Bispecific antibodies for use in the treatment of patients with XIAP deficiency or CDC42 mutations.

Abstract

The present invention relates to a bivalent, bispecific monoclonal antibody (bbmAb) or a variant thereof for use in treating or alleviating symptoms of autoinflammatory or disease-related conditions in subjects requiring such treatment or elimination of CDC42 mutations or XIAP deficiency.

Description

[Technical Field]

[0001] The present invention relates to treatment with a bivalent, bispecific monoclonal antibody for use in treating autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutation in patients requiring such treatment. The disclosure also relates to methods and treatment schemes for treating autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutation by using a bispecific antibody that simultaneously targets both IL-1β and IL-18. In some cases, for example, bbmAb (or its variants) may be used to treat subjects who have mutations in the gene encoding the XIAP gene or the CDC43 gene, and who suffer from, for example, hypogammaglobulinemia, cytopenia, inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, hemophagocytic lymphohistiocytosis, neonatal-onset cytopenia, syndromeal forms of thrombocytopenia, megathrombocytopenic thrombocytopenia, hematopoietic disorders, autoinflammation, symptomatic immunodeficiency, or recurrent hemophagocytic lymphohistiocytosis (HLH), autoinflammation with infantile enteritis (AIFEC), or macrophage activation syndrome (MAS). [Background technology]

[0002] Inflammasomes are intracellular multiprotein complexes that are typically formed and activated in response to pathogen- or danger-associated molecular patterns (PAMP / DAMP). Inflammasome diseases are a group of mechanistically related disorders resulting from the hyperactivation of individual inflammasomes, leading to differentiated clinical phenotypes that depend on the effector cytokines produced and their tissue-specific expression. X-linked inhibitor of apoptosis (XIAP) deficiency, also known as X-linked lymphoproliferative syndrome type 2 (XLP2), is an autoinflammatory or inflammasome disease characterized by hyperinflammation and adaptive immunodeficiency with immunodysregulation (Geerlinks et al., Journal of Clinical Immunology (2022) 42:901-903). XIAP deficiency, first described in 2006, is caused by pathogenic variants of the XIAP / BIRC4 gene (identifiers for the XIAP gene: HGNC:592; NCBI Gene:331; Ensembl:ENSG00000101966; OMIM(registered trademark):300079; UniProtKB / Swiss-Prot:P98170) and results in multiple clinical manifestations, most commonly hemophagocytic lymphohistiocytosis (HLH), inflammatory bowel disease, and splenomegaly.

[0003] Cell division cycle 42 (CDC42) (identifier for the CDC42 gene: HGNC:1736 NCBI Gene:998 Ensembl:ENSG00000070831 OMIM(registered trademark):116952 UniProtKB / Swiss-Prot:P60953) is an intracellular member of Ras homology (Rho) GTPases that regulate cell polarity by modulating the assembly of actin cytoskeleton structures. From an immunological perspective, CDC42 regulates several cellular processes, including migration, immunological synapse formation, and polarization cytokine secretion. CDC42 also plays an important role in cell proliferation and hematopoiesis (Miyazawa H and Wada T (2022) Immune-mediated inflammatory diseases with chronic excess of serum interleukin-18. Front.Immunol.13:930141).

[0004] Patients with XIAP deficiency or CDC42 mutation-related autoinflammatory diseases generally have significantly elevated levels of IL-1β and / or IL-18. These elevated effector cytokines cause the associated clinical symptoms described above, which are concentrated in neurogenesis, hematopoiesis, and immune responses (Takenouchi et al 2015, Asiri et al 2021, Coppola et al 2022). We believe that only the combination of an anti-IL-1 receptor (e.g., anakinra) and recombinant IL-18 binding protein (e.g., IL-18BP) has been reported to be clinically effective in a limited number of infant cases of XIAP deficiency.

[0005] There are no approved therapeutic agents that directly and specifically target potential IL-1β and IL-18-mediated autoinflammatory processes to improve the overall clinical outcomes of patients with XIAP deficiency-based autoinflammatory or disease-related or CDC42 mutation-based autoinflammatory or disease-related conditions. Therefore, there is a long-awaited and unmet need in the art for improved treatments for XIAP deficiency or CDC42 mutation-based autoinflammatory or disease-related or inflammasome diseases. [Overview of the project]

[0006] This document describes bispecific antibodies or functional fragments thereof that simultaneously target both IL-1β and IL-18 for use in the prevention or treatment of autoinflammatory or disease or inflammasome disease based on XIAP deficiency or CDC42 mutations in the subject. In some cases, bispecific antibodies or functional fragments thereof that simultaneously target both IL-1β and IL-18 are intended for use in the treatment of subjects who are XIAP deficiency or harbor CDC42 mutations, or who exhibit or suffer from the clinical manifestations of, or are suffering from, hypogammaglobulinemia, cytopenia, inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, hemophagocytic lymphohistiocytosis, neonatal-onset cytopenia, syndromes of thrombocytopenia, megathrombocytopenic thrombocytopenia, hematopoietic disorders, autoinflammatory disease, symptomatic immunodeficiency, or recurrent hemophagocytic lymphohistiocytosis (HLH). In some cases, use for the prevention or treatment of autoinflammatory or disease based on XIAP deficiency or CDC42 mutation in subjects exhibiting clinical symptoms of autoinflammatory or macrophage activation syndrome with infantile enteritis (AIFEC) by simultaneously administering a therapeutically effective dose of a bispecific antibody that simultaneously targets both IL-1β and IL-18. Methods for preventing or treating autoinflammatory or disease based on XIAP deficiency or CDC42 mutation by administering a therapeutically effective dose of a bispecific antibody that simultaneously targets both IL-1β and IL-18 to subjects in need thereof are also described herein. In some cases, this method includes the treatment of autoinflammatory or macrophage activation syndrome (MAS) with infantile enteritis (AIFEC) in subjects exhibiting clinical symptoms of disease who are XIAP deficiency or harbor a CDC42 mutation, by administering a therapeutically effective dose of a bispecific antibody that simultaneously targets both IL-1β and IL-18.

[0007] Specific dosing regimens for the methods described herein, or for the use of bispecific antibodies (e.g., bbmAb) that simultaneously target both IL-1β and IL-18, are further provided herein. In one embodiment, the method or treatment of the above use of bispecific antibodies that simultaneously target both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations, comprises administering about 1 mg / kg to about 35 mg / kg of the bispecific antibody to a subject requiring it. In another embodiment, about 10 mg / kg of the bispecific antibody is administered to the subject, and the bispecific antibody is administered intravenously or subcutaneously. In a different embodiment, 10 mg / kg of bispecific antibodies that simultaneously target both IL-1β and IL-18 is administered intravenously, and the antibody is optionally administered every other week. In another embodiment, the dose of bispecific IL-1β and IL-18 antibodies administered is about 50 mg to about 900 mg, administered subcutaneously.

[0008] In addition, embodiments further described herein relate to combinations of pharmaceuticals and pharmaceutical compositions for use in the treatment or prevention of autoinflammatory or disease-related conditions, such as inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, hemophagocytic lymphohistiocytosis, neonatal cytopenia, autoinflammatory disease, recurrent hemophagocytic lymphohistiocytosis (HLH), AIFEC, or macrophage activation syndrome (MAS), for use in the treatment of inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, hemophagocytic lymphohistiocytosis, neonatal cytopenia, autoinflammatory disease, recurrent hemophagocytic lymphohistiocytosis (HLH), AIFEC, or macrophage activation syndrome (MAS), comprising a bispecific antibody (e.g., bbmAb) that simultaneously targets both IL-1β and IL-18 in the presence of an optionally pharmaceutically acceptable carrier. Further features and advantages of the described methods and uses will become apparent from the detailed description below.

[0009] In a first aspect, the present disclosure relates to a method for treating or preventing symptoms of autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutation, the method comprising administering a therapeutically effective amount of a bispecific antibody to the subject, the antibody being a. A first portion of immunoglobulin having a first variable light chain (VL1) and a first variable heavy chain (VH1) that specifically bind to IL1β, and a first constant heavy chain (CH1) having heterodimerization modification, and b. The immunoglobulin comprises a second portion having a second variable light chain (VL2) and a second variable heavy chain (VH2) that specifically bind to IL-18, and a second steady heavy chain (CH2) having a heterodimerization modification complementary to the heterodimerization modification of the first steady heavy chain.

[0010] In a second aspect, the disclosure relates to a method for delaying, cessating, or reducing the severity of symptoms of autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutation in subjects requiring such treatment, the method comprising administering a therapeutically effective amount of a bispecific antibody to the subject, the antibody being a. A first portion of immunoglobulin having a first variable light chain (VL1) and a first variable heavy chain (VH1) that specifically bind to IL1β, and a first constant heavy chain (CH1) having heterodimerization modification, and b. The immunoglobulin comprises a second portion having a second variable light chain (VL2) and a second variable heavy chain (VH2) that specifically bind to IL-18, and a second steady heavy chain (CH2) having a heterodimerization modification complementary to the heterodimerization modification of the first steady heavy chain.

[0011] In a third aspect, the disclosure relates to a bispecific antibody for use in treating or preventing autoinflammatory or disease-related conditions such as XIAP deficiency or CDC42 mutation in subjects requiring such treatment, wherein the bispecific antibody is a. A first portion of immunoglobulin having a first variable light chain (VL1) and a first variable heavy chain (VH1) that specifically bind to IL1β, and a first constant heavy chain (CH1) having heterodimerization modification, and b. The immunoglobulin comprises a second portion having a second variable light chain (VL2) and a second variable heavy chain (VH2) that specifically bind to IL-18, and a second steady heavy chain (CH2) having a heterodimerization modification complementary to the heterodimerization modification of the first steady heavy chain.

[0012] In a fourth aspect, the disclosure relates to the methods and treatments of the first, second, and third aspects, in which a bispecific antibody targeting both IL-1β and IL-18 simultaneously is administered to the patient at a dose of approximately 1 mg / kg to approximately 35 mg / kg. In a preferred embodiment of the fourth aspect, approximately 10 mg / kg of the bispecific antibody is administered to the subject being treated.

[0013] In one aspect of this disclosure, a bispecific antibody that simultaneously targets both IL-1β and IL-18 is administered intravenously or subcutaneously to a subject.

[0014] In a more preferred embodiment, a bispecific antibody that simultaneously targets both IL-1β and IL-18 is administered intravenously to the subject being treated at a dose of approximately 10 mg / kg.

[0015] In one embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient only once on day 1. In another embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient on days 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and / or 14. In a further embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient on days 1 and 14. In a further embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks. In one embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for a period of up to 28 weeks. In another embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for a period of up to 24 weeks.

[0016] In one embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for a period of up to three years. In another embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for two weeks. In yet another embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for eight weeks. In yet another embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for fourteen weeks. In yet another embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for twenty-four weeks. In one embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for at least two weeks. In another embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for at least eight weeks. In yet another embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for at least fourteen weeks. In yet another embodiment, a bispecific antibody targeting both IL-1β and IL-18 simultaneously at a dose of 10 mg / kg is administered intravenously to the patient once every two weeks for at least twenty-four weeks.

[0017] In a preferred embodiment, a bispecific antibody that simultaneously targets both IL-1β and IL-18 is administered to the patient once every two weeks, for example, intravenously, at a dose of 10 mg / kg or approximately 10 mg / kg.

[0018] In another embodiment of the foregoing aspects of the present disclosure, a bispecific antibody targeting both IL-1β and IL-18 is administered in combination with at least one further therapeutic agent.

[0019] In any particular embodiment of the aforementioned aspects of the present disclosure, the first and second constant heavy chains of the bispecific antibody are human IgA, IgD, IgE, IgG, or IgM, preferably IgD, IgE, or IgG, for example, human IgG1, IgG2, IgG3, or IgG4, preferably IgG1.

[0020] In any other embodiment of the aforementioned aspects of this disclosure, the first and second constant heavy chains of the bispecific antibody are IgG1, a. The first stationary heavy chain has a point mutation that generates a knob structure, and the second stationary heavy chain has a point mutation that generates a hole structure, or b. The first stationary heavy chain has a point mutation that generates a hole structure, and the second stationary heavy chain has a point mutation that generates a knob structure, and optionally c. The first and second constant heavy chains have mutations that result in disulfide bridges.

[0021] In particularly preferred embodiments of the first, second, and third aspects of the methods and uses described herein, the first immunoglobulin VH1 domain of the bispecific antibody is i. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 76, CDR2 has amino acid sequence number 77, and CDR3 has amino acid sequence number 78; or ii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 79, CDR2 has amino acid sequence number 80, and CDR3 has amino acid sequence number 81. Includes; The first immunoglobulin VL1 domain of the bispecific antibody is iii. Hypervariable regions CDR1, CDR2 and CDR3, wherein CDR1 has amino acid sequence number 92, CDR2 has amino acid sequence number 93, and CDR3 has amino acid sequence number 94, or iv. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 95, CDR2 has amino acid sequence number 96, and CDR3 has amino acid sequence number 97. Includes; The second immunoglobulin VH2 domain of the bispecific antibody is v. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 44, CDR2 has amino acid sequence number 45, and CDR3 has amino acid sequence number 46; or vi. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 47, CDR2 has amino acid sequence number 48, and CDR3 has amino acid sequence number 49. Includes; The second immunoglobulin VL2 domain of the bispecific antibody is vii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 60, CDR2 has amino acid sequence number 61, and CDR3 has amino acid sequence number 62, or viii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 63, CDR2 has amino acid sequence number 64, and CDR3 has amino acid sequence number 65. Includes.

[0022] In another preferred embodiment of this disclosure, the antibody used in the method / treatment according to any of the above embodiments is: a. The first immunoglobulin VH1 domain of sequence number 85 of the amino acid sequence, b. The first immunoglobulin VL1 domain of sequence number 101 of the amino acid sequence, c. The second immunoglobulin VH2 domain of sequence number 53 of the amino acid sequence and d. Contains the second immunoglobulin VL2 domain of amino acid sequence number 69.

[0023] In another preferred embodiment of this disclosure, the antibody used in the method / treatment according to any of the above embodiments is: e. The first immunoglobulin heavy chain of amino acid sequence number 87, f. The first immunoglobulin light chain of sequence number 103 of the amino acid sequence, g. The second immunoglobulin heavy chain of the amino acid sequence of SEQ ID NO: 55 and h. Contains the second immunoglobulin light chain of amino acid sequence number 71.

[0024] In another embodiment of the aforementioned aspects of this disclosure, the subject to be treated has autoinflammatory or disease-related XIAP deficiency or CDC42 mutation. In another embodiment of the aforementioned aspects of this disclosure, the subject to be treated has a loss-of-function mutation in the XIAP / BIRC4 gene encoding the XIAP protein (as disclosed herein) or a mutation in the CDC42 gene resulting in abnormal palmitoylation of the CDC42 protein or a missense mutation at the C-terminus of the CDC42 protein affecting the localization of the CDC42 protein (as disclosed herein).

[0025] In some cases, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations have excessively elevated IL-18 and IL-1β levels compared to a control population of subjects without autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations. Excessively elevated IL-18 and / or IL-1β levels refer to a situation where the patient has IL-18 and / or IL-1β levels significantly above the upper limit for healthy individuals. In some cases, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations have excessively elevated serum IL-18 and IL-1β levels compared to a control population of subjects without autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations. Excessively elevated serum IL-18 levels refer to excessively elevated serum total IL-18 levels. In some cases, excessively elevated serum IL-18 levels refer to excessively elevated serum free IL-18 levels. In some cases, subjects may have higher serum C-reactive protein (CRP) levels compared to the control population. In some cases, subjects may have higher serum ferritin levels compared to controls.

[0026] In a preferred embodiment, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutation have excessively elevated serum total IL-18 levels compared to a control population of subjects not exhibiting autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutation. In some cases, the excessively elevated serum total IL-18 level is above 1,000 pg / mL. In some cases, the excessively elevated serum total IL-18 level is above 5,000 pg / mL. In some cases, the excessively elevated serum total IL-18 level is above 10,000 pg / mL. In some cases, the excessively elevated serum total IL-18 level is between approximately 1,000 pg / mL and approximately 20,000 pg / mL. In some cases, the excessively elevated serum total IL-18 level is between approximately 5,000 pg / mL and approximately 20,000 pg / mL. In some cases, excessively elevated serum total IL-18 levels range from approximately 10,000 pg / mL to approximately 20,000 pg / mL. In some cases, excessively elevated serum total IL-18 levels range from approximately 1,000 pg / mL to approximately 25,000 pg / mL. In some cases, excessively elevated serum total IL-18 levels range from approximately 5,000 pg / mL to approximately 25,000 pg / mL. In some cases, excessively elevated serum total IL-18 levels range from approximately 10,000 pg / mL to approximately 25,000 pg / mL.

[0027] In some cases, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations have excessively elevated serum free IL-18 levels compared to a control population that does not exhibit autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations. In some cases, these excessively elevated serum free IL-18 levels exceed 5,000 pg / mL.

[0028] In some cases, excessively elevated serum IL-1β levels exceed 5 pg / mL. In some cases, excessively elevated serum IL-1β levels exceed 10 pg / mL. In some cases, excessively elevated serum IL-1β levels range from approximately 5 pg / mL to approximately 25 pg / mL. In some cases, excessively elevated serum IL-1β levels range from approximately 10 pg / mL to approximately 25 pg / mL.

[0029] In some cases, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations are under 17 years of age and weigh at least 3 kg. In some cases, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations are under 10 years of age and weigh at least 3 kg. In some cases, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations are under 5 years of age and weigh at least 3 kg. In some cases, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations are infants weighing at least 3 kg who have both infant enteritis and excessively elevated total IL-18 serum levels. In some cases, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations are infants weighing at least 3 kg who have both infant enteritis and excessively elevated free IL-18 serum levels.

[0030] In a particularly preferred embodiment of the aforementioned aspects of this disclosure, the subject to be treated has AIFEC. In a more preferred embodiment, the subject to be treated has AIFEC and an elevated total IL-18 serum level. In another embodiment, the subject to be treated has AIFEC and an elevated free IL-18 serum level.

[0031] In particularly preferred embodiments of the aforementioned aspects of this disclosure, the XIAP or CDC42 gene to be treated includes mutations such as one or more point mutations or deletions (small or large exon deletions) and insertions resulting in nonsense and missense mutations, intronic or frameshift mutations. These mutations may result in the absence, truncation, or dysfunction of functionally expressed XIAP and CDC42 proteins, respectively. A detailed overview of 90 disease-causing mutations in the XIAP gene is disclosed in Mudde et al., (2021) Evolution of Our Understanding of XIAP Deficiency. Front. Pediatr. 9:660520. The contents of Figure 1 of Mudde et al. are incorporated herein by reference. As disclosed by Martinelli and co-authors (The American Journal of Human Genetics 102,309-320, February 1, 2018), nine different gene mutations have been identified in the CDC42 gene (two amino acid substitutions affect the N-terminal α-helix (residues Ile21 and Tyr23), three involve adjacent residues within the switch II motif (Tyr64, Arg66, and Arg68), two are located on the fourth β-strand (Cys81 and Ser83), and the remaining two are localized close to the C-terminus (Ala159 and Glu171). Gernez and co-authors identified three variants affecting the C-terminus of CDC42 (p.R186C, p.C188Y, and p. * 192Cext *Regarding 24), the inflammatory and hematological phenotypes of four heterozygous patients are described (Gernez Y, de Jesus AA, Alsaleem H, Macaubas C, Roy A, Lovell D, et al. Severe autoinflammation in 4 patients with C-terminal variants in cell division control protein 42 homolog (CDC42) successfully treated with IL-1b inhibition. J Allergy Clin Immunol 2019;144:1122-5.e6).

[0032] In one embodiment, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutation have serum C-reactive protein (CRP) levels higher than 20 mg / L. In another embodiment, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutation have serum ferritin levels higher than 600 μg / L. In a more preferred embodiment, subjects requiring treatment for autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutation have serum CRP levels higher than 20 mg / L and serum ferritin levels higher than 600 μg / L.

[0033] In one embodiment of the aforementioned aspects, treatment with a bispecific antibody targeting both IL-1β and IL-18 extends the patient's lifespan compared to standard treatment. In another embodiment, treatment with a bispecific antibody targeting both IL-1β and IL-18 lowers serum CRP and / or serum ferritin levels 14 days after treatment compared to standard treatment (SoC). In yet another embodiment, treatment with a bispecific antibody targeting both IL-1β and IL-18 lowers serum CRP and / or serum ferritin levels 28 days after treatment compared to standard treatment (SoC).

[0034] In another embodiment, treatment with a bispecific antibody targeting both IL-1β and IL-18 reduces the patient's serum CRP level 7 days after treatment compared to standard treatment. In another embodiment, treatment with a bispecific antibody targeting both IL-1β and IL-18 reduces the patient's serum CRP level 14 days after treatment compared to standard treatment. In another embodiment, treatment with a bispecific antibody targeting both IL-1β and IL-18 reduces the patient's serum CRP level 28 days after treatment compared to standard treatment. In another embodiment, treatment with a bispecific antibody targeting both IL-1β and IL-18 reduces the patient's serum ferritin level 7 days after treatment compared to standard treatment. In another embodiment, treatment with a bispecific antibody targeting both IL-1β and IL-18 reduces the patient's serum ferritin level 14 days after treatment compared to standard treatment. In another embodiment, treatment with bispecific antibodies targeting both IL-1β and IL-18 reduces the patient's serum ferritin levels 28 days after treatment compared to standard treatment.

[0035] In one embodiment, a bispecific antibody targeting both IL-1β and IL-18, such as a bbmAb, is provided herein for use in reducing serum C-reactive protein (CRP) levels in subjects having autoinflammatory or disease-related XIAP deficiency or CDC42 mutation. In several embodiments, the use of a bispecific antibody targeting both IL-1β and IL-18, such as a bbmAb, for the manufacture of a drug for reducing serum C-reactive protein (CRP) levels in subjects having autoinflammatory or disease-related XIAP deficiency or CDC42 mutation is provided herein. In some embodiments, serum CRP levels in subjects are reduced by at least 1 mg / l, at least 2 mg / l, at least 3 mg / l, at least 4 mg / l, or at least 5 mg / l. In some embodiments, serum CRP levels in subjects with autoinflammatory or disease-based autoinflammatory disease due to XIAP deficiency or CDC42 mutation, who received a bispecific antibody targeting both IL-1β and IL-18, such as bbmAb, are reduced by at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% from baseline compared to patients who did not receive the same treatment, such as those who received standard care (SOC). In some embodiments, the reduction in serum CRP levels occurs 2, 3, 4, 5, 6, or 7 days after administration of a bispecific antibody targeting both IL-1β and IL-18, such as bbmAb. In some embodiments, the reduction in serum CRP levels occurs 14 or 28 days after administration of a bispecific antibody targeting both IL-1β and IL-18, such as bbmAb.

[0036] In one embodiment, a method is provided herein for reducing serum ferritin levels in a subject having autoinflammatory disease or a disease based on XIAP deficiency or CDC42 mutation, the method comprising administering a therapeutically effective amount of a bispecific antibody, e.g., bbmAb, targeting both IL-1β and IL-18 to the subject. In one embodiment, a bispecific antibody, e.g., bbmAb, targeting both IL-1β and IL-18, is provided herein for use in reducing serum ferritin levels in a subject having autoinflammatory disease or a disease based on XIAP deficiency or CDC42 mutation. In some embodiments, the use of a bispecific antibody, e.g., bbmAb, targeting both IL-1β and IL-18, for the manufacture of a pharmaceutical product for reducing serum ferritin levels in a subject having autoinflammatory disease or a disease based on XIAP deficiency or CDC42 mutation is provided herein. In some embodiments, the subject's serum ferritin level is reduced by at least 100 ng / l, at least 200 ng / l, at least 300 ng / l, at least 400 ng / l, or at least 500 ng / l. In some embodiments, serum ferritin levels in subjects treated with a bispecific antibody targeting both IL-1β and IL-18, such as bbmAb, are reduced by at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% from baseline compared to patients who have not received the same treatment, such as patients who have received standard care (SOC). In some embodiments, the reduction in serum ferritin levels occurs 2, 3, 4, 5, 6, or 7 days after administration of a bispecific antibody targeting both IL-1β and IL-18, such as bbmAb. In some embodiments, the reduction in serum ferritin levels occurs 14 or 28 days after administration of a bispecific antibody targeting both IL-1β and IL-18, such as bbmAb.

[0037] In one embodiment, a method is provided herein for reducing serum levels of a biomarker selected from the group consisting of CXCL9, CXCL10 (IP-10), IL-6, and sIL2R in a subject having autoinflammatory disease or a disease based on XIAP deficiency or CDC42 mutation, the method comprising administering a therapeutically effective amount of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 to the subject. In one embodiment, a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 is provided herein for use in reducing serum levels of a biomarker selected from the group consisting of CXCL9, CXCL10 (IP-10), IL-6, and sIL2R in a subject having autoinflammatory disease or a disease based on XIAP deficiency or CDC42 mutation. In some embodiments, the use of a bispecific antibody targeting both IL-1β and IL-18, such as a bbmAb, in the manufacture of a pharmaceutical product for reducing serum levels of a biomarker selected from the group consisting of CXCL9, CXCL10 (IP-10), IL-6, and sIL2R in subjects having autoinflammatory or disease-related conditions such as XIAP deficiency or CDC42 mutations is provided herein. In some embodiments, serum levels of a biomarker selected from the group consisting of CXCL9, CXCL10 (IP-10), IL-6, and sIL2R in subjects treated with a bispecific antibody targeting both IL-1β and IL-18, such as a bbmAb, are reduced by at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% from baseline compared to patients who have not received the same treatment, for example, patients who have received standard care (SOC). In some embodiments, a decrease in serum levels of a biomarker selected from the group consisting of CXCL9, CXCL10 (IP-10), IL-6, and sIL2R occurs 2, 3, 4, 5, 6, or 7 days after administration of a bispecific antibody targeting both IL-1β and IL-18, such as a bbmAb.

[0038] An eighth aspect of this disclosure provides a method for preventing or reducing the onset or severity of fever in subjects having autoinflammatory or disease-related XIAP deficiency or CDC42 mutation, the method comprising administering a therapeutically effective amount of a bispecific antibody, e.g., bbmAb, targeting both IL-1β and IL-18 to the subject. In one embodiment, a bispecific antibody, e.g., bbmAb, targeting both IL-1β and IL-18, for use in preventing or reducing the onset or severity of fever in subjects having autoinflammatory or disease-related XIAP deficiency or CDC42 mutation, is provided herein. In some embodiments, the use of a bispecific antibody, e.g., bbmAb, targeting both IL-1β and IL-18, in the manufacture of a pharmaceutical product for preventing or reducing the onset or severity of fever in subjects having autoinflammatory or disease-related XIAP deficiency or CDC42 mutation, is provided herein.

[0039] A ninth aspect of this disclosure provides a method for preventing or mitigating the occurrence or severity of diarrhea in subjects having autoinflammatory or disease-related XIAP deficiency or CDC42 mutation, comprising administering a therapeutically effective dose of a bispecific antibody, such as bbmAb, that targets both IL-1β and IL-18 to the subject. In one embodiment, a bispecific antibody, such as bbmAb, that targets both IL-1β and IL-18, for use in preventing or mitigating the occurrence or severity of diarrhea in subjects having autoinflammatory or disease-related XIAP deficiency or CDC42 mutation, is provided herein. In some embodiments, the use of a bispecific antibody, such as bbmAb, that targets both IL-1β and IL-18, in the manufacture of a pharmaceutical product for preventing or mitigating the occurrence or severity of diarrhea in subjects having autoinflammatory or disease-related XIAP deficiency or CDC42 mutation, is provided herein.

[0040] Various embodiments of the aforementioned models can be advantageously combined with other treatments for autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations in subjects requiring such treatment. Such treatments may be, for example, any known treatments for the disease, disorder, condition, or syndrome being treated. As a non-limiting set of examples, at least one additional therapeutic agent may be selected from a list consisting of nonsteroidal anti-inflammatory drugs, cyclosporine, glucocorticoids, IL-18 binding proteins (IL-18BP), and combinations thereof.

[0041] In some cases, treatment with the bispecific antibodies described herein provides a reduction or elimination of the maintenance dose of glucocorticoids necessary to treat the subject. In some cases, treatment includes administration of the bispecific antibodies described herein and discontinuation of glucocorticoid administration. In some cases, treatment includes administration of the bispecific antibodies described herein and discontinuation of cyclosporine administration.

[0042] In some cases, treatment includes the administration of the bispecific antibodies described herein and the tapering of additional therapeutic drugs. In some cases, treatment includes the administration of the bispecific antibodies described herein and the tapering of glucocorticoids. In some embodiments, treatment includes the reduction, tapering, or discontinuation of glucocorticoid administration in subjects who have been administered glucocorticoids and bispecific antibodies. In some cases, treatment includes the reduction or tapering to a dose equivalent to or less than 0.2 mg / kg / day of prednisone. In some cases, treatment includes the reduction or tapering of prednisone to a dose of 0.2 mg / kg / day or less. In some cases, subjects who have been treated maintain at least a partial or complete response to the bispecific antibodies for at least two weeks after being tapered to a dose equivalent to 0.2 mg / kg / day of prednisone. In some embodiments, treatment includes the reduction, tapering, or discontinuation of glucocorticoid administration and discontinuation of cyclosporine in subjects who have been administered bispecific antibodies, glucocorticoids and cyclosporine.

[0043] In some embodiments, subjects requiring it have been or will be administered cyclosporine, anti-TNFα, corticosteroid, anti-IFNγ, anti-IL-1β, or anti-IL-18 therapy, or a combination thereof. In some embodiments, subjects requiring it were not adequately controlled by administration of cyclosporine, anti-TNFα, corticosteroid, anti-IFNγ, anti-IL-1β, or anti-IL-18 therapy, or a combination thereof, for autoinflammatory or disease based on XIAP deficiency or CDC42 mutation. In some embodiments, autoinflammatory or disease based on XIAP deficiency or CDC42 mutation in subjects requiring it is resistant to cyclosporine, anti-TNFα, corticosteroid, anti-IFNγ, anti-IL-1β therapy, or a combination thereof as monotherapy. In some cases, autoinflammatory or disease based on XIAP deficiency or CDC42 mutation does not respond to cyclosporine, anti-TNFα, corticosteroid, anti-IFNγ, anti-IL-1β, anti-IL-18 therapy, or a combination thereof. In some cases, tolerance and / or insufficient control is indicated by a PPGA score not falling below 2 as described herein. In some cases, tolerance and / or insufficient control is indicated by a PPGA score not falling below 1 as described herein. In some cases, no response is indicated by a PPGA score not decreasing as described herein.

[0044] In some embodiments, the treatment reduces or prevents the occurrence of disease relapse in the subject requiring it, compared to standard treatment (SoC), 7, 14, 21, or 29 days after the treatment. In some embodiments, the reduction or prevention of disease relapse in the subject is for at least about 1, 2, 3, or 4 weeks.

[0045] In some embodiments, the treatment reduces or prevents the occurrence of one or more MAS features in the subject, the MAS features being selected from the group consisting of fever, rash, tachycardia, cytopenia, liver dysfunction, and coagulation disorders. In some cases, the treatment reduces or prevents enteritis in the subject. In some cases, the treatment reduces or prevents severe, refractory neonatal diarrhea in the subject. In some cases, the treatment restores gastrointestinal symptoms in the patient.

