Treatment of diseases associated with intervertebral disc degeneration

Abstract

An object of the present invention is to use MMP-7 as an active ingredient in a treatment for diseases associated with intervertebral disc degeneration, even in cases where the treatment is intended for humans. [Solution] The present invention provides a treatment for a disease associated with intervertebral disc degeneration selected from the group consisting of intervertebral disc herniation, lower back pain, intervertebral disc disease, kyphoscoliosis and spondylosis degenerativeis, which contains MMP-7 as an active ingredient and has a single dose of 100 μg to 700 μg of MMP-7.

Description

[Technical field]

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

[0002] Lumbar disc herniation is common among young and middle-aged people aged 20 to 40 years, and is accompanied by severe lower back and lower limb pain and nerve disorders in the acute phase, which greatly restricts socioeconomic activities. On the other hand, it has been reported that pain in about 70% of lumbar disc herniation patients is relieved within 6 weeks of onset (Non-Patent Document 1). As 60% of symptomatic disc herniation is absorbed within 3 months of onset, pain and nerve symptoms may improve.

[0003] The principle of treatment for lumbar disc herniation is conservative therapy, and as a drug therapy, treatment with analgesics, muscle relaxants, peripheral neuropathic pain medications, etc. is generally performed in countries around the world, but the clear effectiveness of specific drugs has not been shown in drug therapy aimed at improving pain and physical function in patients with lumbar disc herniation (Non-Patent Document 1). In addition, the effectiveness of physical therapy and alternative therapies such as exercise therapy, traction therapy, ultrasound therapy, and corsets has not been fully demonstrated, and their therapeutic effects are considered to be limited (Non-Patent Document 1). In other words, the conservative treatment currently performed in Japan is a symptomatic treatment, and is not a radical treatment for the pathology of this disease in which the degenerated intervertebral disc bulges and escapes from the spinal canal or intervertebral foramen, compressing the nerve roots and dural canal and causing inflammation. On the other hand, evidence for surgical treatment has been established, especially in the short term, and surgery is useful when surgical indications are met, but in the long term, past evidence has also been evaluated in a divided manner, and it is considered important to determine whether or not surgery is indicated (Non-Patent Document 1). Condoliase has been marketed as an intradiscal therapeutic agent to replace surgery, but because it is a heterologous protein, there is a risk of serious side effects such as shock and anaphylaxis (Non-Patent Documents 2 to 3). In addition, its only application is "lumbar disc herniation of the type in which prolapse of the posterior longitudinal ligament is not sufficient for conservative treatment," and only a single administration into the high intervertebral disc that is the cause of the symptoms is permitted, and it is not possible to administer the drug again.

[0004] KTP-001 is a novel chemonucleolysis agent containing recombinant human matrix metalloproteinase-7 (MMP-7) (rhMMP-7) as an active ingredient, which was developed based on the results of the inventor's basic research. MMP-7 enzymatically cleaves proteoglycan, the main component of the extracellular matrix produced by intervertebral disc nucleus pulposus cells. It has been confirmed that MMP-7 is expressed in the natural regression mechanism of herniated discs, and administration of MMP-7 into the intervertebral disc is considered to be similar to the mechanism that physiologically promotes the natural regression mechanism.

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

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

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

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

[0009] In fact, in a clinical trial of the present preparation MMP-7 (KTP-001) conducted by the present inventors in the United States, 5 μg of MMP-7 was administered to humans, but except for one exceptional case, no effect of intradiscal injection therapy was observed, and 15 μg of MMP-7 was administered to humans, but all cases were herniated discs, which were merely a natural progression, and no clear therapeutic effect was obtained. Therefore, it was suspected that MMP-7 cannot be used as a therapeutic agent for intervertebral disc degeneration when the subject is humans, unlike when the subject is rabbits or dogs.

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

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

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

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

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

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

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

[0017] The present invention provides a treatment for a disease associated with intervertebral disc degeneration selected from the group consisting of intervertebral disc herniation, lower back pain, intervertebral disc disease, kyphoscoliosis, and spondylosis degenerativeis, comprising MMP-7 as an active ingredient, wherein the dosage of MMP-7 per administration is 100 μg to 700 μg.

