalent antibody or a VHH variable domain). The second polypeptide can, for example, enhance the in vivo stability of the bispecific construct, target a different therapeutic target, or place two antigens in close proximity (e.g., thereby targeting a first bound antigen to a second bound antigen). In some embodiments, the second polypeptide is an albumin-binding molecule, albumin-binding peptide, or anti-albumin antibody (e.g., a monovalent antibody), or a modified form thereof (e.g., a variable domain of a llama antibody that specifically binds to human serum albumin). In addition to the present disclosure, albumin-binding peptides are known in the art (see WO 2007 / 106120 (see Tables 1-9); Dennis, M. et al., J. Biol. Chem., 277:35035-43, 2002; the disclosures of which are incorporated herein by reference).

[0048] The antibodies described herein can inhibit properdin binding to, for example, C3b, C3Bb, and C3bBb. Inhibition of properdin results in reduced alternative pathway complement activation and has therapeutic utility for patients suffering from alternative pathway dysregulation diseases in which the alternative pathway is overactivated.

[0049] The anti-properdin antibodies described herein can be produced using full-length properdin, properdin polypeptides, and / or antigenic properdin epitope-bearing polypeptides, such as fragments of properdin polypeptides. Properdin peptides and polypeptides can be isolated and used to generate antibodies as natural polypeptides, recombinant polypeptides, or synthetic recombinant polypeptides. Any antigen useful for raising anti-properdin antibodies can be used to generate monovalent antibodies. Suitable monovalent antibody formats and methods for producing them are known in the art (WO 2007 / 048037 and WO 2007 / 059782, the entire contents of which are incorporated herein by reference).

[0050] Anti-properdin antibodies may be monoclonal or may be derived from monoclonal antibodies. Suitable monoclonal antibodies against a selected antigen may be prepared by known techniques (see, for example, "Monoclonal Antibodies: A manual of techniques," Zola (CRC Press, 1988); "Monoclonal Hybridoma Antibodies: Techniques and Applications," Hurrell (CRC Press, 1982), the entire contents of which are incorporated herein by reference).

[0051] In other embodiments, the antibody may be a single-domain antibody, such as a VHH. Such antibodies naturally occur in camelids and sharks (Saerens, D. et al., Curr. Opin. Pharmacol., 8:600-8, 2008). Camelid antibodies are described, for example, in U.S. Patent Nos. 5,759,808; 5,800,988; 5,840,526; 5,874,541; 6,005,079; and 6,015,695, the entire contents of each of which are incorporated herein by reference. The cloned and isolated VHH domain is a stable polypeptide characterized by the full antigen-binding capacity of the original heavy-chain antibody. VHH domains possess unique structural and functional properties that combine the advantages of conventional antibodies (high target specificity, high target affinity, and low inherent toxicity) with important features of small molecule drugs (the ability to inhibit enzymes and access receptor clefts). Furthermore, they are stable, have the potential to be administered by means other than injection, are easier to manufacture, and can be humanized (U.S. Pat. Nos. 5,840,526; 5,874,541; 6,005,079; 6,765,087; EP 1 589 107; WO 97 / 34103; WO 97 / 49805; U.S. Pat. No. 5,800,988; 5,874,541; and 6,015,695, the contents of each of which are incorporated herein by reference in their entirety).

[0052] The anti-properdin component of the bispecific antibodies described herein is a CDR sequence comprising: CDR-H1 having an amino acid sequence at least 90% identical to GRISSIIHMA (SEQ ID NO: 2); CDR-H2 having an amino acid sequence at least 90% identical (e.g., at least 95%, 96%, 97%, 98%, 99%, or 100% identical) to RVGTTVYADSVKG (SEQ ID NO: 3) and at least 90% identical (e.g., at least 95%, 96%, 97%, 98%, 99%, or 100% identical) to LQYEKHGGADY (SEQ ID NO: 4). The bispecific antibodies described herein may comprise CDR-H1 having the amino acid sequence of GRISSIIHMA (SEQ ID NO: 2); CDR-H2 having the amino acid sequence of RVGTTVYADSVKG (SEQ ID NO: 3); and CDR-H3 having the amino acid sequence of LQYEKHGGADY (SEQ ID NO: 4).

[0053] Furthermore, the engineered fusion proteins described herein may specifically bind to serum albumin such that, when the engineered protein is bound to or otherwise associated with a serum albumin molecule, binding of the serum albumin molecule to FcRn is not significantly reduced or inhibited compared to binding of the serum albumin molecule to FcRn when the polypeptide is not bound. In this embodiment, "not significantly reduced or inhibited" means that the binding affinity of serum albumin to FcRn (e.g., as measured using a suitable assay such as SPR) is not reduced by more than 50%, or more than 30%, or more than 10%, or more than 5%, or is not reduced at all. In this embodiment, "not significantly reduced or inhibited" also means that the half-life of the serum albumin molecule is not significantly reduced. In particular, the engineered polypeptide may bind to amino acid residues on serum albumin that are not involved in binding of serum albumin to FcRn. More particularly, the engineered polypeptides are capable of binding to amino acid residues or sequences of serum albumin that do not form part of domain III of serum albumin, for example, to engineered polypeptides that are capable of binding to amino acid residues or sequences of serum albumin that form part of domain I and / or domain II.

[0054] The anti-albumin component of the bispecific antibodies described herein may comprise CDR sequences including: CDR-H1 having an amino acid sequence at least 87% identical to GRPVSNYA (SEQ ID NO:5); CDR-H2 having an amino acid sequence at least 87% identical to NWQKTAT (SEQ ID NO:6) and at least 90% identical (e.g., at least 95%, 96%, 97%, 98%, 99%, or 100% identical) to AAVFRVVAPKTQYDYDY (SEQ ID NO:7). The bispecific antibodies described herein may comprise CDR-H1 having the amino acid sequence of GRPVSNYA (SEQ ID NO:5); CDR-H2 having the amino acid sequence of INWQKTAT (SEQ ID NO:6); and CDR-H3 having the amino acid sequence of AAVFRVVAPKTQYDYDY (SEQ ID NO:7).

[0055] In some embodiments, the fusion protein comprises an anti-properdin binding portion and an anti-albumin binding portion. In some embodiments, where the anti-properdin binding domain has an exposed N-terminus, the N-terminal glutamine can be converted to a cyclized pyroglutamic acid. Such modifications are known in the art (see, e.g., Liu et al., The Journal of Biological Chemistry 286(13:11211-11217, 2011). The portion encoding the anti-properdin binding portion comprises: [ka] The amino acid sequence may have at least 90% (e.g., at least 95%, 96%, 97%, 98%, 99% or 100%) identity to the amino acid sequence of

[0056] In some embodiments, the anti-properdin binding portion of the fusion protein comprises SEQ ID NO:55.

[0057] The portion encoding the anti-albumin binding moiety is [ka] The amino acid sequence may have at least 90% (e.g., at least 95%, 96%, 97%, 98%, 99% or 100%) identity to the amino acid sequence of

[0058] In some embodiments, the anti-properdin binding portion of the fusion protein comprises SEQ ID NO:56.

[0059] In some embodiments, the fusion protein comprises: [ka] and is encoded by a nucleic acid sequence having at least 80% (e.g., at least 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% or 100%) identity to a nucleic acid sequence of

[0060] In some embodiments, the fusion protein is encoded by a nucleic acid sequence having at least 90% (e.g., at least 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% or 100%) identity to the nucleic acid sequence of SEQ ID NO: 57. In some embodiments, the fusion protein is encoded by the nucleic acid sequence of SEQ ID NO: 57.

[0061] In some embodiments, the fusion protein has the amino acid sequence: [ka] and has an amino acid sequence that has at least 90% (e.g., 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% or 100%) identity to

[0062] In some embodiments, the fusion protein has an amino acid sequence that has at least 95% (e.g., 95%, 96%, 97%, 98%, 99% or 100%) identity to SEQ ID NO: 1. In some embodiments, the fusion protein has the amino acid sequence of SEQ ID NO: 1.

[0063] In some embodiments, the C-terminal residue of the properdin-binding domain of the fusion protein can be fused to the N-terminal residue of the human serum albumin-binding domain either directly or via a linker. In other embodiments, the C-terminal residue of the complement component human serum albumin-binding domain of the fusion protein can be fused to the N-terminal residue of the properdin-binding domain either directly or via a peptide. The fusion proteins described herein can contain one or more modified amino acid residues. For example, the amino acid sequence of SEQ ID NO: 1 can contain one or more amino acid modifications. The amino acid modifications described herein include all amino acid modifications known in the art (see, e.g., Liu et al., The Journal of Biological Chemistry 286(13:11211-11217, 2011 and Manning et al., Pharmaceutical Research 27(4):544-575, 2010). In all contexts, known conversions of specific amino acids, such as those during processing or purification of the fusion polypeptide, should be included, e.g., conversion of an exposed N-terminal glutamine to pyroglutamic acid.

[0064] Linker As described herein, linker is used to describe a bond or linkage between polypeptide or protein domains and / or associated non-protein moieties. In some embodiments, a linker is a bond or linkage between at least two polypeptide constructs, such as, for example, two polypeptide constructs linked to each other in tandem (e.g., a monovalent antibody linked to a second polypeptide or monovalent antibody). A linker can attach the N-terminus or C-terminus of one antibody construct to the N-terminus or C-terminus of a second polypeptide construct.

[0065] Described herein are fusion proteins comprising engineered proteins that specifically bind to albumin and properdin, where the engineered proteins are directly fused or linked via one or more suitable linkers or spacers. A peptide linker can be inserted or included, for example, at the transition between the engineered proteins of the fusion protein at the sequence level. The identity and sequence of amino acid residues within the linker can vary depending on the desired secondary structure.

[0066] The linker can be a simple covalent bond, such as a peptide bond, a synthetic polymer, such as a polyethylene glycol (PEG) polymer, or any type of bond formed by a chemical reaction, such as chemical conjugation. When the linker is a peptide bond, a carboxylic acid group at the C-terminus of one protein domain can react with an amino group at the N-terminus of another protein domain in a condensation reaction to form a peptide bond. Specifically, the peptide bond can be formed by synthetic means via conventional organic chemical reactions well known in the art or by natural production from host cells, and a polynucleotide sequence encoding both proteins, for example, the DNA sequences of two antibody constructs in a tandem series, can be directly transcribed and translated into a continuous polypeptide encoding both proteins by the necessary molecular machinery in the host cell, such as DNA polymerase and ribosomes.

[0067] When the linker is a synthetic polymer, such as a PEG polymer, the polymer is functionalized at each end with reactive chemical groups that can react with the terminal amino acids at the connecting ends of the two proteins.

[0068] When the linker is produced by chemical reaction (excluding the peptide bond described above), a chemical functional group, such as an amine, a carboxylic acid, an ester, an azide, or another functional group commonly used in the art, can be synthetically attached to the C-terminus of one protein and the N-terminus of another protein, respectively. The two functional groups can then react via synthetic chemical means to form a chemical bond, thereby linking the two proteins together. Such chemical conjugation procedures are routine for those skilled in the art.

[0069] As described herein, the linker between two peptide constructs can be an amino acid linker containing 1 to 200 amino acids (e.g., 1 to 4, 1 to 10, 1 to 20, 1 to 30, 1 to 40, 2 to 10, 2 to 12, 2 to 16, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 40, 50, 60, 70, 80, 90, 100, 150, 200). Suitable peptide linkers are known in the art and include, for example, peptide linkers containing flexible amino acid residues such as glycine and serine.