[0046] In some embodiments, the treatment extends the time to the patient's first relapse, for example, by about (or at least about) one week, one month, two months, three months, six months, or one year. In some embodiments, the treatment further includes inducing serological remission in the patient. Serological remission may be indicated by complete suppression of serum IL-18 to undetectable levels or levels seen in healthy individuals (e.g., less than 500 pg / mL, less than 1000 pg / mL, or less than 5000 pg / mL).

[0047] In some embodiments, the patient has an XIAP mutation in the XIAP gene resulting in a truncated or dysfunctional XIAP protein, and the mutation may be a nonsense or missense mutation, a point mutation resulting in an intronic or frameshift mutation, a deletion (small or large exon deletion), or an insertion.

[0048] In some embodiments, patients have CDC42 mutations in the CDC42 gene resulting in a truncated or dysfunctional CDC42 protein, and the mutations may be nonsense and missense mutations, point mutations resulting in intronic or frameshift mutations, deletions (small or large exon deletions), or insertions. In particular, the mutations may affect the N-terminal alpha helix (residues Ile21 and Tyr23), or adjacent residues within the switch II motif (Tyr64, Arg66, and Arg68), or amino acid substitutions in the fourth beta strand (Cys81 and Ser83), the C-terminus (Ala159 and Glu171), or mutations such as p.R186C, p.C188Y, and p. R * 192Cext * It could be 24.

[0049] In some embodiments, the patient is a newborn. In some embodiments, the patient is a child (under 18 years of age). In some embodiments, the patient is under 1 year of age. In some embodiments, the patient is between 1 week and 1 year of age. In some embodiments, the patient is between 1 month and 1 year of age. In some embodiments, the patient is at least 1 week old. In some embodiments, the patient is at least 1 month old. [Brief explanation of the drawing]

[0050] [Figure 1] Figure 1 is a schematic diagram of a clinical trial treatment protocol for autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations, using a bispecific antibody targeting both IL-1β and IL-18, such as a bbmAb. [Figure 2-1]Figure 2: Figure 2 is a schematic diagram of the treatment protocols for periods 1 (2A), 2 (2B), and 3 (2C). Figure 2A: Period 1 is an open-label treatment period in which responders to bbmAb treatment can be identified and these patients can be tapered down their glucocorticoid dose and / or discontinue cyclosporine treatment. Period 1 is divided into three sub-parts (periods 1a, 1b, and 1c). Figure 2B: Period 2 consists of a 24-week placebo-controlled, double-blind, randomized treatment discontinuation period primarily to evaluate the efficacy of bbmAb compared to placebo. At the start of Period 2, bbmAb responders (full response to treatment at the end of the open-label treatment period 1) are randomized in a 1:1 ratio to receive bbmAb treatment (i.e., continue at 10 mg / kg) or placebo. The first scheduled blinded dose following randomization in Period 2 will be two weeks after the last dose in Period 1c, and doses will continue every two weeks until disease relapse occurs or 24 weeks have passed in Period 2. Figure 2C: Period 3 consists of a 3-year long-term safety phase with open-label bbmAb treatment (10 mg / kg). For Cohort 1, the first scheduled dose in Period 3 will be two weeks after the last dose in Period 1 or Period 2, and doses will continue with a minimum two-week interval. For Cohort 2, doses will be scheduled after confirmation that screening and baseline visits have been completed and all cohort-specific eligibility criteria have been met. Doses in Period 3 will continue approximately every two weeks, and protocol evaluations will have a reduced frequency of visits as outlined in the evaluation schedule. [Figure 2-2] (As stated above.) [Figure 2-3] (As stated above.) [Figure 3] Figure 3 shows the predicted (line) and measured (data points) time-course profiles of bbmAb serum concentrations from the first human health volunteer study. [Figure 4] Figure 4 shows the predicted free IL-18 and IL-1β concentrations after intravenous administration of a 10 mg / kg bispecific antibody targeting both IL-1β and IL-18, such as bbmAb, compared to recombinant IL-18 BP and canakinumab treatment (gray shading). The dashed line represents the limit of quantification (LLOQ). [Modes for carrying out the invention]

[0051] X-linked apoptosis inhibitor protein deficiency (XIAP, or XIAP deficiency) is a rare hereditary immunodeficiency that occurs almost without exception in young men (Rigaud et al 2006). XIAP has multifaceted functions in cell survival, innate immunity, and inflammation. In particular, in addition to its role in regulating caspase activity, XIAP is considered an essential regulator of NLRP3 inflammasome activation (Miyazawa and Wado 2022). Major features of XIAP deficiency include inflammatory bowel disease, often presenting as abdominal pain and diarrhea, recurrent fever, splenomegaly, and hemophagocytic lymphohistiocytosis (HLH). The latter symptoms are often triggered by Epstein-Barr virus (EBV) infection. Once diagnosed, the initial treatment goal is generally to suppress inflammation using corticosteroids and biotherapy. Inflammatory bowel disease can be treated with standard immunosuppressants, but the response rate is generally low. EBV infection can be treated with specific antiviral therapy, and in some cases, immunoglobulin therapy is used. Currently, the only potentially curative treatment for XIAP deficiency is hematopoietic stem cell transplantation (HSCT). However, due to the characteristics of the underlying disease, low-intensity pre-transplant conditioning is required, and outcomes from HSCT are often worse than the standard for patients of this age. Although the life expectancy of patients with XIAP has increased over the past decade, significant morbidity and mortality still exist in this condition (Mudde et al 2021). Loss of XIAP leads to inflammasome dysfunction, overproduction of inflammasome-activating cytokines, including IL-18, and cell death (Wada et al 2014). In patients with XIAP deficiency, IL-18 levels are severely elevated during HLH episodes, overriding IL-18BP blocking ability, and free IL-18 levels are detected in the peripheral blood. A combined IL-1 and IL-18 blockade approach has been used to alleviate clinical disease activity, including HLH and gastrointestinal symptoms, in one published case (Geerlinks et al 2022). An 8-year-old male presented with recurrent fever since childhood, followed by abdominal pain and diarrhea associated with transaminasis.This patient was hypersensitive to anakinra and was unable to discontinue steroids in association with multiple immunotherapies, including canakinumab, tocilizumab, colchicine, etanercept, infliximab, mesalamine, rituximab, and vedolizumab. After treatment with recombinant IL-18BP tadenig alfa, the patient was able to discontinue oral steroids and achieved near-complete symptom remission for over two years of treatment, with the exception of one episode of fever and diarrhea (Geerlinks et al 2022).

[0052] Cell division regulatory protein 42 (CDC42) belongs to the Rho family of small monomeric GTPases (Heasman et al 2008). It influences multiple cellular processes, including cell division and migration, and regulates the nervous, immune, and hematopoietic systems (Melendez et al 2011). Pathogenic mutations in CDC42 can affect protein function in various ways, leading to an increasing recognition of the diversity of disease phenotypes concentrated in neurogenesis, hematopoiesis, and immune responses (Takenouchi et al 2015, Asiri et al 2021, Coppola et al 2022). In particular, it has been shown that abnormal palmitoylation of CDC42R186C can lead to the capture of CDC42 in the Golgi apparatus, which can induce pyrin inflammasome hyperactivation and a significant increase in IL-1β and IL-18 (Coppola et al 2022). In four pediatric patients, a C-terminal de novo missense mutation (p.R186C) has been shown to affect CDC42 localization, causing a specific group of neonatal-onset cytopenia, autoinflammatory disease, and recurrent HLH (Lam et al 2019). The presence of chronic elevated serum IL-18 after clinical response to anti-IL-1 therapy suggests that IL-18 is a promising therapeutic target for CDC42 C-terminal disease (Lam et al 2019). In the only surviving patient in the case series of four patients with identified CDC42R186C mutations, ongoing HLH was associated with an overall and prolonged elevation of IL-18. Pharmacological interventions with glucocorticoid pulse therapy, cyclosporine A, and high-dose anakinra (10 mg / kg / day) failed to prevent ongoing HLH episodes, and episodes responded only to emaparmab, a monoclonal antibody targeting IFN-γ, a downstream mediator of IL18 activity. This patient eventually underwent a curative hematopoietic stem cell transplant, after which IL18 levels normalized, and the patient remained HLH-free (Lam et al 2019).

[0053] As used herein, the collective term autoinflammatory or disease based on XIAP deficiency or CDC42 mutation is used when it best reflects the underlying pathogenesis of the disease.

[0054] Autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutation include / may result from the following clinical symptoms: hypogammaglobulinemia, cytopenia, inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, hemophagocytic lymphohistiocytosis, neonatal cytopenia, syndrome-type thrombocytopenia, megathrombocytopenic thrombocytopenia, hematopoietic disorders, autoinflammatory conditions, symptomatic immunodeficiency, recurrent hemophagocytic lymphohistiocytosis (HLH), macrophage activation syndrome, or AIFEC.

[0055] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptom is hypogammaglobulinemia.

[0056] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptom is cytopenia.

[0057] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on XIAP deficiency, where the clinical symptoms are inflammatory bowel disease.

[0058] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptoms are abdominal pain and diarrhea.

[0059] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptom is recurrent fever.

[0060] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptom is splenomegaly.

[0061] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical manifestation is hemophagocytic lymphohistiocytosis.

[0062] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptom is neonatal-onset cytopenia.

[0063] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptoms are a syndrome type of thrombocytopenia.

[0064] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical manifestation is giant thrombocytopenia.

[0065] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on XIAP deficiency, where the clinical symptoms are hematopoietic abnormalities.

[0066] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on XIAP deficiency, where the clinical symptoms are autoinflammatory.

[0067] In one embodiment, the disclosure relates to the use or method of bispecific antibodies, such as bbmAb, that target both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptoms are symptomatic immunodeficiency.

[0068] In one embodiment, the disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptom is recurrent hemophagocytic lymphohistiocytosis (HLH).

[0069] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptom is macrophage activation syndrome (MAS).

[0070] In one embodiment, the disclosure relates to the use or method of a bispecific antibody, e.g., bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based XIAP deficiency in which the clinical symptom is AIFEC. Autoinflammatory or disease-based CDC42 mutations refer to / may result in the following clinical symptoms: hypogammaglobulinemia, cytopenia, inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, hemophagocytic lymphohistiocytosis, neonatal-onset cytopenia, syndrome type of thrombocytopenia, megathrombocytopenic thrombocytopenia, hematopoietic abnormalities, autoinflammatory disease, symptomatic immunodeficiency, or recurrent hemophagocytic lymphohistiocytosis (HLH). In one embodiment, the disclosure relates to the use or method of a bispecific antibody, e.g., bbmAb, that targets both IL-1β and IL-18, for the treatment of autoinflammatory or disease-based CDC42 mutation in which the clinical symptom is hypogammaglobulinemia.

[0071] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, in which the clinical symptom is cytopenia.

[0072] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, where the clinical symptom is inflammatory bowel disease.

[0073] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, in which the clinical symptoms are abdominal pain and diarrhea.

[0074] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, in which the clinical symptom is recurrent fever.

[0075] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, in which the clinical symptom is splenomegaly.

[0076] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-based CDC42 mutations in which the clinical manifestation is hemophagocytic lymphohistiocytosis.

[0077] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, in which the clinical symptom is neonatal-onset cytopenia.

[0078] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-based CDC42 mutations in which the clinical symptoms are a syndrome type of thrombocytopenia.

[0079] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-based CDC42 mutations in which the clinical manifestation is giant thrombocytopenia.

[0080] In one embodiment, the present disclosure relates to the use or method of bispecific antibodies, such as bbmAb, that target both IL-1β and IL-18, for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, in which the clinical manifestation is hematopoietic abnormalities.

[0081] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, where the clinical symptoms are autoinflammatory.

[0082] In one embodiment, the present disclosure relates to the use or method of bispecific antibodies, such as bbmAb, that target both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations in which the clinical manifestation is symptomatic immunodeficiency.

[0083] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, the clinical manifestation of recurrent hemophagocytic lymphohistiocytosis (HLH).

[0084] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, the clinical manifestation of which is macrophage activation syndrome (MAS).

[0085] In one embodiment, the present disclosure relates to the use or method of a bispecific antibody, such as a bbmAb, that targets both IL-1β and IL-18 for the treatment of autoinflammatory or disease-related conditions based on CDC42 mutations, where the clinical symptom is AIFEC.

[0086] In certain populations, such as infants, it is hypothesized that early intervention of MAS-like features and enteritis can prevent disease progression to irreversible end-organ damage, which generally leads to fatal consequences (Romberg et al 2014, Moghaddas et al 2018). In severely affected pediatric populations, the disease has been shown to be resistant to cyclosporine, anti-TNFα treatment, systemic glucocorticoids, and anti-IL-1β therapy, either individually or in combination. Currently, apart from supportive care and immunosuppression, which offer limited benefits to this population, there are no approved therapies that directly and specifically target the underlying IL-1β and IL-18 autoinflammatory processes to improve the overall clinical outcomes of patients with autoinflammatory or disease-related autoinflammatory conditions due to XIAP deficiency or CDC42 mutations.

[0087] This specification describes a method for treating or preventing autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutation by administering an effective amount of a bispecific antibody (e.g., bbmAb) or a functional fragment thereof that simultaneously targets both IL-1β and IL-18 to a subject in need. Accordingly, one embodiment provides a method for preventing or treating AIFEC, comprising administering an effective amount of a bispecific antibody (e.g., bbmAb) that simultaneously targets both IL-1β and IL-18 to a subject in need.

[0088] This disclosure relates to bispecific monoclonal antibodies (bbmAbs), e.g., bispecific antibodies (e.g., bbmAbs) that simultaneously target both IL-1β and IL-18, or variants thereof, for use in the treatment of patients with autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations, who have excessively elevated IL-1β and / or IL-18. This disclosure also relates to methods, treatment plans, uses, kits, and therapeutics for treating autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations by using bispecific antibodies that simultaneously target both IL-1β and IL-18.

[0089] Data such as those described herein suggest that the combination of simultaneous neutralization of IL-1β and IL-18 may more potently reduce the production of IFN-γ (and other pro-inflammatory cytokines) compared to the individual neutralization of IL-1β or IL-18 with either an anti-IL-1 or anti-IL-18 mAb. Accordingly, this disclosure is based, in particular, on the unexpected finding that certain antibodies that simultaneously neutralize IL-1β and IL-18 more potently reduce the production of IFN-γ (and other pro-inflammatory cytokines) compared to single IL-1β or IL-18 neutralization alone, and the inventors believe that this finding is an effective treatment for (i) autoinflammatory or disease based on XIAP deficiency or CDC42 mutation, or (ii) autoinflammatory or disease based on CDC42 mutation, or (iii) AIFEC in patients with XIAP deficiency or CDC42 mutation.

[0090] Furthermore, the inventors hypothesize that treatment with an antibody that simultaneously neutralizes IL-1β and IL-18 (e.g., bbmAb) may enable a significant reduction in the frequency of administration in patients with autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations, compared to more complex combinations under investigation that may require anti-IL-1β (every two weeks in the case of canakinumab, or daily in the case of anakinra) along with glucocorticoids, cyclosporine, and IL-18BP (every two days).

[0091] 1.Definition For the purposes of interpreting this Spec., the following definitions apply, and wherever appropriate, a term used in the singular also includes its plural form, and vice versa. Additional definitions are provided throughout the detailed description. All references, publications, patents, and database accession codes, including GenBank and OMIM and their contents, are incorporated herein by reference in their entirety for all purposes.

[0092] In the context of treating autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutation, the term “relapse” refers to the following: • In the comprehensive physician assessment of disease activity described herein, an increase in disease activity from no disease activity or minimal activity to disease activity exceeding minimal activity; • A 60% increase from the normalized level in treated patients with serum ferritin and / or C-reactive protein (CRP). Normalized levels indicate minimal or absent autoinflammatory or disease activity based on XIAP deficiency or CDC42 mutation (e.g., CRP < 20 mg / L; ferritin < 600 ng) / L); or • Elevated serum ferritin levels exceeding 2500 ng / mL and / or elevated CRP levels exceeding 20 mg / mL.

[0093] The term "IL-18" is synonymous with IL-18 polypeptide, interleukin-18 polypeptide, IFN-gamma-inducible factor, or interferon-gamma-inducible factor or INF-γ-inducible factor. Unless otherwise specified, the term "IL-18" refers to human IL-18. IL-18 is well known to those skilled in the art and is available, for example, from MBL® International Corporation under product number #B001-5. Throughout this application, the term IL-18 is interchangeable with both pro-IL-18 (precursor to mature IL-18 before protease cleavage) and mature IL-18 (after protease cleavage) unless otherwise specified.

[0094] The terms "IL-1β" or "IL-1b" are synonyms for IL-1β polypeptide and interleukin-1β polypeptide. The term "IL-1β" refers to human IL-1β unless a different species is specified. IL-1β is well known to those skilled in the art and is available, for example, from Sino Biological under product number #10139-HNAE-5.

[0095] The term "antibody" refers to intact immunoglobulins or their functional fragments. Natural antibodies generally consist of a tetramer, typically comprising at least two heavy (H) chains and at least two light (L) chains. Each heavy chain consists of a heavy chain variable region (abbreviated herein as VH) and a heavy chain constant region, typically comprising three domains (CH1, CH2, and CH3). The heavy chain may be of any isotype, including IgG (IgG1, IgG2, IgG3, and IgG4 subtypes), IgA (IgA1 and IgA2 subtypes), IgM, and IgE. Each light chain consists of a light chain variable region (abbreviated herein as VL) and a light chain constant region (CL). The light chain includes kappa (κ) chains and lambda (λ) chains. The variable regions of the heavy and light chains are generally involved in antigen recognition, while the constant regions of the heavy and light chains can mediate the binding of immunoglobulins to host tissues or factors, including various cells of the immune system (e.g., effector cells) and the first component of the classical complement system (Clq). The VH and VL regions can be further subdivided into hypervariable regions called complementarity-determining regions (CDRs), which are interspersed with more conserved regions called framework regions (FRs). Each VH and VL consists of three CDRs and four FRs, arranged from the amino terminus to the carboxyl 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.

[0096] The term “antigen-binding moiety” (or simply “antigen moiety”) of an antibody, as used herein, refers to the full-length or one or more fragments of an antibody that possess the ability to specifically bind to the IL-18 or IL-1β antigen. Antigen-binding function of an antibody has been shown to be performed by fragments of the full-length antibody. Examples of binding fragments encompassed within the term “antigen-binding moiety” of an antibody include the Fab fragment, a monovalent fragment consisting of VL, VH, CL, and CH1 domains; the F(ab)2 fragment, a fragment containing two monovalent Fab fragments linked by disulfide crosslinking at the hinge region; the Fd fragment consisting of VH and CH1 domains; the Fv fragment consisting of the VL and VH domains of a single arm of the antibody; the dAb fragment consisting of the VH domain (Ward et al., (1989) Nature; 341:544-546); and isolated complementarity-determining regions (CDRs).

[0097] Furthermore, although the Fv fragment, with its two domains VL and VH, is encoded by separate genes, they can be linked using recombination by a flexible linker that allows them to be produced as a single protein chain, where the VL and VH regions pair to form a monovalent molecule (known as single-chain Fv (scFv); e.g., Bird et al., (1988) Science 242:423-426; and Huston et al., (1988) Proc Natl Acad Sc; 85:5879-5883). Such single-chain antibodies are also included within the term "antigen-binding portion" of the antibody. These antibody fragments are obtained using prior art known to those skilled in the art, and the fragments are screened for utility in the same way as they would be for intact antibodies.

[0098] The term "isolated" means, throughout this application, that immunoglobulins, antibodies, or polynucleotides may, as may be, exist in a physical environment different from that in which they may occur naturally.

[0099] Throughout this application, a complementarity-determining region ("CDR") is defined according to Kabat's definition unless it is indicated that a CDR is defined according to a different definition. The precise amino acid sequence boundaries of a given CDR are defined in Kabat et al. (1991) "Sequences of Proteins of Immunological Interest," 5th Ed. Public Health Service, National Institutes of Health, Bethesda, MD ("Kabat" numbering scheme), Al-Lazikani et al., (1997) JMB 273, 927-948 ("Chothia" numbering scheme) and ImMunoGenTics (IMGT) numbering (Lefranc, M.-P., The Immunologist, 7, 132-136 (1999); Lefranc, M.-P. et al., Dev. Comp. Immunol., 27, 55-77 (2003) ("IMGT" numbering scheme) It can be determined using any of the many well-known schemes, including the one described in the scheme. For example, in the classical form, under Kabat, the CDR amino acid residues in the heavy chain variable domain (VH) are numbers 31-35 (HCDR1), 50-65 (HCDR2), and 95-102 (HCDR3); the CDR amino acid residues in the light chain variable domain (VL) are numbers 24-34 (LCDR1), 50-56 (LCDR2), and 89-97 (LCDR3). Under Chothia, the CDR amino acids in VH are numbers 26-32 (HCDR1 ), 52-56 (HCDR2) and 95-102 (HCDR3); the amino acid residues in VL are numbered 26-32 (LCDR1), 50-52 (LCDR2) and 91-96 (LCDR3). By combining the CDR definitions of both Kabat and Chothia, the CDR consists of amino acid residues 26-35 (HCDR1), 50-65 (HCDR2) and 95-102 (HCDR3) in human VH and amino acid residues 24-34 (LCDR1), 50-56 (LCDR2) and 89-97 (LCDR3) in human VL.Under IMGT, the CDR amino acid residues in VH are approximately 26-35 (CDR1), 51-57 (CDR2), and 93-102 (CDR3), and the CDR amino acid residues in VL are approximately 27-32 (CDR1), 50-52 (CDR2), and 89-97 (CDR3) (numbered according to "Kabat"). Under IMGT, the CDR region of the antibody can be determined using the IMGT / DomainGap Align program.

[0100] By convention, the CDR regions in the heavy chain are generally called H-CDR1, H-CDR2, and H-CDR3, while those in the light chain are called L-CDR1, LCDR2, and L-CDR3. These are numbered sequentially from the amino terminus to the carboxyl terminus.

[0101] The terms "monoclonal antibody" or "monoclonal antibody composition," as used herein, refer to a preparation of an antibody molecule in a single-molecule composition. Monoclonal antibody compositions exhibit a single binding specificity and affinity to a specific epitope.

[0102] As used herein, the term "human antibody" includes antibodies having a variable region in which both the framework and CDR regions are derived from human sequences. Furthermore, if an antibody contains a constant region, the constant region is also derived from an antibody containing such human sequences, e.g., a human germline sequence or a mutant of a human germline sequence or a consensus framework sequence derived from human framework sequence analysis, as described in, for example, Knappik, et al., (2000) J Mol Biol; 296: 57-86).

[0103] The human antibodies of the present invention may contain amino acid residues not encoded by the human sequence (for example, mutations introduced by random or site-directed mutagenesis in vitro or by somatic mutation in vivo). However, as used herein, the term "human antibody" does not include antibodies in which a CDR sequence derived from the germline of another mammalian species, such as mouse, has been transplanted onto a human framework sequence.

[0104] The term "human monoclonal antibody" refers to a single antibody exhibiting binding specificity that has a variable region in which both the framework and CDR region are derived from human sequences.

[0105] When used herein, the term “recombinant human antibody” includes all human antibodies prepared, expressed, produced, or isolated by recombinant means, such as antibodies isolated from animals (e.g., mice) or hybridomas prepared therefrom that are transgenic or transducible to human immunoglobulin genes; antibodies isolated from host cells transformed to express human antibodies from transfectomas; antibodies isolated from recombinant, combinatorial human antibody libraries; and antibodies prepared, expressed, produced, or isolated by any other means, including splicing of all or part of human immunoglobulin genes. Such recombinant human antibodies have a variable region in which the framework and CDR region are derived from human germline immunoglobulin sequences. However, in certain embodiments, such recombinant human antibodies may be subjected to in vitro mutagenesis (or in vivo somatic mutagenesis if an animal transgenic to the human Ig sequence is used), and therefore the amino acid sequences of the VH and VL regions of the recombinant antibody are derived from and related to human germline VH and VL sequences, while being sequences that do not naturally exist within the in vivo human antibody germline repertoire.

[0106] The phrases “antibody that recognizes an antigen” and “antibody that is specific to an antigen” are interchangeable herein with the term “antibody that specifically binds to an antigen.”

[0107] As used herein, the binding molecule that "specifically binds to IL-18" is defined as a K molecule with a mass of 100 nM or less, 10 nM or less, or 1 nM or less. D This refers to a binding molecule that binds to human IL-18.

[0108] As used herein, the binding molecule that "specifically binds to IL-1β" is defined as a K molecule with a mass of 100 nM or less, 10 nM or less, or 1 nM or less. D This refers to a binding molecule that binds to human IL-1β.

[0109] As used herein, the term “antagonist” refers to a binding molecule that inhibits signal transduction activity in the presence of an activating compound. For example, in the case of IL-18, the IL-18 antagonist is a binding molecule that inhibits signal transduction activity in the presence of IL-18 in human cell assays, such as the IL-18-dependent interferon-gamma (IFN-γ) production assay in human blood cells. An example of the IL-18-dependent IFN-γ production assay in human blood cells is detailed in the following examples.

[0110] The term "bivalent bispecific antibody," or "bivalent bispecific antibody" (plural), refers to antibody binding to two different targets, such as IL-18 and IL-1β. Typically, each bivalent bispecific antibody binds to its respective target in a monovalent state.

[0111] A bispecific antibody is a "heterodimer," meaning that one portion is derived from a first antibody specific to a first target, and the other portion is derived from a second antibody specific to a second target. "Heterodimerization modification" is a modification of one or both of the antibodies that form a heterodimeric bispecific antibody, and promotes such formation. An example of heterodimerization modification of the Fc domains of two IgG1 moieties of an antibody intended to form bispecificity is the introduction of a "knob" with a bulky amino acid (aa) side chain (S354C, T366W) and a "hole" with a small aa side chain (Y349C, T366S, L368A, Y407V) in the first heavy chain and a further disulfide crosslink in the CH3 region to link the two heavy chains (Merchant et al., Nat. Biotechnol., 16:677-681 (1998), page 678, table 1).

[0112] "K DThe term "dissociation constant", as used herein, refers to the dissociation constant, which is K d and K a The ratio to (i.e., K d / K a ), and is expressed as molar concentration (M). The K D value for an antibody can be determined using methods well established in the art. The K D of an antibody can be determined by using surface plasmon resonance such as a Biacore® system.

[0113] As used herein, the term "affinity" refers to the strength of the interaction between a binding molecule and an antigen at a single antigenic site.

[0114] As used herein, the term "high affinity" for an antibody refers to an antibody having a KD of 1 nM or less for a target antigen.

[0115] As used herein, the term "subject" includes any human subject who receives the bispecific antibody currently described. The term "subject" may additionally or alternatively include any human subject who exhibits or is at risk of symptoms of autoinflammation or disease based on XIAP deficiency or CDC42 mutation, such as those defined above, or inflammasome disease based on XIAP deficiency or CDC42 mutation, or AIFEC.

[0116] The term "immune response" refers to a selective impairment, destruction or elimination from the human body that causes an immune response against an invading pathogen, a cell or tissue infected with a pathogen, a cancerous cell, or in the case of autoimmunity or pathological inflammation, a normal human cell or tissue, for example, the action of lymphocytes, antigen-presenting cells, phagocytes, granulocytes and soluble macromolecules (including antibodies, cytokines and complement) produced by the above cells or the liver.

[0117] The nucleotides in "polynucleotides" or "nucleic acids" may include modifications such as base modifications including bromouridine and inosine derivatives, and ribose modifications including phosphorothioates, phosphorodioates, phosphoroselenoates, phosphorodiselenoates, phosphoranilothioates, phosphoraniladates, and phosphoramidates.

[0118] The terms “to treat,” “to treat,” “treatment,” “prevent,” “prevention,” or “prevention” include therapeutic, preventive, and application measures that reduce the risk of an object developing a disorder or other risk factor. Treatment does not require a complete cure of the disorder and includes the reduction of symptoms or potential risk factors.

[0119] The term "treat or prevent" includes, optionally in combination with at least one further therapeutic agent, administering a compound, such as a bispecific antibody targeting both IL-1β and IL-18, such as a bbmAb, to prevent or delay the onset of symptoms, complications, or biochemical signs of a disease, condition, disorder, or syndrome (e.g., NLRC4 inflammasome disease, XIAP deficiency, or autoinflammatory or disease based on CDC42 mutation, AIFEC), to alleviate symptoms, or to halt or inhibit further progression of the disease, condition, disorder, or syndrome. Treatment may be prophylactic (to prevent or delay the onset of a disease, condition, disorder, or syndrome, or to prevent the manifestation of its clinical or potential symptoms), or therapeutic suppression or alleviation of symptoms after the onset of the disease, condition, disorder, or syndrome.

[0120] As used herein, the terms “prevent,” “prevent,” or “prevent” in relation to a disease, condition, disorder, or syndrome refer to preventive measures taken by an individual at risk of developing a condition (for example, a specific disease, condition, disorder, or syndrome, or its clinical manifestations such as autoinflammatory disease or disease or AIFEC based on XIAP deficiency or CDC42 mutation) that reduce the likelihood of that condition developing.

[0121] The terms “to treat,” “to treat,” and “treatment” refer to both therapeutic treatments and preventive or preventive measures aimed at improving a disease, condition, disorder, or syndrome by reducing or improving at least one physical parameter, including those that are not perceptible to the patient (i.e., delaying, stopping, or reducing the onset of the disease or at least one of its clinical symptoms). The terms “to treat,” “to treat,” and “treatment” also refer to modulating a disease or disorder and / or preventing or delaying the onset, occurrence, or progression of a disease or disorder, physically (e.g., stabilizing identifiable symptoms), physiologically (e.g., stabilizing physical parameters), or both.

[0122] For example, "Treating autoinflammatory or disease based on XIAP deficiency or CDC42 mutation may mean improving, alleviating, or regulating at least one of the symptoms or pathological features associated with autoinflammatory or disease based on XIAP deficiency or CDC42 mutation; for example, elevated serum inflammatory markers (one or more of serum CRP, serum ferritin, serum IL-18, serum total IL-18, serum free IL-18, serum IL-1β, serum total IL-1β, serum free IL-1β, etc.), fever, diarrhea, rash, tachycardia, cytopenia, liver dysfunction and / or coagulation disorders; for example, symptoms or pathological features associated with autoinflammatory or disease based on XIAP deficiency or CDC42 mutation; for example, elevated serum inflammatory markers (one or more of serum CRP, serum ferritin, serum IL-18, etc.), fever, diarrhea" This may also mean slowing, mitigating, or halting the progression of at least one of the following conditions: rash, tachycardia, cytopenia, hepatic dysfunction and / or coagulation disorders or hypogammaglobulinemia, cytopenia, inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, hemophagocytic lymphohistiocytosis, neonatal cytopenia, thrombocytopenia syndrome, megathrombocytopenia, hematopoietic disorders, autoinflammation, symptomatic immunodeficiency, or recurrent hemophagocytic lymphohistiocytosis (HLH), MAS, or AIFEC. This phrase may also mean preventing or delaying one or more of the conditions described, e.g., slowing, halting, or reversing the progression of a disease, condition, disorder, or syndrome, and improving clinical outcomes (e.g., preventing fatal progression of AIFEC and improving survival rates).