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

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

[0020] The MMP-7 is preferably a recombinant human MMP-7. MMP-7 is an extracellular matrix degrading enzyme. MMP-7 is one of the matrix metalloproteases (hereinafter sometimes referred to as "MMP") belonging to the zinc-type metalloprotease family having a zinc molecule at the active site. MMP is produced as a precursor, and during extracellular secretion, the signal sequence is processed, and then the prosequence is processed to become an active form. While MMP secreted extracellularly controls the metabolism of the extracellular matrix, MMP-7 is mainly secreted by cancer cells and has been reported to be involved in invasion and metastasis. MMP-7 does not have the hinge or hemopexin-like domain that many other MMPs have, and is composed of the smallest molecular unit among MMPs, and uses collagen and components that constitute the extracellular matrix (fibronectin, vitronectin, laminin, aggrecan) as substrates. MMP-7 is presumed to be involved in the natural regression of herniated masses because it uses aggrecan, the main component of cartilage tissue, as a substrate, macrophages derived from surgical specimens of herniated discs express MMP-7, and a study using MMP-7-deficient mice showed no activation of inflammatory cytokines involved in the regression of herniated discs. The MMP-7 contained as an active ingredient in the treatment agent of the present invention may be full-length MMP-7, or a portion of MMP-7. For example, full-length MMP-7 may be a known one (SEQ ID NO: 2) (https: / / www-ncbi-nlm-nih-gov.translate.goog / protein / NP_002414?_x_tr_sl=en&_x_tr_tl=ja&_x_tr_hl=ja&_x_tr_pto=sc), and the portion of MMP-7 may be one described in the examples below (SEQ ID NO: 1), and equivalents thereof are also included. The precursor of human matrix metalloproteinase-7 (MMP-7) has a molecular weight of about 29 kDa, and the active form of human matrix metalloproteinase-7 (MMP-7) has a molecular weight of about 19 kDa (173 amino acids). MMP-7 is activated (cleaved) from a precursor of about 29 KDa to an active form of about 19 kDa, which exhibits enzyme activity. The MMP-7 is preferably an active form of MMP-7.

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

[0022] The treatment agent of the present invention may be, for example, for administration into an intervertebral disc, particularly into an intervertebral disc near a herniation and / or into the nucleus pulposus, particularly into the herniated portion of the nucleus pulposus. For example, in a disc puncture, a puncture needle is advanced percutaneously under X-ray fluoroscopy to puncture into the intervertebral disc. For example, an inner cylinder is advanced from there in the direction of the herniated disc, selectively puncturing the herniated disc, and the treatment agent of the present invention is injected. For example, the affected intervertebral height of the lumbar disc herniation is identified under X-ray fluoroscopy. Then, for example, in a prone or semi-lateral position, the patient is positioned so that the target disc space does not overlap with the adjacent end plate under X-ray fluoroscopy. Then, for example, a disinfection treatment is performed on the body surface from the lumbar region to the pelvis, and a sterilized disc puncture needle is used to puncture the skin under X-ray fluoroscopy to puncture the outer layer of the annulus fibrosus of the intervertebral disc. In the case of skin puncture, a local anesthetic may be administered subcutaneously. Thereafter, for example, X-ray fluoroscopy is performed from the front, side, and oblique positions at appropriate times, and the tip of the intervertebral puncture needle is placed in the center of the intervertebral disc. For example, in order to administer the treatment agent more accurately to the herniated disc mass, a device may be used in which the inner cylinder of the intervertebral disc puncture needle is bent toward the herniated orifice where the herniated disc bulges or prolapses. Preferably, the treatment agent of the present invention is then injected. Alternatively, in order to administer the treatment agent more accurately to the herniated disc mass, the intervertebral disc puncture needle may be inserted into the intervertebral disc under X-ray fluoroscopy via the intervertebral foramen or intervertebral space, and the treatment agent of the present invention may be administered. Alternatively, it may be assumed that it is difficult to insert the puncture needle into the intervertebral disc due to the anatomical characteristics of the subject. In this case, for example, the treatment agent of the present invention is administered into the epidural space via the intervertebral foramen or intervertebral space.