[0070] Glycine, serine, and alanine are useful for linkers with maximum flexibility. Any amino acid residue can be considered a linker, optionally combined with one or more other amino acid residues to construct larger peptide linkers depending on the desired properties, which can be the same or different from the first amino acid residue. In another embodiment, the linker is GGGGEGGGGEGGGGE (SEQ ID NO: 10). In another embodiment, the linker is GGGGSGGGGSGGGGGS (SEQ ID NO: 11). Additional peptide linkers suitable for making the fusion proteins described herein include, for example, G4S (SEQ ID NO: 12), (G4S)2 (SEQ ID NO: 13), (G4S)3 (SEQ ID NO: 14), (G4S)4 (SEQ ID NO: 15), (G4S)5 (SEQ ID NO: 16), (G4S)6 (SEQ ID NO: 17), (EAAAK)3 (SEQ ID NO: 18), PAPAP (SEQ ID NO: 19), G4SPAPAP (SEQ ID NO: 20), PAPAPG4S ( SEQ ID NO: 21), (GGGDS)2 (SEQ ID NO: 22), (GGGES)2 (SEQ ID NO: 23), GGGDSGGGGS (SEQ ID NO: 24), GGGASGGGGS (SEQ ID NO: 25), GGGESGGGGS (SEQ ID NO: 26), ASTKGP (SEQ ID NO: 27), ASTKGPSVFPLAP (SEQ ID NO: 28), G3P (SEQ ID NO: 29), G7P (SEQ ID NO: 30), PAPNLLGGP (SEQ ID NO: 31), G6 (SEQ ID NO: 32), G 12(SEQ ID NO: 33), APELPGGP (SEQ ID NO: 34), SEPQPQPG (SEQ ID NO: 35), (G3S2)3 (SEQ ID NO: 36), GGGGGGGGGSGGGS (SEQ ID NO: 37), GGGGSGGGGGGGGGS (SEQ ID NO: 38), (GGSSS)3 (SEQ ID NO: 39), (GS4)3 (SEQ ID NO: 40), G4A(G4S)2 (SEQ ID NO: 41), G4SG4AG4S (SEQ ID NO: 42), G3AS(G4S)2 (SEQ ID NO: 43), G4SG3ASG4S( G4SG4EG4S (SEQ ID NO: 52), (G4E)2G4S (SEQ ID NO: 53), and GGGGAGGGGAGGGGS (SEQ ID NO: 54). Those skilled in the art can select linkers to, for example, reduce or eliminate post-translational modifications, such as glycosylation, for example xylosylation. In certain embodiments, the fusion protein comprises at least two sdAbs, Dabs, VHH antibodies, VHH antibody fragments or a combination thereof, wherein at least one of the sdAbs, Dabs, VHH antibodies or VHH antibody fragments is directed against albumin and one of the sdAbs, Dabs, VHH antibodies or VHH antibody fragments is directed against properdin, such that the resulting fusion protein is multivalent or multispecific. The binding domains or moieties may, for example, be directed against HSA, cynomolgus serum albumin, human properdin and / or cynomolgus properdin.

[0071] How to Treat Sickle Cell Disease Provided herein are methods for treating sickle cell disease (SCD) in a human patient, comprising administering to the patient, according to a specific clinical dosing regimen (i.e., at a specific dose and according to a specific schedule), a fusion polypeptide comprising an engineered polypeptide that specifically binds human properdin fused via a peptide linker to a polypeptide that specifically binds human serum albumin.

[0072] In one embodiment, the fusion polypeptide is administered to a patient at a dose of 300 mg. In some embodiments, the fusion polypeptide is administered weekly. The fusion polypeptide may be administered to a patient for 1 to 13 weeks (e.g., 1 to 12 weeks, 1 to 10 weeks, 1 to 8 weeks, 1 to 6 weeks, 1 to 4 weeks, 4 to 13 weeks, 6 to 13 weeks, 8 to 13 weeks, 10 to 13 weeks, or 12 to 13 weeks).

[0073] In some embodiments, the fusion polypeptide is administered once a week, twice a week, three times a week, four times a week, five times a week, six times a week, or daily. In another embodiment, the fusion polypeptide is administered twice daily. In another embodiment, the fusion polypeptide is administered once every two weeks, once every three weeks, once every four weeks, once every five weeks, once every six weeks, once every seven weeks, once every eight weeks, once every nine weeks, once every ten weeks, once every eleven weeks, or once every twelve weeks.

[0074] In another embodiment, the fusion polypeptide is administered to the patient every two weeks (e.g., once every two weeks). The fusion polypeptide may be administered for up to 12 weeks. In some embodiments, the fusion polypeptide is administered up to six times (e.g., 1, 2, 3, 4, 5, or 6 times). In some embodiments, the fusion polypeptide is administered up to four times (e.g., 1, 2, 3, or 4 times).

[0075] In another embodiment, the fusion polypeptide is administered to the patient at a dose of 600 mg. In some embodiments, the fusion polypeptide is administered to the patient every four weeks. The fusion polypeptide may be administered to the patient up to four times (e.g., one, two, three, or four times).

[0076] The patient receiving the fusion polypeptide may have been clinically diagnosed by a clinician with sickle cell disease, including HbSS or HbSβ. 0The human patient may be aged 18 to 65 years. In some embodiments, the human patient has a body weight of ≥ 40 kg. In some embodiments, the patient is further administered hydroxyurea. In some embodiments, the patient has been receiving a stable dose of hydroxyurea for at least 3 months prior to administration of the antibody or antigen-binding fragment thereof. In another embodiment, the patient has not been receiving hydroxyurea for at least 30 days prior to administration of the antibody or antigen-binding fragment thereof.

[0077] In some embodiments, the fusion polypeptide is formulated for subcutaneous administration. For example, the fusion polypeptide can be formulated at a concentration of 150 mg / mL in an aqueous solution containing 20 nM sodium acetate, 250 mM sucrose, and 0.05% polysorbate-80 at a pH of 5.4.

[0078] In some embodiments, fusion polypeptide is administered using pre-filled syringe.In other embodiments, fusion polypeptide is administered using auto-injector device.For example, auto-injector device can include single vial system, such as pen-type injector device for solution delivery. Such devices include BD Pens, BD Autojector®, Humaject®, NovoPen®, BD® Pen, AutoPen® and OptiPen®, GenotropinPen®, Genotronorm Pen®, Humatro Pen®, Reco-Pen®, Roferon Pen®, Biojector®, Iject®, J-tip Needle-Free Injector®, DosePro®, Medi-Ject®, and others, such as those available from Becton Dickinson (Franklin Lakes, NJ), Ypsomed (Burgdorf, Switzerland, www.ypsomed.com); Bioject, Portland, OR; National Medical Products, Weston Medical (Peterborough, UK), and Medi-Ject. Autoinjectors are commercially available from manufacturers such as those made or developed by YpsoMate 2.25 or YpsoMate 2.25 Pro (Ypsomed) disposable injection devices. Recognized devices containing dual-vial systems include pen-type injector systems for reconstituting lyophilized drugs in a cartridge to deliver a reconstituted solution, such as HumatroPen®. In one embodiment, the autoinjector is a YpsoMate 2.25 or YpsoMate 2.25 Pro (Ypsomed) disposable injection device.

[0079] In some embodiments, patients treated according to the methods described herein have been vaccinated against meningococcal infection within three years prior to or at the time of initiation of the study drug. In one embodiment, patients who begin treatment less than two weeks after receiving a meningococcal vaccination receive appropriate prophylactic antibiotic treatment for up to two weeks after vaccination. In another embodiment, patients treated according to the methods described herein are vaccinated against meningococcal serogroups A, C, Y, W135, and / or B.

[0080] Evaluation items In some embodiments, administration of any one of the fusion polypeptides described herein can result in patients not experiencing treatment-emergent adverse events after 12 weeks of treatment.In some embodiments, patients not experiencing serious adverse events after 12 weeks of treatment.In some embodiments, patients not experiencing adverse events after 12 weeks of treatment.

[0081] In some embodiments, changes in serum concentrations of the fusion polypeptide may be measured for up to 30 weeks after initiation of treatment. For example, changes in serum concentrations of the fusion polypeptide may be measured for up to 12 weeks after initiation of treatment. In some embodiments, changes in blood concentrations of anti-drug antibodies may be measured for up to 30 weeks after initiation of treatment. For example, changes in blood concentrations of anti-drug antibodies may be measured for up to 12 weeks after initiation of treatment. In some embodiments, changes from baseline in serum concentrations of total properdin and free properdin may be measured after up to 30 weeks of treatment. For example, changes from baseline in serum concentrations of total properdin and free properdin may be measured after up to 30 weeks of treatment.

[0082] In some embodiments, the patient experiences a change from baseline in serum concentrations of complement component Ba (Ba), complement component C3a (C3a), or soluble complement component C5B-9 (sC5B9) after 12 weeks of treatment. In another embodiment, the patient may experience a change from baseline in blood or serum concentrations of hemopexin, nitric oxide, an inflammation marker, or a cell adhesion marker after 12 weeks of treatment. The inflammation marker may be interleukin-1. The cell adhesion marker may be soluble P-selectin.

[0083] In some embodiments, after 12 weeks of treatment, patients may experience a change from baseline in hemoglobin levels after 12 weeks of treatment. In another embodiment, patients may experience a change from baseline in serum LDH levels, indirect bilirubin, haptoglobin, or hemopexin after 12 weeks of treatment. In another embodiment, patients may experience a change from baseline in reticulocyte levels after 12 weeks.

[0084] In some embodiments, patients may experience a decrease in the rate of vaso-occlusive episodes after 12 weeks of treatment compared to baseline. In some embodiments, patients may experience an increase in the time to first vaso-occlusive episode after 12 weeks of treatment compared to baseline. A vaso-occlusive episode can occur when red blood cells block blood flow to the point that tissues are deprived of oxygen, which can lead to an inflammatory response as the body tries to correct the problem, resulting in symptoms including pain, and can affect any part of the body, but most commonly occurs in the back, chest, or extremities.

[0085] Kits and Unit Dosage Forms Also provided herein are kits comprising a pharmaceutical composition containing a fusion polypeptide described herein, such as a fusion polypeptide having the amino acid sequence of SEQ ID NO: 1, and a pharmaceutically acceptable carrier, in a therapeutically effective amount adapted for use in the aforementioned methods. The kit may also optionally contain instructions, including, for example, a dosing schedule, that enable a practitioner (e.g., a doctor, nurse, or patient) to administer the composition contained therein to administer the composition to a patient with MG. The kit may also include a syringe.

[0086] The kit can optionally include a plurality of packages of single-dose pharmaceutical compositions, each containing an effective amount of fusion polypeptide for single administration according to the method provided above.The kit can also include the equipment or device required for administering the pharmaceutical composition.The kit can provide one or more pre-filled syringes containing a certain amount of fusion polypeptide.The kit can also include one or more autoinjectors containing a certain amount of fusion polypeptide.

[0087] The following examples are illustrative only and should not be construed as limiting the scope of the disclosure in any way, as numerous variations and equivalents will become apparent to those of skill in the art upon reading this disclosure. The contents of all references, Genbank entries, patents and published patent applications cited throughout this application are expressly incorporated herein by reference. [Example]

[0088] The following examples illustrate specific embodiments of the present disclosure and various uses thereof. They are provided for illustrative purposes only and should not be construed as limiting the scope of the invention in any way.

[0089] Example 1: A Phase 2a, Randomized, Open-Label Study to Evaluate Multiple Dosing Regimens of Subcutaneous Anti-Properdin / Anti-Serum Albumin Bispecific Single Variable Domain Antibody in Adult Patients with Sickle Cell Disease 1.1 Rationale for conducting the test The fusion polypeptides described herein (anti-properdin / anti-serum albumin bispecific single variable domains on heavy chain [VHH] antibodies) are novel properdin blockers being developed for the treatment of diseases involving dysregulated complement activity. The fusion polypeptide molecules described herein are bispecific, containing a VHH antibody domain that binds to and blocks properdin linked via a linker to a VHH domain that binds serum albumin, thereby conferring a long circulating half-life to the molecule. The fusion polypeptide formulations described herein are designed for subcutaneous (SC) administration. The objective of this study is to evaluate the safety, tolerability, efficacy, pharmacokinetics (PK), pharmacodynamics (PD), and immunogenicity of multiple doses and administration regimens of the fusion polypeptides described herein in patients with sickle cell disease (SCD).

[0090] The study will include up to three cohorts, and data from this study is expected to inform the design of future trials in patients with SCD and other complement-mediated diseases.

[0091] Objectives and evaluation items

[0092] [Table 1]

[0093] 1.2 Overall study design This is due to the SCD (HbSS and HbSβ 0 A Phase 2a study using up to three multiple-dose cohorts of open-label fusion polypeptide SC described herein in adult patients with rheumatoid arthritis (rheumatoid arthritis).