[0123] Total IL-18 in serum can be measured by conjugating an anti-human IL-18 antibody (e.g., clone 125H, MBL International) to Bio-plex Magnetic COOH beads (Bio-Rad, Inc.) and detecting it using biotinylated anti-human IL-18 (clone 159-12B, MBL), with the concentration calculated using IL-18 included in the Group II Cytokine Standard Curve (Bio-Rad, Inc.). Free IL-18 can be measured as described in Girard et al. Rheumatology (Oxford). 2016 Dec;55(12):2237-2247.

[0124] Serum IL-1β can be measured using a commercially available ELISA kit (88-7261-88, eBioscience) which is used according to the manufacturer's instructions.

[0125] In some embodiments, the reduction of one or more elevated serum inflammatory markers by administration of a bispecific antibody or functional fragment thereof that simultaneously targets both IL-1β and IL-18 may be at least 10% from baseline compared to patients who have not received the same treatment, e.g., patients who have received standard care (SOC). In some embodiments, the reduction of one or more elevated serum inflammatory markers by administration of a bispecific antibody or functional fragment thereof that simultaneously targets both IL-1β and IL-18 may be at least 30% from baseline compared to patients who have not received the same treatment, e.g., patients who have received standard care (SOC). In some embodiments, the reduction of one or more elevated serum inflammatory markers by administration of a bispecific antibody or functional fragment thereof that simultaneously targets both IL-1β and IL-18 may be at least 40% from baseline compared to patients who have not received the same treatment, e.g., patients who have received standard care (SOC). In some embodiments, the reduction of one or more elevated serum inflammatory markers by administration of a bispecific antibody or functional fragment thereof that simultaneously targets both IL-1β and IL-18 may be at least 50% lower from baseline compared to patients who have not received the same treatment, for example, patients who have received standard care (SOC).

[0126] As an example, autoinflammatory or disease-related conditions based on XIAP deficiencies or CDC42 mutations suitable for treatment by the compositions and methods described herein include those caused by or related to nonsense and missense mutations, point mutations resulting in intronic or frameshift mutations, deletions (small or large exon deletions), or insertions.

[0127] In some embodiments, suitable subjects or subjects requiring such subjects have one of the 90 mutations in the XIAP gene disclosed in Mudde et al., (2021) Evolution of Our Understanding of XIAP Deficiency. Front. Pediatr. 9:660520, or a mutation in the CDC42 gene resulting in a truncated or dysfunctional CDC42 protein, wherein the mutations include nonsense and missense mutations, point mutations resulting in intronic or frameshift mutations, deletions (small or large exon deletions), or insertions, particularly mutations in the N-terminal alpha helix (e.g., residues Ile21 and Tyr23), or in the switch II motif (e.g., Tyr64, Arg66, and Arg68), or in the fourth beta strand (e.g., Cys81 and Ser83), or in the C-terminus (e.g., Ala159 and Glu171, or deletion), or p.R186C, p.C188Y, and p. * 192Cext * It may be mutation 24 (disclosed in Gernez Y, et al., J Allergy Clin Immunol 2019;144:1122-5.e6).

[0128] Furthermore, "treating" may refer to slowing, stopping, or reversing the progression of a disease, condition, disorder, or syndrome to improve the clinical outcome, for example, by lowering the score on the original five-category scale from a high number to a low number, as shown below.

[0129] [Table 1]

[0130] Where used herein, the term “therapeutic effective dose” of a compound described herein refers to an amount of the compound that induces a biological or medical response in a subject, such as improving symptoms, alleviating a condition, slowing or delaying disease progression, or preventing a disease, condition, disorder, or syndrome. In a non-limiting embodiment, the term “therapeutic effective dose” refers to an amount of the compound described herein that, when administered to a subject, is effective in at least partially alleviating, inhibiting, preventing and / or improving autoinflammatory or disease based on XIAP deficiency or CDC42 mutation. In a non-limiting embodiment, the term “therapeutic effective dose” refers to an amount of the compound described herein that, when administered to a subject, is effective in at least partially alleviating, inhibiting, preventing and / or improving autoinflammatory or disease based on XIAP deficiency or CDC42 mutation that exhibits elevated levels of IL-18 and IL-1β. In a non-limiting embodiment, the term “therapeutic effective dose” refers to an amount of the compound described herein that, when administered to a subject, is effective in at least partially alleviating, inhibiting, preventing and / or improving AIFEC.

[0131] As used herein, human antibodies or fragments thereof include heavy or light chain variable regions or full-length heavy or light chains that are “products” of or “derived” from a particular germline sequence, if the variable region or full-length chain of the antibody is obtained from a system using a human germline immunoglobulin gene. Such a system includes immunizing transgenic mice possessing a human immunoglobulin gene with an antigen of interest, or screening a human immunoglobulin gene library presented on phages using an antigen of interest. Human antibodies or fragments thereof that are “products” of or “derived” from a human germline immunoglobulin sequence can be identified as such by comparing the amino acid sequence of the human germline immunoglobulin with the amino acid sequence of the human antibody and selecting the human germline immunoglobulin sequence that is closest in sequence to (i.e., has the greatest % identity) to the sequence of the human antibody. Human antibodies that are “products” of or “derived” from a particular human germline immunoglobulin sequence may contain amino acid differences when compared to the germline sequence, for example, due to natural somatic mutations or the intentional introduction of site-directed mutations. However, the selected human antibodies generally have an amino acid sequence that is at least 90% identical to the amino acid sequence encoded by the human germline immunoglobulin gene, and contain amino acid residues that identify the antibody as human when compared to the germline immunoglobulin amino acid sequence of another species (e.g., mouse germline sequence). In certain cases, the amino acid sequence of a human antibody may be at least 60%, 70%, 80%, 90%, or at least 95%, or even at least 96%, 97%, 98%, or 99%, identical to the amino acid sequence encoded by the germline immunoglobulin gene. Generally, a human antibody derived from a particular human germline sequence has 10 or fewer amino acid differences from the amino acid sequence encoded by the human germline immunoglobulin gene. In certain cases, the human antibody may show 5 or fewer amino acid differences from the amino acid sequence encoded by the germline immunoglobulin gene, or even 4, 3, 2, or 1 or fewer amino acids.

[0132] 2.IL-18 antibody The particularly preferred IL-18 antibody or its antigen-binding fragment used in the disclosed method is a human antibody.

[0133] For ease of reference, based on the Kabat and Chothia definitions, the amino acid sequence of the hypervariable region of a specific IL-18 antibody called mAb1 and V L and V H The domains, full heavy chain, and light chain are provided in Table 1 below.

[0134] [Table 2]

[0135] In one embodiment, the IL-18 antibody or its antigen-binding fragment comprises at least one immunoglobulin heavy chain variable domain (V) including hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has the amino acid sequence SEQ ID NO: 1, CDR2 has the amino acid sequence SEQ ID NO: 2, and CDR3 has the amino acid sequence SEQ ID NO: 3. H ) comprises. In one embodiment, the IL-18 antibody or its antigen-binding fragment comprises at least one immunoglobulin heavy chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 4, CDR2 has amino acid sequence number 5, and CDR3 has amino acid sequence number 6. H ) includes.

[0136] In one embodiment, the IL-18 antibody or its antigen-binding fragment comprises at least one immunoglobulin light chain variable domain (V) including hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has the amino acid sequence SEQ ID NO: 11, CDR2 has the amino acid sequence SEQ ID NO: 12, and CDR3 has the amino acid sequence SEQ ID NO: 13. L) comprises. In one embodiment, the IL-18 antibody or its antigen-binding fragment comprises at least one immunoglobulin light chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 14, CDR2 has amino acid sequence number 15, and CDR3 has amino acid sequence number 16. L ) includes.

[0137] In one embodiment, the IL-18 antibody or its antigen-binding fragment is at least one immunoglobulin V H domain and at least one immunoglobulin V L Including the domain, a) immunoglobulin V H The domains (for example in the sequence) include: i) hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has amino acid sequence number 1, CDR2 has amino acid sequence number 2, and CDR3 has amino acid sequence number 3; or ii) hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has amino acid sequence number 4, CDR2 has amino acid sequence number 5, and CDR3 has amino acid sequence number 6; b) immunoglobulin V L The domains (for example in the sequence) include: i) hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has amino acid sequence number 11, CDR2 has amino acid sequence number 12, and CDR3 has amino acid sequence number 13; or ii) hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has amino acid sequence number 14, CDR2 has amino acid sequence number 15, and CDR3 has amino acid sequence number 16.

[0138] In one embodiment, the IL-18 antibody or its antigen-binding fragment is a) an immunoglobulin heavy chain variable domain (V) containing the amino acid sequence shown as SEQ ID NO: 7 H );b) Immunoglobulin light chain variable domain (V) containing the amino acid sequence shown as Sequence ID No. 17 L );c) Immunoglobulin V containing the amino acid sequence shown as Sequence ID No. 7 HImmunoglobulin V containing the domain and the amino acid sequence shown as SEQ ID NO: 17 L Domain; d) Immunoglobulin V containing the hypervariable region indicated as SEQ ID NO: 1, SEQ ID NO: 2, and SEQ ID NO: 3 H Domain; e) Immunoglobulin V containing the hypervariable region shown as SEQ ID NO: 11, SEQ ID NO: 12, and SEQ ID NO: 13 L Domain; f) Immunoglobulin V containing the hypervariable region shown as SEQ ID NOs: 4, 5, and 6 H Domain; g) Immunoglobulin V containing the hypervariable region shown as SEQ ID NO: 14, SEQ ID NO: 15, and SEQ ID NO: 16 L Domain; h) Immunoglobulin V containing the hypervariable region shown as SEQ ID NO: 1, SEQ ID NO: 2, and SEQ ID NO: 3 H Immunoglobulin V containing the domain and the hypervariable region indicated as SEQ ID NO: 11, SEQ ID NO: 12, and SEQ ID NO: 13 L Domain; i) Immunoglobulin V containing the hypervariable region shown as SEQ ID NOs: 4, 5, and 6 H Immunoglobulin V containing the domain and the hypervariable region indicated as SEQ ID NO: 14, SEQ ID NO: 15, and SEQ ID NO: 16 L Domain; j) light chain containing sequence number 19; k) heavy chain containing sequence number 9; or l) light chain containing sequence number 19 and heavy chain containing sequence number 9.

[0139] In some embodiments, the IL-18 antibody or its antigen-binding fragment (e.g., mAb1) contains three CDRs of SEQ ID NO: 7. In other embodiments, the IL-18 antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 17. In other embodiments, the IL-18 antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 7 and three CDRs of SEQ ID NO: 17. In some embodiments, the IL-18 antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 9. In other embodiments, the IL-18 antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 19. In other embodiments, the IL-18 antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 9 and three CDRs of SEQ ID NO: 19.

[0140] In one embodiment, the IL-18 antibody or its antigen-binding fragment (e.g., mAb1) is selected from a human IL-18 antibody comprising at least: a) an immunoglobulin heavy chain or fragment thereof comprising a variable domain containing hypervariable regions CDR1, CDR2, and CDR3 in their sequence, where CDR1 has amino acid sequence number 1, CDR2 has amino acid sequence number 2, and CDR3 has amino acid sequence number 3, and a constant portion or fragment thereof of a human heavy chain; and b) an immunoglobulin light chain or fragment thereof comprising a variable domain containing hypervariable regions CDR1, CDR2, and CDR3 in their sequence, where CDR1 has amino acid sequence number 11, CDR2 has amino acid sequence number 12, and CDR3 has amino acid sequence number 13, and a constant portion or fragment thereof of a human light chain.

[0141] In one embodiment, the IL-18 antibody or its antigen-binding fragment (e.g., mAb1) is selected from a human IL-18 antibody comprising at least: a) an immunoglobulin heavy chain or fragment thereof comprising a variable domain containing hypervariable regions CDR1, CDR2, and CDR3 in their sequence, where CDR1 has amino acid sequence number 4, CDR2 has amino acid sequence number 5, and CDR3 has amino acid sequence number 6, and a constant portion or fragment thereof of a human heavy chain; and b) an immunoglobulin light chain or fragment thereof comprising a variable domain containing hypervariable regions CDR1, CDR2, and CDR3 in their sequence, where CDR1 has amino acid sequence number 14, CDR2 has amino acid sequence number 15, and CDR3 has amino acid sequence number 16, and a constant portion or fragment thereof of a human light chain.

[0142] In one embodiment, the IL-18 antibody or its antigen-binding fragment is selected from a single-chain antibody or its antigen-binding fragment, which includes an antigen-binding site comprising: a) a first domain containing hypervariable regions CDR1, CDR2, and CDR3 in its sequence, where CDR1 has amino acid sequence number 1, CDR2 has amino acid sequence number 2, and CDR3 has amino acid sequence number 3; b) a second domain containing hypervariable regions CDR1, CDR2, and CDR3 in its sequence, where CDR1 has amino acid sequence number 11, CDR2 has amino acid sequence number 12, and CDR3 has amino acid sequence number 13; and c) a peptide linker that binds to either the N-terminus of the first domain and the C-terminus of the second domain, or the C-terminus of the first domain and the N-terminus of the second domain.

[0143] In one embodiment, the IL-18 antibody or its antigen-binding fragment (e.g., mAb1) is selected from a single-chain antibody or its antigen-binding fragment, which includes an antigen-binding site comprising: a) a first domain containing hypervariable regions CDR1, CDR2, and CDR3 in its sequence, where CDR1 has amino acid sequence number 4, CDR2 has amino acid sequence number 5, and CDR3 has amino acid sequence number 6; b) a second domain containing hypervariable regions CDR1, CDR2, and CDR3 in its sequence, where CDR1 has amino acid sequence number 14, CDR2 has amino acid sequence number 15, and CDR3 has amino acid sequence number 16; and c) a peptide linker that binds to either the N-terminus of the first domain and the C-terminus of the second domain, or to either the C-terminus of the first domain and the N-terminus of the second domain.

[0144] V of the IL-18 antibody or its antigen-binding fragment used in the disclosed method H or V L The domain is V, as shown in sequence numbers 7 and 17. H or V L V is essentially the same as the domain. H and / or V LIt may have domains. The human IL-18 antibody disclosed herein may include a heavy chain substantially identical to that shown as SEQ ID NO: 9 and / or a light chain substantially identical to that shown as SEQ ID NO: 19. The human IL-18 antibody disclosed herein may include a) a heavy chain including a variable domain having an amino acid sequence substantially identical to that shown as SEQ ID NO: 7 and a constant portion of a human heavy chain, and b) a light chain including a variable domain having an amino acid sequence substantially identical to that shown as SEQ ID NO: 17 and a constant portion of a human light chain.

[0145] Other preferred IL-18 antagonists (e.g., antibodies) for use in the disclosed methods, kits, and therapeutic plans are those shown in U.S. Patent No. 9,376,489, which is incorporated herein by reference in its entirety.

[0146] 3.IL-1β antibody The particularly preferred IL-1β antibody or its antigen-binding fragment used in the disclosed method is a human antibody.

[0147] For ease of reference, the hypervariable region of the specific IL-1β antibody called mAb2, and V, based on the Kabat and Chothia definitions, are described. L and V H The amino acid sequences of the domain and the complete heavy and light chains are provided in Table 2 below.

[0148] [Table 3]

[0149] In one embodiment, the IL-1β antibody or its antigen-binding fragment comprises at least one immunoglobulin heavy chain variable domain (V) including hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has the amino acid sequence SEQ ID NO: 21, CDR2 has the amino acid sequence SEQ ID NO: 22, and CDR3 has the amino acid sequence SEQ ID NO: 23.H ) comprises. In one embodiment, the IL-1β antibody or its antigen-binding fragment comprises at least one immunoglobulin heavy chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 24, CDR2 has amino acid sequence number 25, and CDR3 has amino acid sequence number 26. H ) includes.

[0150] In one embodiment, the IL-1β antibody or its antigen-binding fragment comprises at least one immunoglobulin light chain variable domain (V) including hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has the amino acid sequence SEQ ID NO: 31, CDR2 has the amino acid sequence SEQ ID NO: 32, and CDR3 has the amino acid sequence SEQ ID NO: 33. L ) comprises. In one embodiment, the IL-1β antibody or its antigen-binding fragment comprises at least one immunoglobulin light chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 34, CDR2 has amino acid sequence number 35, and CDR3 has amino acid sequence number 36. L ) includes.

[0151] In one embodiment, an IL-1β antibody or its antigen-binding fragment is at least one immunoglobulin V H domain and at least one immunoglobulin V L Including the domain, a) immunoglobulin V H The domains include (for example in the sequence): i) hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has amino acid sequence number 21, CDR2 has amino acid sequence number 22, and CDR3 has amino acid sequence number 23; or ii) hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has amino acid sequence number 24, CDR2 has amino acid sequence number 25, and CDR3 has amino acid sequence number 26; b) immunoglobulin V LThe domain includes (for example in the sequence): i) hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has amino acid sequence number 31, CDR2 has amino acid sequence number 32, and CDR3 has amino acid sequence number 33; or ii) hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has amino acid sequence number 34, CDR2 has amino acid sequence number 35, and CDR3 has amino acid sequence number 36.

[0152] In one embodiment, the IL-1β antibody or its antigen-binding fragment is: a) an immunoglobulin heavy chain variable domain (V) containing the amino acid sequence shown as SEQ ID NO: 27 H );b) Immunoglobulin light chain variable domain (V) containing the amino acid sequence shown as Sequence ID No. 37 L );c) Immunoglobulin V containing the amino acid sequence shown as SEQ ID NO: 27 H Immunoglobulin V containing the domain and the amino acid sequence shown as SEQ ID NO: 37 L Domain; d) Immunoglobulin V containing the hypervariable region shown as SEQ ID NOs: 21, 22, and 23 H Domain; e) Immunoglobulin V containing the hypervariable region shown as SEQ ID NO: 31, SEQ ID NO: 32, and SEQ ID NO: 33 L Domain; f) Immunoglobulin V containing the hypervariable region shown as SEQ ID NOs: 24, 25, and 26 H Domain; g) Immunoglobulin V containing the hypervariable region shown as SEQ ID NOs: 34, 35, and 36 L Domain; h) Immunoglobulin V containing the hypervariable region shown as SEQ ID NOs: 21, 22, and 23 H Immunoglobulin V containing the domain and the hypervariable region indicated as SEQ ID NO: 31, SEQ ID NO: 32, and SEQ ID NO: 33 L Domain; i) Immunoglobulin V containing the hypervariable region shown as SEQ ID NOs: 24, 25, and 26 H Immunoglobulin V containing the domain and the hypervariable region indicated as SEQ ID NO: 34, SEQ ID NO: 35, and SEQ ID NO: 36 LDomain; j) light chain containing sequence number 37; k) heavy chain containing sequence number 29; or l) light chain containing sequence number 39 and heavy chain containing sequence number 29.

[0153] In some embodiments, the IL-1β antibody or its antigen-binding fragment (e.g., mAb2) contains three CDRs of SEQ ID NO: 37. In other embodiments, the IL-1β antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 27. In other embodiments, the IL-1β antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 37 and three CDRs of SEQ ID NO: 27. In some embodiments, the IL-1β antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 39. In other embodiments, the IL-1β antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 29. In other embodiments, the IL-1β antibody or its antigen-binding fragment contains three CDRs of SEQ ID NO: 39 and three CDRs of SEQ ID NO: 29.

[0154] In one embodiment, the IL-1β antibody or its antigen-binding fragment (e.g., mAb2) is selected from a human IL-1β antibody comprising at least: a) an immunoglobulin heavy chain or fragment thereof comprising a variable domain containing hypervariable regions CDR1, CDR2, and CDR3 in their sequence, where CDR1 has amino acid sequence number 21, CDR2 has amino acid sequence number 22, and CDR3 has amino acid sequence number 23, and a constant portion or fragment thereof of a human heavy chain; and b) an immunoglobulin light chain or fragment thereof comprising a variable domain containing hypervariable regions CDR1, CDR2, and CDR3 in their sequence, where CDR1 has amino acid sequence number 31, CDR2 has amino acid sequence number 32, and CDR3 has amino acid sequence number 33, and a constant portion or fragment thereof of a human light chain.

[0155] In one embodiment, the IL-1β antibody or its antigen-binding fragment (e.g., mAb2) is selected from a human IL-1β antibody comprising at least: a) an immunoglobulin heavy chain or fragment thereof comprising a variable domain containing hypervariable regions CDR1, CDR2, and CDR3 in their sequence, where CDR1 has amino acid sequence number 24, CDR2 has amino acid sequence number 25, and CDR3 has amino acid sequence number 26, and a constant portion or fragment thereof of a human heavy chain; and b) an immunoglobulin light chain or fragment thereof comprising a variable domain containing hypervariable regions CDR1, CDR2, and CDR3 in their sequence, where CDR1 has amino acid sequence number 34, CDR2 has amino acid sequence number 35, and CDR3 has amino acid sequence number 36, and a constant portion or fragment thereof of a human light chain.

[0156] In one embodiment, the IL-1β antibody or its antigen-binding fragment is selected from a single-chain antibody or its antigen-binding fragment, which includes an antigen-binding site comprising: a) a first domain containing hypervariable regions CDR1, CDR2, and CDR3 in its sequence, where CDR1 has amino acid sequence number 21, CDR2 has amino acid sequence number 22, and CDR3 has amino acid sequence number 23; b) a second domain containing hypervariable regions CDR1, CDR2, and CDR3 in its sequence, where CDR1 has amino acid sequence number 31, CDR2 has amino acid sequence number 32, and CDR3 has amino acid sequence number 33; and c) a peptide linker that binds to either the N-terminus of the first domain and the C-terminus of the second domain, or to either the C-terminus of the first domain and the N-terminus of the second domain.

[0157] In one embodiment, an IL-1β antibody or its antigen-binding fragment (e.g., mAb2) is selected from a single-chain antibody or its antigen-binding fragment, which includes an antigen-binding site comprising: a) a first domain having sequences of hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 24, CDR2 has amino acid sequence number 25, and CDR3 has amino acid sequence number 26; b) a second domain having sequences of hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 34, CDR2 has amino acid sequence number 35, and CDR3 has amino acid sequence number 36; and c) a peptide linker that binds to either the N-terminus of the first domain and the C-terminus of the second domain, or to either the C-terminus of the first domain and the N-terminus of the second domain.

[0158] V of the IL-1β antibody used in the disclosed method H Or V L The domain or its antigen-binding fragment is V, as shown in SEQ ID NOs. 27 and 37. H or V L V is essentially the same as the domain. H and / or V L It may have a domain. The human IL-1β antibody disclosed herein may include a heavy chain substantially identical to that shown as SEQ ID NO: 29 and / or a light chain substantially identical to that shown as SEQ ID NO: 39. The human IL-1β antibody disclosed herein may include: a) one heavy chain including a variable domain having an amino acid sequence substantially identical to that shown as SEQ ID NO: 27 and a constant portion of a human heavy chain; and b) one light chain including a variable domain having an amino acid sequence substantially identical to that shown as SEQ ID NO: 37 and a constant portion of a human light chain.

[0159] Other preferred IL-1β antagonists (e.g., antibodies) for use in the disclosed methods, kits, and therapeutic plans are those shown in U.S. Patent No. 7,446,175, No. 7,993,878, or No. 8,273,350, which are incorporated herein by reference in their entirety.

[0160] 4.Fc modification In addition to, or instead of, modifications made within the framework or CDR region, the antibodies of the present invention may be manipulated to alter one or more functional properties of the antibody, such as serum half-life, complement binding, Fc receptor binding, and / or antigen-dependent cytotoxicity, by including modifications within the Fc region. Furthermore, the antibodies of the present invention may be chemically modified (e.g., one or more chemical moieties may be linked to the antibody) or modified to alter their glycosylation, again to alter one or more functional properties of the antibody. Each of these embodiments is described in further detail below. The numbering of residues in the Fc region follows the EU numbering scheme of Edelman et al., PNAS, 1969 May, 63(1):78-85.

[0161] In one embodiment, the hinge region of CH1 is modified to change the number of cysteine ​​residues in the hinge region, for example, by increasing or decreasing it. This approach is further described in U.S. Patent No. 5,677,425 by Bodmer et al. The number of cysteine ​​residues in the hinge region of CH1 is changed, for example, to promote the assembly of light and heavy chains or to increase or decrease the stability of the antibody.

[0162] In another embodiment, mutations are introduced into the Fc hinge region of an antibody to shorten its biological half-life. More specifically, one or more amino acid mutations are introduced into the CH2-CH3 domain boundary region of the Fc-hinge fragment such that the antibody's binding to Staphylococcus protein A (SpA) is impaired compared to native Fc-hinge domain SpA binding. This approach is described in more detail in U.S. Patent No. 6,165,745 by Ward et al.

[0163] In another embodiment, the antibody is modified to extend its biological half-life. Various approaches are possible. For example, one or more of the following mutations may be introduced into Ward, as described in U.S. Patent No. 6,277,375: T252L, T254S, T256F. Alternatively, to extend the biological half-life, the antibody may be modified within the CH1 or CL region to contain a salvage receptor-binding epitope derived from the two loops of the CH2 domain in the Fc region of IgG, as described in U.S. Patents Nos. 5,869,046 and 6,121,022 by Presta et al.

[0164] In other embodiments, the Fc region is modified by replacing at least one amino acid residue with a different amino acid residue to alter the effector function of the antibody. For example, one or more amino acids may be replaced with different amino acid residues so as to change the antibody's affinity for the effector ligand while preserving the antigen-binding ability of the parent antibody. The effector ligand that alters the affinity may be, for example, the Fc receptor or the C1 component of complement. This approach is described in more detail in U.S. Patent Nos. 5,624,821 and 5,648,260, both by Winter et al.

[0165] In another embodiment, one or more amino acids selected from amino acid residues may be replaced with different amino acid residues so as to alter the C1q binding of the antibody and / or reduce or eliminate complement-dependent cytotoxicity (CDC). This approach is described in more detail in U.S. Patent No. 6,194,551 by Idusogie et al.

[0166] In another embodiment, one or more amino acid residues are altered to change the ability of the antibody to fixate on complement. This approach is further described in international publication brochure 94 / 29351 by Bodmer et al.

[0167] In another embodiment, the Fc region is modified to enhance the antibody's ability to mediate antibody-dependent cytotoxicity and / or to improve the antibody's affinity for the Fcγ receptor by modifying one or more amino acids. This approach is further described in Presta's international publication pamphlet 00 / 42072. Furthermore, binding sites on human IgG1 for FcγRI, FcγRII, FcγRIII, and FcRn have been mapped, and variants with improved binding affinity have been described (see Shields, R. Let al, (2001) J Biol Chem 276:6591-6604).

[0168] In certain embodiments, the Fc domain of an IgG1 isotype is used. In some specific embodiments, mutants of the IgG1 Fc fragment, such as silent IgG1 Fc that reduce or eliminate the ability of a fusion polypeptide to mediate antibody-dependent cytotoxicity (ADCC) and / or bind to the Fcγ receptor, are used. An example of a silent mutant of an IgG1 isotype in which leucine residues at amino acid positions 234 and 235 are replaced by alanine residues is described in Hezareh et al, J. Virol (2001); 75(24): 12161-8.

[0169] In certain embodiments, the Fc domain is a mutant that prevents glycosylation at position 297 of the Fc domain. For example, the Fc domain contains an amino acid substitution of an asparagine residue at position 297. Examples of such amino acid substitutions include the substitution of N297 with glycine or alanine.

[0170] Mutations in the Fc region of antibodies can suppress effector function, as described in the art: LALA and N297A (Strohl, W., 2009, Curr. Opin. Biotechnol. vol. 20(6): 685-691); and D265A (Baudino et al., 2008, J. lmmunol. 181: 6664-69; Strohl, W. above); and DAPA (D265A and P329A) (Shields RL., J Biol Chem. 2001; 276(9): 6591-604; U.S. Patent Application Publication No. 2015 / 0320880). Examples of silent Fc IgG1 antibodies include LALA mutants containing the so-called L234A and L235A mutations in the IgG1 Fc amino acid sequence. Another example of a silent IgG1 antibody contains the D265A mutation. Another example of a silent IgG1 antibody is the so-called DAPA mutant, which contains D265A and P329A mutations in the IgG1 Fc amino acid sequence. Another silent IgG1 antibody contains the N297A mutation, resulting in an aglycosylated / non-glycosylated antibody. Further Fc mutations resulting in effector function suppression are described in International Publication No. 2014 / 145806 (e.g., Figure 7 in International Publication No. 2014 / 145806), which is incorporated herein by reference in its entirety. Examples of silent IgG1 antibodies from International Publication No. 2014 / 145806 include the E233P, L234V, L235A, and S267K mutations and the G236 deletion (G236del). Another example from the international publication brochure 2014 / 145806 of silent IgG1 antibodies includes E233P, L234V, and L235A mutations and G236 deletion (G236del). Another example from the international publication brochure 2014 / 145806 of silent IgG1 antibodies includes the S267K mutation.

[0171] In yet another embodiment, the glycosylation of the antibody is modified. For example, an aglycosylated antibody (i.e., an antibody lacking glycosylation) can be produced. Modifying glycosylation can, for example, improve the affinity of the antibody to an antigen. Such carbohydrate modification can be carried out, for example, by modifying one or more glycosylation sites within the antibody sequence. For example, one or more amino acid substitutions can be made, which exclude one or more variable region framework glycosylation sites, thereby removing glycosylation at those sites. Such aglycosylation can improve the affinity of the antibody to an antigen. Such approaches are described in further detail in U.S. Patent Nos. 5,714,350 and 6,350,861 by Co et al.

[0172] Furthermore, antibodies with altered glycosylation types can be produced, such as hypofucosylated antibodies with reduced amounts of fucosyl residues or antibodies with increased bifurcation of the GlcNac structure. Such modified glycosylation patterns have been shown to improve the ADCC activity of antibodies. Such carbohydrate modifications can be carried out, for example, by expressing antibodies in host cells with a modified glycosylation mechanism. Cells with modified glycosylation mechanisms can be used as host cells, as described in the Art, to express the recombinant antibodies of the present invention and thereby produce antibodies with altered glycosylation. For example, European Patent No. 1,176,195 by Hang et al. describes a cell line in which the FUT8 gene, which encodes fucosyltransferase, is functionally disrupted, and antibodies expressed in such cell lines exhibit hypofucosylation. Thus, in one embodiment, antibodies of the present invention are produced by recombinant expression in cell lines exhibiting a hypofucosylation pattern, such as mammalian cell lines with insufficient expression of the FUT8 gene encoding fucosyltransferase. Presta's international publication 03 / 035835 describes Lecl3 cells, a mutant CHO cell line with reduced ability to attach fucose to Asn(297) linked carbohydrates, resulting in hypofucosylation of antibodies expressed in its host cells (see also Shields, R. Let al., 2002 J. Biol. Chem. 277:26733-26740). Umana et al.'s international publication 99 / 54342 describes a cell line modified to express glycoprotein-modified glycosyltransferases (e.g., beta(1,4)-N acetylglucosaminyltransferase III (GnTIII)) such that antibodies expressed in the modified cell line exhibit increased bifidative GlcNac structure, which enhances the ADCC activity of the antibodies (see also Umana et al., 1999 Nat. Biotech. 17:176-180).Alternatively, the antibodies of the present invention may be produced in yeast or filamentous fungi that have been modified for a mammalian-like glycosylation pattern and are capable of producing antibodies lacking fucose as a glycosylation pattern (see, for example, European Patent No. 1297172B1).