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

[0024] The treatment agent of the present invention may be administered using a device such as the puncture device described in Japanese Patent No. 4181599. The puncture device described in Japanese Patent No. 4181599 is characterized by comprising a lumen-shaped puncture body having a protruding opening on the side, an acting body that is housed in the puncture body and has an acting part that acts inside the body, and a guide means for protruding the acting part of the acting body laterally from the protruding opening. Furthermore, the puncture device described in Japanese Patent No. 4,181,599 more specifically comprises a lumen-shaped puncture body having an opening on the side, an acting body contained within the puncture body and having an acting part that acts inside the body, and a guide means for causing the acting part of the acting body to protrude laterally from the opening, the guide means comprising a wire contained within the puncture body and guiding the acting body, and a moving means for freely moving the wire from the opening to the side of the puncture body, the tip of the wire being fixed to the puncture body, and the moving means moving the wire in the length direction relative to the puncture body, thereby bending the wire and causing a part of it to protrude from the opening, and causing the acting part to protrude laterally from the opening.

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

[0026] The therapeutic agent of the present invention may be, for example, one that is administered to a patient with the disease once per day. The number of times that the therapeutic agent is administered to a patient with the disease per day is, for example, 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 times.

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

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

[0029] The treatment agent of the present invention may be, for example, for administration to a patient with the disease immediately after a diagnosis for confirming the disease. Here, the diagnosis for confirming the disease may be, for example, performed using MRI. The diagnosis for confirming the disease may include, for example, a diagnosis for confirming the presence of a neurological symptom such as radiculopathy, cauda equina, or myelopathy, and a diagnosis for confirming the state of nerve compression and intervertebral disc degeneration, for example, the site and extent of herniation, by magnetic resonance imaging (MRI). In addition, in the diagnosis for confirming the disease, the site and extent of herniation may be accurately determined by imaging the herniated mass at the site to be treated by a discography. Therefore, the treatment agent of the present invention may be for administering directly to the herniated area according to the pathology when MRI and discography are performed on a patient suspected of disc degeneration (for example, hernia) and disc degeneration (for example, hernia) is found in the patient. The administration of the treatment agent of the present invention in such an embodiment can promote the natural regression of herniated tissue.

[0030] The treatment agent of the present invention may be formulated in a dosage form for oral use, such as tablets, capsules, elixirs, and microcapsules, or in a dosage form for parenteral use, such as injections, ointments, and patches. That is, the treatment agent of the present invention may be, for example, an injection, and the amount of each dose may be 2cc or more. The amount of each dose of the treatment agent of the present invention, which is an injection, is, for example, 2cc or more, 3cc or more, 4cc or more, 5cc or more, 6cc or more, 7cc or more, 8cc or more, or 9cc or more. The amount of each dose of the treatment agent of the present invention, which is an injection, is, for example, 10cc or less, 9cc or less, 8cc or less, 7cc or less, 6cc or less, 5cc or less, 4cc or less, or 3cc or less. In the US clinical trial described below, a solution amount of 1cc was used. However, in discography, administration of 1cc of contrast agent into the disc did not allow complete imaging from the center of the disc to the herniated disc. It is preferable to administer at least 2cc to 3cc of contrast medium to image the herniated disc mass. Therefore, from the viewpoint of spreading the active ingredient to the affected area sufficiently, the dosage of the treatment agent of the present invention per administration is preferably 2cc or more. Another treatment agent for herniated disc, Hernicore (registered trademark), is administered in an amount of 1cc, but its therapeutic effect has only been confirmed for lumbar disc herniation of subligamentous extrusion type according to the Macnab classification, and pharmaceutical approval has only been obtained for lumbar disc herniation of subligamentous extrusion type.In contrast, the present inventors have found that the treatment agent of the present invention, which is administered in an amount of 2 cc or more, is expected to reach the affected area based on findings in intervertebral discography, and is therefore expected to be effective in treating not only subligamentous extrusion, but also bulging / protrusion, transligamentous extrusion, sequestration, and the like, preferably subligamentous extrusion, protrusion, and transligamentous extrusion, and more preferably subligamentous extrusion and transligamentous extrusion. In particular, in non-clinical trials, it was confirmed that KTP-001 did not cause pathological or physiological abnormalities when administered epidurally or intrathecally, and MMP-7 positive cells were confirmed in the tissue of herniated discs in surgical specimens, so it is believed that it can be safely administered to subligamentous extrusion and transligamentous extrusion. Therefore, from the viewpoint of obtaining a wide range of therapeutic effects for herniated discs, not limited to subligamentous extrusion, the dosage of the treatment agent of the present invention per administration is preferably 2 cc or more.