[0094] The study will be conducted in up to 30 adult patients with SCD enrolled in up to three open-label cohorts (Cohorts 1, 2, and 3 [optional]) to receive multiple SC administrations of the open-label fusion polypeptides described herein. The fusion polypeptides described herein will be administered as described in Table 2.

[0095] [Table 2]

[0096] The doses and dosing intervals for Cohorts 1 and 2 were determined using cumulative safety data, interim PK / PD analyses from participants enrolled in the studies described herein, and data from a 6-month Good Laboratory Practice (GLP) toxicity study in monkeys. An optional Cohort 3 will be initiated at the discretion of the study assessor after evaluation of the safety and PK / PD data from Cohorts 1 and 2.

[0097] Cohort 1 and Cohort 2 will be conducted in parallel, and upon eligibility determination, patients will be randomized 1:1 to one of the cohorts. The decision to start optional Cohort 3 will be made at the discretion of the investigator and will be based on PK / PD and safety analyses after at least eight patients (four from each cohort) from Cohorts 1 and 2 have been enrolled. Furthermore, enrollment for optional Cohort 3 will begin after Cohorts 1 and 2 have been fully enrolled. Each cohort will be stratified to ensure inclusion of patients with SCD who are being treated with stable doses of hydroxyurea and patients with SCD who are not currently being treated with hydroxyurea. The treatment period will be 12 weeks for Cohorts 1 and 2 and 6 weeks for Cohort 3. Patients previously treated with hydroxyurea but not currently using hydroxyurea must have discontinued treatment at least 30 days before providing informed consent.

[0098] At the investigator's discretion, after consultation with the Data Monitoring Committee (DMC), if a participant discontinues during the dosing period for reasons other than a drug-related adverse event (AE), additional participants with SCD may be enrolled as supplemental participants.

[0099] Disclosure Statement This is an open-label, parallel-group interventional study with up to three treatment arms.

[0100] Number of participants: A maximum of 30 patients with SCD (HbSS and HbSβ 0 Adult patients with SCD (thalassemia-serotonin-1 (SCD)) will be enrolled in up to three cohorts and will receive multiple open-label, SC administrations of the fusion polypeptides described herein. Cohorts will include both patients with SCD who are being treated with a stable dose of hydroxyurea and patients with SCD who are not currently being treated with hydroxyurea. Patients previously treated with hydroxyurea but not currently being treated must have discontinued treatment at least 30 days prior to providing informed consent.

[0101] Intervention group and duration: The planned study duration is approximately 38 weeks for Cohorts 1 and 2: a maximum of 56 days (8 weeks) for screening, 84 days (12 weeks) for treatment, and 126 days (18 weeks) for follow-up. Patients will participate in outpatient visits and have the option to stay in an inpatient facility during the treatment and follow-up periods. The end of study (EOS) for each individual patient is expected to be Day 211 (Day 210) or when complement activity returns to 80% of baseline if within the normal range or after Day 211.

[0102] The planned study duration is approximately 32 weeks for optional Cohort 3: up to 56 days (8 weeks) for screening, 42 days (6 weeks) for treatment, and 126 days (18 weeks) for follow-up. Patients will participate in outpatient visits and have the option to stay in an inpatient facility during treatment and follow-up. The EOS for each individual patient is expected to be day 169 (day 168) or when complement activity returns to 80% of baseline if within normal range or after day 169. A schematic diagram of the study is presented in Figure 1.

[0103] Data Monitoring Committee: This study will use an independent DMC to monitor safety and conduct planned interim analyses of the study.

[0104] Statistical analysis - all cohorts: Population for analysis For the purposes of analysis, the following populations are defined:

[0105] [Table 15]

[0106] Safety analysis All safety analyses will be performed on the safety population and reported by each cohort and treatment group.

[0107] Safety analyses will include analysis of all treatment-emergent adverse events (TEAEs), electrocardiograms (ECGs), clinical laboratory data, physical examinations, and vital sign measurements using descriptive statistics. No inferential statistical analyses are planned for the safety parameters of this study. The prevalence of AEs and serious adverse events (SAEs) will be summarized by system organ class (SOC) and preferred term for each cohort and treatment group, and by relationship to study drug within each treatment group overall. AEs will be summarized by cohort and by severity overall. SAEs and AEs resulting in withdrawal from the study will be listed. Participants with multiple AEs within a category (e.g., overall, SOC, preferred term) will be counted once in that category. For severity tables, the participant's most severe event within a category will be counted.

[0108] All concomitant medications were coded using the World Health Organization Drug Dictionary, and the frequency and proportion of concomitant medications were summarized.

[0109] Efficacy analysis Absolute and percent change from baseline in complement biomarkers, hemoglobin, and hemolysis markers will be assessed at the end of the 12-week treatment period for Cohort 1 and Cohort 2. Time to hemoglobin response (defined as an increase in hemoglobin levels of >1 g / dL from baseline) will be assessed for Cohort 1 and Cohort 2 at the end of the 12-week treatment period.

[0110] Pharmacokinetic analysis Individual serum concentration data from participants receiving SC administration of the fusion polypeptides described herein, along with actual sampling dates and times, will be used to characterize PK using population PK analysis approaches.

[0111] Pharmacodynamic analysis The PD effect of SC administration of all fusion polypeptides described herein will be evaluated by assessing changes in serum total and free properdin concentrations and alternative complement pathway (CAP) activity using the Wieslab alternative pathway (AP) assay. Additionally, other measures of classical complement pathway activity and properdin activity over time may be deemed appropriate (Section 8.6).

[0112] Immunogenicity analysis Immunogenicity, as measured by the incidence of anti-drug antibodies (ADA) against the fusion polypeptides described herein, is summarized.

[0113] Exploratory analysis Further exploratory analyses of biomarker assays and clinical efficacy endpoints may be performed. Details of these analyses are provided in the Statistical Analysis Plan (SAP).

[0114] Interim analysis Interim analyses may be performed after at least 12 patients (6 from each cohort) from Cohorts 1 and 2 have been enrolled and have completed the treatment period (12 weeks). Details of these analyses are provided in the SAP.

[0115] 1.3 Schedule of Exams (SoA) The SoAs for once-weekly (QW) dosing for multi-dose Cohort 1 for screening through Day 85 are presented in Table 3.

[0116] The SoAs for the once every four weeks (Q4W) dose for multiple dose cohort 2 for screening through Day 85 are presented in Table 4.

[0117] Table 5 presents the SoAs for focused PK / PD sampling for a subset of participants in Cohorts 1 and 2. Table 6 presents the SoAs for Cohorts 1 and 2 from Day 99 to the end of the follow-up period.

[0118] The SoAs for the optional multiple dose Cohort 3 once every two weeks (Q2W) administration for screening through Day 43 are presented in Table 7. Table 8 presents the SoAs for Cohort 3 from Day 57 to the end of the follow-up period.

[0119] [Table 3-1]

[0120] [Table 3-2]

[0121] [Table 3-3]

[0122] [Table 3-4]

[0123] [Table 4-1]

[0124] [Table 4-2]

[0125] [Table 4-3]

[0126] [Table 5]

[0127] [Table 6-1]

[0128] [Table 6-2]

[0129] [Table 7-1]

[0130] [Table 7-2]

[0131] [Table 7-3]

[0132] [Table 8-1]

[0133] [Table 8-2]

[0134] 2. Introduction 2.1 Rationale for conducting the test The fusion polypeptides described herein (anti-properdin / anti-serum albumin bispecific VHH antibodies) are novel properdin blockers being developed for the treatment of diseases involving dysregulated CAP activity. The fusion polypeptide molecules described herein are bispecific, comprising a VHH antibody domain that binds to and blocks properdin linked via a linker to a VHH domain that binds serum albumin, thereby conferring an extended circulating half-life to the molecule.

[0135] The fusion polypeptides described herein bind with high affinity to properdin, preventing the stabilization of CAP complement component C3 (C3) and complement component C5 (C5), which cleaves C3 and C5 into their activated products. Quantitative blockade of properdin has been shown to be safe in humans based on experience with properdin-binding antibodies (see Section 4.3). The fusion polypeptides described herein are currently being evaluated in an ongoing Phase 1 study in healthy adult participants, with the dose and dosing regimen for participants determined using cumulative safety data and interim PK / PD analyses from participants enrolled in the ongoing Phase 1 study and data from a 6-month GLP toxicity study in monkeys.

[0136] The objective of this study in patients with SCD is to evaluate the safety, tolerability, efficacy, PK, PD, and immunogenicity of multiple doses and dosing regimens of the fusion polypeptides described herein administered subcutaneously.

[0137] The study will involve up to three cohorts with multiple SC administrations and dosing regimens of the open-label fusion polypeptides described herein in adult patients with SCD. Data obtained from this study is expected to inform the design of future studies in patients with SCD and other complement-mediated diseases.

[0138] 2.2 Background A detailed description of the chemical, pharmacological and toxicological data available for the fusion polypeptides described herein is provided in the Investigator Brochure (IB).

[0139] 2.2.1 Chemistry The fusion polypeptide described herein is a recombinant, humanized VHH bispecific antibody that binds to human properdin and serum albumin. The antibody consists of a 256-amino acid single-chain polypeptide composed of an anti-albumin domain at the N-terminus fused to an anti-properdin domain at the C-terminus via a 15-amino acid linker. The variable region domains that form the serum albumin and properdin binding sites consist of llama complementarity-determining regions grafted onto a human germline framework. Within the framework region, the llama residue at position 11 was left unchanged to maintain antigen binding, water solubility, and overall stability. There are two intrachain disulfide bonds, one located in each VHH domain. The theoretical average molecular weight of the antibody is 27,350.2 Da. At pH 7.4, the fusion polypeptide described herein exhibits a binding dissociation constant (K) of 323 pM for human properdin. D ) and a K of 439 pM for human serum albumin D The IC for blockade of human CAP hemolysis by the fusion polypeptides described herein (20% v / v final serum) was shown. 50 The fusion polypeptides described herein had IC values ​​of approximately 20 nM (C3), 15 nM (properdin), and 19 nM (C9). 50 At this value, it blocked the deposition of C3 fragments, properdin, and complement component C9 (C9) onto a myeloperoxidase substrate by human serum (20% v / v).

[0140] 2.2.2 Nonclinical pharmacology In testing the efficacy of the fusion polypeptides described herein for blocking in vitro CAP hemolysis using serum from a range of species, significant species cross-reactivity was observed only when serum from cynomolgus and rhesus monkeys was used. CAP hemolytic activity in serum from mice, rats, guinea pigs, minipigs, beagle dogs, and rabbits was not inhibited by the highest concentration (>100 μg / mL) of the fusion polypeptides described herein tested. The IC for blocking CAP hemolysis in cynomolgus monkeys by the fusion polypeptides described herein (20% v / v final serum) was 0.01. 50 The fusion polypeptide described herein had a binding K of 2.9 nM for cynomolgus monkey properdin. D and a binding K of 2.1 nM for cynomolgus monkey serum albumin D The fusion polypeptides described herein exhibited IC values ​​of approximately 11 nM (C3), 9 nM (properdin), and 17 nM (C9). 50 At values ​​of 0.01, cynomolgus monkey serum (20% v / v) blocked the deposition of C3 fragments, properdin, and C9 onto myeloperoxidase substrates. The lack of species cross-reactivity beyond primates precluded testing the biological activity of the fusion polypeptides described herein in conventional rodent models of diseases involving dysregulated complement activity. Thus, collectively, nonclinical in vitro and in vivo studies to evaluate the pharmacological, PK, PD, and toxicological properties of the fusion polypeptides described herein have been conducted in cynomolgus monkeys.