[0173] Another modification of antibodies as envisioned by the present invention is pegylation. Antibodies may be pegylated, for example, to extend their biological (e.g., serum) half-life. To pegylate an antibody, the antibody or its fragment is generally reacted with polyethylene glycol (PEG), such as a reactive ester or aldehyde derivative of PEG, under conditions such that one or more PEG groups are linked to the antibody or antibody fragment. PEGylation may be carried out using a reactive PEG molecule (or a similarly reactive water-soluble polymer) by an acylation or alkylation reaction. As used herein, the term "polyethylene glycol" encompasses any form of PEG used to derivatize other proteins, such as mono(C1-C10) alkoxy- or aryloxy-polyethylene glycol or polyethylene glycol-maleimide. In certain embodiments, the antibody to be pegylated is an aglycosylated antibody. Methods for pegylation of proteins are known in the art and may be applied to the antibodies of the present invention. For example, see European Patent No. 0154316 by Nishimura et al. and European Patent No. 0401384 by Ishikawa et al.

[0174] Another modification of the antibody intended by the present invention is the conjugation or protein fusion of at least the antigen-binding region of the antibody of the present invention with a serum protein, such as human serum albumin or a fragment thereof, to extend the half-life of the resulting molecule. Such an approach is described, for example, in Balance et al. European Patent No. 0322094.

[0175] Another modification of antibodies intended by the present invention is one or more modifications to increase the formation of heterodimerized bispecific antibodies. For example, various approaches available in the art can be used to promote the dimerization of two heavy-chain domains of a bispecific antibody, such as bbmAb, as disclosed in European Patent No. 1870459A1; U.S. Patent No. 5,582,996; U.S. Patent No. 5,731,168; U.S. Patent No. 5,910,573; U.S. Patent No. 5,932,448; U.S. Patent No. 6,833,441; U.S. Patent No. 7,183,076; U.S. Patent Application Publication No. 2006204493A1; and International Publication No. 2009 / 089004A1, the contents of which are incorporated herein in their entirety.

[0176] The preparation of bispecific antibodies using knobs-into-holes is disclosed, for example, in International Publication No. 1996 / 027011, Ridgway et al., (1996) and Merchant et al. (1998).

[0177] In some implementations of the treatment or use methods of this disclosure, a therapeutically effective dose of a bispecific antibody, such as a bbmAb, that simultaneously targets both IL-1β and IL-18 must be administered to the subject in need. It is understood that modifications to the administration schedule may be appropriate for certain patients. Therefore, the administration (of, for example, a bbmAb) may be more frequent, such as daily, every other week, or weekly.

[0178] Some patients may benefit from an initial loading dose regimen (e.g., daily doses over several days [e.g., days 1-4, e.g., administered on days 0, 1, 2 and / or 3]) followed by a maintenance dose regimen initiated in, for example, week 3 or 4, in which bbmAb may be administered weekly, bi-weekly, or every four weeks for several weeks. In some embodiments, the duration of administration of a bispecific antibody targeting both IL-1β and IL-18 simultaneously, such as bbmAb, may be 1 day, 2 days, 3 days, 4 days, etc. These are 1 day, 5 days, 6 days, and 7 days. In some embodiments, the duration of administration of a bispecific antibody that simultaneously targets both IL-1β and IL-18, such as bbmAb, is 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, or longer.

[0179] It should be understood that dose escalation may be appropriate for certain patients, for example, those with a disease severity, or those showing an inadequate response to bbmAb treatment. Therefore, the intravenous (iv) dose may exceed approximately 10 mg / kg, for example, approximately 11 mg / kg, 12 mg / kg, 15 mg / kg, 20 mg / kg, 25 mg / kg, 30 mg / kg, 35 mg / kg, etc. Furthermore, the subcutaneous (sc) dose (initial loading or maintenance dose) may range from approximately 50 mg to approximately 900 mg sc, for example, approximately 75 mg, approximately 100 mg, approximately 125 mg, approximately 175 mg, approximately 200 mg, approximately 250 mg, approximately 350 mg, approximately 400 mg, approximately 450 mg, approximately 500 mg, approximately 600 mg, etc.

[0180] It should be understood that dose reduction may also be appropriate for certain patients, such as those experiencing adverse events or reactions to bbmAb treatment. Therefore, the dosage may be less than approximately 10 mg / kg, for example, approximately 1 mg / kg, 2 mg / kg, 3 mg / kg, 4 mg / kg, 5 mg / kg, 6 mg / kg, 7 mg / kg, 8 mg / kg, or 9 mg / kg. In some embodiments, the bbmAB1 dose may be adjusted as determined by the physician.

[0181] In some embodiments, the bbmAB1 antibody may be administered to the patient as a single dose of 10 mg / kg delivered intravenously, and this dose may be adjusted as needed, as determined by the physician, to higher or lower doses, for example, about 1 mg / kg, about 2 mg / kg, about 3 mg / kg, about 4 mg / kg, about 5 mg / kg, about 6 mg / kg, about 7 mg / kg, about 8 mg / kg or about 9 mg / kg, or for example, about 11 mg / kg, 12 mg / kg, 15 mg / kg, 20 mg / kg, 25 mg / kg, 30 mg / kg, 35 mg / kg, etc.

[0182] In some embodiments, the bbmAB1 antibody may be administered to the patient in an initial dose of 10 mg / kg delivered intravenously, and the dose may then be adjusted to a higher or lower dose as needed, as determined by the physician.

[0183] In a specific embodiment, 10 mg / kg of bbmAB1 is administered on day 1.

[0184] In a specific embodiment, 10 mg / kg bbmAB1 is administered on day 1 (D1), and on days 2 (D2), D3, D4, D5, D6, D7, D8, D9, D10, D11, D12, D13 and / or D14.

[0185] In another specific embodiment, 10 mg / kg bbmAB1 is administered intravenously on day 1. [Examples]

[0186] Example 1: The preparation of bbmAb1 is described in detail in Examples 1-5 of the patent application, International Publication Brochure No. 2018 / 229612. Example 1 of International Publication Brochure No. 2018 / 229612, which includes (1) vector construction, (2) host cell line and gene transfer, (3) cell selection and sorting, (4) cell proliferation, (5) clonal stability, (6) manufacturing, (7) analytical characterization and purity assessment, and (8) analytical results, is incorporated herein by reference in its entirety.

[0187] bbmAb is a bispecific IgG1 with an LALA silencing mutation that simultaneously binds to two distinct targets, IL-1β and IL-18. This antibody combines two distinct antigen-binding arms (Fab fragments); the Fab for IL-1β is based on mAb2 and contains a kappa light chain (Vk6), while the Fab for IL-18 is based on mAb1 and consists of a lambda light chain (Vλ1). To promote heterodimerization of the Fc domain during expression, a "knob" with bulky amino acid (aa) side chains (S354C and T366W) and a "hole" with small aa side chains (Y349C, T366S, L368A, Y407V) were introduced into the mAb2 heavy chain.

[0188] For ease of reference, the ultra-variable region of bbmAb based on Kabat and Chothia definitions and V L and V H The amino acid sequences of the domain, full heavy chain, and light chain are provided in Table 3 below.

[0189] [Table 4]

[0190] [Table 5]

[0191] In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a first immunoglobulin heavy chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 76, CDR2 has amino acid sequence number 77, and CDR3 has amino acid sequence number 78. H1 ) comprises. In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a first immunoglobulin heavy chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 79, CDR2 has amino acid sequence number 80, and CDR3 has amino acid sequence number 81. H1 ) comprises. In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a first immunoglobulin heavy chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 82, CDR2 has amino acid sequence number 83, and CDR3 has amino acid sequence number 84. H1 ) includes.

[0192] In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a second immunoglobulin heavy chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 44, CDR2 has amino acid sequence number 45, and CDR3 has amino acid sequence number 46. H2 ) comprises. In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a second immunoglobulin heavy chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 47, CDR2 has amino acid sequence number 48, and CDR3 has amino acid sequence number 49. H2 ) comprises. In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a second immunoglobulin heavy chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 50, CDR2 has amino acid sequence number 51, and CDR3 has amino acid sequence number 52. H2 ) includes.

[0193] In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a first immunoglobulin light chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 92, CDR2 has amino acid sequence number 93, and CDR3 has amino acid sequence number 94. L1 ) comprises. In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a first immunoglobulin light chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 95, CDR2 has amino acid sequence number 96, and CDR3 has amino acid sequence number 97. L1 ) comprises. In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a first immunoglobulin light chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 98, CDR2 has amino acid sequence number 99, and CDR3 has amino acid sequence number 100. L1 ) includes.

[0194] In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a second immunoglobulin light chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 60, CDR2 has amino acid sequence number 61, and CDR3 has amino acid sequence number 62. L2 ) comprises. In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a second immunoglobulin light chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 63, CDR2 has amino acid sequence number 64, and CDR3 has amino acid sequence number 65. L2 ) comprises. In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises a second immunoglobulin light chain variable domain (V) comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 66, CDR2 has amino acid sequence number 67, and CDR3 has amino acid sequence number 68. L2 ) includes.

[0195] In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, is a first immunoglobulin VH1 Domain and first immunoglobulin V L1 domain, and a) the first immunoglobulin V H1 domain has (e.g., in the sequence): i) hypervariable regions CDR1, CDR2, and CDR3 where CDR1 has the amino acid sequence of SEQ ID NO: 76, CDR2 has the amino acid sequence of SEQ ID NO: 77, and CDR3 has the amino acid sequence of SEQ ID NO: 78; or ii) hypervariable regions CDR1, CDR2, and CDR3 where CDR1 has the amino acid sequence of SEQ ID NO: 79, CDR2 has the amino acid sequence of SEQ ID NO: 80, and CDR3 has the amino acid sequence of SEQ ID NO: 81; or iii) hypervariable regions CDR1, CDR2, and CDR3 where CDR1 has the amino acid sequence of SEQ ID NO: 82, CDR2 has the amino acid sequence of SEQ ID NO: 83, and CDR3 has the amino acid sequence of SEQ ID NO: 84, and b) the first immunoglobulin V L1 domain has (e.g., in the sequence): i) hypervariable regions CDR1, CDR2, and CDR3 where CDR1 has the amino acid sequence of SEQ ID NO: 92, CDR2 has the amino acid sequence of SEQ ID NO: 93, and CDR3 has the amino acid sequence of SEQ ID NO: 94; or ii) hypervariable regions CDR1, CDR2, and CDR3 where CDR1 has the amino acid sequence of SEQ ID NO: 95, CDR2 has the amino acid sequence of SEQ ID NO: 96, and CDR3 has the amino acid sequence of SEQ ID NO: 97; or iii) hypervariable regions CDR1, CDR2, and CDR3 where CDR1 has the amino acid sequence of SEQ ID NO: 98, CDR2 has the amino acid sequence of SEQ ID NO: 99, and CDR3 has the amino acid sequence of SEQ ID NO: 100.

[0196] In one embodiment, the IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, has a second immunoglobulin V H2 domain and a second immunoglobulin V L2 domain, and a) the second immunoglobulin V H2The domains (for example, in sequences) include: i) hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 44, CDR2 has amino acid sequence number 45, and CDR3 has amino acid sequence number 46; or ii) hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 47, CDR2 has amino acid sequence number 48, and CDR3 has amino acid sequence number 49; or iii) hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has amino acid sequence number 50, CDR2 has amino acid sequence number 51, and CDR3 has amino acid sequence number 52; and b) a second immunoglobulin V L2 The domains include (for example, in sequences): i) hypervariable regions CDR1, CDR2, and CDR3 having amino acid sequence number 60, CDR2 having amino acid sequence number 61, and CDR3 having amino acid sequence number 62; or ii) hypervariable regions CDR1, CDR2, and CDR3 having amino acid sequence number 63, CDR2 having amino acid sequence number 64, and CDR3 having amino acid sequence number 65; or iii) hypervariable regions CDR1, CDR2, and CDR3 having amino acid sequence number 66, CDR2 having amino acid sequence number 67, and CDR3 having amino acid sequence number 68.

[0197] In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises: a) a first immunoglobulin heavy chain variable domain (VH1) comprising the amino acid sequence shown as SEQ ID NO: 85; b) a first immunoglobulin light chain variable domain (VH1) comprising the amino acid sequence shown as SEQ ID NO: 101 L1 ); c) First immunoglobulin V containing the amino acid sequence shown as SEQ ID NO: 85 H1 The first immunoglobulin V, comprising the domain and the amino acid sequence shown as SEQ ID NO: 101. L1Domain; d) a first immunoglobulin V domain comprising hypervariable regions shown as SEQ ID NO: 76, SEQ ID NO: 77, and SEQ ID NO: 78 H1 Domain; e) a first immunoglobulin V domain comprising hypervariable regions shown as SEQ ID NO: 92, SEQ ID NO: 93, and SEQ ID NO: 94 L1 Domain; f) a first immunoglobulin V domain comprising hypervariable regions shown as SEQ ID NO: 79, SEQ ID NO: 80, and SEQ ID NO: 81 H1 Domain; g) a first immunoglobulin V domain comprising hypervariable regions shown as SEQ ID NO: 95, SEQ ID NO: 96, and SEQ ID NO: 97 L1 Domain; h) a first immunoglobulin V domain comprising hypervariable regions shown as SEQ ID NO: 76, SEQ ID NO: 77, and SEQ ID NO: 78 H1 Domain, and a first immunoglobulin V domain comprising hypervariable regions shown as SEQ ID NO: 92, SEQ ID NO: 93, and SEQ ID NO: 94 L1 Domain; i) a first immunoglobulin V domain comprising hypervariable regions shown as SEQ ID NO: 79, SEQ ID NO: 80, and SEQ ID NO: 81 H1 Domain, and a first immunoglobulin V domain comprising hypervariable regions shown as SEQ ID NO: 95, SEQ ID NO: 96, and SEQ ID NO: 97 L1 Domain; j) a first light chain comprising SEQ ID NO: 103; k) a first heavy chain comprising SEQ ID NO: 87; or l) a first light chain comprising SEQ ID NO: 103 and a first heavy chain comprising SEQ ID NO: 87.

[0198] In one embodiment, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) a disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome comprises: a) a second immunoglobulin heavy chain variable domain (VH2) comprising the amino acid sequence shown as SEQ ID NO: 53; b) a second immunoglobulin light chain variable domain (V L2 ); c) a second immunoglobulin V domain comprising the amino acid sequence shown as SEQ ID NO: 53 and a second immunoglobulin V domain comprising the amino acid sequence shown as SEQ ID NO: 69 H2 DomainL2 Domain; d) Second immunoglobulin V including the hypervariable region shown as SEQ ID NOs: 44, 45, and 46 H2 Domain; e) Second immunoglobulin V including the hypervariable region shown as SEQ ID NO: 60, SEQ ID NO: 61, and SEQ ID NO: 62 L2 Domain; f) Second immunoglobulin V including the hypervariable region shown as SEQ ID NOs: 47, 48, and 49 H2 Domain; g) Second immunoglobulin V containing the hypervariable region shown as SEQ ID NOs: 63, 64, and 65 L2 domain ; h) A second immunoglobulin V containing a hypervariable region, as shown in SEQ ID NOs. 44, 45, and 46. H2 A second immunoglobulin V including a domain and a hypervariable region indicated as SEQ ID NO: 60, SEQ ID NO: 61, and SEQ ID NO: 62. L2 Domain; i) Second immunoglobulin V containing the hypervariable region shown as SEQ ID NOs: 47, 48, and 49 H2 A second immunoglobulin V including a domain and a hypervariable region indicated as SEQ ID NOs. 63, 64, and 65. L2 Domain; j) Second light chain containing sequence number 81; k) Second heavy chain containing sequence number 55; or l) Second light chain containing sequence number 81 and second heavy chain containing sequence number 55.

[0199] In some embodiments, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises three CDRs of SEQ ID NO: 53. In other embodiments, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises three CDRs of SEQ ID NO: 69. In other embodiments, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises three CDRs of SEQ ID NO: 53 and three CDRs of SEQ ID NO: 69. In some embodiments, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises three CDRs of SEQ ID NO: 85. In other embodiments, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises three CDRs of SEQ ID NO: 101. In other embodiments, an IL-18 / IL-1β bispecific antibody for use in (i) the disclosed treatment or prevention of cytokine release syndrome or cytokine storm syndrome, or (ii) the disclosed method for the treatment or prevention of cytokine release syndrome or cytokine storm syndrome, comprises three CDRs of SEQ ID NO: 85 and three CDRs of SEQ ID NO: 101.

[0200] In some embodiments, (i) an IL-18 / IL-1β bispecific antibody for use in the disclosed treatment of autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations comprises three CDRs of SEQ ID NO: 85. In other embodiments, (i) an IL-18 / IL-1β bispecific antibody for use in the disclosed treatment or prevention of autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations comprises three CDRs of SEQ ID NO: 101. In other embodiments, (i) an IL-18 / IL-1β bispecific antibody for use in the disclosed treatment or prevention of autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations comprises three CDRs of SEQ ID NO: 85 and three CDRs of SEQ ID NO: 101. In some embodiments, (i) an IL-18 / IL-1β bispecific antibody for use in the disclosed treatment or prevention of autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations comprises three CDRs of SEQ ID NO: 53. In other embodiments, (i) an IL-18 / IL-1β bispecific antibody for use in the disclosed treatment or prevention of autoinflammatory disease or disease based on XIAP deficiency or CDC42 mutation comprises three CDRs of SEQ ID NO: 69. In other embodiments, (i) an IL-18 / IL-1β bispecific antibody for use in the disclosed treatment or prevention of autoinflammatory disease or disease based on XIAP deficiency or CDC42 mutation comprises three CDRs of SEQ ID NO: 53 and three CDRs of SEQ ID NO: 69. In one embodiment, (i) an IL-18 / IL-1β bispecific antibody for use in the disclosed treatment or prevention of autoinflammatory disease or disease based on XIAP deficiency or CDC42 mutation comprises three CDRs of SEQ ID NO: 85, three CDRs of SEQ ID NO: 101, three CDRs of SEQ ID NO: 53 and three CDRs of SEQ ID NO: 69.

[0201] In one embodiment, the first portion of an IL-18 / IL-1β bispecific antibody for use in the disclosed treatment or prevention of autoinflammatory or disease-related XIAP deficiency or CDC42 mutation is selected from at least: a) an immunoglobulin heavy chain or fragment thereof comprising a variable domain including hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has the amino acid sequence of SEQ ID NO: 76, CDR2 has the amino acid sequence of SEQ ID NO: 77, and CDR3 has the amino acid sequence of SEQ ID NO: 78, and a constant portion or fragment thereof of a human heavy chain; and b) a human IL-18 antibody comprising a variable domain including hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has the amino acid sequence of SEQ ID NO: 92, CDR2 has the amino acid sequence of SEQ ID NO: 93, and CDR3 has the amino acid sequence of SEQ ID NO: 94, and an immunoglobulin light chain or fragment thereof comprising a constant portion or fragment thereof of a human light chain. Furthermore, the second portion of the IL-18 / IL-1β bispecific antibody is selected from at least: a) an immunoglobulin heavy chain or fragment thereof containing a variable domain comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has the amino acid sequence of SEQ ID NO: 44, CDR2 has the amino acid sequence of SEQ ID NO: 45, and CDR3 has the amino acid sequence of SEQ ID NO: 46, as well as the constant portion or fragment thereof of a human heavy chain; and b) a human IL-1β antibody containing a variable domain comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has the amino acid sequence of SEQ ID NO: 60, CDR2 has the amino acid sequence of SEQ ID NO: 61, and CDR3 has the amino acid sequence of SEQ ID NO: 62, as well as the constant portion or fragment thereof of a human light chain, as well as the immunoglobulin light chain or fragment thereof.

[0202] In one embodiment, the first portion of an IL-18 / IL-1β bispecific antibody for use in the disclosed treatment or prevention of autoinflammatory or disease-related XIAP deficiency or CDC42 mutation is selected from at least: a) an immunoglobulin heavy chain or fragment thereof comprising a variable domain including hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has the amino acid sequence of SEQ ID NO: 76, CDR2 has the amino acid sequence of SEQ ID NO: 77, and CDR3 has the amino acid sequence of SEQ ID NO: 78, and a constant portion or fragment thereof of a human heavy chain; and b) a human IL-18 antibody comprising a variable domain including hypervariable regions CDR1, CDR2 and CDR3, where CDR1 has the amino acid sequence of SEQ ID NO: 92, CDR2 has the amino acid sequence of SEQ ID NO: 93, and CDR3 has the amino acid sequence of SEQ ID NO: 94, and an immunoglobulin light chain or fragment thereof comprising a constant portion or fragment thereof of a human light chain. Furthermore, the second portion of the IL-18 / IL-1β bispecific antibody is selected from at least: a) an immunoglobulin heavy chain or fragment thereof containing a variable domain comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has the amino acid sequence of SEQ ID NO: 44, CDR2 has the amino acid sequence of SEQ ID NO: 45, and CDR3 has the amino acid sequence of SEQ ID NO: 46, as well as the constant portion or fragment thereof of a human heavy chain; and b) a human IL-1β antibody containing a variable domain comprising hypervariable regions CDR1, CDR2, and CDR3, where CDR1 has the amino acid sequence of SEQ ID NO: 60, CDR2 has the amino acid sequence of SEQ ID NO: 61, and CDR3 has the amino acid sequence of SEQ ID NO: 62, as well as the constant portion or fragment thereof of a human light chain, as well as the immunoglobulin light chain or fragment thereof.

[0203] The first V of the IL-18 / IL-1β bispecific antibody used in the disclosed method H1 or V L1 The domain is V, as shown in Sequence IDs 85 and 101. H or V L The first V is substantially identical to the domain. H1 and / or the first V L1It may have domains. The IL-18 / IL-1β bispecific antibody disclosed herein for use in the disclosed treatment or prevention of autoinflammatory or disease based on XIAP deficiency or CDC42 mutation may comprise a first heavy chain substantially identical to that shown as SEQ ID NO: 87 and / or a first light chain substantially identical to that shown as SEQ ID NO: 103. The IL-18 / IL-1β bispecific antibody disclosed herein for use in the disclosed treatment or prevention of autoinflammatory or disease based on XIAP deficiency or CDC42 mutation may comprise a first heavy chain containing SEQ ID NO: 87 and a first light chain containing SEQ ID NO: 103. The IL-18 / IL-1β bispecific antibodies disclosed herein for use in the disclosed treatment or prevention of autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutation may comprise: a) a first heavy chain comprising a variable domain having an amino acid sequence substantially identical to that shown in SEQ ID NO: 85 and a constant portion of a human heavy chain having heterodimerization modifications; and b) a first light chain comprising a variable domain having an amino acid sequence substantially identical to that shown in SEQ ID NO: 101 and a constant portion of a human light chain. The constant portion of the human heavy chain may be IgG1. In one embodiment, IgG1 is human IgG1 without effector mutations. In one embodiment, the human heavy chain IgG1 comprises silencing mutations N297A, D265A, or a combination of L234A and L235A. In a particular embodiment, the human heavy chain IgG1 comprises a silencing mutation which is a combination of L234A and L235A, as shown in SEQ ID NO: 87.

[0204] The second V of the IL-18 / IL-1β bispecific antibody used in the disclosed method H2 or V L2 The domain is V, as shown in Sequence IDs 53 and 69. H or V L The second V is essentially identical to the domain. H2 and / or the first V L2It may have domains. The IL-18 / IL-1β bispecific antibody disclosed herein for use in the disclosed treatment or prevention of autoinflammatory or disease based on XIAP deficiency or CDC42 mutation may include a second heavy chain substantially identical to that shown as SEQ ID NO: 55 and / or a second light chain substantially identical to that shown as SEQ ID NO: 71. The IL-18 / IL-1β bispecific antibody disclosed herein for use in the disclosed treatment or prevention of autoinflammatory or disease based on XIAP deficiency or CDC42 mutation may include a second heavy chain containing SEQ ID NO: 53 and a second light chain containing SEQ ID NO: 69. The IL-18 / IL-1β bispecific antibodies disclosed herein for use in the disclosed treatment or prevention of autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations may comprise: a) a second heavy chain comprising a variable domain having an amino acid sequence substantially identical to that shown in SEQ ID NO: 53 and a constant portion of a human heavy chain having a heterodimerization modification complementary to the heterodimerization of the first heavy chain; and (b) a second light chain comprising a variable domain having an amino acid sequence substantially identical to that shown in SEQ ID NO: 69 and a constant portion of a human light chain. The constant portion of the human heavy chain may be IgG1. In one embodiment, IgG1 is human IgG1 without effector mutations. In one embodiment, the human heavy chain IgG1 comprises silencing mutations N297A, D265A, or a combination of L234A and L235A. In a particular embodiment, the human heavy chain IgG1 comprises a silencing mutation which is a combination of L234A and L235A, as shown in SEQ ID NO: 55.

[0205] Other preferred IL-18 antagonists (e.g., antibodies) for use as the first part of a bispecific antibody in the disclosed methods, kits, and dosing regimens are those shown in U.S. Patent No. 9,376,489, which is incorporated herein by reference in its entirety.

[0206] Other preferred IL-1β antagonists (e.g., antibodies) for use as the second part of the bispecificity in the disclosed method are those shown in U.S. Patent No. 7,446,175, No. 7,993,878, or No. 8,273,350, which are incorporated by reference in their entirety herein.

[0207] Example 2: In vitro activity of bbmAb1 The binding activity of bbmAb was tested in various different cell assays.

[0208] (1) Materials and methods (a) In the case of a solution equilibrium titration (SET) assay The following materials were used. Recombinant human IL-18, biotinylated (BTP25828) Recombinant cynomolgus macaque IL-1β (Novartis) Anti-human IgG antibody, sulfo-TAG labeled (Meso Scale discovery (MSD) #R32AJ-5) Goat anti-human Fab-specific compound with MSD sulfo-TAG NHS ester (Jackson Immuno Research #109-005-097, MSD #R91AN-1) BSA (Sigma #A-9647) MSD read buffer containing surfactant (MSD#R92TC-1) Phosphate-buffered saline (PBS) 10x (Teknova #P0195), Tris-buffered saline, pH 7.5 (TBS) 10x (Teknova #T1680), Tween-20 (Fluka #93773) Polypropylene Microtiter Plate (MTP) (Greiner #781280) 384-well plate, standard (MSD#L21XA)

[0209] (b) In the case of cell assays and SET assays mAb2 as described in the IL-1β antibody section. mAb1 as described in the IL-18 antibody section. A bbmAb as described in Example 1. Recombinant human IL-18 (BTP25829) purchased from MBL Int.Corp. (#B001-5) Recombinant marmoset IL-1β (Novartis) Recombinant Marmoset IL-18 (Novartis) Recombinant human IL-12 (#573008) was purchased from Biolegend. KG-1 cell line (ATCC#CCL-246) Normal human dermal fibroblasts (#CC-2509) were purchased from Lonza. Marmoset skin fibroblasts (#42637F(510)) HEK-Blue(trademark) IL-18 / IL-1β cells (#hkb-il18) were purchased from InvivoGen. PBMC was isolated from Buffycoat and obtained from Blutspendezentrum Bern. The marmoset blood was obtained from SILABE, Niederhausbergen. IL-6 ELISA: Human (BioLegend, #430503); Marmoset (U-CyTech biosciences, CT974-5) IFNγ ELISA: Human (BD555142) and marmoset (U-CyTech biosciences#CT340A) The QUANTI-Blue® assembly (#rep-qb1) for SEAP detection was purchased from InvivoGen. Cell medium: RPMI1640 (Invitrogen#31870) supplemented with 10% fetal bovine serum (Invitrogen#10108-157), 1% L-glutamine (Invitrogen#25030-03), 1% penicillin / streptomycin (Invitrogen#15140-148), 10 μM 2-mercaptoethanol (Gibco#31350-010), and 5 mM Hepes (Gibco#15630-080). Round-bottom, tissue culture treated 96-well plate (Costar #3799) Flat-bottom, tissue culture-treated 96-well plate (Costar #3596) Ficoll-Pacque (trademark) Plus (GE Healthcare Life Sciences #17-1440-02), PBS 1X, calcium and magnesium free (Gibco #14190094) Leucosep tube with porous membrane, 50 mL, polypropylene (Greiner bio-one #227290) Falcon 15 mL polypropylene conical tube (BD #352096) Falcon 50 mL polypropylene conical tube (BD #352070)

[0210] (c) Affinity measurement by SET SET individual target binding assay Prepare serial 1.6-fold dilutions of 22 types of antigens (maximum concentrations: huIL-18, 5 nM; marIL-18, 10 nM; huIL-1β, 0.5 nM; marIL-1β, 0.5 nM) in sample buffer (PBS containing 0.5% bovine serum albumin (BSA) and 0.02% Tween-20), and add a certain concentration of antibody (10 pM for IL-18 reading, 1 pM for IL-1β reading). Dispense 60 μL / well volumes of each antigen-antibody mixture in duplicate into a 384-well polypropylene microtiter plate (MTP). Use sample buffer as the negative control and a sample containing only the antibody as the positive control (maximum electrochemiluminescence signal without antigen, B max ). Seal the plate and incubate overnight (o / n, at least 16 hours) at room temperature (RT) on a shaker.

[0211] IL-18 reading: Coat a streptavidin-coated 384-well MSD array MTP with 30 μL / well of biotinylated huIL-18 (0.1 μg / mL, PBS) and incubate for of 1 hour at RT on a shaker.

[0212] IL-1β readings: Standard 384-well MSD array MTPs were coated with 30 μL / well of huIL-1 (3 μg / mL, PBS) diluted in PBS as a supplement, and left overnight at 4°C.

[0213] The plate was blocked at room temperature (RT) for 1 hour (h) with 50 μL / well blocking buffer (PBS containing 5% BSA). After washing (TBST, TBS containing 0.05% Tween20), 30 μL / well of the equilibrated antigen-antibody mixture was transferred to an MSD plate coated from polypropylene MTP and incubated at RT for 20 minutes. After a further washing step, 30 μL of sulfotag-labeled anti-IgG detection antibody (0.5 μg / mL), diluted in sample buffer, was added to each well and incubated on a shaker at RT for 30 minutes. The MSD plate was washed, 35 μL / well MSD read buffer was added, and incubated at RT for 5 minutes. Electrochemiluminescence (ECL) signals were generated and measured using an MSD Sector Imager 6000.

[0214] SET simultaneous target binding assay Except for assay A, the SET assay was performed as described above: K of the other target D While evaluating the effects, the equilibration step (antibody / antigen mixture) was performed in the presence of an excess amount of one target (either 500 pM IL-18 or IL-1β). Assay B: Simultaneously, the equilibration step (antibody / antigen mixture) was performed with both targets in serial dilutions of a single mixture (constant antibody concentration of 10 pM, maximum antigen concentration, see above). Next, the same mixture was analyzed for its free antibody concentration on IL-18 and IL-1β coated plates as described above.