[0031] The contents of MMP-7 contained in the treatment materials of this disclosure are: 100 μg or more, 110 μg or more, 120 μg or more, 130 μg or more, 140 μg or more, 150 μg or more, 160 μg or more, 170 μg or more, 180 μg or more, 190 μg or more, 200 μg or more, 210 μg or more, 220 μg or more, 230 μg or more, 240 μg or more, 250 μg or more, 260 μg or more, 270 μg or more, 280 μg or more, 290 μg or more, 300 μg or more, 310 μg or more, 320 μg or more, 330 μg or more, 340 μg or more, 350 μg or more, 360 μg or more, 370 μg or more, 380 μg or more, 390 100 μg or more, 102 μg or more, 104 μg or more, 106 μg or more, 107 μg or more, 108 μg or more, 109 μg or more, 110 μg or more, 111 μg or more, 112 μg or more, 113 μg or more, 114 μg or more, 115 μg or more, 116 μg or more, 117 μg or more, 118 μg or more, 119 μg or more, 120 μg or more, 121 μg or more, 122 μg or more, 123 μg or more, 124 μg or more, 125 μg or more, 126 μg or more, 127 μg or more, 128 μg or more, 129 μg or more, 130 μg or more, 131 μg or more, 132 μg or more, 133 μg or more, 134 μg or more, 135 μg or more, 136 μg or more, 137 μg or more, 138 μg or more, 139 μg or more, 140 μg or more, 141 μg or more, 142 μg or more, 143 μg or more, 144 μg or more

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

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

[0034] As shown in the Examples below, by administering the treatment agent of the present invention to a subject, it is possible to treat a disease associated with intervertebral disc degeneration in the subject, the disease being selected from the group consisting of herniated disc, low back pain, discopathy, kyphoscoliosis, and degenerative spondylosis. Here, examples of herniated disc include, for example, protrusion, subligamentous extrusion, transligamentous extrusion, and sequestrated disc or sequestration, based on the Macnab classification. The treatment agent of the present invention can treat any of these herniated discs. However, the treatment agent of the present invention can preferably treat protrusion, subligamentous extrusion, and transligamentous extrusion, and more preferably treat subligamentous extrusion and transligamentous extrusion. The term "sequestrated disc" refers to the movement of the disc from the high level to the cranial or caudal side. Disease treatment includes disease prevention as well as disease treatment. Treatment of a disease includes complete cure of the disease, as well as amelioration or alleviation of symptoms of the disease.

[0035] The subject may be, for example, a vertebrate. The vertebrate may be, for example, a mammal, such as a mouse, a rat, a rabbit, a pig, a cow, a monkey, or a human. The mammal is preferably a human. The subject may be of any age, including infants, young adults, adolescents, adults, and elderly people.

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

[0037] Examples of pharma- ceutically acceptable carriers include solvents such as sterile water and saline; binders such as gelatin, corn starch, gum tragacanth, and gum arabic; excipients such as crystalline cellulose; and bulking agents such as corn starch, gelatin, and alginic acid.

[0038] The pharma- ceutically acceptable carrier may include additives, such as lubricants (e.g., magnesium stearate), sweeteners (e.g., sucrose, lactose, saccharin), flavorings (e.g., peppermint, scallion oil), stabilizers (e.g., benzyl alcohol, phenol), buffers (e.g., phosphates, sodium acetate), solubilizers (e.g., benzyl benzoate, benzyl alcohol), antioxidants, preservatives, surfactants, emulsifiers, etc.