[0141] 2.2.3 Toxicity The nonclinical safety profile of the fusion polypeptides described herein has been evaluated in an in vitro GLP tissue cross-reactivity (TCR) study in cynomolgus monkeys and in both non-GLP and GLP in vivo studies. In GLP toxicity studies, the fusion polypeptides described herein were administered intravenously (IV) (single doses up to 100 mg / kg) and SC (26-week doses up to 300 mg / kg / week). The fusion polypeptides described herein did not demonstrate any nonspecific binding to human tissues in the TCR study. Based on the absence of any adverse systemic or local toxicity in cynomolgus monkeys, 300 mg / kg / week was considered the no-observed-adverse-effect level (NOAEL) for SC administration, and 100 mg / kg was considered the NOAEL for IV administration of the fusion polypeptides described herein. After the final dose at the NOAEL in the SC group, systemic exposure (maximum observed serum concentrations [C] of 8,570 μg / mL and 1,160,000 μg·hr / mL, respectively) was observed. max ] and the area under the concentration-time curve from time 0 to 168 hours [AUC 0~168 ]) resulted in an approximately 30-fold increase in exposure over the predicted human dose of 300 mg QW. Anti-drug antibodies, when observed in very small numbers of monkeys, did not have any effect on systemic exposure or toxicity profiles.

[0142] 2.3 Benefit / Risk Assessment There may be potential benefits for patients with SCD (see Section 2.3.2). Identified and potential risks are described below. More detailed information about the known expected benefits and risks and reasonably expected AEs of the fusion polypeptides described herein can be found in IB. Potential risk mitigation strategies are described in Table 9.

[0143] 2.3.1 Risk Assessment In addition to a first-in-human (FIH) Phase 1 study in healthy participants, this study represents the second human exposure to the fusion polypeptide described herein and the first exposure to patients with SCD. Due to limited clinical experience to date, potential risks are based on the class of molecule and its mechanism of action. Repeated-dose toxicity studies in cynomolgus monkeys with the fusion polypeptide described herein have not identified potential risks after 26 weeks of SC administration at doses up to 300 mg / kg / week or a single IV dose at doses up to 100 mg / kg, and no safety concerns have been identified in healthy participants as of March 11, 2022, after 5 weeks of SC administration at doses up to 150 mg or a single SC dose at 1200 mg.

[0144] 2.3.1.1 Neisseria meningitidis infection Increased susceptibility to infection with Neisseria meningitidis is a known risk associated with properdin deficiency and has been well described in properdin-deficient patients (Figueroa, 1991). As with properdin deficiency, the primary risk associated with the use of the fusion polypeptides (properdin inhibitors) described herein is expected to be the risk of meningococcal infection. Specific risk mitigation measures have been implemented to address this risk.

[0145] Clinically, the risk of N. meningitidis is reduced in properdin-deficient patients by vaccinating all patients with the quadrivalent meningococcal conjugate vaccine (MCV4) and serogroup B vaccine against N. meningitidis prior to administration.

[0146] Patients will receive MCV4 and serogroup B meningococcal vaccines at least 14 days before dosing if they have not yet been vaccinated within 3 years prior to the first dose (or according to national / regional guidelines). Participants who start study intervention treatment less than 14 days after meningococcal vaccination must receive appropriate prophylactic antibiotic treatment for at least 2 weeks after vaccination. Every effort should be made to start the meningococcal vaccination series at least 14 days before randomization.

[0147] Additionally, participants may be treated with prophylactic antibiotics at the investigator's discretion.

[0148] 2.3.1.2 Immunogenicity and hypersensitivity The fusion polypeptides described herein may be immunogenic and may be associated with hypersensitivity reactions.It is also known that some healthy participants have pre-existing antibodies against VHH antibodies.Antibodies against the fusion polypeptides described herein were observed in 14 of the serum samples of 100 healthy participants tested in vitro screening assay.

[0149] Immunogenicity monitoring for the fusion polypeptides described herein will be performed for this study as specified in the SoA (section 1.3).

[0150] [Table 9]

[0151] 2.3.1.3 Coronavirus disease 2019 The global pandemic of SARS-COV-2 disease (coronavirus disease 2019 [COVID-19]) is active in many countries at the time of this protocol amendment. Given these unique circumstances, specific consideration has been given to the risks and benefits of this study as they may relate to COVID-19, as well as the global and regional changes that exist as a result of the pandemic.

[0152] 2.3.2. Benefit assessment The potential benefit of treating SCD with the fusion polypeptides described herein is measured by assessment of anemia and hemolysis. An increase in hemoglobin of ≥ 1 g / dL from baseline is considered clinically meaningful. In addition, a positive treatment effect would also be indicated by a reduction in hemolysis, including an improvement in serum levels of markers of hemolysis (i.e., lactate dehydrogenase [LDH], indirect bilirubin, and haptoglobin). Other exploratory endpoints (such as vaso-occlusive events [VOC]) may be assessed.

[0153] 2.3.2 Overall Benefit: Risk Conclusions The fusion polypeptides described herein have been and are currently being evaluated in ongoing Phase 1 trials, which represent the second human exposure to the fusion polypeptides described herein.

[0154] This study will be conducted in patients with SCD, and dosing will begin based on a review of safety, tolerability, and PK / PD data from the Phase 1 study. The dose administered in this study is expected to result in lower exposures than the highest dose tested in previous studies, and the expected patient exposures are lower than the NOAEL exposures established in 6-week and 6-month GLP monkey toxicity studies. Strict inclusion / exclusion criteria and a robust safety monitoring and risk mitigation plan are in place. The DMC will evaluate available study data at pre-specified time points for participant safety and make recommendations regarding dose modification or study termination. The selected dose is intended to deliver complete inhibition of properdin, providing patients with SCD with the potential benefits of the fusion polypeptides described herein at a positive benefit / risk ratio.

[0155] Data from this study are expected to inform future clinical trials in patients with SCD.

[0156] 3. Objectives and evaluation items The study objectives and corresponding endpoints are presented in Table 10.

[0157] [Table 10]

[0158] 4. Study Design 4.1 Overall study design This is due to the SCD (HbSS and HbSβ 0 This is a Phase 2a study using up to three multiple-dose cohorts of open-label SC of the fusion polypeptide described herein in adult patients with rheumatoid arthritis (rheumatoid arthritis).

[0159] The study will be conducted in up to 30 adult patients with SCD who will be enrolled in up to three open-label cohorts (Cohorts 1, 2, and 3 [optional]) to receive multiple SC administrations of the open-label fusion polypeptides described herein. The fusion polypeptides described herein will be administered as described in Table 11.

[0160] [Table 11]

[0161] The dose and dosing interval for Cohorts 1 and 2 were determined using cumulative safety data, interim PK / PD analyses from participants enrolled in Phase 1, and data from a 6-month GLP toxicity study in monkeys. Optional Cohort 3 will be initiated after evaluation of safety and PK / PD data from Cohorts 1 and 2.

[0162] Cohort 1 and Cohort 2 will be conducted in parallel, and upon eligibility determination, patients will be randomized 1:1 to one of the cohorts. The decision to initiate optional Cohort 3 will be made at the investigator's discretion and will be based on PK / PD and safety analyses after at least eight patients (four from each cohort) from Cohorts 1 and 2 have been enrolled. Furthermore, enrollment for optional Cohort 3 will begin after Cohorts 1 and 2 are fully enrolled. Each cohort will be stratified to ensure inclusion of patients with SCD who are being treated with a stable dose of hydroxyurea and patients with SCD who are not currently being treated with hydroxyurea. Patients previously treated with hydroxyurea but not currently using hydroxyurea must discontinue treatment at least 30 days before providing informed consent.

[0163] This study will use an independent DMC to monitor safety and conduct planned interim analyses of the study. At the investigator's discretion and after consultation with the DMC, if a participant discontinues during the treatment period for reasons other than drug-related AEs, additional participants with SCD may be enrolled as supplemental participants.

[0164] 4.2 Scientific rationale for study design The first indication for the fusion polypeptides described herein is SCD. SCD affects 20-25 million people worldwide (Aliyu, 2008) and approximately 100,000 people in the United States (Hassell, 2010). The prevalence of SCD among newborns and SCD carriers in the EU is 1-5 in 10,000 and 1 in 150, respectively (Engert, 2016). Some available life expectancy estimates for SCD patients in the US or EU vary widely, ranging from 45 to 65 years, approximately 20 years lower than the general population (Gardner, 2016; Lubeck, 2019; Payne, 2020; Platt, 1994).

[0165] SCD is a group of genetic disorders. Mutations in the β-hemoglobin gene are involved in the synthesis of sickle cell hemoglobin (HbS). The most common genotypes in SCD are HbSS, HbSC, and HbSβ. + Thalassemia. The most common clinical manifestations of SCD are chronic hemolysis and VOCs (Kato, 2018; Pecker, 2021).

[0166] HbS has abnormal physicochemical properties and is prone to polymerization under low oxygen concentrations, causing red blood cells (RBCs) to deform with a characteristic sickle shape. Sickling has numerous adverse consequences for RBCs and multiple organs. Sickled RBCs have a limited lifespan due to hemolysis. Hemolysis is thought to occur primarily via extravascular phagocytosis (approximately two-thirds) and intravascular hemolysis (approximately one-third), leading to anemia. Intravascular hemolysis of sickled RBCs results in the release of free hemoglobin, which in turn activates CAP (via free heme), depletes nitric oxide, and contributes to endothelial damage. RBC hemolysis and sickling lead to endothelial cell activation, accompanied by increased adhesion molecule expression and activation of neutrophils, monocytes, and platelets (Kato, 2018). VOCs resulting from these processes lead to the interruption of blood flow to vital organs such as the kidneys, liver, lungs, and heart, promoting ischemia, acute pain episodes, and necrosis. The subsequent ischemia / reperfusion injury leads to the generation of reactive oxygen species, which in turn leads to a chronic inflammatory state (Kato, 2018; Piel, 2017). Patients are also at increased vulnerability to infections, particularly from encapsulated bacteria, as a result of functional or actual asplenia. Collectively, these mechanisms contribute to the development of chronic organ damage, including sickle cell nephropathy, pulmonary hypertension, avascular necrosis, chronic lung disease, and shortened life expectancy (Kato, 2018).

[0167] In the United States, universal newborn screening has been established to allow for early diagnosis and treatment of infants with SCD to reduce morbidity and mortality. 0-It is recommended that all infants with thalassemia receive penicillin prophylaxis and the 23-valent pneumococcal polysaccharide vaccine to prevent invasive pneumococcal disease (Kato, 2018; Pecker, 2021).

[0168] Hydroxyurea, RBC transfusions, and opioids are commonly used treatments to manage the symptoms of SCD. Recently, several new drugs have been approved for the treatment of sickle cell complications: L-glutamine (Endari®), voxelotor (Oxbryta®), and crizanlizumab (Adakveo®). However, none of these treatments address both anemia (hemolysis) and VOCs. The only curative treatment option for SCD is hematopoietic stem cell transplantation. However, this is reserved for severely affected patients due to the risk of life-threatening complications (Pecker, 2021).

[0169] In recent years, much attention has been focused on the role of the innate immune system in SCD, particularly the role of complement activation in the pathophysiology of SCD (Tampaki, 2021; Varelas, 2021). In investigator-initiated studies, eculizumab demonstrated clinical benefit in SCD patients with delayed hemolytic transfusion reactions, VOCs, and drug-induced immune hemolytic anemia (Chonat, 2020). Compared to C5 inhibitors, CAP inhibitors have potential advantages in the treatment of SCD. A growing number of publications support the hypothesis that sickled RBCs are the focus of C3 opsonization on the cell surface and CAP activation, which leads to complement-mediated RBC hemolysis. Intravascular hemolysis is one of the major causes of anemia and contributes to further amplification of CAP activation by releasing free heme from RBCs. C3 opsonization of sickled RBCs also promotes anemia through extravascular hemolysis via the reticuloendothelial system. Furthermore, C3 opsonization has been shown to be an important contributor to VOCs. It has also been demonstrated that C3 opsonization can be precipitated by the exposure of phosphatidylserine on sickle RBCs, contributing to VOCs by enhancing its interaction with adhesion molecules such as P-selectin and complement receptor 3 on activated endothelial cells (Lombardi, 2019). Thus, the nonclinical literature on SCD as a whole emphasizes the role of CAP activation in SCD pathophysiology.