[0215] SET data was exported to Xlfit, MS Excel add-in software. The mean ECL signal was calculated from the paired measurements within each assay. The data were baseline-adjusted by subtracting the lowest value from all data points and plotted against the corresponding antigen concentration to create titration curves. The plots were fitted using the following: D The value was determined:

[0216] 1:2 binding model for monospecific Ab

number

number

[0217] (d) Cell culture 2x10 5 ~1x10 6 KG-1 cells were grown in RPMI1640 supplemented with 10% fetal bovine serum, 1% L-glutamine, and 1% penicillin / streptomycin at a density of 100 viable cells / mL.

[0218] Normal human fibroblasts and marmoset fibroblasts were grown in FBM (Clonetics, CC-3131) containing bFGF (1 ng / mL, CC-4065), insulin (5 μg / mL, CC-4021), and 2% FCS (CC-4101). Fibroblast basal medium (LONZA#CC-3131) was used as the starvation medium.

[0219] HEK-Blue® IL-18 / IL-1β cells were grown in growth medium (DMEM, 4.5 g / L glucose, 10% (v / v) fetal bovine serum, 50 U / mL penicillin, 50 mg / mL streptomycin, 100 mg / mL Normocin®, 2 mM L-glutamine) supplemented with 30 μg / mL blastosidine, 200 μg / mL HygroGold®, and 100 μg / mL Zeocin®.

[0220] Following the manufacturer's instructions, human peripheral blood mononuclear cells (PBMCs) were isolated fresh from buffy coat using LeucoSep tubes. Briefly, 13 mL of Ficoll-Paque was pre-filled into 14 mL LeucoSep tubes by centrifugation at 1,000 x g for 30 seconds. Heparinized whole blood samples were diluted with an equal volume of PBS, and 25 mL of the diluted blood was added to the LeucoSep tubes. The cell isolation tubes were centrifuged at 800 x g for 15 minutes without disruption at room temperature. The cell suspension layer was collected, and the cells were washed twice with PBS (two consecutive washes at 640 x g and 470 x g for 10 minutes each) and resuspended in culture medium before counting.

[0221] Marmoset blood was collected in heparinized tubes and filtered using a 70 μm cell strainer (BD Biosciences #352350).

[0222] (e) IL-1β neutralization assay With slight modifications, the IL-1β-induced IL-6 production assay in fibroblasts was performed essentially as described (Gram2000). Briefly, fibroblasts were seeded at a density of 5 x 10³ cells / well (100 μL) in a 96-well flat-bottom tissue culture plate. The following day, the cells were starved in starvation medium for 5 hours before adding the recombinant IL-1β / compound solution mixture (IL-1β concentrations are shown in the table). The IL-1β / compound solution mixture was pre-prepared by incubating recombinant IL-1β with compounds within the concentration range at 37°C for 30 minutes. After o / n incubation at 37°C, the cell supernatant was collected, and the amount of released IL-6 was determined by ELISA. The IL-1β-induced IL-6 production assay in PBMCs was performed as follows: 3 x 10³ cells 5 PBMCs were seeded at a rate of 1 cell / well (in 100 μL) in a 96-well tissue culture plate and incubated at 37°C for 24 hours with recombinant IL-1β / compound solution mixture (IL-1β concentrations are shown in the table). Recombinant IL-1β / compound solution mixtures were pre-prepared by incubation at 37°C for 30 minutes with compounds within the specified concentration range. Cell supernatant was collected 24 hours after stimulation, and the amount of released IL-6 was determined by ELISA.

[0223] (f) IL-18 neutralization assay The assay was basically performed as follows: 3 x 10 5 KG-1 cells (pre-starved in PBS + 1% FCS for 1 hour) or PBMCs were seeded at a density of / well into a round-bottom 96-well cell culture plate and incubated with a recombinant IL-18 / IL-12 solution mixture along with compounds within the specified concentration range (IL-18 / IL-12 concentrations are shown in the table). After incubation at 37°C for 24 hours, the supernatant was collected and the amount of released IFNγ was determined by ELISA. For assays using marmoset blood, 85 μL / well of blood was used.

[0224] (g) Dual IL1β / IL-18 neutralization in HEK-Blue® cells The assay was performed essentially as described in the manufacturer's operating procedure. Briefly, HEK-Blue™ cells were seeded at a density of 4x10 4 / well in a 96-well cell culture plate and incubated with a solution mixture of recombinant IL-1β and IL-18 together with compounds in a concentration range (to generate a 1:1 SEAP signal). After incubation at 37°C for 24 hours, the supernatant was recovered and the amount of released SEAP was determined by using the QUANTI-Blue™ method according to the manufacturer's instructions.

[0225] All data were exported to EXCEL software and the IC50 value was calculated by plotting a dose-response curve against a logarithmic curve fitting function using either EXCEL / XLfit4 or GraphPad Prism software.

[0226] (2) Results (a) Affinity for recombinant human and marmoset IL1β and IL-18 The binding affinity of bbmAb for human and marmoset recombinant IL-1β and IL-18 proteins was measured by solution equilibrium titration (SET) titration, and the resulting K D values were compared with mAb2 for IL-1β and mAb1 for IL-18 binding. Comparing the binding affinities in individual target binding assays, bbmAb showed similar mean KD values compared to mAb1 for human and marmoset IL-18 (Table 4). For human IL-1β binding, the mean KD value was slightly higher for bbmAb (2.6 pM) compared to mAb2 (0.6 pM), but was in the same low pM range. Subsequent measurements in a simultaneous dual-target binding assay (Table 5) confirmed that the bbmAb binding KD value for IL-1β was similar to that of mAb2 for preclinical as well as clinical grade materials. Thus, bbmAb retains binding affinity for both targets in human and marmoset, which are similar to mAb2 and mAb1 respectively.

[0227] [Table 6]

[0228] In addition to the individual target binding results, K of other targets D The simultaneous dual-target binding affinity of bbmAb was investigated by applying either one of the excess targets during the evaluation of binding (Assay A), or by applying a mixture of both targets during serial dilution (Assay B) (Table 5). From the simultaneous IL-1β / IL-18 affinity determination, no significant difference was shown between Assay A (excess one antigen) and Assay B (mixture of both antigens in serial dilution), demonstrating that both targets bind simultaneously without affecting the binding of the other target. Furthermore, the K obtained from the simultaneous dual-binding assay... D The value is K obtained in a standard assay. D The values ​​were similar (Table 4; in the absence of the second antigen), demonstrating that bbmAb can independently bind to both antigens. Therefore, bbmAb binds to both human IL-1β and IL-18 simultaneously and independently, and cross-reacts completely with the corresponding marmoset proteins.

[0229] [Table 7]

[0230] (b) Neutralizing activity of bbmAb in human and marmoset cell assays The neutralizing activity of bbmAb against both cytokines (IL1β and IL-18) was evaluated (mAb2mAb1). Furthermore, the efficacy of bbmAb in neutralizing marmoset IL-1β and IL-18 was evaluated using a marmoset cell assay system (see section d).

[0231] (c) Individual and simultaneous IL-1β and IL-18 neutralization in human cells The neutralizing activity of bbmAb on IL-1β was evaluated by inhibiting recombinant IL-1β-induced IL-6 production in human dermal fibroblasts (using IL-1β at 6 pM) and human PBMCs (using IL-1β at 60 pM). The neutralizing activity of bbmAb on IL-18 was measured by inhibiting recombinant IL-18-induced IFN-γ production in KG-1 cells and human PBMCs (both cells were activated with 3 nM recombinant human IL-18 along with 1 ng / mL recombinant human IL-12). The inhibitory efficacy of bbmAb on IL-1β and IL-18 was always compared to either mAb2 or mAb1, respectively. Depending on the assay, the mean IC50 values ​​of bbmAb were in the sub-nM or single-digit nM range, and were up to 2-4 times higher than mAb2 (for IL-1β) and mAb1 (for IL-18), respectively, in direct comparison (Tables 6 and 7). The monovalent form of bbmAb compared to the bivalent form of mAb2 / mAb1, and potentially KiH mutations, could also be reasons for this slight difference in the potency of bbmAb.

[0232] [Table 8]

[0233] [Table 9]

[0234] bbmAb was able to simultaneously neutralize the bioactivity of both IL-1β and IL-18, as demonstrated in HEK Blue® reporter cells that produce SEAP in response to 1+1 stimulation with recombinant IL-1β and IL-18 (Table 88). Similar inhibition of SEAP in this assay system was only achievable with the combination of mAb2 and mAb1, and not with the use of individual antibodies.

[0235] [Table 10]

[0236] (d) Neutralizing activity of bbmAb in marmoset IL-1β and marmoset IL-18 in marmoset cell assays. To elucidate the inhibitory activity of bbmAb1 in marmosets, a similar in vitro assay was performed using marmoset cells, similar to that used with human cells, but with recombinant marmoset IL-1β and IL-18 for stimulation. When evaluating the inhibition of recombinant marmoset IL-1β-induced IL-6 production in marmoset dermal fibroblasts, bbmAb1 showed subnM potency with an IC50 value 2-3 times higher than mAb2 (Table 99). Tests of bbmAb1 using human dermal fibroblasts stimulated with marmoset IL-1β yielded an inhibitory profile similar to that obtained with human IL-6.

[0237] [Table 11]

[0238] The neutralizing activity of bbmAb1 against marmoset IL-18, as measured by an IFNγ production assay using marmoset blood cells, was confirmed by the one- to two-digit nM IC50 values ​​of bbmAb1 (Tables 4-7). A similar inhibition profile was obtained from bbmAb1 tests using human PBMCs stimulated with marmoset IL-18, as was observed when human IFNγ production was measured.

[0239] Therefore, bbmAb1 was shown to be fully cross-reactive with marmoset IL-1β and marmoset IL-18 in a functional assay using marmoset-responsive cells.

[0240] [Table 12]

[0241] In various different cell assays, bbmAb1, a KiH-type IL-1β / IL-18 bispecific mAb, was found to retain high affinity binding and cytokine neutralizing efficacy against two distinct targets, IL-1β and IL-18, compared to mAb, mAb2, and mAb1. The dual IL-1β and IL-18 neutralizing properties of bbmAb1 were demonstrated not only against human cytokines / cells but also against corresponding marmoset cytokines / cells, facilitating appropriate toxicological studies. The up to 2-4 times higher IC50 values ​​observed in some cell assays for IL-1β and IL-18 neutralization may be a result of monovalent binding of bbmAb1, in contrast to the divalent binding of mAb2 and mAb1, respectively. Nevertheless, the dual cytokine neutralization by bbmAb1 may result in additive or synergistic inhibitory activity in vivo that cannot be accurately represented in our in vitro cell lines.

[0242] Example 3: Effects of stimulating and blocking a combination of IL-1β and IL-18 in PBMCs Inflammasome activation-dependent cleavage of effector cytokines IL-1β and IL-18 leads to the induction of secondary pro-inflammatory mediators, promoting immune cell recruitment / activation not only systemically but also at the site of inflammation. In two different mouse models for lethal systemic inflammation, (a) an LPS injection model and (b) FCAS mice (activating missense mutation in NLRP3), simultaneous deficiency / inhibition of both IL-1β and IL-18 was more protective against lethality compared to single IL-1β or single IL-18 deficiency / inhibition, revealing additive or synergistic mechanisms for immune activation (Brydges 2013, van den Berghe 2014). bbmAb1 is a human / marmoset IL-1β / IL-18-responsive bispecific mAb that does not cross-react with rodents and therefore cannot be tested in mouse models. Therefore, to clarify the additive or synergistic inhibitory effects of the bbmAb1-mediated IL-1β / IL-18 neutralization combination, the inventors mimicked in vitro inflammasome-dependent pathway activation in response to stimulation of human PBMCs using LPS / IL-12 and performed unbiased gene expression analysis using microarrays. As complementary activity, the inventors also compared the gene expression profiles of PBMCs from different donors stimulated with either recombinant IL-1β and recombinant IL-18 combinations or single cytokines alone.

[0243] (3) Materials and methods (a) Cell culture and ELISA RPMI1640 (Invitrogen#31870 or Gibco#61870-010) supplemented with 10% fetal bovine serum (Invitrogen#10108-157), 1% L-glutamine (Invitrogen#25030-03), 1% penicillin / streptomycin (Invitrogen#15140-148), 10 μM 2-mercaptoethanol (Gibco#31350-010), and 5 mM Hepes (Gibco#15630-080). Recombinant human IL-1β was purchased from Sino Biological Inc. (#10139-HNAE-5). Recombinant human IL-18 was purchased from MBL (#B001-5). Recombinant human IL-12 was purchased from Biolegend (#573008). IFNγ ELISA: MAX Standard Set, BioLegend, #430103 or BD OptEIA Human IFNγ ELISA Set, BD#555142 IL-6 ELISA:MAX Standard Set, BioLegend, #430503 IL-26 ELISA:Cloud Clone Corp #SEB695Hu mAb2 as described in the IL-1β antibody section. mAb1 as described in the IL-18 antibody section. bbmAb1 as described in Example 1. LPS derived from Salmonella enterica serotype enteritidis, Sigma #L7770 PBMC was isolated from buffy coat obtained from Blutspendezentrum Bern. Round-bottom tissue culture treated 96-well plates (Costar #3799), flat-bottom tissue culture treated 96-well plates (Costar #3596), Ficoll-Pacque (trademark) Plus (GE Healthcare Life Sciences #17-1440-02), PBS 1X, calcium and magnesium free (Gibco #14190094) Falcon 15mL Polypropylene Conical Tube (BD#352096) Falcon 50mL Polypropylene Conical Tube (BD#352070) Leucosep™ tube with porous diaphragm, 50 mL, Greiner bio-one #227290 Cell strainer 70 μM, BD Biosciences #352350 Tripan Blue, Sigma #T8154 RNA isolation, quantification, and quality control, and qPCR: Nuclease-free, Ambion #AM9938 Rnase Zap, Ambion #AM9780 1.5 mL Eppendorf tube, sterile, RNase and DNase-free. RLT buffer, Qiagen#1015762 Rneasy Mini Kit, Qiagen#74104 RNase-Free DNase Set, Qiagen#79254 Agilent RNA 6000 Nano Kit, Agilent#5067-1511 Chip priming station, Agilent #5065-4401 IKA Vortex Mixer RNaseZAP (registered trademark), Ambion #9780 Agilent 2100 Bioanalyzer High Capacity cDNA Reverse Transcription Kit, Applied Biosystems, #PN4374966 Nase-free, thin-walled, forsted lid 0.2 mL PCR tube, Ambion #AM12225 MicroAmp Optical 384-well reaction plate, Applied Biosystems #4309849 TaqMan GenEx Master Mix, Applied Biosystems#4369514 PCR primers (Applied Biosystems)

[0244] [Table 13]

[0245] PBMC Preparation: Following the manufacturer's instructions, PBMCs were isolated from buffy coat by Ficoll-Paque gradient centrifugation in a Leucosep tube. Briefly, 15 mL of Histopaque was placed in a 50 mL Leucosep™ tube and centrifuged at 1300 rpm for 30 seconds on RT. Using a pipette, 30 mL of diluted suspension of buffy coat was added to the top of the Histopaque solution and centrifuged at 1000 g for 15 minutes on RT without disruption. The plasma (approximately 20 mL) was discarded, the annular portion of the interface (= human PBMCs) was collected and transferred to a 50 mL Falcon tube. This tube was filled with 50 mL of sterile PBS and centrifuged once at 1200 rpm for 5 minutes on RT. This centrifugation was repeated twice. The supernatant was gently discarded, and the cells were resuspended in 50 mL of PBS containing 2% FCS and 2 mM EDTA. The cell suspension was filtered using a 70 μm cell strainer, and the cells were counted using trypan blue staining (500 μL trypan blue + 200 μL cells + 300 μL PBS).

[0246] LPS / IL-12 stimulation of PBMCs: Cytokine production in the supernatant was prepared as follows: 250,000 cells / well in a final volume of 100 μL was distributed in a 96-well round-bottom plate. LPS was used at concentrations of 0.3 μg / mL to 3000 μg / mL together with recombinant IL-12 at 10 ng / mL. The supernatant was collected after 24 hours at 37°C and 10% CO2.

[0247] RNA extraction from the cell pellet was performed as follows: 3 x 10 cells in a final volume of 1000 μL. 6 Cells were distributed per well in a flat-bottomed 24-well plate. LPS was administered at 3 μg / mL along with recombinant IL-12 at 10 ng / mL. Cells were harvested after 24 hours at 37°C and 10% CO2.

[0248] Stimulation of PBMCs with recombinant cytokines: 7 x 10 per well in a 12-well plate in 1.5 mL of final complete RPMI medium. 6Individual PBMCs were used. Recombinant cytokines were added at the following final concentrations: 10 ng / mL recombinant IL-1β, 3 nM recombinant IL-18, and 1 ng / mL recombinant IL-12. Both the supernatant and cells were collected after 4 and 24 hours at 37°C and 10% CO2.

[0249] RNA isolation, quantification, and quality assessment: Cells were pelletized and dissolved in 350 μL of Qiagen RTL buffer with 2% β-mercaptoethanol. The pellets were frozen at -20°C or -80°C until all test samples were recovered. RNA isolation was performed using the Qiagen standard protocol. Briefly, 350 μL of 70% ethanol was added to all samples before transferring them to the RNeasy spin column, and the column was centrifuged at 8000 g for 15 seconds. After discarding the flow-through, 350 μL of buffer RW1 was added, and the column was centrifuged at 8000 g for 15 seconds to wash the spin column membrane. A DNase I warming mixture was prepared according to the manufacturer's instructions, added to the RNeasy spin column, and warmed at RT for 15 minutes. After washing with 350 μL and 500 μL of buffer RW1, the RNeasy spin column was placed in a new 2 mL recovery tube and centrifuged at full speed for 1 minute. RNA was finally recovered by directly adding 35 μL of RNase-free water to the spin column membrane, and the RNA was eluted by centrifugation at 8000 g for 1 minute. The amount of RNA was measured using Nanodrop ND-1000, and the RNA was stored at -20°C. RIN measurement was performed for RNA quality assessment according to the manufacturer's instructions. Briefly, 1 μL of RNA or ladder was pipetted into an Agilent RNA 6000 Nano tip and measured using an Agilent 2100 Bioanalyser.

[0250] Cytokine gene expression analysis by qPCR: This procedure was performed in accordance with the manufacturer's instructions. Briefly, 400 ng of RNA was reverse transcribed using a High-Capacity cDNA Reverse Transcription Kit according to the instructions. The cDNA solution was diluted 1 / 10 in RNA / DNA-free water, and 1 μL of cDNA was transferred to a 384-well reaction plate. This plate was then mixed with 1 μL of 20X TaqMan® Gene Expression Assay target FAM gene, 10 μL of 2x TaqMan® Gene Expression Master Mix, and 10 μL of RNA / DNA-free water. The plate was placed on an Applied Biosystems ViiA® 7 Real-Time PCR System, using the following instrument settings:

[0251] [Table 14]

[0252] The housekeeping genes used in this study were HPRT1 and RLP27. The following formula was used to calculate the relative expression levels of the target genes: 1)Ct[Ref]=(Ct[HPRT1]+Ct[RLP27]) / 2 2) dCt[Ref] = 40 - Ct[Ref] 3)dCt[Target]=Ct[Target]-Ct[Ref] 4) ddCt = dCt[Ref] - dCt[Target] 5) Relative target gene expression = 2^ddCt

[0253] Microarray analysis was performed as follows: Samples were processed using CiToxLAB France on an Affymetrix HG_U133_Plus2 microarray. These were RMA normalized and analyzed using GeneSpring 11.5.1 (Agilent Technologies, Santa Clara, CA). Pathway analysis was performed using Ingenuity Pathway Analysis (IPA) and Nextbio (Illumina). The two datasets were processed independently.

[0254] First, the data was submitted to standard quality control (QC) by CiToxLAB, in-house QC, using the R script (MA_AffyQC.R) in RStudio suite and GeneSpring (PCA, hybrid formation control). Subsequently, it was filtered to remove unreliable expression levels: entities (probe sets) were maintained in which at least 100 percent of the samples had values ​​above the 20th percentile under any one of the experimental conditions.

[0255] In GeneSpring, differentially expressed genes (DEGs) were identified using the "filter on volcano plot" feature. Using the filtered genes (expression at the 20th to 100th percentiles) along with independent t-tests, probe sets with corrected p-values ​​below 0.05 and a metric change above 2.0 were considered differentially expressed. Where possible, i.e., in LPS (NUID-0000-0202-4150) testing, Benjamini-Hochberg multiple testing correction was used.

[0256] In cytokine stimulation experiments, the synergistic effect was calculated using the following formula: Signal A + B / (Signal A + Signal B - Control) ≥ 1.5.

[0257] Using individual signatures (or DEG lists), p-values ​​were calculated using Fisher's exact test to represent the statistical significance of observing overlaps between signatures and the "disease gene lists" (lesion vs. non-lesion) in the publicly available dataset. To do this, lists were uploaded to the Illumina Base Space Correlation Engine (formerly Nextbio) and compared using meta-analysis characteristics and keyword searches for diseases.

[0258] All data is exported to Excel software, and the dose-response curve is plotted against a logistic curve fitting function using either Excel / XLfit4 or GraphPad Prism software to obtain IC. 50 The values ​​were calculated. Differences between treatment groups were analyzed using GraphPad Prism software by performing one-way ANOVA followed by Dunnett's multiple comparisons, and the results were considered statistically significant at p<0.05.

[0259] (4) Results (a) bbmAb1 is highly effective in inhibiting LPS / IL-12-induced IFNγ production in whole blood. Exposure of human whole blood to LPS supplemented with 10 ng / mL IL-12 results in an IFNγ response that is highly dependent on, but not solely, "native" IL-18 produced by blood cells. The addition of IL-12 enhances the LPS-induced IFNγ response, likely through upregulation of IL-18 receptors in responding cells.

[0260] Under the experimental conditions used, IL-18 neutralization with mAb1 resulted in only incomplete inhibition of IFNγ production, while IL-1β inhibition (using mAb2) had only a small effect on the IFNγ response. Interestingly, the combined inhibition of IL-1β and IL-18 by either bbmAb1 or a combination of mAb2 and mAb1 resulted in deeper and more complete inhibition of IFNγ production compared to single cytokine neutralization.

[0261] Aside from IFNγ, none of the other cytokines tested in the inventors' cell assays (IL-2, -4, -6, -8, -10, -13, and TNFα) were additively inhibited by the combination of neutralization of IL-1β and IL-18 (data not shown). The potency of bbmAb1 was within the same range as the combination (combo) of mAb2 and mAb1, considering the monovalent form of the bispecific molecule.

[0262] (b) IFNγ was additively inhibited by bbmAb1 (i.e., a combination of IL-1β / IL-18 inhibition) in LPS / IL-12 activated human PBMCs compared with single IL-1β or IL-18 inhibition. To elucidate further additive effects of the IL-1β / IL-18 inhibition combination using bbmAb1 (separate from IFNγ), an unbiased transcriptomics evaluation was necessary. Since whole blood is not optimal for transcriptomics analysis, the inventors adapted the LPS / IL-12 stimulation assay conditions described in the Materials and Methods section above to human PBMC samples. Using PBMCs from a total of nine donors, the inventors were able to confirm that bbmAb1 additively inhibited IFNγ protein secretion into the PBMC supernatant. IFNγ production was inhibited using individual mAbs at approximately 10-fold lower concentrations compared to whole blood experiments. Importantly, similar inhibition patterns were observed at the mRNA level for IFNγ, confirming the suitability of the samples for gene expression analysis based on unbiased microarrays. The data demonstrate the inhibition of LPS (0.3 μg / mL) / IL-12-induced IFNγ protein production and IFNγ gene expression in human PBMCs by bbmAb1, mAb2, and mAb1 (each at 10 nM concentration).

[0263] Affymetrix microarrays were performed on n=5 donors from PBMCs sampled from the LPS / IL-12 stimulation experiments described in the Materials and Methods section above. Unfortunately, the overall evaluation of gene expression profiles revealed a potent LPS / IL-12 stimulation effect, and PCA showed clustering by donor rather than by compounds within the stimulated or unstimulated groups. Nevertheless, comparison of LPS / IL-12 stimulated samples with stimulation + bbmAb1 for differentially expressed genes revealed a final candidate list of genes downregulated by the IL-1β / IL-18 blockade combination with bbmAb1 (Table 11). Apart from the potent downregulation of the IFNγ gene, which was re-examined using the inventors' microarray data, the IL-26 gene was another cytokine gene that was additively inhibited by bbmAb1 compared to single IL-1β inhibition (by mAb2) or IL-18 inhibition (by mAb1). Microarray data revealed that in LPS (0.3 μg / ml) / IL-12-stimulated PBMCs, gene expression levels and inhibition of IFNγ and IL-26 were observed after 24 hours, induced by bbmAb1, mAb2, and mAb1 (10 nM each).

[0264] [Table 15]

[0265] (c) IL-26 is another pro-inflammatory cytokine that is additively inhibited by bbmAb1 in LPS / IL-12 stimulated PBMCs. To further confirm that LPS / IL-12-driven IL-26 gene expression and protein production are most effectively inhibited by the IL-1β / IL-18 blockade combination, the study was expanded to a total of n=9 PBMC donors using bbmAb1. IL-26 gene expression was examined by qPCR and IL-26 protein production by ELISA. The results confirmed significant inhibition of IL-26 gene expression obtained using the microarray approach. Interestingly, IL-26 protein levels in the supernatant were only partially reduced after 24 hours by the addition of the mAb. The reason for this difference is unclear, but it may be related to dynamic differences between IL-26 gene expression and protein production, as well as differences in IL-26 consumption compared to IFNγ. Nevertheless, bbmAb1 was superior to mAb2 and mAb1 in reducing IL-26 protein levels in PBMC supernatant. The results showed that bbmAb1, mAb2, and mAb1 (10 nM each) in human PBMCs inhibited LPS (0.3 ug / ml) / IL-12-induced IL-26 gene expression (by qPCR) and IL-26 protein levels.

[0266] (d) IL1β / IL18 signaling signatures correlate with disease. By combining previously established PBMC culture conditions in which recombinant IL-1β stimulation resulted in IL-6 production, or recombinant IL-18 / IL-12 stimulation resulted in IFNγ production, additive or synergistic downstream target genes or signatures were identified (data not shown). Affymetrix microarray evaluation was performed for unbiased assessment of gene expression profiles using PBMCs from n=4 donors sampled at two different time points (6 hours and 24 hours). Genes synergistically upregulated at 6 and 24 hours using combinations of IL-1β and IL-18 stimulation were identified (data not shown). Addition of IL-12 to the IL-1β / IL-18 combination significantly enhanced the synergistic effect on a set of upregulated genes. To examine patient-derived datasets across several autoimmune diseases, generated signaling signatures for single or combined IL-1β / IL-18 pathway stimulation (upregulated genes only) were used. For example, correlations were observed with publicly available sarcoidosis datasets. P-values ​​(calculated using Fisher's exact test) show significant correlations with several published studies comparing diseased tissue from sarcoidosis patients with healthy tissue. Tissues include skin, as well as lung, lacrimal gland, and preorbital region. In all datasets, signaling of the IL1β / IL18 combination showed the best correlation with disease, followed by signaling of the IL-1β and IL-18 combination. IL-1β / IL-18 differentially upregulated the gene (DEG) in PBMC (x-axis) compared to "pathological and healthy" DEGs in five different sarcoidosis tissues. P-values ​​(y-axis) represent the statistical significance of observing overlap between signatures and the "disease gene list". Black bars represent skin from cutaneous sarcoidosis lesions and skin from healthy patients. Light gray bars represent skin from cutaneous sarcoidosis lesions and skin without lesions. White bars represent lacrimal glands from sarcoidosis patients and healthy individuals. The dark gray bars represent anterior orbital tissue from sarcoidosis patients and healthy individuals. The striped bars represent lung samples from progressive fibrous pulmonary sarcoidosis and nodular self-limiting pulmonary sarcoidosis.

[0267] (e) Conclusion LPS and recombinant IL-12 were used to mimic pathogen-associated molecular pattern (PAMP)-dependent NLRP3 inflammasome activation within the first 24 hours of in vitro culture. The combination of IL-1β and IL-18 inhibition using bbmAb was found to additively reduce / inhibit IFNγ production in LPS / IL-12-stimulated PBMCs. While IL-12 has previously been described as acting synergistically with IL-18 to induce IFNγ production in T, B, NK cells, macrophages, and dendritic cells (as outlined by Nakanishi, 2001), a further stimulating effect of IL-1β on IFNγ production was revealed under the experimental conditions used. Therefore, co-incubation of PBMCs with LPS / IL-12 effectively promotes the production of "native" IL-1β and IL-18, both contributing to a potent IFNγ response. By using unbiased microarray transcriptomics, further genes additively downregulated by IL-1β / IL-18 neutralization combinations were identified in response to single IL-1β or IL-18 blockade. Among the members of the IL-20 cytokine subfamily (IL-19, IL-20, IL-22, IL-24, and IL-26), which are conserved in most vertebrate species but absent in most rodent lineages (including mice and rats), IL-26 was particularly noteworthy (Donnelly 2010). It signals through a heterodimeric receptor complex composed of IL-20R1 and IL-10R2 chains. The IL-26 receptor is primarily expressed in non-hematopoietic cell types, especially epithelial cells. Elevated levels of IL-26 have been reported in the serum and particularly in synovial fluid of RA patients, suggesting it may act as a factor promoting Th17 cell proliferation and differentiation. Unfortunately, the discovery of further genes / pathways induced by combined blockade of IL-1β and IL-18 was hindered by the potent effect of LPS / IL-12 stimulation on PBMC samples.Nevertheless, both IFNγ and IL-26, as well as IL-22, are among the genes synergistically upregulated by the combined stimulation of recombinant IL-1β and IL-18 in PBMCs, confirming that these two factors are downstream effectors in this activation pathway. Therefore, the IL-20 subfamily of cytokines (including IL-26 and IL-22) appears to be strongly dependent on simultaneous signaling from IL-1β and IL-18. With due consideration to the selectivity and potential blocking effects of individual signaling signatures, comparisons of these are useful in demonstrating the activity of individual pathways in various inflammatory diseases.

[0268] Example 4: Therapeutic use A three-period, multicenter trial using a randomized, treatment-discontinued, double-blind, placebo-controlled design to evaluate the clinical efficacy, safety, and tolerability of bbmAb in autoinflammatory or disease-related conditions such as XIAP deficiency or CDC42 mutation.