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

[0040] When the pharmaceutical composition is an injection, the solvent for the injection may be, for example, an isotonic solution containing an auxiliary agent such as physiological saline, glucose, D-sorbitol, D-mannose, D-mannitol, sodium chloride, etc. The solvent for the injection may contain alcohol such as ethanol, polyalcohol such as propylene glycol, polyethylene glycol, nonionic surfactant such as Polysorbate 80 (trademark), HCO-50, etc.

[0041] The treatment agent of the present invention may be accompanied by an instruction manual. The instruction manual may include, for example, an explanation of the active ingredient contained, the dose of the active ingredient MMP-7 per administration, the number of administrations per day, the administration method, the total number of administrations, the amount administered per administration, etc. The instruction manual does not necessarily have to be physically present in writing, and may be attached via an electric communication line such as the Internet.

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

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

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

[0045] List of abbreviations [Table 1]

[0046] Introduction As a result of non-clinical trials, rhMMP-7 had the ability to degrade human herniated disc specimens and beagle dog discs, but had no effect on nerve tissue, ligament, or epidural tissue. In addition, rhMMP-7 has high decomposition ability for aggrecan, but only extremely low decomposition ability for type I and type II collagen, and it was considered to have strong tissue specificity or decomposition specificity (Non-Patent Document 4). In toxicity tests using single and repeated intravenous administration for 2 weeks to rats and dogs, hemorrhagic and inflammatory changes were observed at very high doses compared to the exposure level assumed when all of KTP-001 administered into the intervertebral disc in humans was assumed to have migrated into the blood. These hemorrhagic and inflammatory changes are thought to be due to the enzyme action of excessive levels of KTP-001 administered intravenously affecting blood vessels. In reproductive and developmental toxicity tests using rats and rabbits, there was no effect on the reproductive function, early embryonic development, or embryo-fetal development of female animals. No evidence of teratogenicity to fetuses was obtained.

[0047] In the United States, a phase I / II clinical trial was conducted in 2013 with the primary objective of confirming the safety and tolerability of a single intradiscal injection of KTP-001 in patients with lumbar disc herniation. Six patients were administered 5 μg, 15 μg, 50 μg, and 150 μg, and no serious complications were observed in any of the patients, and no blood KTP-001 concentrations or antibodies were detected. It was reported that administration of up to 150 μg to patients with disc herniation was safe. The main adverse events were injection site pain, bronchitis, procedural pain, back pain, pain in the extremities, musculoskeletal pain, muscle spasms, and disc bulging. The distribution of adverse events was similar between all doses, and no deaths occurred during the trial. Four patients experienced serious adverse events (appendicitis, diverticulitis, urinary tract infection, menorrhagia), but none of these adverse events were determined to be causally related to the investigational drug. In addition, no clear changes were observed in serum keratan sulfate concentrations, except in the 150 μg group. In the 150 μg group, the mean serum concentration of keratan sulfate increased 24 hours after administration, reached a peak concentration one week after administration, and gradually decreased until four weeks after administration. In conclusion, KTP-001 was safe and well tolerated at the dose used in this clinical trial, and all serum KTP-001 concentrations were below the limit of quantification, and anti-KTP-001 antibodies were negative in all cases. Regarding efficacy, leg pain (worst pain and average pain over the past 24 hours) assessed using the Numeric Rating Scale (NRS) showed a significant decrease from baseline in the 15 μg and 50 μg groups compared to the 5 μg group. Furthermore, in more than half of the subjects in both groups, the leg elevation test results changed from positive at baseline to negative at Week 6 and Week 13. For the femoral nerve extension test, one patient changed from positive at baseline to negative at Week 6, and three patients changed from positive at baseline to negative at Week 13.

[0048] In this investigator-initiated clinical trial, the main objective is to confirm the safety and tolerability of a single intradiscal administration of KTP-001 to patients with lumbar disc herniation, but as a secondary objective, the target is subposterior longitudinal ligament herniation, which is less susceptible to early spontaneous regression. In a Phase I / II clinical trial conducted in the United States, there were cases in which an increase in serum keratan sulfate was confirmed only after the KTP-001 dose was gradually increased to 150 μg. Since an increase in serum keratan sulfate is a marker indicating the decomposition of the herniated disc nucleus pulposus, the drug is expected to be effective in decomposing herniation by increasing the KTP-001 dose to 150 μg or more. Therefore, in this clinical trial, KTP-001 was administered from 150 μg to 600 μg to patients with lumbar disc herniation, and the tolerability, safety, and efficacy as a secondary evaluation were confirmed at each dose.