[0170] The fusion polypeptides described herein bind with high affinity to human properdin, a component of CAP, preventing stabilization of the CAP C3 and C5 convertases, which cleave C3 and C5 into their activated products. By binding to properdin, the fusion polypeptides described herein prevent activation of the alternative complement system, thereby potentially treating SCD. In support of this, studies conducted in a mouse model of SCD demonstrated that pretreatment of animals with mouse anti-properdin antibodies significantly improved signs of hemolysis and vaso-occlusion, two major clinical features of SCD.

[0171] The current non-clinical data and data from the first-in-human study support further investigation of the fusion polypeptides described herein as a potential treatment for patients with SCD. This study is designed to allow preliminary assessment of changes in SCD disease-associated biomarkers and to guide the design of further clinical trials in patients with SCD.

[0172] 4.3 Rationale for dose setting The dose and dosing frequency are based on all available data, including overall safety, tolerability, and PK / PD modeling from ongoing cohorts in Phase 1 studies; available nonclinical data, including PK, PD, and efficacy in SCD mouse models; and toxicity data from GLP 6-week and 6-month studies in cynomolgus monkeys.

[0173] A preliminary PK / PD model has been established based on data from a Phase 1 study in healthy participants. This semi-mechanistic model assumed the monovalent fusion polypeptide described herein binding to trimeric properdin, which has three binding sites. The relationship between free properdin and CAP activity is determined by a sigmoid E max The model was characterized. This model provided a good fit to the observed data (fusion polypeptide, total and free properdin, and CAP activity as determined by the model diagnostic method described herein). To estimate the therapeutic dose in SCD patients, the following assumptions were made: Complete suppression of CAP activity (<1% of baseline activity) is required for clinical efficacy based on data from mouse SCD models (fusion polypeptides described in detail herein in Section IB) Baseline properdin concentrations are approximately 20% higher in sickle cell disease patients than in healthy subjects (Strauss, 1977)

[0174] Additionally, the impact of increased clearance on exposure and CAP inhibition was assessed by setting the clearance of the fusion polypeptides described herein in sickle cell disease patients to be similar to or 40% higher than that in healthy participants (as seen with other antibody treatments for SCD (Crizanlizumab, 2019)). Based on these assumptions and analysis, a 300 mg QW dose is predicted to inhibit CAP activity to <1% of baseline values ​​(upper limit of the 90% prediction interval) and maintain this effect throughout the treatment period. The 600 mg Q4W or 300 mg Q2W doses also demonstrated <1% inhibition of CAP activity during the majority of the dosing interval. CAP activity slowly recovered and returned to baseline after cessation of administration of the fusion polypeptides described herein. The margin of safety at 300 mg QW is approximately 30-fold based on the NOAEL exposure established in a 6-month (or 26-week) monkey toxicity study. The margin of safety at 600 mg Q4W or 300 mg Q2W is approximately 60-fold based on the NOAEL exposure.

[0175] 4.4 Definition of Test Completion Participants were considered to have completed the study if they completed all phases of the study, including the last scheduled procedure (Section 1.3) as indicated in the SoA.

[0176] End of study (EOS) will be defined as the date on which the last participant completed their last visit, as indicated in the SoA (section 1.3).

[0177] 5. Study population Future approval of protocol deviations from the supplemental and enrollment criteria, also known as protocol waivers or exemptions, will not be permitted.

[0178] 5.1 Recruitment criteria age 1. Participants must be between 18 and 65 years of age at the time of signing the informed consent. Participant type and disease characteristics 2. SCD (HbSS or HbSβ 0 -Confirmed diagnosis of thalassemia. body weight 3.Weight ≥ 40 kg (inclusive) at screening. sex 4. Use of contraceptives or devices by men or women must be consistent with local regulations regarding contraceptive methods for people participating in clinical trials. Female participants of childbearing potential and male participants with female partners of childbearing potential must be willing to follow the contraceptive guidance specified in the clinical trial protocol during treatment and for at least 6 months after the last dose of investigational product. Other inclusion criteria 5. Hemoglobin must be 5.5-10g / dL at screening. 6. Have had 1 to 10 VOCs in the past 12 months. 7. Patients receiving hydroxyurea must have been on a stable dose for ≥ 3 months before providing informed consent, and no need for dose adjustments is anticipated during the study. For patients who have previously used hydroxyurea but are not currently receiving hydroxyurea therapy (due to non-response, intolerance, or unwillingness to receive hydroxyurea), hydroxyurea therapy must be discontinued at least 30 days before providing informed consent. 8. Patients will receive MCV4 and serogroup B meningococcal vaccines at least 14 days prior to dosing if they have not yet been vaccinated within 3 years prior to the first dose (or according to national / regional guidelines). Participants who start study intervention treatment less than 14 days after meningococcal vaccination must receive appropriate prophylactic antibiotic treatment for at least 2 weeks after vaccination. 9. Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae vaccinations are up to date according to current national / regional vaccination guidelines for individuals with SCD. 10. Must be willing to comply with all study requirements and restrictions. Informed consent 11. Able to give signed informed consent (or assent, if applicable), including compliance with the requirements and restrictions set forth in the ICF and this protocol.

[0179] 5.2 Exclusion criteria Participants will be excluded from the study if they meet any of the following criteria: 1. There is a scheduled start, stop, or dose change of hydroxyurea during the study. 2. If you have received voxelotor (OXBRYTA) or crizanlizumab (ADAKVEO) within 60 days of providing informed consent. 3. If receiving treatment with recombinant human erythropoietin (e.g., epoetin alfa). 4. Treatment with a complement inhibitor within 6 months prior to the first dose. 5. Patients who have received blood transfusions for a long period of time or within 60 days of the first administration. 6. Has any serious illness or disorder that, in the opinion of the investigator, may put the participant at risk. 7. History of complement deficiency. 8. History of meningococcal (N meningitidis), Streptococcus pneumoniae (S pneumoniae) or Haemophilus influenzae infection. 9. History of malignancy, except non-melanoma skin cancer or cervical intraepithelial neoplasia that has been treated without evidence of recurrence within 5 years. 10. Evidence of hepatitis B (hepatitis surface antigen [HBsAg] positive or core antibody (anti-HBc) positive with surface antibody negative [anti-HBs]) or hepatitis C virus infection (hepatitis C virus [HCV] antibody positive, except in patients with proven successful treatment and demonstrated sustained virologic response) at screening. 11. Active systemic bacterial, viral, or fungal infection within 14 days prior to dosing. Previous / concurrent clinical trial experience 12. Participation in a clinical trial (i.e., last protocol-required study visit) within 90 days or 5 half-lives (whichever is longer) of an investigational drug prior to initiation of dosing on Day 1. 13. Participation in more than one clinical trial of a monoclonal antibody (mAb) (i.e., the last protocol-required study visit) or clinical trial of a mAb (i.e., the last protocol-required study visit) (during which the participant was exposed to the active investigational drug) within 6 months or 5 half-lives of the mAb (whichever is longer) prior to screening. Diagnostic evaluation 14. Severe renal dysfunction (estimated glomerular filtration rate [eGFR] < 30 mL / min / 1.73 m 2 ) or undergoing long-term dialysis. Other exclusions 15. Pregnant or breastfeeding female participants. 16. History of allergy or hypersensitivity to any excipient of the fusion polypeptides described herein (e.g., polysorbate 80).

[0180] 5.3 Consideration of lifestyle habits Not applicable; the study described herein does not include specific lifestyle considerations.

[0181] 5.4 Screening Ineligibility A screen failure is defined as a participant who consents to participate in a clinical trial but is not assigned to an investigational drug because they did not meet the eligibility criteria. To ensure transparent reporting of screen failure participants, meet the publication requirements of the Consolidated Standards for Clinical Trial Reporting, and respond to inquiries from regulatory authorities, minimum screen failure information is required. This minimum information includes demographics, details of the screen failure (e.g., eligibility criteria not met), and any SAEs occurring during the screening period, including any related concomitant medications.

[0182] Participants who are expected to recover or who, due to reasons of recovery, do not meet the criteria for inclusion in the study (i.e., screening failure) may be rescreened in consultation and agreement with the investigator and medical monitor. Any abnormal laboratory parameter results outside the reference range at screening may be repeated at the investigator's discretion for the purpose of further determining eligibility.

[0183] 6. Study intervention A study intervention is defined as any clinical trial intervention, commercially available product, placebo, or medical device intended to be administered to study participants in accordance with the study's protocol. In the present study described herein, the study intervention is a fusion polypeptide described herein, also referred to as the investigational drug throughout this study protocol.

[0184] 6.1 Study interventions administered The investigational drug compositions of the fusion polypeptides described herein and the doses (open label, SC) to be administered in this study are shown in Table 12.

[0185] [Table 12]

[0186] 6.2 Preparation / Handling / Storage / Management Details regarding the preparation, handling, storage, control, and administration of investigational products are discussed below. Additional guidance is provided in the Investigational Product Management Procedures. 1. The fusion polypeptides described herein should be stored at 2-8°C. The investigator or designee must ensure that appropriate temperature conditions are maintained during transportation for all administered investigational products, and any discrepancies will be reported and resolved prior to use of the investigational product. 2. Only participants enrolled in the study may receive the investigational product, and only authorized on-site staff may supply or administer the investigational product. All investigational products must be stored in a secure, environmentally controlled, and monitored (manual or automated) area in accordance with labeled storage conditions, as long as they are accessible to the investigator and authorized on-site staff. 3. The investigator's site pharmacy staff will be responsible for the management, verification, and record-keeping of the investigational drug (i.e., receipt, verification, and final disposition records). The site pharmacy will assemble the supplies into individual, labeled participant administration syringes and perform qualified personnel authentication of the assembled products. Further guidance and information regarding the preparation, handling, storage, and management of the final disposition of unused study intervention drug is provided in the Investigational Drug Management Procedures.

[0187] 6.3 Measures to Minimize Bias: Randomization and Blinding All eligible participants who meet all inclusion and exclusion criteria in Cohorts 1, 2 and optional Cohort 3 will receive the open-label fusion polypeptide described herein.

[0188] 6.4 Adherence to Study Interventions Administration of study interventions to participants will be under the supervision of the investigator or his / her designee to ensure that participants receive the appropriate dose at the appropriate time during the study.

[0189] The date and time of each dose administered at the clinic will be recorded on the source document and case report form (CRF).

[0190] The dose of the study intervention and study participant identification will be verified at the time of administration by a member of the study site staff other than the person administering the study intervention.

[0191] For additional information regarding adherence and administration of study intervention medications, please refer to the Investigational Drug Administration Procedures.

[0192] 6.5 Combination Therapy Any medications (including over-the-counter or prescription drugs, vitamins and / or herbal supplements), vaccines, or other areas of particular interest that participants are receiving at the time of enrollment or will receive during the study must be recorded along with the following: ·Reason for use Dates of administration, including start and end dates Dosage information, including dose and frequency If there are any questions regarding concomitant or previous therapy, the medical monitor should be contacted.

[0193] 6.5.1 Permitted Drugs and Therapies Multivitamins, contraceptives, and paracetamol (i.e., acetaminophen at doses ≤2 g / day) are permitted for use during the study at the investigator's discretion. Topical skin preparations should not be administered at the investigational drug injection site from 24 hours before until 24 hours after investigational drug administration.

[0194] See Section 8.2.8 for details on the dosing and duration of concomitant antibiotic prophylaxis to reduce the risk of N. meningitidis infection associated with complement inhibition.

[0195] Other concomitant medications may be considered on a case-by-case basis by the Investigator in consultation with the Medical Monitor as appropriate. Concomitant treatments will not be permitted unless medically necessary.

[0196] Medications and therapies for SCD are permitted except those listed in Section 6.5.2.

[0197] 6.5.2 Unauthorized Drugs and Therapies During the screening and treatment period, if the patient is not currently being treated with hydroxyurea, hydroxyurea should not be initiated. If the patient is receiving a stable dose of hydroxyurea, the dose of hydroxyurea should not be changed or discontinued. The use of voxelotor, crizanlizumab, erythropoietin, other complement inhibitors, and blood transfusions is not permitted. If any of the above medications / therapies are used, the patient will be discontinued per Section 7.1. The above medications / therapies are permitted during the safety follow-up period.