[0269] [Table 16]

[0270] [Table 17]

[0271] [Table 18]

[0272] [Table 19]

[0273] 1. Introduction 1.1. Background X-linked apoptosis inhibitor protein (XIAP) deficiency X-linked apoptosis inhibitor protein (XIAP) deficiency is a rare hereditary immunodeficiency that occurs almost without exception in young males (Rigaud et al 2006). XIAP exhibits multifaceted functions in cell survival, innate immunity, and inflammation. In particular, in addition to its role in regulating caspase activity, XIAP is considered an essential regulator of NLRP3 inflammasome activation (Miyazawa and Wado 2022). Major features of XIAP deficiency include inflammatory bowel disease, often presenting as abdominal pain and diarrhea, recurrent fever, splenomegaly, and hemophagocytic lymphohistiocytosis (HLH). The latter symptoms are often triggered by Epstein-Barr virus (EBV) infection. Once diagnosed, the initial treatment goal is generally to suppress inflammation using corticosteroids and biotherapy. Inflammatory bowel disease can be treated with standard immunosuppressants, but the response rate is generally low. EBV infection can be treated with specific antiviral therapy, and in some cases, immunoglobulin therapy is used. Currently, the only potentially curative treatment for XIAP deficiency is hematopoietic stem cell transplantation (HSCT). However, due to the characteristics of the underlying disease, low-intensity pre-transplant conditioning is required, and outcomes from HSCT are often worse than the standard for patients of this age. Although the life expectancy of patients with XIAP has increased over the past decade, significant morbidity and mortality rates still exist in this condition (Mudde et al 2021).

[0274] CDC42 mutation Cell division regulatory protein 42 (CDC42) belongs to the Rho family of small monomeric GTPases (Heasman et al 2008). It influences multiple cellular processes, including cell division and migration, and regulates the nervous, immune, and hematopoietic systems (Melendez et al 2011). Pathogenic mutations in CDC42 can affect protein function in various ways, leading to an increasing recognition of the diversity of disease phenotypes concentrated in neurogenesis, hematopoiesis, and immune responses (Takenouchi et al 2015, Asiri et al 2021, Coppola et al 2022). In particular, it has been shown that abnormal palmitoylation of CDC42R186C can lead to the capture of CDC42 in the Golgi apparatus, which can induce pyrin inflammasome hyperactivation and a significant increase in IL-1β and IL-18 (Coppola et al 2022). In four pediatric patients, a C-terminal de novo missense mutation (p.R186C) has been shown to affect CDC42 localization, causing a specific group of neonatal-onset cytopenia, autoinflammatory disease, and recurrent HLH (Lam et al 2019). The presence of chronic elevated serum IL-18 levels after clinical response to anti-IL-1 therapy suggests that IL-18 is a promising therapeutic target for CDC42 C-terminal disorders (Lam et al 2019).

[0275] [Table 20]

[0276] summary bbmAb is a heterodimer Fc, monovalent, bispecific IgG1 monoclonal antibody (mAb) composed of Novartis' clinical-stage anti-IL-1β and anti-IL-18mAb in a single molecule. By simultaneously targeting and neutralizing both IL-1β and IL-18, inflammasome effector cytokines, bbmAb may have superior clinical efficacy in autoinflammatory states where the inflammasome is excessively activated, such as hypogammaglobulinemia, cytopenia, inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, hemophagocytic lymphohistiocytosis, neonatal-onset cytopenia, syndromes of thrombocytopenia, megathrombocytopenic thrombocytopenia, hematopoietic disorders, autoinflammatory conditions, symptomatic immunodeficiency, or recurrent hemophagocytic lymphohistiocytosis (HLH), macrophage activation syndrome, or AIFEC, in which both IL-1β and IL-18 directly contribute to the pathophysiology of the disease.

[0277] Nonclinical data Nonclinical pharmacology BBMABs simultaneously bind to both IL-1β and IL-18 with single- to double-order-order pM affinity, resulting in sub-nM inhibition of cytokine signaling in most cell assays. Although BBMABs bind to IL-1β and IL-18 monovalently, the in vitro efficacy of BBMABs in neutralizing human IL-1β and IL-18 is in the same range as that of bivalent mAb1 and mAb2, exhibiting similar inhibitory activity against primary marmoset cells.

[0278] Clinical data Clinical Human Pharmacokinetics Preliminary pharmacokinetic data from an ongoing FIH trial in healthy volunteers (HV) were consistent with predictions based on marmoset monkey data and modeling (i.e., typical human IgG1 immunoglobulin). bbmAb peak serum concentrations were observed immediately after the end of its intravenous infusion. The median Tmax was approximately 3 hours from the start of the infusion (120-minute duration). Cmax and AUCinf increased slightly hyperproportional with increasing dose. The mean elimination half-life (T1 / 2) ranged from approximately 21 days at 0.1 mg / kg to approximately 28 days at 30 mg / kg. The volume of distribution was low, with a mean Vz of approximately 5.2 L to approximately 6.4 L. In addition, bbmAb was administered subcutaneously at doses of 100 mg, 300 mg, and 600 mg. The mean Cmax of bbmAb ranged from 7.1 to 54.7 ug / mL approximately 7 days post-administration. Exposure in Japanese subjects at 10 mg / kg IV was approximately 1.16 times higher than in non-Japanese subjects based on AUCinf, while exposure after 600 mg sc was 1.25 times higher compared to non-Japanese subjects. For the Japanese cohort, the bioavailability at the 600 mg sc dose was approximately 65% ​​compared to the 10 mg / kg IV dose. For the non-Japanese cohort, the bioavailability at the 100 mg sc, 300 mg sc, and 600 mg sc doses was approximately 45%, 69%, and 65%, respectively, compared to the 10 mg / kg IV dose.

[0279] 2. Objectives and endpoints related to XIAP deficiency or CDC42 mutation.

[0280] [Table 21]

[0281] Main estimation targets The main clinical questions regarding autoinflammatory or disease-related conditions based on XIAP deficiency or CDC42 mutations of interest are as follows: What is the effect of continuing bbmAb treatment in patients with autoinflammatory or disease-related conditions due to XIAP deficiency or CDC42 mutations, who achieved a complete clinical response after approximately 28 weeks of bbmAb treatment despite discontinuation of glucocorticoids for disease relapse over 24 weeks?

[0282] The main estimation targets include the following components: 1. Population: Patients with XIAP deficiency or autoinflammatory disease based on CDC42 mutations who have achieved a complete response after approximately 28 weeks of bbmAb treatment and have discontinued cyclosporine and glucocorticoids, or are continuing maintenance / replacement doses (less than 0.2 mg / kg / day) of glucocorticoids. 2. Endpoint: Occurrence of disease relapse within 24 weeks. 3. Eligible treatments: Randomized clinical trial treatments (investigational treatments of bbmAb or placebo). 4. Handling of Concomitant Events: Treatment strategies will be used in the primary analysis; therefore, discontinuation of treatment for reasons other than disease relapse will be ignored. Patients who discontinued treatment early in period 2 (not due to disease relapse) will be analyzed in the same way as patients who continued treatment as planned. 5. Summary: Differences in the proportion of patients with disease relapse between treatment groups.

[0283] 3. Test Design As shown in Figure 1, this is a three-period trial, including period 1: open-label, single-arm active treatment, followed by period 2: randomized treatment discontinuation, placebo-controlled, double-blind design, and period 3: open-label, long-term safety follow-up. Patients receiving bbmAb who have been diagnosed with a criterion-measuring XIAP deficiency or CDC42 mutation are eligible to enter period 3 directly for the open-label long-term safety follow-up.

[0284] Patients will be assigned to the following relevant cohorts: • Cohort 1: Patients with a confirmed diagnosis of XIAP deficiency or CDC42 mutation are included in Period 1 of the study in order to randomize patients to Period 2 of the study. • Cohort 2: Additional patients taking bbmAb who have been diagnosed with XIAP deficiency or CDC42 mutation can be directly transferred to Period 3 of the study after completing screening / baseline. The total study duration from screening to end of study (EoS) is expected to be 3-4 years.

[0285] The overall test design is outlined in Figure 1.

[0286] These three-period exams include the following: screening: A period of approximately 30 days to confirm that the inclusion and exclusion criteria for the study are met. The screening period also allows for the safe discontinuation or dose stabilization of medications permitted in Period 1 for Cohort 1. For Cohort 2, patients can directly participate in Period 3 after screening and baseline completion. Necessary assessments may be carried out over several days if it is in the patient's best interest or for logistical reasons. If results are available, clinical tests completed as part of the patient's routine care the day before screening can be used to avoid taking additional blood samples from patients.

[0287] The screening window can be extended in the following situations (if informed consent has been obtained): • To ensure sufficient time to demonstrate the presence of active disease after discontinuation of the current treatment, as outlined in the inclusion and exclusion criteria for Cohort 1. • For patients for whom molecular diagnostics for NLRC4, XIAP deficiency, or CDC42 mutations have not been documented, the results from those molecular diagnostics will be made available (Cohort 1). All other screening evaluations (excluding informed consent) should be performed within the screening window after the molecular diagnostics become available.

[0288] Baseline: Patients who meet the eligibility criteria will be admitted to the hospital if they are not already hospitalized, and evaluated at their baseline visit: this may be done on day 1, or combined with day 1 prior to administration.

[0289] To mitigate the possibility of SARS-CoV-2 transmission between patients, follow the guidance and requirements provided by local regulatory authorities or local facility-specific SOPs (for example, patients may be screened for SARS-CoV-2 by PCR or an equivalent approved method before admission to a testing / hospital facility for an overnight stay in accordance with local facility-specific SOPs).

[0290] All baseline safety evaluation results must be available before administration. If results are available, clinical tests completed as part of the patient's routine care a few days prior to baseline can be used to avoid taking additional blood samples from the patient.

[0291] Period 1, Open-label treatment period: Applies only to Cohort 1. Period 1 is an open-label treatment period in which responders to bbmAb treatment can be identified and these patients can be tapered off from glucocorticoids and / or discontinued from cyclosporine treatment. Period 1 is divided into three subparts (Periods 1a, 1b, and 1c).

[0292] Patients who meet the eligibility criteria will enter Period 1 and receive their first dose of bbmAb (10 mg / kg) intravenously on Day 1 of Period 1a. Due to the nature of the disease, patients may remain hospitalized throughout Period 1, but this is not mandatory, and the principal investigator will need to determine when the patient can be discharged based on their condition. During Period 1, patients will undergo efficacy, PK, and PD evaluations as outlined in the evaluation schedule (Table 14).

[0293] Period 1a Period 1a lasts for 4 weeks, during which bbmAb is administered every 2 weeks.

[0294] In patients currently taking a fixed dose of glucocorticoids and / or cyclosporine, these doses should remain stable throughout period 1a. No tapering of glucocorticoids or cyclosporine is observed.

[0295] On day 29 (week 4), the evaluation of responses using PGA, CRP, and ferritin will be completed. Patients who show at least a partial response will proceed to period 1b of the study. Patients who do not achieve a partial response during period 1a will be discontinued from the study.

[0296] If a patient discontinues treatment during period 1a, the patient must return for a follow-up visit approximately one month after discontinuation to complete the end-of-period evaluation (i.e., period 1c, week 28 of the evaluation schedule).

[0297] Period 1b (Gradual tapering of glucocorticoids and discontinuation of cyclosporine) Period 1b lasts up to 20 weeks, with bbmAb administered every two weeks. Patients transition to Period 1b after successfully completing Period 1a.

[0298] Patients taking a fixed dose of glucocorticoids will gradually tape their dose to the lowest possible level over four weeks prior to randomization at the start of the randomization treatment discontinuation period (period 2). Similarly, all patients taking a fixed dose of cyclosporine will reduce their dose to the lowest possible level over four weeks prior to randomization at the start of the randomization treatment discontinuation period (period 2) with the aim of achieving cyclosporine discontinuation. Guidelines regarding glucocorticoid tapering, cyclosporine discontinuation, and patient eligibility to move to periods 1c and 2 are described in section 6.2.1.1.

[0299] To monitor the response during glucocorticoid tapering, patients who are not hospitalized during period 1b will receive weekly phone calls from the facility to the patient / parent / guardian.

[0300] Patients who meet the eligibility criteria to move to period 1c before week 24 may move to period 1c earlier, but must complete the assessments listed in week 24, as detailed in the assessment schedule, before moving to period 1c.

[0301] For patients who are not taking glucocorticoids and cyclosporine at the start of the study (period 1a), i.e., patients who do not require tapering of glucocorticoids or discontinuation of cyclosporine in period 1b, upon completion of period 1a, the patient will transition to period 1b and complete only the evaluations and treatments listed at weeks 22 and 24 of period 1b before transitioning to period 1c. This ensures that all patients receive at least 12 weeks of treatment with bbmAb in period 1 of the study.

[0302] Patients who are unable to reduce their glucocorticoid dose or discontinue cyclosporine treatment by week 24 may be discontinued from the study. If a patient discontinues treatment during period 1b, they must return within approximately one month of discontinuation to complete the period 1 end-of-treatment evaluation (i.e., period 1c, week 28 of the evaluation schedule) as a follow-up visit. Patients who achieve a partial response (discontinuation of cyclosporine, with or without glucocorticoid tapering) as evaluated at the period 1 end-of-treatment visit may, at the discretion of the principal investigator and their family, directly participate in the open-label treatment of period 3.

[0303] Period 1c Period 1c lasts for 4 weeks, during which bbmAb is administered every 2 weeks.

[0304] After successfully completing period 1b, the patient will transition to period 1c at the next scheduled bbmAb administration.

[0305] All patients continuing glucocorticoid treatment must maintain their medication throughout the entire duration of period 1c. Neither tapering of glucocorticoids nor treatment with cyclosporine is permitted during period 1c.

[0306] The objective of period 1c is to ensure that all patients who have discontinued cyclosporine treatment and / or tapered off glucocorticoids, and who are maintaining low-dose glucocorticoids, are clinically stable for at least 4 weeks before moving on to period 2.

[0307] At the end of period 1c (day 197, week 28), the response will be assessed using PGA, CRP, and ferritin, and patients with a complete response will be randomized to period 2 of the study. Patients who do not meet the criteria for a complete response but have achieved a partial response (patients who have discontinued cyclosporine, with or without glucocorticoid tapering) may, at the discretion of the principal investigator and their family, directly participate in the open-label treatment of period 3.

[0308] If a patient discontinues treatment during period 1c, they must return to the clinic within approximately one month of discontinuation to complete the final evaluation of period 1 (i.e., period 1c, week 28 of the evaluation schedule).

[0309] Period 2, period of discontinuation of randomization treatment: Applies only to Cohort 1. Period 2 consists of a 24-week placebo-controlled, double-blind, randomized treatment discontinuation period primarily to evaluate the efficacy of bbmAb compared to placebo. At the start of Period 2, bbmAb responders (those with a complete response to treatment at the end of the open-label treatment period 1) will be randomized in a 1:1 ratio to receive either bbmAb treatment (i.e., continued at 10 mg / kg) or placebo.

[0310] The first scheduled blinded dose following randomization in Period 2 will be administered two weeks after the last dose of Period 1c, and doses will continue every two weeks until a disease relapse occurs or until 24 weeks have passed in Period 2. Patients may remain hospitalized throughout Period 2, but this is not mandatory, and the principal investigator will need to determine when the patient can be discharged based on their condition.

[0311] If the patient meets the relapse criteria in period 2, an unscheduled visit will be required as detailed in the evaluation schedule, the blinded treatment will be discontinued, and the patient will transition to open-label bbmAb treatment to continue for the remainder of period 2.

[0312] If a patient discontinues treatment during Period 2, they must return to the clinic within approximately one month of discontinuation as part of their final treatment visit to complete the Period 2 final evaluation (i.e., Week 24 of the evaluation schedule for Period 2).

[0313] Duration 3, long-term safety, open-label procedure: Period 3 consists of a 3-year long-term safety phase with open-label bbmAb treatment (10 mg / kg).

[0314] The first scheduled dose in Period 3 will be two weeks after the last dose in Period 1 or Period 2, with a minimum two-week interval before continuing medication. For Cohort 2, medication will be scheduled after confirmation that screening and baseline visits have been completed and all cohort-specific eligibility criteria have been met.

[0315] Medication in Period 3 will continue approximately every two weeks, and protocol evaluations will involve a decrease in the frequency of visits, as outlined in the evaluation schedule. Any visits in Period 3 may be conducted at an alternative sponsor-approved site (e.g., a satellite site that may be more convenient for the patient), only if agreed upon by the principal investigator who maintains responsibility as the principal investigator and permitted by local regulations.

[0316] At the discretion of the principal investigator, if the patient remains clinically stable without evidence of increased disease activity, the medication for period 3 may be administered approximately every 14 days using the windows specified in Table 14, allowing for flexibility based on the individual patient's response.

[0317] For patients taking maintenance doses of glucocorticoids, further tapering of glucocorticoids to complete discontinuation, if possible, should be considered. All patients not maintaining a minimal partial response may be discontinued unless the loss of response is considered to be a result of glucocorticoid tapering. Patients in Cohort 2 who moved to the study will continue for period 3 as long as there is a clinical benefit as judged by the treating physician.

[0318] If a patient discontinues treatment during Period 3, they must return to the clinic within approximately one month of discontinuation to complete the evaluation at the end of Period 3 (i.e., Week 152 of the evaluation schedule for Period 3).

[0319] Screening and baseline visits will be used to confirm that the inclusion and exclusion criteria for the study are met, and baseline clinical observation and biological sampling will be performed. Patients enrolled in this study may be treated with anakinra, canakinumab, emapalumab, and / or investigational IL-18 / IL-1 / IFN conjugate or blockade therapy, and may be screened. The study will begin approximately 30 days after screening with bbmAb treatment, which will be administered as soon as the criteria for active disease are met. This run-in phase for previously treated patients will result in a shorter washout time compared to conventional designs, but is considered justified due to the fact that subjects may require emergency enrollment to bbmAb after other treatment options have failed.

[0320] Period 1 is an open-label, intensive treatment period to identify patients with monogenic IL-18-mediated autoinflammatory disease, including XIAP deficiency and CDC42 mutations, that respond to bbmAb treatment, and then to enable patients taking glucocorticoids and / or cyclosporine to tapered / discontinue these therapies. Patients in Period 1a are initially treated with two doses of bbmAb to ensure a definite response to treatment by day 29, specifically to simultaneously achieve control of MAS and resolution of clinical bowel symptoms (colitis) over several weeks. In Period 1b, obvious bbmAb responders to cyclosporine and glucocorticoids are to discontinue cyclosporine and gradually tapered or reduced glucocorticoids to maintenance / supplement doses over up to 20 weeks to avoid long-term morbidity associated with both treatments in the pediatric population. In Period 1c, patients are to be confirmed to be clinically stable for at least 4 weeks on discontinued or maintenance / supplement doses of glucocorticoids before evaluating the response to BBMAB1 treatment at the end of Period 1.

[0321] At the start of the randomization treatment discontinuation period (period 2), patients who have fully responded to bbmAb and discontinued glucocorticoids, or who are on maintenance / replacement doses, will be randomized in a double-blind 1:1 ratio to receive treatment with either bbmAb or the corresponding placebo. This design allows patients who have discontinued bbmAb treatment (placebo patients) to resume bbmAb treatment immediately after reaching the trial endpoint (occurrence of disease relapse), thereby addressing both the clinical issue and patient preference regarding placebo assignment by minimizing the time patients receive potentially ineffective treatment. All patients who experience a relapse at any point in period 2 will discontinue blinded treatment, and patients will transition to open-label bbmAb treatment to continue for the remainder of period 2 at the discretion of both the investigator and the family. A 1:1 randomization ratio was chosen to maximize the statistical power of the primary analysis while minimizing the overall sample size considering the rarity of the conditions. Blinding is reasonable in preventing conscious or unconscious bias in the trial design and its implementation. The duration of the randomization treatment discontinuation period in the trial is based on clinical trial experience of relapses in similar pediatric populations with autoinflammatory conditions treated with canakinumab (such as CAPS and SJIA), and on modeling of free IL-18 levels expected to increase and cause relapses in patients with monogenic IL-18-mediated autoinflammatory diseases, including XIAP deficiency and CDC42 mutations, in the absence of effective treatment.

[0322] An open-label long-term safety study (period 3) in patients who responded to bbmAb allows patients to continue bbmAb treatment and provide long-term safety data.

[0323] Rationale for dosage / plan Intravenous administration of bbmAb has been evaluated in single-dose dose-escalation studies (FIH) up to 30 mg / kg iv in healthy volunteers and up to 10 mg / kg iv in COVID-19 patients without any drug-related SAEs; the PK of bbmAb in humans is as expected for a typical IgG1 antibody that binds to a soluble ligand cytokine target. In PK analysis of FIH studies pre-planned to allow subcutaneous administration, bbmAb showed dose-proportional increase in exposure consistent with the predicted human PK. Peak serum concentrations of bbmAb were observed immediately after its intravenous infusion. The median Tmax was approximately 0.146 days, or approximately 3.5 hours, from the start of infusion. Cmax and AUC0-inf increased proportionally with increasing dose. bbmAb concentrations decreased exponentially, with mean terminal phase elimination half-lives (T1 / 2) ranging from 21.1 to 286.3 days. The volume of distribution was low, with a mean Vz of 0.06662–0.083 mL / kg. In addition, subcutaneous administration of bbmAb at a dose of 100 mg resulted in a Cmax of approximately 7 μg / mL approximately 9 days after administration. Bioavailability was estimated to be 70% by comparing the value obtained by dividing AUCinf by the dose of 100 mg sc during the duration with the value obtained by dividing AUCinf by the dose of 1 mg / kg iv. Cmax and AUCinf increased slightly hyperproportionally with increasing dose. The mean terminal phase elimination half-life (T1 / 2) ranged from approximately 21 days at 0.1 mg / kg to 28 days at 30 mg / kg. The volume of distribution was low, with a mean Vz of approximately 5.2 L–6.4 L. In addition, bbmAb was administered subcutaneously at doses of 100 mg, 300 mg, and 600 mg. The mean Cmax of bbmAb ranged from 7.1 to 54.7 ug / mL approximately 7 days after administration. Exposure in Japanese subjects at 10 mg / kg IV was approximately 1.16 times higher than in non-Japanese subjects based on AUCinf, while exposure after 600 mg sc was 1.25 times higher compared to non-Japanese subjects. In the Japanese cohort, the bioavailability at the 600 mg sc dose was approximately 65% ​​compared to the 10 mg / kg IV dose.In the non-Japanese cohort, the bioavailability of the 100 mg sc, 300 mg sc, and 600 mg sc doses was approximately 45%, 69%, and 65% compared to the 10 mg / kg IV dose, respectively (Figure 5).

[0324] All subjects in all cohorts (including bbmAb-treated and placebo subjects) were test negative (i.e., treated with anti-bbmAb antibodies) at 29 days post-administration, with the exception of one subject from cohort A4 (3 mg / kg iv) at 29 days post-administration, one subject from cohort A5 (10 mg / kg iv) at 197 days post-administration, one subject from cohort A6 (30 mg / kg iv) at 197 days post-administration, and one subject from cohort D1 (10 mg / kg, iv Japanese) at 197 days post-administration. Therefore, all were considered to have transient ADA responses. On day 15, one subject from cohort A5 (10 mg / kg iv) was test positive. All subjects from cohort A6 (bbmAb-treated and placebo subjects) were test negative at day 253.

[0325] 4. Rationale Rationale for dosage / plan In patients with autoinflammatory diseases caused by monogenic IL-18, including XIAP deficiency or CDC42 mutations, serum free IL-18 levels are significantly and chronically elevated. The dynamics of free IL-18 can limit the effectiveness of bispecific antibodies, thus determining the administration principle for these patients. Under normal physiological conditions, almost all circulating IL-18 is bound to its binding protein (IL-18BP) and is biologically inactive; however, in severe inflammatory states, IL-18 levels exceed available IL-18BP, resulting in a higher ratio of free / bioactive IL-18 and exacerbation of the disease. Modeling using measurements of total IL-18, IL-18BP, and free IL-18 from pediatric patients with NLRC4-GOF mutations (Weiss et al 2018) supports the expectation that a 10 mg mg / kg iv bbmAb dose is likely to achieve a rapid and sustained reduction of free IL-18 in both pediatric and adult populations with NLRC4-GOF, XIAP deficiency, or CDC42 mutations. bbmAb

[0326] The models used to predict the dynamics of anti-IL-18 / IL-1β bispecific antibodies and their targets in serum consist of a general competitive binding model describing the free and total IL-18 dynamics of the IL-18 arm (Yan et al 2012), and a previously published canakinumab model with parameters fitted to bbmAb for the IL-1β arm (Chakraborty et al 2012). Baseline values ​​of free IL-18, total IL-18, and IL-18BP in serum from patients with several autoimmune diseases, including NLRC4-GOF (Weiss et al 2018), and in-house measurements were used to adjust the models, and neonatal patient weight was assumed to be 3 kg. Based on simulations of the effect of bbmAb on free IL-18 during intravenous administration, complete control (neutralization) of free IL-18 at a dose of 10 mg / kg is expected for approximately 14 days, and it also neutralizes IL-1β to completely control inflammatory syndromes, enabling recovery of gastrointestinal pathology and clinical features such as MAS or HLH in these patients during treatment.

[0327] Simulations of the effects of bbmAb 10 mg / kg on patients with elevated free IL-18 and IL-1β suggest an immediate and sustained response. Compared to rhIL-18BP (tadekynig alfa) (Tak et al 2006) at a therapeutic range of 2 mg / kg q2d dose, which is clinically effective in NLRC4-GOF infants (Canna et al 2017, Moghaddas et al 2018) and currently being evaluated in a Phase 3 trial (NCT03113760), the 10 mg / kg q2W dose of bbmAb is predicted to neutralize free IL-18 to a comparable degree within 2 weeks and then completely suppress free / bioactive IL-18 to undetectable levels similar to those in healthy individuals for the following weeks.

[0328] The 10 mg / kg ivq2w bbmAb dose for this study is further justified by: This dose is expected to result in rapid and simultaneous neutralization of free IL-18 and IL-1β, promptly inducing a clinical response in patients (where elevated levels of IL-1β and IL-18 are measured and anticipated in pediatric patients enrolled in this study). A single intravenous dose of 10 mg / kg was administered to healthy volunteers with FIH to establish the safety of this dose and enable treatment of patients with gain-of-function mutations resulting in overexpression of IL-1β and IL-18 (e.g., NLRC4 mutation (Romberg et al 2014)). This dose in healthy volunteers provided multi-month-long inhibition by the combination of IL-18 and IL-1β and is currently being administered to COVID-19 patients with no safety concerns identified. Modeling IL-18BP treatment in NLRC4-GOF pediatric patients to estimate clinically effective bbmAb doses suggests that patients with IL-18-mediated disease, including XIAP deficiency or CDC42 mutations, need to achieve a sustained clinical response with 10 mg / kg ivq 2w, requiring approximately 14 days of neutralization of free IL-18. Lower doses with longer intervals between doses may result in a failure to achieve a complete response and a risk of relapse due to inadequate treatment. In open-label period 3, patients with stable disease may have intervals of up to 28 days between doses, with close monitoring of the patient's clinical condition by the investigator. • Clinical experience with canakinumab treatment in pediatric patients with severe CAPS. These patients, particularly those under 2 years of age, may require higher doses (more than 8 mg / kg of canakinumab) than usual to achieve a complete clinical response and may require more frequent dose escalations compared to adults. Allometric scaling of the pop-PK parameter of bbmAb from a 70kg individual to a 3kg neonatal predicts higher clearance per body weight in neonates and infants. Therefore, the expected lower exposure per single dose provides justification for higher doses in the pediatric population to maximize clinical response. No significant accumulation is expected after multiple doses in this population at the proposed dose of 10 mg / kg ivq 2w. Similarly, in young pediatric patients, increased body weight-based clearance (L / day / kg) and decreased exposure to canakinumab were observed (Zhung et al 2019). • Whole-body exposure in this trial is expected to be considerably lower than the exposure achieved in the 26-week Marmoset trial, with an exposure ratio to non-clinical NOEL exposure expected to be 14.4 times in AUC and 14.4 times in Cmax in 3kg neonates. In a 26-week toxicity study of NHP, no adverse events occurred and no adverse effects were observed even with administration of 100 mg / kg twice weekly.

[0329] In summary, depending on the disease state, a dose of 10 mg / kg q2-q4w has been shown to be likely effective, while the risks in pediatric and adult populations are minimal based on available data.

[0330] 5. Test group The study population included approximately 18 patients in total: • Cohort 1: Patients with autoinflammatory diseases caused by monogenic IL-18, including XIAP deficiency or CDC42 mutation. • Cohort 2: Patients who directly enter Period 3 and have a confirmed diagnosis of XIAP deficiency or CDC42 mutation.

[0331] Recruitment criteria For all patients: Patients who can be selected for this trial must meet all of the following criteria: 1. Male and female patients weighing at least 3 kg at the time of screening. 2. Before any trial-specific assessments are conducted, written informed consent from the parent / legal guardian of the pediatric patient and consent from the pediatric patient (as required by local regulations) must be obtained. For adult patients, written informed consent must be obtained from the patient who is able to consent, or, if the patient is unable to consent, from their legal / official representative (as permitted by local regulations). Cohort 1 specific recruitment criteria: 3. Patients with monogenic IL-18-mediated autoinflammatory disease who have been genetically diagnosed with either XIAP loss or CDC42 mutation (if this analysis is not yet available, it may be performed as part of the screening procedure). 3a. In patients with XIAP deficiency or CDC42 mutations, if the patient shows evidence of primary or secondary graft failure with evidence of relapse of XIAP / CDC42-related disease or clinically significant mixed chimeric phenomenon, or evidence of failure to achieve phenotypic correction, prior bone marrow transplantation may be permitted. 4. A medical history and investigation consistent with autoinflammatory and infantile enteritis, XIAP, or CDC42, including elevated IL-18 levels (if this analysis is not yet available, it may be performed as part of the screening procedure). 4a. XIAP patients only: Patients must have persistent disease or be resistant to escalation therapy. 5. At the time of the first treatment (Day 1 of Period 1), evidence of active disease is assessed by the following: a. Disease activity PGA > minimum, b. Ferritin > 600 ng / ml, or c. Elevated CRP > 20 mg / l. Cohort 2 specific recruitment criteria: Patients who have been treated with bbmAb in the Novartis Managed Access Program (MAP), have demonstrated treatment failure to other immunomodulatory therapies, and have no available alternative treatment options from their treating physician, and who are genetically diagnosed with elevated IL-18 and / or IL-1β, XIAP deficiency, or CDC42 mutation.