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

[0050] 1. Clinical trial planning

[0051] 1.1 Overall Study Design and Plan

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

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

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

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

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

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

[0058] 1.1.7 Trial Allocation Method The principal investigator or clinical trial collaborator randomly assigned the registered subjects using the electronic data capture system (EDC). Three subjects in cohort 1 were randomly assigned to the sham group and three to the 150 μg group. No assignment was performed for cohorts 2, 3, and additional cases.

[0059] 1.1.8 Sequence and length of trial periods This clinical trial consisted of a single dose in both cohorts. The administration schedule is shown in Figure 1. For each cohort, 150 μg or sham, 300 μg, or 600 μg of KTP-001 was injected into the intervertebral disc. Local anesthetics were allowed to be used at the discretion of the investigator. All cohorts were single-blinded and subjects were unaware of which cohort they were in. The items to be performed at each visit are described in detail in “1.5.1.2 Observation and test items and their timing.”

[0060] 1.1.9 Various committees established and their roles An efficacy and safety evaluation committee was established for this clinical trial. It examined and evaluated the occurrence of serious adverse events of concern, and gave advice and recommendations to the coordinating investigator regarding the addition of cases to the highest dose cohort that were deemed safe. This was stipulated in the procedure manual for the efficacy and safety evaluation committee, which is separately stipulated.

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

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

[0063] 1.3 Selection of Study Population

[0064] 1.3.1 Inclusion Criteria

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

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

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

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

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

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

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

[0072] 1.4 Treatment

[0073] 1.4.1 Treatment

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

[0075] 1.4.1.2 Transition to next cohort

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

[0077] [Transition from Cohort 2 to Cohort 3, decision to add cases] * If no events corresponding to "1.4.1.2.2 Safety Assessment, 1)2)" were observed among the 6 patients in the 300 μg group, the coordinating investigator would consult with the principal investigator and clinical trial advisor via email or web conference, etc., and if they unanimously determined that there were no safety issues in accordance with the criteria in "1.4.1.2.2 Safety Assessment", they would move on to cohort 3. * If any of the six patients in the 300 μg group experienced an event corresponding to "1.4.1.2.2 Safety Assessment, 1)2)", the coordinating investigator would consult with the Efficacy and Safety Assessment Committee regarding whether or not to continue the clinical trial, following the procedures in "1.4.1.2.2 Safety Assessment". *If the Efficacy and Safety Evaluation Committee determines that there are no problems with continuing the clinical trial, the trial will be able to move on to Cohort 3. * If the Efficacy and Safety Evaluation Committee determines that there are safety issues, the Efficacy and Safety Evaluation Committee will advise and recommend to the coordinating investigator about adding cases administered 150 μg in Cohort 1. The coordinating investigator will follow the advice and recommendation of the Efficacy and Safety Evaluation Committee and add cases to the highest dose cohort (150 μg group) that is determined to have no safety issues, to further examine the safety and efficacy of the drug (the maximum number of additional cases will be 5, and as many as possible will be added within the clinical trial period).