[0198] 6.6 Dose Modifications The decision to continue or change the dose will be made by the investigator and / or the DMC after review of the safety data. The DMC may also make recommendations regarding safety issues, study conduct, or study discontinuation.

[0199] 6.7 Post-trial interventions No follow-up interventions are planned.

[0200] 7. Discontinuation of study intervention medication and participant withdrawal / withdrawal 7.1 Discontinuation of study intervention In rare cases, it may be necessary for a participant to discontinue the study intervention completely (final discontinuation). If the study intervention is eventually discontinued, the participant should remain in the study and be assessed for safety follow-up. See the SoA for data to be collected at the time of discontinuation of the study intervention and at follow-up, as well as any further assessments that need to be completed (Section 1.3).

[0201] 7.2 Stopping Criteria 7.2.1 Individual Stopping Rules A participant should be considered for discontinuation of the intervention medication if any of the following occurs during the study: ·Severe hypersensitivity reactions; Grade 3 or higher injection site reaction; ·Severe uncontrolled infection; ·Severe meningococcal (N meningitidis), Streptococcus pneumoniae (S pneumoniae) or Haemophilus influenzae infection; · Use of unauthorized medications as defined in Section 6.5.2; Pregnancy or planned pregnancy; or Any AE, laboratory abnormality, or intercurrent illness that, in the opinion of the investigator, presents a substantial clinical risk to the patient if continued on study drug.

[0202] 7.2.2 Test Stop Rules A study may be terminated at the recommendation of the DMC if the following occurs and are deemed related to the investigational drug: ·Two or more meningococcal infections; ·Two or more severe (≥grade 3) pneumococcal infections; ·Two or more severe (≥grade 3) H influenzae infections; One meningococcal, pneumococcal or Haemophilus influenzae infection that can have fatal consequences.

[0203] 7.3 Participant Withdrawal / Withdrawal from the Study Every effort should be made to ensure that participants are willing to comply with study participation before screening procedures are administered. Study staff must notify the investigator and their site monitor of all study withdrawals as soon as possible. The reason for a participant's withdrawal should be recorded in the source documentation and on the electronic case report form (eCRF).

[0204] Participants may withdraw from the study at any time at their own request or at the investigator's discretion for safety, behavioral, compliance, or administrative reasons. This is expected to be rare.

[0205] When discontinuing the study, an early discontinuation visit should occur, if possible, as outlined in the SoA (Section 1.3). Please refer to the SoA for data to be collected at study discontinuation and follow-up, as well as any further assessments that may need to be completed.

[0206] At that point, the participant will be permanently discontinued from both the investigational drug and the study.

[0207] If a participant withdraws consent for future disclosures, the investigator may retain and continue to use any data collected before such consent was withdrawn.

[0208] If a participant withdraws from the study, they may request the destruction of any samples that were collected but not tested, and the investigator must document this in the site study records.

[0209] Participants who discontinue during the screening or dosing period for reasons other than study drug-related AEs may be replaced.

[0210] 7.4 Loss to follow-up Participants are considered lost to follow-up if they repeatedly miss scheduled visits and cannot be contacted by the study site. If a participant does not return to the clinic for a required study visit, the following actions must be taken: The investigational site must attempt to contact the participant and reschedule any missed visits as soon as possible, advise the participant on the importance of maintaining their assigned visit schedule, and ascertain whether the participant wishes and / or should continue in the study. Before a participant is considered lost to follow-up, the investigator or designee must make every effort to re-establish contact with the participant (by email, three phone calls, if possible, and, if necessary, by sending a letter of confirmation to the participant's current address or local equivalent). These contact attempts must be documented in the participant's medical record. If participants continue to be unable to be contacted, they will be considered lost to follow-up.

[0211] 8. Test Evaluation and Procedures The testing procedures and timing are outlined in the SoA (Section 1.3). No waivers or exemptions from the protocol will be granted.

[0212] Participants should immediately discuss any safety concerns with the investigator as soon as they arise or become aware of them to determine whether they should continue or discontinue the fusion polypeptides described herein.

[0213] Adherence to study design requirements, including those specified in the SoA, is essential and necessary for the conduct of the study.

[0214] All screening assessments must be completed and reviewed to ensure that, where possible, all participants meet the eligibility criteria. The investigator will maintain a screening log to record the details of all participants screened and to confirm eligibility or, where appropriate, record the reason for screening ineligibility. Procedures performed as part of the participant's routine clinical management and obtained before signing the ICF may be utilized for screening or baseline purposes, provided that the procedures meet the criteria specified in the protocol and are consistent with the institution's standard operating procedures, and are performed within the timeframe defined in the SoA.

[0215] 8.1 Effectiveness Evaluation The timing of collection of assessments for Cohort 1 is detailed in Section 1.3, Tables 3 and 6. The timing of focused collection of PK and PD samples for Cohort 1 and Cohort 2 is detailed in Section 1.3, Table 5. The timing of collection of assessments for Cohort 2 is detailed in Section 1.3, Tables 4 and 6. The timing of collection of assessments for optional Cohort 3, if performed, is detailed in Tables 7 and 8.

[0216] 8.1.1 Changes in complement biomarkers The following complement markers (absolute and percent change from baseline) will be measured during the study: Complement component Ba (Ba) Complement component C3a (C3a) Soluble complement component C5B-9 (sC5B9) Where possible, other complement markers may be assessed.

[0217] 8.1.2 VOC-related biomarker changes During the study, the following markers of VOCs (absolute change and percent change from baseline) may be measured: Hemopexin Nitric oxide Inflammatory markers (e.g., interleukin-1) Cell adhesion markers (e.g., soluble P-selectin) Other markers may be evaluated when possible.

[0218] 8.1.3 Changes in hemoglobin Blood samples are taken to assess hemoglobin change from baseline.

[0219] 8.1.4 Markers of hemolysis During the study, the following markers of hemolysis are measured: Serum LDH level Absolute reticulocyte count Serum indirect bilirubin Serum haptoglobin and hemopexin

[0220] 8.1.5 VOC Evaluation Sickle cell disease-associated pain episodes (VOC) will be collected throughout the study as detailed in the SoA (section 1.3).

[0221] After signing informed consent, patients will be issued a paper diary to record their VOC symptoms. The diary will be collected by the investigator or designee at each site visit and a new diary will be provided.

[0222] 8.2 Safety Assessment The planned time points for all safety assessments for all cohorts will be provided in the SoA (Section 1.3).

[0223] 8.2.1 Physical Examination A complete physical examination will include, at a minimum, an evaluation of the general appearance; skin; head, ears, eyes, nose, and throat; neck; lymph nodes; chest; heart; abdominal cavity; extremities; central nervous system; and musculoskeletal system.

[0224] A brief physical examination will include evaluation of at least the skin, lungs, cardiovascular system, and abdomen (liver and spleen).

[0225] Height, weight and BMI will be recorded according to Section 1.3, SoA.

[0226] Investigators should pay particular attention to clinical signs associated with a previous severe stage of disease.

[0227] 8.2.2 Vital signs Vital signs will be measured after participants have rested for at least 5 minutes in a supine or semi-supine position and will include temperature (tympanic or oral), respiratory rate, and supine blood pressure or pulse. Ideally, the same arm should be used for BP and pulse measurement for each participant. Standing (orthostatic) blood pressure will only be measured at screening.

[0228] Timing of vital sign measurements is described in the SoA (Section 1.3).

[0229] Any blood pressure or pulse readings that are out of range will be repeated at the investigator's discretion. Any confirmed clinically significant vital sign readings will be recorded as an AE.

[0230] 8.2.3 Electrocardiogram Record three consecutive 12-lead ECGs at the time points described in SoA (section 1.3) to obtain heart rate, PR, QRS, and QT intervals. 12-lead ECG recordings are performed after the participant has rested in the supine position for at least 10 minutes.

[0231] At each time point where three consecutive ECGs are required, three separate ECG tracings must be obtained as closely as possible in succession, with no more than two minutes between each.

[0232] 8.2.3.1 Safety Review of 12-Lead ECG All recorded ECGs will be reviewed by the investigator or medically qualified designee. If a participant exhibits an abnormal ECG, additional safety recording may be conducted and the abnormality will be followed and resolved.

[0233] 8.2.4 Laboratory Evaluation See Table 13 for a list of laboratory tests to be performed and the SoA (Section 1.3) for timing and frequency. Laboratory evaluations will be performed by a central laboratory unless otherwise specified.

[0234] The investigator must review laboratory reports, document this review, and record any clinically relevant changes that occurred during the study in the AE section of the eCRF. Laboratory reports must be submitted with source documentation. Clinically significant abnormal laboratory findings are those not related to an underlying disease unless the investigator determines that the findings are more severe than would be expected for the participant's condition.

[0235] All laboratory tests with values ​​considered clinically significant abnormal during study participation should be repeated until the values ​​return to normal or baseline or are no longer considered clinically significant by the investigator or medical monitor. If such values ​​do not return to normal / baseline within a period deemed reasonable by the investigator, the cause should be identified and the investigator notified. All protocol-required clinical laboratory evaluations must be performed in accordance with the laboratory manual and SoA.

[0236] If a laboratory value from a non-protocol clinical laboratory assessment performed at the site's local laboratory requires a change in participant management or is deemed clinically significant by the investigator (e.g., an SAE or AE or dose modification), the result must be recorded on the eCRF.

[0237] 8.2.5 Laboratory Evaluation of Clinical Safety 8.2.5.1 Viral serology Blood samples collected at screening will be analyzed for HIV-1, HIV-2, HbsAg, anti-HBc (anti-HBc IgG+IgM if IgG positive), and HCV antibody titers.

[0238] 8.2.6 Injection site assessment Subcutaneous injection site evaluations will be performed at the time points specified in the SoA (section 1.3). Injection site reactions will be recorded as AEs unless deemed clinically significant.

[0239] 8.2.7 Injection-related reactions Infusion-related reactions were defined as systemic AEs (e.g., fever, chills, flushing, changes in heart rate and blood pressure, dyspnea, nausea, vomiting, diarrhea, and generalized skin rash) occurring during or within 24 hours of the start of the SC injection that were assessed by the investigator as related to the study drug.

[0240] 8.2.8 Vaccines and Prophylactic Antibiotics To reduce the risk of N. meningitidis infection associated with complement inhibition, participants will receive: 1. Patients will receive MCV4 and serogroup B meningococcal vaccines, if available, at least 14 days prior to administration if they have not yet been vaccinated within 3 years prior to the first dose (or according to national / regional guidelines). 2. Patients will be treated with prophylactic antibiotics at the investigator's discretion. Patients should be vaccinated against other pathogens (e.g., Haemophilus influenzae, Streptococcus pneumoniae) according to current national / regional guidelines.

[0241] 8.3 Adverse Events and Serious Adverse Events All AEs will be reported by the participant (or, where appropriate, by the caregiver, proxy, or legally authorized representative of the participant) to the investigator or medically qualified designee.

[0242] The investigator and any medically qualified designee will be responsible for detecting, documenting, and recording events that meet the definition of an AE or SAE, and for the follow-up of AEs that are serious, considered related to the study intervention or study treatment, or that cause the participant to discontinue the study intervention (see Section 7).

[0243] 8.3.1 Duration and Frequency for Collecting AE and SAE Information All AEs and SAEs will be collected from the time the ICF is signed until the last follow-up visit. All SAEs will be recorded and reported to the investigator or designee immediately, and under no circumstances should this exceed 24 hours. The investigator will provide updated SAE data to the investigator within 24 hours of the date the investigational site becomes aware of the event.

[0244] Investigators are under no obligation to proactively seek AE or SAE data after study participation has ended. However, if the investigator learns of any SAE, including death, at any time after a participant has been discharged from the study and believes the event is reasonably related to the study intervention or study participation, the investigator must promptly notify the study personnel.

[0245] 8.3.2 Methods for detecting AEs and SAEs Care should be taken to avoid introducing bias in detecting AEs and / or SAEs. Open-ended, non-leading verbal questioning of participants is the preferred method for inquiring about the occurrence of AEs.

[0246] 8.3.3 Follow-up of AEs and SAEs After the first AE / SAE report, investigators are expected to actively follow up with each participant at subsequent visits / contacts. All SAEs will be followed up until recovery, stabilization, the event is otherwise explained, or the participant is lost to follow-up (as defined in Section 7.4).