[0332] Exclusion criteria Patients who meet any of the following criteria cannot be included in this trial: 1. A history of hypersensitivity to any of the investigational drugs, or any drugs of a similar chemical class, or any of the excipients. 2. Evidence of clinically significant active bacterial, fungal, or viral infection, as determined by the principal investigator. If appropriate therapy is initiated and there are no signs of infection progression at the time of screening, the infection is considered controlled. Infection progression is defined as sepsis caused by the infection, new symptoms, worsening of physical signs, or hemodynamic instability resulting from radiographic findings. Persistent fever without other signs and symptoms is not considered an ongoing infection. 3. COVID-19 Specific: Where in accordance with health and government authority guidance, it is strongly recommended that COVID-19 PCR or an equivalent approved method be completed at least one week prior to the first dose. If testing is performed, a negative test result is required before participation in the study. Additional testing may be performed at the discretion of the investigator. COVID-19 testing must be completed via nasal or throat swab or other approved route for pediatric patients. If testing is not performed, the principal investigator must document in the source documentation the discussion with the patient / parent / guardian regarding testing and the reasons for not performing the test. This requirement may be disregarded if the country where the facility is located declares the pandemic over and may be reinstated if the pandemic recurs. 4. Any condition or significant medical problem that, in the opinion of the principal investigator, would expose the patient to an unacceptable risk of bbmAb therapy (this can be discussed with Novartis on a case-by-case basis if uncertain). 5. Prior treatment with rejection inhibitors and / or immunomodulators (or any prohibited treatment as described in Section 6.2.2) within the past 28 days or 5 half-lives (whichever is longer) of the immunomodulatory therapeutic antibody prior to bbmAb treatment. The exceptions are as follows: • Drugs listed in Section 6.2.2 of the Prohibited Drugs section, which require a washout period as outlined therein. • For at least 24 hours prior to treatment with bbmAb, administer a constant dose of oral prednisone (or equivalent, regardless of route of administration or administration schedule) of 2.0 mg / kg / day or less (maximum 60 mg / day for patients weighing over 30 kg) or a glucocorticoid. • A constant dose of cyclosporine less than 5 mg / kg / day for at least 3 days prior to treatment with bbmAb. Anakinra, canakinumab, emaparmab, and / or investigational IL-18 / IL-1 / IFN-γ conjugate or blockade therapy must be discontinued before bbmAb treatment (see Section 6.2.2). Patients may receive bbmAb treatment as soon as the criteria for evidence of active disease are met (according to Inclusion Criterion 5). 5. Participation in other clinical trials within 4 weeks prior to administration or longer, as required by local regulations, except for treatment with anakinra, canakinumab, or emaparmab and / or conjugate or blockade therapy of clinical trials IL-18 / IL-18BP / IL-1 / IFN-□. Participation in Novartis MAP using bbmAb is not excluded. 6. The HIV test result (ELISA and Western blot) at the time of screening was positive. Evidence from a prior test within the last three months is sufficient. 7. A positive result for hepatitis B surface antigen (HBsAg) or hepatitis C at the time of screening. Evidence from a prior test within the last three months is sufficient. 8. Presence of tuberculosis infection, defined by a positive tuberculosis test at the time of screening. Evidence from a prior test within the last three months is sufficient. 9. Live vaccine administration within one month prior to bbmAb treatment, during the study, and within a maximum of three months from the last dose. 10. A history of treated or untreated malignancies of organ systems, including post-transplant lymphoproliferative disorders, within the past five years, regardless of whether there is evidence of local recurrence or metastasis (excluding appropriately treated focal basal cell carcinoma of the skin or carcinoma of the cervix in situ). 11. Pregnant or lactating women. Pregnancy is defined as the state of a woman from conception to the end of pregnancy, as confirmed by a positive hCG clinical test. 12. Female patients who are sexually active or may become sexually active and who may become pregnant (or have Tanner stage 2 or higher) should be informed about the potential teratogenic risks of bbmAb and the need for and consent to use highly effective contraception to prevent pregnancy during bbmAb therapy. If IL-18 and IL-1β are not expected to be neutralized by bbmAb, a highly effective method of contraception (abstinence, oral, injectable or implantable hormonal contraception, or placement of an intrauterine device (IUD) or intrauterine system (IUS), or other forms of hormonal contraception with equivalent effectiveness (failure rate less than 1%), such as a hormonal vaginal ring or transdermal hormonal contraception) should be used during the trial and for 5 months after discontinuation of bbmAb treatment. Decisions regarding the method of contraception should be reviewed at least every 3 months to assess the individual needs and suitability of the chosen method. Please note that you must use only highly effective contraceptive methods approved in accordance with local regulations. A woman is considered postmenopausal if she has experienced 12 months of spontaneous amenorrhea accompanied by a suitable clinical profile (e.g., a history of age-appropriate vasomotor symptoms). A woman is considered non-fertile if she is postmenopausal or has undergone surgical bilateral oophorectomy (with or without hysterectomy), total hysterectomy, or bilateral tubal ligation at least 6 weeks prior. In the case of oophorectomy alone, a woman is considered non-fertile only if her reproductive status is confirmed by follow-up hormone level assessment. 13. Patients weighing over 160 kg at the time of screening. 14. In the case of patients with CDC42 mutations: Takeuchi-Kozaki syndrome - CDC42 mutations associated with a variety of syndromes characterized by variable growth retardation and cardiac, cerebrovascular, and hematological abnormalities.

[0333] 6. Treatment 6.1. Clinical Trial Procedures Detailed requirements for the storage and management of clinical trial procedures, as well as patient numbering, prescription / dispensing, and instructions to follow when receiving clinical trial procedures, are outlined in the pharmacy manual.

[0334] 6.1.1. Investigational drug and control drug bbmAb is still under development, and the investigational drug and control drug will be the same as those administered in Phase 1 and Phase 2 trials. The investigational drug bbmAb and its corresponding placebo will be prepared by Novartis and provided as open-label bulk drugs to pharmacists at unblinded facilities. Dispensing the investigational drug requires an unblinded pharmacist or an authorized designated person. The drug will be administered by a researcher as an intravenous infusion over approximately 120 minutes in a clinical setting, according to the specified study procedure.

[0335] During outbreaks or pandemics that restrict or hinder clinical visits to facilities (such as the COVID-19 pandemic), facility staff may arrange visits to patients' homes to continue clinical trial procedures in accordance with the protocol, as permitted by local regulations.

[0336] [Table 22]

[0337] 6.1.2. Additional Clinical Trial Procedures This clinical trial does not include any treatments other than the investigational drug. Supportive care provided in addition to the investigational treatment will be offered at the clinical trial site.

[0338] 6.1.3. Treatment Arm / Group Period 1 - Open-label treatment period (Cohort 1) Patients are assigned a dose of 10 mg / kg q2w iv of bbmAb on day 1. Period 2 - Randomization treatment discontinuation period (Cohort 1) Responding patients will be randomly assigned in a 1:1 ratio to one of the following treatment arms / groups at the end of Period 1: 10mg / kg IVQ2W BBmAb • Corresponding placebo for ivq2w Period 3 - Open-label long-term safety (all cohorts) Patients will receive a dose of BBmAb 10 mg / kg q2w intravenously, starting on day 1 of period 3 (week 0). The frequency of administration may be adjusted at the discretion of the principal investigator within the permitted window described in Table 14.

[0339] 6.1.4. Access after the clinical trial Novartis proposes to provide bbmAb to patients who have completed the clinical trial, insofar as there is evidence of clinical benefit to the patient, as required or permitted by local law, or until the following: • The principal investigator discontinues the procedure. • The product or alternative treatment becomes commercially available.

[0340] 6.2. Other measures 6.2.1. Combination Therapy All major medications, procedures, and significant non-pharmacological therapies (including physiotherapy and blood transfusions) administered to treat the disease under investigation during the six months prior to the patient's enrollment in the trial (if applicable) must be documented in the appropriate case report form.

[0341] All medications, procedures, and significant non-pharmacological treatments (including physiotherapy and blood transfusions) administered to patients after they have been enrolled in the trial must be documented in the appropriate case report form.

[0342] Each concomitant medication must be individually evaluated against all exclusion criteria / prohibited drugs. If in doubt, the principal investigator must contact Novartis's medical monitor before enrolling the patient or authorizing the initiation of a new medication. If the patient is already enrolled, contact Novartis to determine whether the patient should continue participating in the trial.

[0343] During the trial and prior to screening, patients may receive gastric protection, folic acid, paracetamol, NSAIDs, analgesics, antibiotics, vasopressors, and nutritional supplements (e.g., vitamins, liquid supplements, enteral nutrition, parenteral nutrition) and other medications / treatments, which constitute part of the supportive care for the disease during the trial at participating sites (as medically determined).

[0344] 6.2.1.1. Approved combination therapies requiring attention and / or action Period 1 - Glucocorticoid tapering This applies only to Cohort 1. During the 4-week treatment period 1a to stabilize patients taking bbmAb, patients taking a constant dose of glucocorticoids will be permitted to participate in the study and will receive a first dose (10 mg / kg) of bbmAb intravenously. The glucocorticoid dose must be maintained for the entire duration of period 1a, at least until day 29.

[0345] Following day 29, the principal investigator must initiate glucocorticoid tapering four weeks before randomization at the start of the randomization treatment discontinuation period (period 2) to gradually reduce the dose with the aim of discontinuing glucocorticoids (as medically determined) or achieving a constant maintenance dose of glucocorticoids (prednisone or equivalent) of 0.2 mg / kg / day or less.

[0346] If the patient has achieved at least a partial response, tapering of steroids can be initiated after day 29 (Section 8.3.5).

[0347] [Table 23]

[0348] • In the following cases, the gradual reduction can be continued: 1. In weekly in-facility phone calls between trial visits, patients / parents have not reported any loss of response based on their responses to the standardized phone questionnaire. 2. The patient maintains at least a partial response to bbmAb during their visit.

[0349] • Continue tapering off glucocorticoids until one of the following occurs first: 1. The patient has achieved discontinuation of glucocorticoids and is not using steroids. 2. The patient reached the maximum 20-week period of glucocorticoid tapering. 3. The patient failed three times in attempts to tape off glucocorticoids.

[0350] • All patients who cannot maintain at least a partial response to bbmAb may discontinue the trial unless the loss of response is considered a result of glucocorticoid tapering: 1. If a patient loses response to bbmAb during glucocorticoid tapering, the glucocorticoid dose may be increased to the previous level, and the patient may remain in period 1b; the increased steroid dose should be maintained for at least two weeks. If the patient does not respond after more than two weeks following the initial event after the increase to the previous steroid dose, the patient may be discontinued. 2. In patients who have lost their response during tapering, further attempts at steroid tapering may only be made if the patient has been taking a constant dose of steroids for at least two weeks and has shown at least a partial response.

[0351] A patient is eligible to enter Period 2 of the examination directly if one of the following conditions is met: 1. Patients who have achieved discontinuation of glucocorticoids and have not used steroids for a period of 1c (4 weeks). 2. Patients who have taken a constant maintenance dose of glucocorticoid (prednisone or equivalent) of 0.2 mg / kg / day or less (for patients weighing over 30 kg) or 0.4 mg / kg / day or less (for pediatric patients who may require a higher supplemental dose) for 4 weeks (period 1c).

[0352] If a patient discontinues treatment during Period 1, the evaluation at the end of Period 1 (i.e., Period 1c, week 28 of the evaluation schedule) must be completed as a follow-up visit at the end of treatment. Patients who achieve a partial response as evaluated at the follow-up visit at the end of Period 1 (discontinued cyclosporine, with or without glucocorticoid tapering) may, at the discretion of the principal investigator and family, directly participate in the open-label treatment of Period 3.

[0353] Period 2 - Glucocorticoids (randomized treatment discontinuation period) During Period 2, patients who achieved a constant maintenance dose of glucocorticoids (prednisone or equivalent) of 0.2 mg / kg / day or less (for patients weighing over 30 kg) or 0.4 mg / kg / day or less (for pediatric patients) during Period 1c must maintain this dose, and gradual reduction of glucocorticoids is not permitted during Period 2.

[0354] Emergency medication - glucocorticoids Patients experiencing a relapse (see Section 8.3.5) may, in accordance with medical judgment and local guidance, receive an increased maintenance dose of glucocorticoids as emergency medication or intermittent glucocorticoid treatment for a limited period.

[0355] Period 1 - Discontinuation of cyclosporine During the 4-week treatment period 1a to stabilize patients taking bbmAb, patients taking a certain dose of cyclosporine are permitted to receive bbmAb treatment. The cyclosporine dose must be kept stable by the principal investigator for the entire duration of period 1a, at least until day 29.

[0356] Following day 29, the principal investigator must gradually reduce the cyclosporine dose (as per medical judgment) at the start of the randomization treatment discontinuation period (period 2), with the aim of achieving cyclosporine discontinuation four weeks prior to randomization. • Once the patient has achieved at least a partial response, dose reduction of cyclosporine can be initiated (Section 8.3.5). • Continue reducing cyclosporine until one of the following occurs first: • The patient successfully discontinued cyclosporine. • The patient reached the maximum 20-week period for cyclosporine discontinuation. • The patient failed three times in attempts to discontinue cyclosporine.

[0357] If cyclosporine is discontinued for 4 weeks, the patient can directly participate in period 2 of the trial.

[0358] All patients who fail to maintain at least a partial response to bbmAb and discontinue cyclosporine may be discontinued from the study. Patients who achieve a partial response as assessed at the end of Period 1 (with or without glucocorticoid tapering, or who have discontinued cyclosporine) may, at the discretion of the principal investigator and their family, directly participate in the open-label treatment of Period 3.

[0359] If a patient discontinues treatment during Period 1, the evaluation at the end of Period 1 (i.e., Period 1c, week 28 of the evaluation schedule) must be completed as a follow-up visit at the end of treatment. Patients who achieve a partial response as evaluated at the follow-up visit at the end of Period 1 (discontinued cyclosporine, with or without glucocorticoid tapering) may, at the discretion of the principal investigator and family, directly participate in the open-label treatment of Period 3.

[0360] contraception While taking bbmAb, the use of oral, injectable, or implantable hormonal contraception is permitted.

[0361] 6.2.2. Prohibited Drugs The following actions are not permitted before Day 1 of Period 1 (the time interval before Day 1 is detailed below) and throughout the entire examination: Etanercept one week prior to day 1 Adalimumab 4 weeks prior to day 1 Infliximab two weeks prior to day 1 Tocilizumab from 3 weeks prior to day 1 Vedolizumab 4 weeks prior to day 1 Intravenous immunoglobulin (ivIg) administration four weeks prior to day 1, except for replacement therapy in patients diagnosed with hypogammaglobulinemia. See Section 6.2.1.1 for guidance on discontinuing immunoglobulin therapy. Other investigative or non-investigative immunomodulatory therapeutic antibodies for the past 30 days prior to day 1 or 5 half-lives (whichever is longer) Leflunomide from 4 weeks prior to day 1 Thalidomide from 4 weeks prior to day 1 6-mercaptopurine, azathioprine, cyclophosphamide, or chlorambucil 12 weeks prior to day 1 Tacrolimus 4 weeks prior to day 1 Colchicine, dapsone, and mycophenolate mofetil from 4 weeks prior to day 1 Ruxolitinib and other JAK inhibitors used 4 weeks prior to day 1 Rejection inhibitors and immunomodulators in other clinical trials or non-clinical trials within the past 28 days prior to day 1 Day 1: Anti-thymocyte globulin and Campath

[0362] Patients receiving glucocorticoid treatment may continue treatment as needed, depending on their clinical condition. The glucocorticoid dose must remain constant for at least 24 hours prior to bbmAb treatment (see Section 6.2.1.1 for glucocorticoid tapering during Period 1).

[0363] Patients receiving cyclosporine treatment may continue treatment as needed, depending on the patient's clinical condition. The cyclosporine dose must remain constant for at least 3 days prior to bbmAb treatment (see Section 6.2.1.1 for discontinuation of cyclosporine during Period 1).

[0364] Patients receiving anakinra, canakinumab, emaparmab, and / or investigational IL-18 / IL-1 / IFN-γ conjugate or blockade therapy must discontinue this treatment. Patients may receive bbmAb treatment as soon as the criteria for evidence of active disease (inclusion criteria in Section 5.1) are met. This pre-observation period shortens the conventional washout phase to a medically meaningful time and avoids unnecessary patient distress if the predefined washout period for each protocol is too long for individual patients.

[0365] Participants must not have received a live vaccine during the trial or within up to three months after the last dose, up to four weeks prior to day 1 of period 1. Approved (including conditional marketing approvals for HA) dead vaccines, inactivated vaccines, peptide vaccines, DNA vaccines, and RNA vaccines may be permitted at the discretion of the principal investigator and in accordance with local guidance.

[0366] Patients who entered the trial using bbmAb in a MAP (Medical Application Program) are required to maintain the conditions from the MAP regarding prohibited and concomitant medications that were permitted during the MAP.

[0367] Medical staff authorized by Novartis are available at any time to consult with the principal investigator regarding medical questions related to the trial concerning combination therapies and prohibited medications.

[0368] 6.2.3. First Aid Medicines An increase in the maintenance dose of glucocorticoids or intermittent steroid treatment may be used as an emergency measure. Information regarding the administration of glucocorticoids to study patients is described in Section 6.2.1.1, which describes the use and tapering of glucocorticoids during this study.

[0369] The use of emergency medications must be recorded on the CRF's concomitant medications page.

[0370] Patients who do not improve with treatment, patients who do not meet the partial response criteria on day 29 of period 1, or patients who experience a relapse not due to glucocorticoid tapering during period 1c may be discontinued from the study and treated according to medical judgment and local practice. Patients who achieve at least a partial response and discontinue cyclosporine may participate in Part 3, in which bbmAb is administered.

[0371] Instructions regarding prescriptions and consultations for clinical trial procedures.

[0372] [Table 24]

[0373] 8. Visit Schedule and Evaluation The evaluation schedule (Table 14) lists all evaluations performed. All data obtained from these evaluations must be documented in the patient's primary records.

[0374] Patients should visit the clinic / for evaluation as outlined in the evaluation schedule (Table 14), or as close as possible to the specified date and time.

[0375] Failure to attend appointments or changes to appointment schedules should not automatically result in termination of the trial. Patients who terminate the trial early for any reason should schedule an appointment as soon as possible, at which time all assessments listed for the final visit should be performed. At this final visit, all dispensed investigational medications should be reviewed, and adverse events and concomitant medications should be recorded in the CRF.

[0376] In Period 3, as outlined in Table 8-1, home medication visits by visiting nurses may be possible, depending on local regulations and capabilities, to maintain q2w medication between scheduled trial visits. Weight should be measured and all adverse events (AEs) assessed with each medication (AE assessments should be performed by the principal investigator or an appropriately delegated member of the trial team, based on information obtained from the visiting nurse). Weight from previous administration days can be used to calculate the dosage for home medication visits.

[0377] If an epidemic or pandemic (e.g., the COVID-19 pandemic) restricts or prevents facility trial visits, alternative methods of providing ongoing care may be implemented. Depending on local regulations and capabilities, telephone calls to patients, virtual contact (e.g., remote consultations), or visits to patients' homes by facility staff may substitute for facility trial visits during the pandemic until it is safe for patients to return to the facility.

[0378] [Table 25]

[0379] [Table 26]

[0380] [Table 27]

[0381] [Table 28]

[0382] [Table 29]

[0383] [Table 30]

[0384] [Table 31]

[0385] [Table 32]

[0386] [Table 33]

[0387] 8.1. Screening screening If the initial screening fails, patients may be rescreened, but each case must be discussed and agreed upon individually with the sponsor. Patients undergoing rescreening must give renewed consent and complete the rescreening CRF. If the safe laboratory assessment at the time of screening is outside the range specified in the exclusion criteria, the assessment may be repeated once before proceeding with the procedure. If the repeated value remains outside the specified range, the patient must be excluded from the trial.

[0388] 8.1.1. Eligibility Screening 8.1.1.1. Hepatitis screening, HIV screening If necessary, patients may be screened for hepatitis B surface antigen (HBsAg), and, if it is standard local practice, also for hepatitis B core antigen (HBcAg). Screening for hepatitis C is based on HCV antibodies, and if positive, HCV RNA levels should be measured. If available, negative test results from the past three months may be used.

[0389] An HIV serological test will be evaluated, and if positive, confirmation will be performed using a second technique available in the laboratory, such as Western blotting. If the confirmatory test is positive, appropriate counseling by the principal investigator will be made available. Notification to state and federal authorities as required by law will be the responsibility of the principal investigator. If available, negative test results from the past three months may be used.

[0390] 8.1.2. Tuberculosis (TB) Testing To assess the status of TB in patients, screening can be performed using one of the following methods, in accordance with local rules / guidelines: • QuantiFERON(registered trademark)-TB assay ·Chest X-ray If possible, negative test results from the past three months can be used.

[0391] Record all important findings in the relevant history / current condition section of the eCRF, as needed.

[0392] 8.1.3. Information to be collected when screening is unsuccessful Patients (or their parents / legal guardians) who sign an informed consent form and are subsequently found to be ineligible will be considered to have failed screening. The reason for screening failure must be entered in the relevant case report form (breakdown report). Pages for visit information, demographic information, informed consent, acceptance / exclusion, and disease-specific (XIAP deficiency or CDC42 mutation) history and breakdown must also be completed for all patients who failed screening. Unless the patient experienced a serious adverse event during the screening phase, no other data should be entered into the clinical database for patients who failed screening. Adverse events that are not SAEs should be tracked by the principal investigator and recorded only in the patient's source data.

[0393] Patients (or their parents / legal guardians) who have signed an informed consent form and are deemed eligible but are unable to initiate treatment for any reason will be considered early terminations. The reason for early termination must be recorded in the appropriate breakdown case report form (breakdown page). If a patient (or their parent / legal guardian) voluntarily withdraws from the trial during the screening phase, all visit information, demographic information, informed consent, NLRC4-GOF medical history, admission / exclusion page, withdrawal of informed consent, and breakdown must be recorded.

[0394] 8.2. Patient Demographics / Other Baseline Characteristics Demographic information When collecting demographic and baseline characteristics in accordance with the CRF, country-specific regulations must be taken into consideration. At the request of health authorities, the racial and ethnic characteristics of patients should be collected and analyzed to identify variability in safety or efficacy due to these factors and to assess the diversity of the study population.

[0395] Patient demographics: Record the year of birth (age), sex, race, dominant ethnicity (if permitted), and relevant medical history / current condition (up to the date of signing the informed consent) in the eCRF. Where possible, record the diagnosis rather than symptoms. Vaccination status should be recorded as part of the collection of medical history / current condition.

[0396] Disease-specific medical history and diagnosis (e.g., NLRC4-GOF, XIAP deficiency, or CDC42 mutation) To show how the patient's condition was managed and diagnosed, a detailed medical history of the patient's condition must be recorded in the eCRF. The details (including the date of assessment) should include the following: Showing symptoms Molecular diagnosis of XIAP deficiency or CDC42 mutation (if not yet available, it can be performed on a facility-by-facility basis using locally approved procedures for screening). IL-18 assay level (If not yet available, it can be performed on a facility-by-facility basis according to locally approved procedures for screening and diagnosis) Treatment intervention and outcome / response Time until relapse and the number of relapses Clinically important laboratory values, such as cytokine levels, CRP, and ferritin levels. Nutritional supplementation hospitalization Family history Other surveys Other clinically relevant information that is considered clinically relevant to support a broader understanding of the disease or diagnosis.

[0397] 8.3. Effectiveness Effectiveness evaluation will be conducted at the points defined in the evaluation schedule (Table 14).

[0398] If an epidemic or pandemic (e.g., the COVID-19 pandemic) restricts or hinders visits to the clinical trial, alternative methods can be implemented to provide continuous care and collect efficacy evaluations.

[0399] 8.3.1. Comprehensive assessment of disease activity by a physician (PGA) The physician's comprehensive assessment of the disease (PGA) (Appendix 4) is performed at the points outlined in the assessment schedule (Table 14).

[0400] To prevent bias in evaluation, the PGA should be performed before CRP results become available from the local laboratory. To ensure consistency between evaluations, it is recommended that one principal investigator evaluate the same patient throughout the entire trial.

[0401] The overall evaluation of the physician is based on a 5-point scale: • 0 = Absence (presence) of disease-related clinical signs and symptoms. • 1 = Minimal disease-related signs and symptoms • 2 = Mild disease-related signs and symptoms • 3 = Moderate disease-related signs and symptoms • 4 = Signs and symptoms related to severe illness

[0402] 8.3.2. Assessment of the severity of signs and symptoms of the disease by a physician. The physician's assessment of the severity of major disease-specific signs and symptoms (Appendix 5) should be performed at the points outlined in the assessment schedule (Table 14). Different assessments should be used for each disease diagnosis, and an appropriate questionnaire should be completed for each diagnosis.

[0403] To ensure consistency between evaluations, it is recommended that the same principal investigator evaluate the same patient throughout the entire trial. The following signs and symptoms should be evaluated: • For patients with XIAP deficiency, evaluate the following signs and symptoms: • Intestinal diseases • Fever ·Cytopenia ·Skin diseases ·Infectious disease ·Splenomegaly ·CNS invasion

[0404] • For patients with the CDC42 mutation, evaluate the following signs and symptoms: • Intestinal diseases • Fever ·Skin diseases ·Splenomegaly ·CNS invasion

[0405] • The severity assessment of major disease-specific signs and symptoms by physicians is based on a 5-point scale: ·0=absent ·1=min 2 = mild ·3=moderate ·4=severe

[0406] 8.3.3. Inflammatory Markers CRP and ferritin should be measured in local laboratories as shown in Table 14. Where possible, the analysis should be included as part of routine safe laboratory monitoring to avoid additional sample collection.

[0407] 8.3.4. Comprehensive Assessment of Disease Activity by Patient / Parent (PPGA) Patient assessments of disease activity (PPGA) are collected on paper CRFs and then transcribed into electronic CRFs (Appendix 6).

[0408] The PPGA must be completed at any given visit before all clinical evaluations. This report should be completed by the patient or parent / guardian at the points outlined in Table 14, depending on the patient's age, according to local guidance. Parent / guardian assistance is permitted if possible. However, for consistency, the same evaluator (the same patient or parent / guardian) should perform the evaluations throughout the entire trial.

[0409] Instruct the patient or parent / guardian to complete the PPGA.

[0410] The principal investigator or site staff should not provide any verbal or non-verbal cues that may influence the response to the PPGA. The principal investigator or site staff are only permitted to verify the completeness of the report.

[0411] PPGA is based on a 5-point rating system: • 0 = Absence (presence) of clinical signs and symptoms related to the disease. • 1 = Minimal disease-related signs and symptoms • 2 = Mild disease-related signs and symptoms • 3 = Moderate disease-related signs and symptoms • 4 = Signs and symptoms related to severe illness

[0412] 8.3.5. Response to Treatment Criteria The response to treatment is collected through PGA (Section 8.3.1) and inflammatory markers (Section 8.3.3).

[0413] Period 1 If a complete response is observed (evaluated on the same day), the patient is considered to have made a complete response. • The physician's overall assessment of disease activity is at or above the minimum level, and • A decrease of 60% or more from baseline, or normalization of either ferritin (<400 ng / mL) and / or CRP (<10 mg / L).

[0414] Partial response criteria: If evaluated on the same day, the patient is considered to have given an incomplete (partial) response. • A one-step improvement in the physician's overall assessment of disease activity compared to baseline, • A decrease of 30% or more from baseline, or either ferritin or CRP levels.

[0415] Period 2 Criteria for relapse: If (evaluated on the same day), the patient is considered to have relapsed: • Overall assessment of disease activity by physician > Minimum, In patients where the levels increased by more than 60% from the start level of period 2, or where the levels normalized, either an increase in ferritin >2500 ng / mL and / or an increase in CRP >20 mg / L was observed.

[0416] When the principal investigator accesses inflammatory markers for response to treatment criteria, they should, in accordance with medical judgment, rule out other common causes of changes in CRP or ferritin in this pediatric study population (e.g., childhood infections, iron supplementation, blood transfusions).

[0417] [Table 34]

[0418] 9. Efficacy and / or pharmacodynamic endpoints The FAS for each trial period will be used in the analysis in this section.

[0419] The following secondary efficacy endpoints will be analyzed: Responses at the end of periods 1 and 2 on day 29 (for Cohort 1) Serological remission at the end of periods 1 and 2 on day 29 (for cohort 1) Glucocorticoid therapy during period 1 (in the case of cohort 1) Time to the first relapse in period 2 (for cohort 1) Physician assessment of disease signs and symptom severity (all cohorts) Comprehensive assessment of disease activity by patients / parents (all cohorts) Comprehensive assessment of disease activity by physicians (all cohorts)

[0420] The proportion of patients who responded to bbmAb treatment from day 29 to the end of period 1 will be calculated. The definition of a bbmAb treatment complete responder is described in protocol section 8.3.6. The proportion of patients who responded to both bbmAb and placebo will also be evaluated at the end of period 2.

[0421] Inflammatory markers (CRP and ferritin) will be summarized based on treatment and visits.

[0422] The percentage of patients who achieve serological remission will be assessed on day 29 and at the end of periods 1 and 2.

[0423] From day 29 until the end of period 1, calculate the percentage of patients who achieved glucocorticoid tapering and cyclosporine reduction. The definitions of glucocorticoid tapering and cyclosporine reduction are described in section 6.2.1.1 of the protocol.

[0424] Rekindling Relapse is assessed by a physician's comprehensive assessment of disease activity, ferritin, and / or CRP, as outlined in the relapse criteria in Section 8.3.6 of the protocol.

[0425] The time to the first relapse is summarized for each treatment in period 2. For graphical representation, a Kaplan-Meier graph is provided, showing each treatment group with a separate line.

[0426] Other Effectiveness Endpoints Summary statistics of absolute values ​​and changes from baseline in the physician's severity assessment of disease signs and symptoms, the patient / parent's overall assessment of disease activity, and the physician's overall assessment of disease activity will be provided at the time of treatment and visit. Frequency distribution tables for each symptom assessed by the physician and patient / parent will be presented at the time of visit. Frequency distributions of severity scores (absent, minimal, mild, moderate, severe) will be calculated at the time of treatment and visit.

[0427] 10. 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Pediatr Dev Pathol;20(6):498-505. 24.Melendez J,Grogg M,Zheng Y(2011)Signaling Role of Cdc42 in Regulating Mammalian Physiology,Journal of Biological Chemistry,Volume 286,Issue 4. 25.Miao EA,Mao DP,Yudkovsky N,et al(2010)Innate immune detection of the type III secretion apparatus through the NLRC4 inflammasome.Proc Natl Acad Sci USA;107:3076-3080. 26.Miyazawa H and Wada T(2022)Immune-mediated inflammatory diseases with chronic excess of serum interleukin-18.Front.Immunol.13:930141.doi:10.3389 / fimmu.2022.930141 27.Moghaddas F,Zeng P,Zhang Y,et al(2018)Autoinflammatory mutation in NLRC4 reveals a leucine-rich repeat(LRR)-LRR oligomerization interface.J Allergy Clin Immunol;142:1956-1967 e1956. 28.Mudde A,Booth C,Marsh R(2021)Evolution of our understanding of XIAP deficiency.Front Pediatr;Jun 17;9;660520. 29.Perez EE,Orange JS,Bonilla F,et al(2017)Update on the use of immunoglobulin in human disease:A review of evidence.J Allergy Clin Immunol;Mar;139(3S):S1-S46. 30.Rigaud S,Fondaneche MC,Lambert N,et al(2006)XIAP deficiency in humans causes an X-linked lymphoproliferative syndrome.Nature;444(7115):110-4. 31.Romberg N,Al Moussawi K,Nelson-Williams C,et al(2014)Mutation of NLRC4 causes a syndrome of enterocolitis and autoinflammation.Nature Genetics;46(10):1135-1139. 32.Romberg N,Vogel TP and Canna SW(2017)NLRC4 inflammasomopathies.Curr Opin Allergy Clin Immunol;17:398-404. 33.Tak PP,Bacchi M and Bertolino M(2006)Pharmacokinetics of IL-18 binding protein in healthy volunteers and subjects with rheumatoid arthritis or plaque psoriasis.Eur J Drug Metab Pharmacokinet;31:109-116. 34.Takenouchi,T,Kosaki,R,Niizuma,T,et al(2015)Macrothrombocytopenia and Developmental Delay with a de novo CDC42 Mutation:Yet Another Locus for Thrombocytopenia and Developmental Delay.Am J Med Genet Part A 167A:2822-2825. 35.Wada T,Kanegane H,Ohta K,et al(2014)Sustained elevation of serum interleukin-18 and its association with hemophagocytic lymphohistiocytosis in XIAP deficiency.Cytokine.2014;65(1):74-8. 36. Weiss ES, Girard-Guyonvarc’h C, Holzinger D, et al (2018) Interleukin-18 diagnostically distinguishes and pathogenically promotes human and murine macrophage activation syndrome. Blood; 131(13):1442-1455. 37. WHO (2020) The WHO Child Growth Standards (internet). Available from: http: / / www.who.int / childgrowth / en / (Accessed 06-Oct-2020) 38. Yan X, Chen Y and Krzyzanski W (2012) Methods of solving rapid binding target-mediated drug disposition model for two drugs competing for the same receptor. Journal of pharmacokinetics and pharmacodynamics; 39(5), pp543-60. 39. Zhao Y, Yang J, Shi J et al (2011) The NLRC4 inflammasome receptors for bacterial flagellin and type III secretion apparatus. Nature; 477:596-600. 40. Zhuang L, Chen J, Yu J et al (2019) Dosage Consideration for Canakinumab in Children With Periodic Fever Syndromes. Clinical Pharmacology & Therapeutics; 106(3):557-567

[0428] Appendix Appendix 1: Clinically Significant Test Values and Vital Signs Any significant test or vital sign abnormality defined below shall be notified to Novartis simultaneously as it becomes available to the Investigator. Novartis will determine whether further consultation with the Investigator is appropriate.