[0078] [Decision to add cases in cohort 3] * If no events corresponding to "1.4.1.2.2 Safety Assessment, 1)2)" were observed among the 6 cases in the 600 μg group, the coordinating investigator decided to consult with the Efficacy and Safety Evaluation Committee on safety data obtained up to 6 weeks after administration in cohort 1 (3 cases), cohort 2 (6 cases), and cohort 3 (6 cases). The Efficacy and Safety Evaluation Committee decided to consider and evaluate the continuation of the clinical trial based on the obtained data, and to advise and recommend to the coordinating investigator on the addition of cases. The coordinating investigator decided to follow the advice and recommendation of the Efficacy and Safety Evaluation Committee and add cases to the highest dose cohort that was judged to have no safety issues, and to further examine the safety and efficacy of this drug (the number of cases to be added was limited to a maximum of 5 cases, and as many as possible were added within the clinical trial period). * If any of the six patients in the 600 μg group experienced an event corresponding to "1.4.1.2.2 Safety Assessment, 1)2)," the coordinating investigator would consult with the Efficacy and Safety Assessment Committee regarding whether or not to continue the clinical trial, following the procedures in "1.4.1.2.2 Safety Assessment." *If the Efficacy and Safety Evaluation Committee determines that there are no problems with continuing the clinical trial, cases will be added to the highest dose cohort that is determined to have no safety issues, and the safety and efficacy of the drug will be further examined. * If the Efficacy and Safety Evaluation Committee determines that there are safety issues, the Efficacy and Safety Evaluation Committee will advise and recommend to the coordinating investigator about adding cases administered 300 μg in Cohort 2. The coordinating investigator will follow the advice and recommendation of the Efficacy and Safety Evaluation Committee and add cases to the highest dose cohort (here, the 300 μg group) that is determined to have no safety issues, to further examine the safety and efficacy of the drug (the maximum number of additional cases will be 5, and as many will be added as possible within the clinical trial period).

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

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

[0081] 1.4.2.1 Investigational Medications KTP-001 is rhMMP-7 and contains 1.0 mg of KTP-001 in a 2.0 mL vial. drug substance Characteristics: KTP-001 is a recombinant human MMP-7 protein that breaks down proteoglycans. No animal-derived raw materials are used in the manufacture of the drug substance used in clinical trials. International Nonproprietary Name: At this stage of development, there is no nonproprietary name for KTP-001. Code name: KTP-001 Structural formula: The amino acid sequence (SEQ ID NO: 1) of the protein expressed by the gene sequence encoding KTP-001 is shown below. [Table 2] Molecular formula:C 860 H 1299 N 239 O 251 S 4 Molecular weight: 19130.23 (theoretical value) Formulation: freeze-dried powder for injection. The KTP-001 formulation was dissolved in 0.5 mL of sterile water for injection, and then diluted with KTP-001 diluent to obtain the dosage. KTP-001 is composed of 173 amino acids, has no disulfide bonds, forms a complex with two zinc ions, and is approximately 19 kDa. Histidines 69, 84, and 97 and aspartic acid 71 are involved in structural zinc ion binding. Histidines 120, 124, and 130 are involved in other catalytic zinc ion binding. [Physical, chemical and biological properties of KTP-001] Appearance: Colorless, transparent liquid UV spectrum: shows an absorption maximum at about 280 nm and an absorption shoulder at about 290 nm. Biological properties: Digestes both the synthetic substrate of matrix metalloprotease (MOCAc-Pro-Leu-Gly-Leu-A2pr (Dnp)-Ala-Arg-NH2) and the natural substrate aggrecan.

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

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

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

[0085] 1.4.3 Method of Allocating Patients to Treatment Groups This is described in "1.1.7 Method of allocation to clinical trials".

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

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

[0088] 1.4.6 Blinding This is described in "1.1.5 Blinded levels and methods".

[0089] 1.4.7 Concomitant medications and therapies

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

[0091] 1.4.7.2 Restricted Concomitant Drugs and Therapies Regarding the following restricted concomitant medications and therapies, if the patient was continuing to take the medication or treatment before consent was obtained, they may continue to do so during the clinical trial period, but changes to the treatment (increasing the dosage or frequency of medication or treatment) are not permitted after consent is obtained. Reductions in the dosage or frequency of medication or treatment are permitted. [Restricted concomitant drugs] * Medications for peripheral neuropathic pain (pregabalin, mirogabalin) * Antiepileptic drugs (such as gabapentin) * Antidepressants (duloxetine, amitriptyline) * N-methyl-D-aspartate receptor antagonists (such as ketamine hydrochloride) * Corticosteroids (excluding topical medications, eye drops, and inhaled medications) * Muscle relaxants, herbal medicines, extracts from inflamed rabbit skin inoculated with vaccinia virus [Concomitant restrictive therapy] Trigger point block, heat therapy, bracing therapy, traction therapy, acupuncture therapy, osteopathy, etc.