[0247] 8.3.4 Regulatory Reporting Requirements for SAEs Prompt notification of SAEs from investigator to investigator is essential to ensure that legal and ethical obligations for the safety of participants and the safety of the investigational intervention under clinical investigation are met.

[0248] The investigator has the legal responsibility to inform both local and other regulatory authorities about the safety of the investigational intervention under clinical investigation. The investigator will comply with country-specific regulatory requirements regarding safety reporting to regulatory authorities, Institutional Review Boards (IRBs) / IECs, and investigators.

[0249] Any suspected unexpected serious adverse reactions must be reported in accordance with local regulatory requirements and forwarded to the investigator as appropriate.

[0250] Upon receiving an Investigator Safety Report from the Investigator describing the SAE or other specific safety information (e.g., a summary or list of SAEs), the Investigator will review and then submit it with the IB and notify the IRB / IEC, if appropriate, according to local requirements.

[0251] 8.4 Treatment of Overdose In this study, any dose of study intervention drug above the protocol-specified dose will be considered an overdose. There is no specific treatment or antidote for an overdose.

[0252] An overdose is a medication error that is not considered an AE unless there is an adverse medical event attributable to the overdose.

[0253] In the event of an overdose or suspected overdose, the investigator should: 1. Immediately contact the medical monitor. 2. Closely monitor participants for any AEs / SAEs. 3. Obtain samples for PK / PD analysis if requested by the medical monitor (determined on a case-by-case basis). 4. Document the amount and duration of the overdose on the eCRF.

[0254] Decisions regarding dose interruptions or changes will be made by the investigator in consultation with the medical monitor based on the participant's clinical evaluation.

[0255] 8.5 Pharmacokinetics Whole blood samples will be collected for measurement of serum concentrations of the fusion polypeptides described herein, as specified in the SoA (Section 1.3). Additional samples may be collected at additional time points during the study if agreement with the investigator is warranted and obtained. The total blood volume will not exceed participant volume limits per national / regional guidelines. To ensure adequate monitoring, the timing of sampling may be altered during the course of the study based on newly available data (e.g., to obtain data closer to the time of peak serum concentration). Instructions for collection and handling of biological specimens will be provided by the investigator. The actual date and time (24-hour clock) of each specimen will be recorded. Samples are used to assess the PK of the fusion polypeptides described herein. Serum concentrations of samples collected for analysis of the fusion polypeptides described herein may also be used to assess safety or efficacy aspects related to concerns that arise during or after the study. The samples may be used in research to develop methods, assays, prognoses and / or companion diagnostics related to dysregulated complement activity.

[0256] 8.6 Pharmacodynamics Whole blood samples will be collected for measurement of serum total and free properdin concentrations, CAP activity, and other potential measures of complement activation as specified in the SoA (Section 1.3). Additional samples may be collected at additional time points during the study if agreement with the investigator is warranted and consent is received from the study participant. The total blood volume will not exceed the participant's blood volume limit per national / regional guidelines. To ensure adequate monitoring, the timing of sampling may be modified during the course of the study based on newly available data (e.g., to obtain data closer to the time of peak plasma concentrations).

[0257] Instructions for collection and handling of biospecimens will be provided by the investigator. The actual date and time (24-hour clock) of each sample will be recorded.

[0258] Samples are used to evaluate the PD of the fusion polypeptides described herein. Sample concentrations collected for analysis of the fusion polypeptides described herein can also be used to evaluate safety or efficacy aspects related to concerns that arise during or after the test. Unused samples can be retained for up to 25 years for additional evaluation, if necessary.

[0259] 8.7 Genetics Genetics will not be assessed in this study.

[0260] 8.8 Biomarkers Collection of samples for biomarker studies (e.g., exploratory) is also part of this study.

[0261] The following samples are required for the biomarker study and will be collected from all participants in this study as specified in the SoA (Section 1.3): ·blood ·urine Samples are taken for testing which may include, but are not limited to, markers of complement dysregulation, inflammation, and endothelial activation / damage.

[0262] 8.9 Immunogenicity Assessment Antibodies against the fusion polypeptide (ADA) will be assessed in whole blood samples collected from all participants according to the SoA (section 1.3).

[0263] Serum samples are screened for ADA. If the screen is positive, the sample is analyzed using a confirmatory ADA assay and the titer of the confirmed positive sample is reported. Detection and characterization of antibodies against the fusion polypeptides described herein is performed by or under the supervision of the investigator using a validated assay. If deemed necessary, samples may be further characterized (as an exploratory analysis) to determine the titer and the presence of neutralizing antibodies.

[0264] Record the actual date and time (24-hour clock) for each sample. Samples may be stored for up to 25 years for additional safety evaluation, if needed.

[0265] Detailed instructions regarding procedures for collecting, processing, storing, and transporting serum samples for immunogenicity analysis are provided in the laboratory manual.

[0266] 9.Statistical considerations 9.1 Statistical Hypothesis Not applicable.

[0267] 9.2 Sample size determination Twelve participants will be enrolled in each of Cohorts 1 and 2. Patients with stable SCD are unlikely to experience changes in hemoglobin levels. Sample size will be determined based on the target change from baseline in hemoglobin, at the lower limit of a two-sided 95% confidence interval, to exclude 0 g / dL. Assuming a standard deviation of 1 g / dL, a sample size of 12 participants will provide 88% power to detect a change from baseline of 1 g / dL at a two-sided significance level of 0.05. In optional Cohort 3, six participants will be enrolled, and the exposure / response relationship of the fusion polypeptides described herein will be defined by combining data from Cohorts 1, 2, and 3 using PK / PD modeling techniques. The sample size for Cohort 3 will not be determined for power purposes.

[0268] 9.3 Populations for Analysis For the purposes of analysis, the following populations are defined:

[0269] [Table 16]

[0270] 9.4 Statistical analysis Generally, descriptive statistics for continuous variables include the number of non-missing values, arithmetic mean, standard deviation, median, minimum, and maximum. Descriptive statistics for PK parameters include the number of observations, arithmetic mean, standard deviation, arithmetic coefficient of variation (%CV), median, minimum, maximum, geometric mean, and geometric %CV. Categorical variables are summarized by cohort and time point using percentages and frequency counts.

[0271] The SAP will be developed and finalized prior to the initial data cutoff / database lock and will further describe the participant populations to be included in the analysis and the procedures to account for missing, unused, and spurious data, as appropriate. This section outlines the planned statistical analyses of the primary and secondary endpoints.

[0272] 9.4.1 Efficacy Analysis 9.4.1.1 Changes in complement biomarkers Absolute and percent change from baseline in complement biomarkers (e.g., Ba, C3a, and sC5B9) will be assessed at the end of treatment (12 weeks) for Cohorts 1 and 2. Additional details are provided in the SAP.

[0273] 9.4.1.2 Changes in hemoglobin Absolute and percent change from baseline in hemoglobin will be assessed at the end of treatment (12 weeks) for Cohorts 1 and 2. Additional details are provided in the SAP.

[0274] 9.4.1.3 Time to hemoglobin response Hemoglobin response is defined as an increase in hemoglobin level of >1 g / dL from baseline. Hemoglobin response will be assessed at the end of treatment (12 weeks) for Cohorts 1 and 2. Additional details are provided in the SAP.

[0275] 9.4.1.4 Markers of hemolysis Absolute and percent changes from baseline in markers of hemolysis (serum LDH level, absolute reticulocyte count, serum indirect bilirubin, serum haptoglobin, and hemopexin) will be assessed at the end of treatment (12 weeks) in Cohorts 1 and 2. Additional details are provided in the SAP.

[0276] 9.4.1.5 Exploratory Analysis of Biomarker Changes Associated with VOCs Biomarkers associated with VOCs may be assessed after treatment completion (12 weeks for Cohorts 1 and 2). Additional details are provided in the SAP.

[0277] 9.4.2 Exploratory assessment of VOCs A sickle cell disease-associated pain crisis (VOC) is defined as an acute episode of pain without a medically determined cause other than the VOC event that results in treatment with oral or parenteral narcotics or parenteral nonsteroidal anti-inflammatory drugs and a medical facility visit. An uncomplicated VOC is defined as the absence of any other SCD complications occurring during the VOC episode. A complicated VOC is defined as any other SCD complication diagnosed during the VOC episode. Acute chest syndrome, focal hepatic necrosis, splenic blood cell storage, and priapism are considered VOC events in this study. Complicated VOC will also be reported as an AE. When possible, the following may also be assessed: Number of VOCs that lead to medical visits Number of uncomplicated VOCs, acute chest syndrome, focal liver necrosis, splenic blood cell storage, and priapism Time to first VOC after first dose of study drug

[0278] 9.4.3 Safety analysis The primary endpoints for the study are safety and tolerability.

[0279] All safety analyses will be performed on the safety analysis set and reported by cohort.

[0280] Safety analyses will include descriptive analysis of all TEAEs, ECGs, clinical laboratory data, physical examinations, and vital sign measurements. No inferential statistical analyses are planned for the safety parameters of this study. The prevalence of AEs and SAEs will be summarized by SOC and preferred term for each cohort and treatment group and overall within each treatment group and by relationship to study drug. AEs will be summarized by cohort and treatment group and overall within each treatment group and by severity. SAEs and AEs resulting in withdrawal from the study will be listed. Participants with multiple AEs within a category (e.g., overall, SOC, preferred term) will be counted once in that category. For severity tables, the participant's most severe event within the category will be counted.

[0281] Changes from baseline in vital sign measurements and clinical laboratory assessments (e.g., clinical chemistry, differential white blood cell count, and urinalysis) will be summarized by each cohort and overall. Laboratory parameter values ​​will be graded according to the Common Terminology Criteria for Adverse Events (CTCAE, v5.0, published November 27, 2017). Shift tables will be generated for these laboratory parameters by cohort and treatment group. These tables will summarize the number of participants at each baseline grade compared to the reference range and the change to the worst grade assessed post-dose during the study.

[0282] All concomitant medications will be coded using the World Health Organization Drug Dictionary, and the frequency and percentage of concomitant medications will be compiled.

[0283] 9.4.3.1 ECG analysis Cardiac assessments will be performed in the safety analysis set.

[0284] ECG parameters, including heart rate, PR, RR, QRS, QT, and QTcF intervals, will be measured at designated time points. The mean of three consecutive ECG readings at each collection time point will be calculated, and changes from pretreatment baseline values ​​will be assessed for each cohort and treatment group.

[0285] An outlier analysis will be performed by cohort and treatment group summarizing the absolute number, frequency, and percentage of participants who meet any of the following outlier criteria at each visit: QT and QTcF intervals >450 ms QT, QTcF interval > 480 ms QT, QTcF interval >500 ms QT and QTcF intervals increase by >30 ms from baseline QT and QTcF intervals increase by >60 ms from baseline Analysis of drug-related QT / QTc interval changes relative to plasma PK concentrations can be performed for all dosing regimens. The principle of this analysis follows the statistical method described by Garnett et al. (Garnett, 2018).

[0286] Detailed analysis is specified in the SAP or a separate ECG analysis plan.

[0287] 9.4.4 Other analyses 9.4.1.1 Pharmacokinetic Analysis All PK analyses will be performed on the PK analysis population and reported by cohort.

[0288] Individual serum concentration data from patients receiving SC administration of the fusion polypeptides described herein, along with actual sampling dates and times, will be used to characterize the PK using population PK analysis techniques, details of which are provided in the SAP.

[0289] 9.4.1.2 Pharmacodynamic analysis All PD analyses will be performed on the PD analysis population and reported by cohort.

[0290] The PD effects of all SC administrations of the fusion polypeptides described herein will be assessed by assessing changes in serum total and free properdin concentrations and CAP activity using the Weislab AP assay. Additionally, exploratory assessment of other measures of properdin activity over time may be deemed appropriate.

[0291] 9.4.1.3 Immunogenicity analysis For the assessment of immunogenicity, the incidence of confirmed positive ADA will be summarized. Additionally, after confirmation of a positive ADA, samples will be evaluated for ADA titer and the presence of neutralizing antibodies (if available).