[0429] Newly developed selected significant test abnormalities in pediatric patients (less than 16 years of age): · Albumin: < LLN · Increase in AST, ALT, and either ALT or AST > 3×ULN, > 5×ULN, > 10×ULN and > 20×ULN * · All increases in bilirubin; to > 1.5×ULN and to > 2×ULN * Increase in bilirubin to · All increases in ALP > 1.5×ULN * · Increase in ALT and / or AST ( > 3×ULN) accompanied by increase in bilirubin ( > 1.5×ULN, > 2×ULN) * · Gamma-glutamyltransferase (GGT): > 3×ULN · Creatinine (serum): ≥ 1.5×ULN · Potassium: ≥ 5.5 mmol / L or ≤ 3.5 mmol / L · Magnesium: ≥ 1.2 mmol / L or ≤ 0.7 mmol / L · Sodium: ≥ 150 mmol / L or ≤ 130 mmol / L · Hemoglobin: Decrease from baseline ≥ 2 g / dL or < 8.5 g / dL · Platelet count: < Lower limit of normal (LLN) · White blood cell count: ≤ 0.8×LLN or ≥ 1.2×ULN · Neutrophils: ≤ 0.9×LLN or ≥ 1.2×ULN · Eosinophils: ≥ 1.1×ULN · Lymphocytes: < LLN or ≥ 1.1×ULN · Proteinuria dipstick: Positive (trace, ≥ +)

[0430] Significant vital sign abnormalities in pediatric patients (less than 16 years of age): Systolic / diastolic blood pressure 1 : • High: Above the 95th percentile in both age and height groups. • Low: Below the 5th percentile in age and height groups. ·Oral body temperature (℃) ·High: ≧38.4℃ ·Low: ≦35.0℃ • Pulse rate (bpm): See Table 17-1

[0431] [Table 35]

[0432] [Table 36]

[0433] Selected significant laboratory abnormalities newly observed in adult patients (16 years and older): ·albumin: <LLN • Elevated AST, ALT, and either ALT or AST (3×ULN, 5×ULN, 10×ULN, and 20×ULN) * • All increases in bilirubin: >1.5 × ULN and >2 × ULN * Increased bilirubin • All increases in ALP > 1.5 × ULN * • Elevated AST and / or ALT (>3×ULN) accompanied by elevated bilirubin (>1.5×ULN, >2×ULN) * Gamma-glutamyltransferase (GGT): >3 × ULN • Creatinine (serum): ≥1.5 × ULN • Creatinine clearance (Cockroft-Gault formula) § : Decrease from baseline ≥ 25% • Potassium: ≥ 5.5 mmol / L or ≤ 3.0 mmol / L Magnesium: ≥1.5 mmol / L or ≤0.5 mmol / L · Sodium: ≥ 150 mmol / L or ≤ 130 mmol / L · Calcium: ≥ 1.2 × ULN or < lower limit of normal value (LLN) · Hemoglobin: Decrease from baseline ≥ 2 g / dL or < 10.0 g / dL · Platelet count: < LLN · White blood cell count: ≤ 0.8 × LLN or ≥ 1.2 × ULN · Neutrophils: ≤ 0.9 × LLN or ≥ 1.2 × ULN · Eosinophils: ≥ 1.1 × ULN · Lymphocytes: < LLN or ≥ 1.1 × ULN · Proteinuria dipstick: ≥ ++

[0434] Newly developed selected significant vital sign abnormalities in adult patients (≥ 16 years old): · Systolic / diastolic blood pressure: Decrease from baseline ≥ 25% or increase ≥ 25%, or ≥ 140 / 90 · Pulse: ≥ 110 bpm with change from baseline ≥ 15% or < 50 bpm with change from baseline ≥ 15% * Source: Draft October 2007 FDA Guidance for Industry Drug-Induced Liver Injury: Premarketing Clinical Evaluation (FDA 2007) Cockroft-Gault formula (for men): Creatinine clearance (mL / min) = [((140 - age (years)) × body weight (kg)) / (serum creatinine (μmol / L) / 88.4) (mg / dL) × 72] Cockroft-Gault formula (for women): Creatinine clearance (mL / min) = [((140 - age (years)) × body weight (kg)) / (serum creatinine (μmol / L) / 88.4) (mg / dL) × 72] × 0.85 Note: Only values after baseline are flagged as significant abnormalities.

[0435]

Table 37

[0436] Appendix 2: Anaphylaxis Anaphylaxis is likely if any one of the following three criteria is met: 1. Acute onset of a disease involving the skin, mucous membranes, or both (within minutes to hours) (e.g., generalized urticaria, itching, or flushing, swelling of the lips, tongue, or uvula) and at least one of the following: a. Respiratory dysfunction (e.g., dyspnea, inspiratory stridor-bronchospasm, expiratory stridor, decreased PEF, hypoxemia) b. Symptoms of decreased blood pressure or related peripheral organ dysfunction (e.g., hypotension [collapse], syncope, incontinence) 2. Two or more of the following symptoms that develop rapidly (from a few minutes to a few hours) after exposure to a major allergen for the patient: a. Infiltration of skin and mucous membrane tissue (e.g., generalized urticaria, itching, or flushing, swelling of the lips, tongue, and uvula) b. Respiratory dysfunction (e.g., dyspnea, inspiratory stridor-bronchospasm, expiratory stridor, decreased PEF, hypoxemia) c. A decrease in blood pressure or related symptoms (e.g., hypotension [collapse], syncope, incontinence) d. Persistent gastrointestinal symptoms (e.g., spasmodic abdominal pain, vomiting) 3. A decrease in blood pressure (from a few minutes to several hours) after the patient's exposure to a known allergen. a. Adults: Systolic blood pressure less than 90 mmHg, or a decrease of more than 30% from baseline.

[0437] Appendix 3: Blood sampling guidelines of the Research Ethics Board (REB) at Toronto Sick Care Hospital. Use the following recommendations from the Toronto Sick Child Hospital Research Ethics Committee to guide the principal investigator in determining the maximum blood volume to be drawn during the trial. The principal investigator should closely monitor the total blood volume drawn to ensure compliance with the limits outlined in the guidance or any local restrictions from the IRB / EC.

[0438] In infant, child, and adolescent studies, this guidance permits total blood collection of up to 5% of the patient's total blood volume over an 8-week period, either in one dose or in installments.

[0439] [Table 38]

[0440] Sequence List Table 13 discloses amino acid and nucleotide sequences useful for carrying out the present invention.

[0441] [Table 39]

[0442] [Table 40]

[0443] [Table 41]

[0444] [Table 42]

[0445] [Table 43]

[0446] [Table 44]

[0447] [Table 45]

[0448] [Table 46]

[0449] Table 47

[0450] Table 48

[0451] Table 49

[0452] Table 50

[0453] Table 51

[0454] Table 52

[0455] Table 53

[0456] Table 54

[0457] Table 55

[0458] Table 56

[0459] [Table 57]

[0460] Throughout the entire text of this application, if there is any inconsistency between the text of this specification (e.g., Table 13) and the sequence list, the text of the specification shall prevail.

Claims

1. A method for treating or preventing autoinflammatory or disease-related XIAP deficiency in a subject requiring such treatment, comprising administering a therapeutically effective amount of a bispecific antibody to the subject, wherein the antibody is a. A first portion of immunoglobulin having a first portion which is immunoglobulin having a first variable light chain (VL1) and a first variable heavy chain (VH1) that specifically bind to IL1β, and a first constant heavy chain (CH1) having heterodimerization modification, and b. A method comprising a second portion which is an immunoglobulin having a second variable light chain (VL2) and a second variable heavy chain (VH2) that specifically bind to IL-18, and a second steady heavy chain (CH2) having a heterodimerization modification complementary to the heterodimerization modification of the first steady heavy chain.

2. The first and second constant heavy chains of the aforementioned bispecific antibody are IgG1, a. The first steady-state heavy chain has a point mutation that generates a knob structure, and the second steady-state heavy chain has a point mutation that generates a hole structure, or b. The first steady-state heavy chain has a point mutation that generates a hole structure, and the second steady-state heavy chain has a point mutation that generates a knob structure, and optionally c. The method according to claim 1, wherein the first and second steady heavy chains have mutations that cause disulfide crosslinking.

3. a. The first immunoglobulin VH1 domain of the bispecific antibody is i. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 76, CDR2 has amino acid sequence number 77, and CDR3 has amino acid sequence number 78; or ii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 79, CDR2 has amino acid sequence number 80, and CDR3 has amino acid sequence number 81; d. The first immunoglobulin VL1 domain of the bispecific antibody is i. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 92, CDR2 has amino acid sequence number 93, and CDR3 has amino acid sequence number 94, or ii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 95, CDR2 has amino acid sequence number 96, and CDR3 has amino acid sequence number 97; e. The second immunoglobulin VH2 domain of the bispecific antibody is i. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 44, CDR2 has amino acid sequence number 45, and CDR3 has amino acid sequence number 46; or ii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 47, CDR2 has amino acid sequence number 48, and CDR3 has amino acid sequence number 49; f. The second immunoglobulin VL2 domain of the bispecific antibody is i. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 60, CDR2 has amino acid sequence number 61, and CDR3 has amino acid sequence number 62, or ii. The method according to claim 1 or 2, comprising hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 63, CDR2 has amino acid sequence number 64, and CDR3 has amino acid sequence number 65.

4. a. The first immunoglobulin VH1 domain of the bispecific antibody contains the amino acid sequence number 85, b. The first immunoglobulin VL1 domain of the bispecific antibody comprises the amino acid sequence number 101, c. The second immunoglobulin VH2 domain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 53, d. The method according to any one of claims 1 to 3, wherein the second immunoglobulin VL2 domain of the bispecific antibody comprises the amino acid sequence number 69.

5. a. The first immunoglobulin heavy chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 87, b. The first immunoglobulin light chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 103, c. The second immunoglobulin heavy chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 55, d. The method according to any one of claims 1 to 4, wherein the second immunoglobulin light chain of the bispecific antibody comprises the amino acid sequence SEQ ID NO:

71.

6. The method according to any one of claims 1 to 5, wherein the subject has a loss-of-function mutation in the XIAP / BIRC4 gene that encodes the XIAP protein.

7. The method according to any one of claims 1 to 6, wherein the subject has macrophage activation syndrome (MAS).

8. The method according to any one of claims 1 to 7, wherein the subject has autoinflammatory disease accompanied by infantile enteritis (AIFEC).

9. The method according to any one of claims 1 to 8, wherein the subject has excessively elevated serum IL-18 and serum IL-1β levels compared to a control group of subjects who do not have autoinflammatory or disease-related XIAP deficiency.

10. The method according to any one of claims 1 to 9, wherein the patient with autoinflammatory disease or disease based on XIAP deficiency is suffering from inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, or hemophagocytic lymphohistiocytosis.

11. The method according to any one of claims 1 to 10, wherein the subject has a serum ferritin level greater than 600 ng / mL or a serum C-reactive protein (CRP) greater than 20 mg / L.

12. The method according to any one of claims 1 to 11, wherein the autoinflammatory or disease based on the XIAP deficiency is resistant to treatment with cyclosporine, anti-TNFα treatment, systemic glucocorticoids, and anti-IL-1β therapy, either alone or in combination thereof.

13. A bispecific antibody for use in the treatment or prevention of autoinflammatory or disease-related XIAP deficiency in subjects requiring it, a. A first portion of immunoglobulin having a first variable light chain (VL1) and a first variable heavy chain (VH1) that specifically bind to IL1β, and a first constant heavy chain (CH1) having heterodimerization modification, and b. A bispecific antibody comprising a second portion which is an immunoglobulin having a second variable light chain (VL2) and a second variable heavy chain (VH2) that specifically bind to IL-18, and a second constant heavy chain (CH2) having a heterodimerization modification complementary to the heterodimerization modification of the first constant heavy chain.

14. The first and second constant heavy chains of the bispecific antibody are IgG1, a. The first steady-state heavy chain has a point mutation that generates a knob structure, and the second steady-state heavy chain has a point mutation that generates a hole structure, or b. The first steady-state heavy chain has a point mutation that generates a hole structure, and the second steady-state heavy chain has a point mutation that generates a knob structure, and optionally c. A bispecific antibody according to claim 13 for use in treating or preventing autoinflammatory or disease-related XIAP deficiency in a subject requiring such treatment, wherein the first and second constant heavy chains have mutations that cause disulfide crosslinking.

15. a. The first immunoglobulin VH1 domain of the bispecific antibody is i. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 76, CDR2 has amino acid sequence number 77, and CDR3 has amino acid sequence number 78; or ii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 79, CDR2 has amino acid sequence number 80, and CDR3 has amino acid sequence number 81; b. The first immunoglobulin VL1 domain of the bispecific antibody is iii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 92, CDR2 has amino acid sequence number 93, and CDR3 has amino acid sequence number 94, or iv. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 95, CDR2 has amino acid sequence number 96, and CDR3 has amino acid sequence number 97; c. The second immunoglobulin VH2 domain of the bispecific antibody is v. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 44, CDR2 has amino acid sequence number 45, and CDR3 has amino acid sequence number 46; or vi. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 47, CDR2 has amino acid sequence number 48, and CDR3 has amino acid sequence number 49; d. The second immunoglobulin VL2 domain of the bispecific antibody is vii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 60, CDR2 has amino acid sequence number 61, and CDR3 has amino acid sequence number 62, or viiii. A bispecific antibody for use in the treatment or prevention of autoinflammatory or disease-related XIAP deficiency in a subject requiring its use, according to claim 13 or 14, comprising hypervariable regions CDR1, CDR2 and CDR3, wherein CDR1 has the amino acid sequence sequence SEQ ID NO: 63, CDR2 has the amino acid sequence sequence SEQ ID NO: 64, and CDR3 has the amino acid sequence SEQ ID NO:

65.

16. a. The first immunoglobulin VH1 domain of the bispecific antibody contains the amino acid sequence number 85, b. The first immunoglobulin VL1 domain of the bispecific antibody comprises the amino acid sequence number 101, c. The second immunoglobulin VH2 domain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 53, d. A bispecific antibody according to any one of claims 13 to 15, for use in the treatment or prevention of autoinflammatory or disease-related XIAP deficiency in a subject requiring such treatment, wherein the second immunoglobulin VL2 domain of the bispecific antibody comprises the amino acid sequence number 69.

17. a. The first immunoglobulin heavy chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 87, b. The first immunoglobulin light chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 103, c. The second immunoglobulin heavy chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 55, d. A bispecific antibody according to any one of claims 13 to 16, for use in the treatment or prevention of autoinflammatory or disease-related XIAP deficiency in a subject requiring such treatment, wherein the second immunoglobulin light chain of the bispecific antibody comprises the amino acid sequence number 71.

18. A bispecific antibody for use in treating or preventing autoinflammation or disease based on XIAP deficiency in a subject having a loss-of-function mutation in the XIAP gene, as described in any one of claims 13 to 17.

19. A bispecific antibody for use in the treatment or prevention of autoinflammatory or disease based on XIAP deficiency in a subject requiring such treatment, as described in any one of claims 13 to 18, wherein the patient with autoinflammatory or disease based on XIAP deficiency is suffering from inflammatory bowel disease, abdominal pain and diarrhea, recurrent fever, splenomegaly, or hemophagocytic lymphohistiocytosis (HLH).

20. A bispecific antibody for use in treating or preventing autoinflammatory or disease-related conditions due to XIAP deficiency in a subject having macrophage activation syndrome (MAS), as described in any one of claims 13 to 19.

21. A bispecific antibody for use in treating or preventing autoinflammatory disease or disease based on XIAP deficiency in a subject requiring such treatment, as described in any one of claims 13 to 20, wherein the subject has autoinflammatory disease accompanied by infantile enteritis (AIFEC).

22. A bispecific antibody for use in treating or preventing autoinflammatory or disease-related conditions due to XIAP deficiency in a subject requiring such treatment, according to any one of claims 13 to 21, wherein the subject has excessively elevated serum IL-18 and serum IL-1β levels compared to a control group of subjects without autoinflammatory or disease-related conditions due to XIAP deficiency.

23. A bispecific antibody for use in treating or preventing autoinflammation or disease based on XIAP deficiency in a subject having a serum ferritin level greater than 600 ng / mL or a serum C-reactive protein (CRP) greater than 20 mg / L, according to any one of claims 13 to 22.

24. The method according to any one of claims 1 to 12, comprising administering the bispecific antibody to the subject in an amount of approximately 1 mg / kg to approximately 35 mg / kg.

25. The method according to claim 24, comprising administering approximately 10 mg / kg of the bispecific antibody to the subject.

26. The method according to claim 25, wherein the bispecific antibody is administered intravenously or subcutaneously.

27. The method according to claim 25 or 26, wherein the dose of the dispecific antibody administered is approximately 10 mg / kg administered intravenously, and the dispecific antibody is optionally administered every other week.

28. The method according to claim 26, wherein the dose of the dispecific antibody administered is approximately 50 mg to approximately 900 mg administered subcutaneously.

29. A bispecific antibody for use in treating or preventing autoinflammatory or disease-related XIAP deficiency in a subject requiring such treatment, according to any one of claims 13 to 23, comprising administering the bispecific antibody to the subject at a dose of 1 mg / kg to 35 mg / kg.

30. A bispecific antibody for use in treating or preventing autoinflammatory or disease-related XIAP deficiency in a subject requiring such treatment, according to claim 29, comprising administering 10 mg / kg of the bispecific antibody intravenously to the subject.

31. A bispecific antibody for use in treating or preventing autoinflammatory or disease-related XIAP deficiency in a subject requiring such treatment, according to any one of claims 13 to 23, wherein the bispecific antibody is administered subcutaneously in a dose of approximately 50 mg to approximately 900 mg.

32. A method for treating or preventing autoinflammatory or disease-related conditions in a subject requiring such treatment, comprising administering a therapeutically effective amount of a bispecific antibody to the subject, wherein the antibody is a. A first portion of immunoglobulin having a first variable light chain (VL1) and a first variable heavy chain (VH1) that specifically bind to IL1β, and a first constant heavy chain (CH1) having heterodimerization modification, and b. A method comprising a second portion which is an immunoglobulin having a second variable light chain (VL2) and a second variable heavy chain (VH2) that specifically bind to IL-18, and a second steady heavy chain (CH2) having a heterodimerization modification complementary to the heterodimerization modification of the first steady heavy chain.

33. The first and second constant heavy chains of the aforementioned bispecific antibody are IgG1, a. The first steady-state heavy chain has a point mutation that generates a knob structure, and the second steady-state heavy chain has a point mutation that generates a hole structure, or b. The first steady-state heavy chain has a point mutation that generates a hole structure, and the second steady-state heavy chain has a point mutation that generates a knob structure, and optionally c. The method according to claim 32, wherein the first and second steady heavy chains have mutations that cause disulfide crosslinking.

34. a. The first immunoglobulin VH1 domain of the bispecific antibody is i. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 76, CDR2 has amino acid sequence number 77, and CDR3 has amino acid sequence number 78; or ii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 79, CDR2 has amino acid sequence number 80, and CDR3 has amino acid sequence number 81; b. The first immunoglobulin VL1 domain of the bispecific antibody is iii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 92, CDR2 has amino acid sequence number 93, and CDR3 has amino acid sequence number 94, or iv. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 95, CDR2 has amino acid sequence number 96, and CDR3 has amino acid sequence number 97; c. The second immunoglobulin VH2 domain of the bispecific antibody is v. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 44, CDR2 has amino acid sequence number 45, and CDR3 has amino acid sequence number 46; or vi. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 47, CDR2 has amino acid sequence number 48, and CDR3 has amino acid sequence number 49; d. The second immunoglobulin VL2 domain of the bispecific antibody is vii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 60, CDR2 has amino acid sequence number 61, and CDR3 has amino acid sequence number 62, or viiii. The method according to claim 32 or 33, comprising hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 63, CDR2 has amino acid sequence number 64, and CDR3 has amino acid sequence number 65.

35. a. The first immunoglobulin VH1 domain of the bispecific antibody contains the amino acid sequence number 85, b. The first immunoglobulin VL1 domain of the bispecific antibody comprises the amino acid sequence number 101, c. The second immunoglobulin VH2 domain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 53, d. The method according to any one of claims 32 to 34, wherein the second immunoglobulin VL2 domain of the bispecific antibody comprises the amino acid sequence number 69.

36. a. The first immunoglobulin heavy chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 87, b. The first immunoglobulin light chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 103, c. The second immunoglobulin heavy chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 55, d. The method according to any one of claims 32 to 35, wherein the second immunoglobulin light chain of the bispecific antibody comprises the amino acid sequence SEQ ID NO:

71.

37. The method according to any one of claims 32 to 36, wherein the subject has a mutation in the CDC42 gene that causes abnormal palmitoylation of the CDC42 protein or a missense mutation at the C-terminus of the CDC42 protein that affects the localization of the CDC42 protein.

38. The method according to any one of claims 32 to 37, wherein the subject has macrophage activation syndrome (MAS).

39. The method according to any one of claims 32 to 37, wherein the subject has autoinflammatory disease accompanied by infantile enteritis (AIFEC).

40. The method according to any one of claims 32 to 39, wherein the subject has excessively elevated serum IL-18 and serum IL-1β levels compared to a control group of subjects that do not have autoinflammatory or disease-related CDC42 mutations.

41. The method according to any one of claims 32 to 40, wherein the patient with autoinflammatory disease or illness based on the CDC42 mutation is suffering from neonatal-onset cytopenia, autoinflammatory disease, or recurrent hemophagocytic lymphohistiocytosis (HLH).

42. The method according to any one of claims 32 to 41, wherein the subject has a serum ferritin level greater than 600 ng / mL or a serum C-reactive protein (CRP) greater than 20 mg / L.

43. The method according to any one of claims 32 to 42, wherein a patient with autoinflammatory disease or illness based on the CDC42 mutation is resistant to cyclosporine treatment, anti-TNFα treatment, monotherapy of systemic glucocorticoids and anti-IL-1β therapy, or a combination thereof.

44. A bispecific antibody for use in the treatment or prevention of autoinflammatory or disease-related conditions in subjects requiring it, a. A first portion which is an immunoglobulin having a first variable light chain (VL1) that specifically binds to IL1β, a first variable heavy chain (VH1), and a first constant heavy chain (CH1) having heterodimerization modification, and b. A bispecific antibody comprising a second portion which is an immunoglobulin having a second variable light chain (VL2) and a second variable heavy chain (VH2) that specifically bind to IL-18, and a second constant heavy chain (CH2) having a heterodimerization modification complementary to the heterodimerization modification of the first constant heavy chain.

45. The first and second constant heavy chains of the bispecific antibody are IgG1, d. The first steady-state heavy chain has a point mutation that generates a knob structure, and the second steady-state heavy chain has a point mutation that generates a hole structure, or e. The first steady-state heavy chain has a point mutation that generates a hole structure, and the second steady-state heavy chain has a point mutation that generates a knob structure, and optionally f. A bispecific antibody according to claim 44 for use in the treatment or prevention of autoinflammatory or disease-related CDC42 mutations in subjects requiring such treatment, wherein the first and second constant heavy chains have mutations that cause disulfide crosslinking.

46. e. The first immunoglobulin VH1 domain of the bispecific antibody is i. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 76, CDR2 has amino acid sequence number 77, and CDR3 has amino acid sequence number 78; or ii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 79, CDR2 has amino acid sequence number 80, and CDR3 has amino acid sequence number 81; f. The first immunoglobulin VL1 domain of the bispecific antibody is iii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 92, CDR2 has amino acid sequence number 93, and CDR3 has amino acid sequence number 94, or iv. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 95, CDR2 has amino acid sequence number 96, and CDR3 has amino acid sequence number 97; g. The second immunoglobulin VH2 domain of the bispecific antibody is v. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 44, CDR2 has amino acid sequence number 45, and CDR3 has amino acid sequence number 46; or vi. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 47, CDR2 has amino acid sequence number 48, and CDR3 has amino acid sequence number 49; h. The second immunoglobulin VL2 domain of the bispecific antibody is vii. Hypervariable regions CDR1, CDR2, and CDR3, wherein CDR1 has amino acid sequence number 60, CDR2 has amino acid sequence number 61, and CDR3 has amino acid sequence number 62, or viiii. A bispecific antibody for use in the treatment or prevention of autoinflammatory conditions or diseases based on CDC42 mutations in subjects requiring such treatment, according to claim 44 or 45, comprising hypervariable regions CDR1, CDR2 and CDR3, wherein CDR1 has amino acid sequence number 63, CDR2 has amino acid sequence number 64, and CDR3 has amino acid sequence number 65.

47. e. The first immunoglobulin VH1 domain of the bispecific antibody contains the amino acid sequence number 85, f. The first immunoglobulin VL1 domain of the bispecific antibody comprises the amino acid sequence SEQ ID NO: 101, g. The second immunoglobulin VH2 domain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 53, h. A bispecific antibody according to any one of claims 44 to 46, for use in the treatment or prevention of autoinflammatory or disease-related CDC42 mutations in a subject requiring such treatment, wherein the second immunoglobulin VL2 domain of the bispecific antibody comprises the amino acid sequence number 69.

48. e. The first immunoglobulin heavy chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 87, f. The first immunoglobulin light chain of the bispecific antibody contains the amino acid sequence SEQ ID NO: 103, g. The second immunoglobulin heavy chain of the bispecific antibody contains the amino acid sequence of SEQ ID NO: 55, h. A bispecific antibody for use in treating or preventing autoinflammatory or disease-related CDC42 mutations in a subject requiring such treatment, according to any one of claims 44 to 47, wherein the second immunoglobulin light chain of the bispecific antibody comprises the amino acid sequence number 71.

49. A bispecific antibody for use in treating or preventing autoinflammation or disease based on CDC42 mutations in a subject requiring such treatment, according to any one of claims 44 to 48, wherein the subject has a mutation in the CDC42 gene that causes abnormal palmitoylation of the CDC42 protein or a missense mutation at the C-terminus of the CDC42 protein that affects the localization of the CDC42 protein.

50. A bispecific antibody for use in treating or preventing autoinflammatory disease or disease based on CDC42 mutations in a subject, as described in any one of claims 44 to 49, wherein the subject suffers from neonatal cytopenia, autoinflammatory disease, or recurrent hemophagocytic lymphohistiocytosis (HLH).

51. A bispecific antibody for use in treating or preventing autoinflammatory or disease-related conditions in a subject having macrophage activation syndrome (MAS), as described in any one of claims 44 to 50, which requires the use of the CDC42 mutation.

52. A bispecific antibody for use in treating or preventing autoinflammatory disease or disease based on CDC42 mutation in a subject requiring such treatment, as described in claim 50, wherein the subject has autoinflammatory disease accompanied by infantile enteritis (AIFEC).

53. A bispecific antibody for use in treating or preventing autoinflammatory or disease-related conditions due to CDC42 mutations in a subject requiring such treatment, according to any one of claims 44 to 52, wherein the subject has excessively elevated serum IL-18 and serum IL-1β levels compared to a control population of subjects without autoinflammatory or disease-related conditions due to CDC42 mutations.

54. A bispecific antibody for use in treating or preventing autoinflammation or disease based on CDC42 mutations in a subject having a serum ferritin level greater than 600 ng / mL or a serum C-reactive protein (CRP) greater than 20 mg / L, as described in any one of claims 44 to 53.

55. The method according to any one of claims 33 to 43, comprising administering the bispecific antibody to the subject in an amount of approximately 1 mg / kg to approximately 35 mg / kg.

56. The method according to claim 55, comprising administering approximately 10 mg / kg of the bispecific antibody to the subject.

57. The method according to claim 56, wherein the two-specific antibody is administered intravenously or subcutaneously.

58. The method according to claim 56 or 57, wherein the dose of the dispecific antibody administered is approximately 10 mg / kg administered intravenously, and the dispecific antibody is optionally administered every other week.

59. The method according to claim 57, wherein the dose of the dispecific antibody administered is approximately 50 mg to approximately 900 mg administered subcutaneously.

60. A bispecific antibody for use in treating or preventing autoinflammatory conditions or diseases based on CDC42 mutations in a subject requiring such treatment, according to any one of claims 44 to 54, comprising administering the bispecific antibody to the subject at a dose of 1 mg / kg to 35 mg / kg.

61. The bispecific antibody according to claim 60 for use in treating or preventing autoinflammatory or disease-related CDC42 mutations in a subject requiring such treatment, comprising administering 10 mg / kg of the bispecific antibody intravenously to the subject.

62. The bispecific antibody described in claim 60 or 61 is used for the treatment or prevention of autoinflammatory or disease-related CDC42 mutations in a subject requiring such treatment, wherein the bispecific antibody is administered subcutaneously in a dose of approximately 50 mg to approximately 900 mg.

63. The method of treatment according to any one of claims 1 to 12, wherein the subject has a loss-of-function mutation in the XIAP gene.

64. The treatment method according to any one of claims 32 to 43, wherein the subject has a loss-of-function mutation in the CDC42 gene.

65. A bispecific antibody for use in treating or preventing autoinflammation or disease based on a CDC42 mutation in a subject having a loss-of-function mutation in the CDC42 gene, as described in any one of claims 44 to 54 and 60 to 62.

66. A bispecific antibody for use in the treatment or prevention of autoinflammatory or disease-related XIAP deficiency in a subject requiring such treatment, as described in any one of claims 15-23 and 29-31, wherein the subject is resistant to cyclosporine treatment, anti-TNFα treatment, monotherapy of systemic glucocorticoids and anti-IL-1β therapy, or a combination thereof.

67. A bispecific antibody for use in the treatment or prevention of autoinflammatory or disease-related CDC42 mutations in a subject requiring such treatment, as described in any one of claims 44-54 and 60-62, wherein the subject is resistant to cyclosporine treatment, anti-TNFα treatment, monotherapy of systemic glucocorticoids and anti-IL-1β therapy, or a combination thereof.

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