[0292] 9.4.1.4 Exploratory analysis Additional exploratory analyses of biomarker assays and clinical efficacy endpoints may be conducted. Details of these analyses are provided in the SAP.

[0293] 9.5 Interim Analysis Interim analyses may be performed after at least 12 patients from Cohorts 1 and 2 (6 from each cohort) have enrolled and completed the treatment period to inform subsequent phases of the study. Interim analyses will include safety, efficacy, PK / PD, and immunogenicity data. Details of these analyses are provided in the SAP.

[0294] 10. Clinical Testing Clinical laboratory tests required in the protocols detailed in Table 13 will be performed by a central laboratory unless otherwise specified.

[0295] [Table 13-1]

[0296] [Table 13-2]

[0297] A list of abbreviations and their descriptions is provided in Table 14.

[0298] [Table 14-1]

[0299] [Table 14-2]

[0300] Example 2. Safety, tolerability, pharmacokinetics, pharmacodynamics, and immunogenicity of anti-properdin / anti-serum albumin bispecific single variable domain antibodies in healthy adults: Results of a Phase 1 study This randomized, double-blind, placebo-controlled study evaluated the safety, tolerability, pharmacokinetics (PK), pharmacodynamics (PD), and immunogenicity of subcutaneous (SC) and intravenous (IV) administration of a fusion polypeptide having the amino acid sequence of SEQ ID NO: 1 or its modifications in healthy adults.

[0301] In this Phase I first-in-human (FIH) study, healthy volunteers aged 18-65 years were randomized (3:1) to receive either the fusion polypeptide or placebo. The fusion polypeptide was administered SC in single and multiple ascending doses and IV as a single dose. Ten dosing cohorts were planned (Figure 2). Because the expected complete inhibition of complement AP was >70 days, two cohorts did not begin enrollment. Due to the potentially increased risk of Neisseria meningitidis infection with properdin inhibition, vaccination was required before receiving the fusion polypeptide described herein, and participants continued antibiotic therapy throughout the treatment period.

[0302] Sixty participants were randomized (fusion polypeptide, n=45; placebo, n=15). Cohorts 1, 3, 4, and 5 had five participants (each) treated with fusion polypeptide; cohorts 2, 6, and 9 had six participants treated with fusion polypeptide; and cohort 8 had seven participants treated with fusion polypeptide. Demographic and baseline characteristics were similar between the fusion polypeptide and placebo groups. Four participants discontinued the study: one was lost to follow-up, one after use of a prohibited substance, and two withdrew consent (one after an adverse event [AE] on placebo). There were no discontinuations due to AEs in participants exposed to fusion polypeptide. The majority of treatment-emergent AEs (TEAEs) were mild and assessed as unrelated to study treatment. There were no serious AEs, serious infectious events, or deaths. TEAE incidence was similar between cohorts. Treatment-related TEAEs occurred more frequently in the fusion polypeptide than in the placebo group (11 [24.4%] vs. 2 [13.3%]); the most common treatment-related TEAEs with the fusion polypeptide were nausea (n = 2), headache (n = 2), and infusion site erythema (n = 2). No N. meningitidis infections were reported.

[0303] Dose proportionality was observed in all single-dose cohorts except for the 50 mg dose. Geometric mean accumulation ratio, R Cmax and R AUCThe mean absolute bioavailability of the SC-administered fusion polypeptide was approximately 2.8 and 3, respectively. The mean absolute bioavailability of the SC-administered fusion polypeptide was 94%. Alternative complement pathway (AP) activity decreased immediately after administration of the fusion polypeptide (Figure 3). As the dose increased, the duration of complete AP blockade (<1% of baseline) increased; in cohorts 4, 5, and 6, complete AP inhibition persisted for >30 days. In all single-dose cohorts, the mean % AP hemolysis returned to baseline by the end of the observation period. In the multiple-dose cohorts, complete inhibition of AP activity was observed for 70 and 84 days (cohorts 8 and 9, respectively). There were no changes in classical pathway (CP) and lectin pathway (LP) activity.

[0304] Four participants had pre-existing immune reactivity at baseline, but none was treatment-induced. Treatment-emergent anti-drug antibodies (ADAs) occurred in 20%, 40%, 100%, and 83.3% of participants in the 150 mg SC, 450 mg IV, and 1200 mg SC groups, respectively; most were low titer and did not affect PK. In the multiple-dose cohorts (Cohorts 8 and 9), 71.4% and 100%, respectively, developed ADAs, most of which were low titer and transient in duration.

[0305] In this FIH study in healthy participants, the fusion polypeptides described herein were well tolerated without any unexpected safety concerns. Complement AP inhibition by the fusion polypeptides described herein was rapid and complete, and CP and LP were unaffected.

[0306] Other embodiments While the foregoing invention has been described in detail by way of illustration and example for purposes of clarity of understanding, the descriptions and examples should not be construed as limiting the scope of the invention. The disclosures of all patent and scientific literature cited herein are expressly incorporated by reference in their entireties.

Claims

1. A method for treating a human patient with sickle cell disease, comprising administering to the patient a properdin-binding antibody or antigen-binding fragment thereof, wherein the properdin-binding antibody or antigen-binding fragment thereof comprises the CDR1, CDR2 and CDR3 sequences set forth in SEQ ID NOs: 2, 3 and 4, respectively.

2. The method of claim 1 , wherein the antibody or antigen-binding fragment thereof further comprises a human serum albumin binding sequence.

3. The method of claim 2, wherein the human serum albumin binding sequence is fused to the C-terminus of the properdin-binding antibody or antigen-binding fragment thereof.

4. The method of claim 3, wherein the human serum albumin binding sequence is fused to the C-terminus of the properdin-binding antibody or antigen-binding fragment thereof via a linker.

5. The method of claim 4, wherein the linker comprises the amino acid sequence of SEQ ID NO:

10.

6. The method of any one of claims 2 to 5, wherein the human serum albumin binding sequence comprises the CDR1, CDR2 and CDR3 sequences set forth in SEQ ID NOs: 5, 6 and 7.

7. The method of any one of claims 1 to 6, wherein the antibody or antigen-binding fragment thereof comprises the sequence of SEQ ID NO: 1 or a modification thereof.

8. 8. The method of claim 7, wherein the modification comprises converting the N-terminal glutamine of the sequence of SEQ ID NO: 1 to pyroglutamic acid.

9. The method of any one of claims 1 to 8, wherein the antibody or antigen-binding fragment thereof is administered to the patient at a dose of 300 mg.

10. 10. The method of claim 9, wherein the antibody or antigen-binding fragment thereof is administered to the patient weekly.

11. 11. The method of claim 9 or 10, wherein the antibody or antigen-binding fragment thereof is administered to the patient for up to 12 weeks.

12. 10. The method of claim 9, wherein the antibody or antigen-binding fragment thereof is administered to the patient once every two weeks.

13. 13. The method of claim 12, wherein the antibody or antigen-binding fragment thereof is administered up to four times.

14. The method of any one of claims 1 to 8, wherein the antibody or antigen-binding fragment thereof is administered to the patient at a dose of 600 mg.

15. 15. The method of claim 14, wherein the antibody or antigen-binding fragment thereof is administered to the patient every four weeks.

16. 16. The method of claim 14 or 15, wherein the antibody or antigen-binding fragment thereof is administered to the patient up to four times.

17. 1. A method of treating a human patient with sickle cell disease, comprising administering to the patient a properdin-binding antibody or antigen-binding fragment thereof, wherein the properdin-binding antibody or antigen-binding fragment thereof comprises the sequence of SEQ ID NO: 1 or a modification thereof, and wherein the antibody or antigen-binding fragment thereof is administered to the patient at a dose of 300 mg weekly for up to 12 weeks.

18. A method of treating a human patient with sickle cell disease, comprising administering to the patient a properdin-binding antibody or antigen-binding fragment thereof, wherein the properdin-binding antibody or antigen-binding fragment thereof comprises the sequence of SEQ ID NO: 1 or a modification thereof, and wherein the antibody or antigen-binding fragment thereof is administered to the patient at a dose of 300 mg every two weeks for up to four doses.

19. A method of treating a human patient with sickle cell disease, comprising administering to the patient a properdin-binding antibody or antigen-binding fragment thereof, wherein the properdin-binding antibody or antigen-binding fragment thereof comprises the sequence of SEQ ID NO: 1 or a modification thereof, and wherein the antibody or antigen-binding fragment thereof is administered to the patient at a dose of 600 mg every four weeks for up to four doses.

20. 20. The method according to any one of claims 17 to 19, wherein the modification comprises converting the N-terminal glutamine of the sequence SEQ ID NO: 1 to pyroglutamic acid.

21. 21. The method of any one of claims 1 to 20, wherein the patient is clinically diagnosed as having sickle cell disease.

22. The sickle cell disease is HbSS or HbSβ ０ - thalassemia.

23. 23. The method of any one of claims 1 to 22, wherein the patient is further administered hydroxyurea.

24. 24. The method of claim 23, wherein the patient is receiving a stable dose of hydroxyurea for at least three months prior to administration of the antibody or antigen-binding fragment thereof.

25. 23. The method of any one of claims 1 to 22, wherein the patient has not received hydroxyurea for at least 30 days prior to administration of the antibody or antigen-binding fragment thereof.

26. 26. The method of any one of claims 1-25, wherein the patient does not experience a treatment-emergent adverse event after 12 weeks of treatment.

27. 27. The method of any one of claims 1 to 26, wherein the patient experiences no serious adverse events after 12 weeks of treatment.

28. 27. The method of any one of claims 1 to 26, wherein the patient experiences no adverse events after 12 weeks of treatment.

29. 29. The method of any one of claims 1 to 28, further comprising measuring changes in serum concentrations of the antibody or antigen-binding fragment thereof for up to 30 weeks after initiation of treatment.

30. 30. The method of any one of claims 1 to 29, further comprising measuring changes in blood levels of anti-drug antibodies for up to 30 weeks after initiation of treatment.

31. 31. The method of any one of claims 1 to 30, wherein the patient experiences a change from baseline in serum concentrations of total and free properdin after up to 30 weeks of treatment.

32. 32. The method of any one of claims 1-31, wherein the patient experiences a change from baseline in serum concentrations of complement component Ba (Ba), complement component C3a (C3a), or soluble complement component C5B-9 (sC5B9) after 12 weeks of treatment.

33. 33. The method of any one of claims 1-32, wherein the patient experiences a change from baseline in blood or serum levels of hemopexin, nitric oxide, a marker of inflammation, or a marker of cell adhesion after 12 weeks of treatment.

34. 34. The method of claim 33, wherein the inflammatory marker comprises interleukin-1.

35. The method of claim 33 or 34, wherein the cell adhesion marker comprises soluble P-selectin.

36. 31. The method of any one of claims 1-30, wherein the patient experiences a change from baseline in hemoglobin levels after 12 weeks of treatment.

37. 37. The method of any one of claims 1 to 36, wherein the patient experiences a change from baseline in serum LDH levels, indirect bilirubin, haptoglobin, or hemopexin after 12 weeks.

38. 38. The method of any one of claims 1-37, wherein the patient experiences a change from baseline in reticulocyte levels after 12 weeks.

39. 39. The method of any one of claims 1 to 38, wherein the patient experiences a reduction in the rate of vascular occlusive episodes after 12 weeks of treatment compared to baseline.

40. 40. The method of any one of claims 1 to 39, wherein the patient experiences an increase in time to first vascular occlusive event after 12 weeks of treatment compared to baseline.

41. 41. The method of any one of claims 1 to 40, wherein the antibody or antigen-binding fragment thereof is formulated for subcutaneous administration.

42. 42. The method of any one of claims 1 to 41, wherein the antibody or antigen-binding fragment thereof is formulated at a concentration of 150 mg / mL in an aqueous solution comprising 20 nM sodium acetate, 250 mM sucrose, and 0.05% polysorbate-80 at a pH of 5.

4.

43. The method of any one of claims 1 to 42, wherein the human patient is aged between 18 and 65 years.

44. 44. The method of any one of claims 1 to 43, wherein the human patient has a body weight of ≥ 40 kg.

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