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

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

[0094] 1.5 Efficacy and Safety Sections

[0095] 1.5.1 Efficacy and Safety Endpoints and Flowchart

[0096] 1.5.1.1 Overview of Study Procedures An overview of the trial procedure is shown in Figure 3. The principal investigator (sub-investigator) explained the purpose and content of the clinical trial to the patient in accordance with the provisions for obtaining consent and the method of obtaining consent, and obtained consent. The principal investigator (sub-investigator) registered the subject in question in the EDC and assigned a subject identification code. The principal investigator (subinvestigator) confirmed that the subject met "1.3.1.1 Target disease" and "1.3.1.2 Inclusion criteria" and did not fall under "1.3.1.3 Exclusion criteria." Before the start of administration, the subjects were observed and examined as specified in the clinical trial protocol. The principal investigator (subinvestigator) enrolled the subject in this clinical trial after final confirmation that the subject met the inclusion criteria and did not violate the exclusion criteria based on the examination before the start of administration. The principal investigator (subinvestigator) or clinical trial collaborator assigned the subject to the EDC. The principal investigator (subinvestigator) initiated administration or treatment of the KTP-001 group or the sham group (Cohort 1 only) according to the group to which the subject was assigned. Observations and examinations specified in the study protocol were performed up to 24 weeks after administration. However, the study was discontinued if any of the following conditions were met: "1.3.2.2 Criteria for discontinuation after administration of the study drug." If the adverse events had not resolved or improved at the time of observation and testing at 24 weeks after administration or at the time of discontinuation, the patient would be followed up as appropriate until the patient had recovered or improved to the state before the adverse events occurred, or until the principal investigator (subinvestigator) judged that further investigation was unnecessary. If the patient did not attend the follow-up investigation at the time of the follow-up investigation, the patient would be followed up by an appropriate method, such as by telephone.

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

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

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

[0100] 3) Observations and examinations at the time of discontinuation For subjects who were discontinued in accordance with "1.3.2.2 Criteria for discontinuation after study drug administration," the observation and examination items at 24 weeks after administration, as specified in Tables 4 and 5 (observation and examination schedule), were promptly conducted after discontinuation. Among the examples of restricted drugs and restricted therapies shown in "1.4.7.2 Restricted Concomitant Drugs and Restricted Therapies," cases in which changes to treatment were made after obtaining consent (increased dosage, increased medication / treatment frequency) and examples of prohibited therapies shown in "1.4.7.3 Prohibited Concomitant Therapies" were considered discontinued cases, but observation and examinations were to be continued even after discontinuation. When continuing observation after discontinuation, evaluation items, etc. were to be specified at the hospital visit after discontinuation. Analysis was to be conducted on safety and MRI image evaluation after discontinuation.

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

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

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

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

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

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

[0107] 1) Pain induction test a) Leg Raise Test In the leg elevation test, subjects were asked to lie supine and raise their legs in three stages (0-30 degrees, 30-70 degrees, and 70 degrees or more), and pain was assessed. The stage at which pain appeared (0-30 degrees, 30-70 degrees, and 70 degrees or more) was recorded in the eCRF. b) Femoral nerve extension test For the femoral nerve extension test, subjects were asked to lie face down, flex their knees and extend their hips, and pain was assessed. The results were recorded as "negative" or "positive" in the eCRF.

[0108] 2) Neurological findings a) Manual muscle testing The principal investigator (co-investigator) or clinical trial collaborator evaluated the degree of force that the subjects' lower limb muscles (iliopsoas, quadriceps, hamstrings, tibialis anterior, gastrocnemius, flexor and extensor muscles of the toes) were able to exert on a six-point scale from 0 (no muscle contraction observed) to 5 (they were able to move across the entire range of motion even with strong resistance). b) Sensory testing The evaluation was done by touch. The subjects' lower limbs were lightly touched with a soft brush or cotton wool. The principal investigator (subinvestigator) wrote a score for the abnormal area on the doll diagram on the questionnaire. c) deep tendon reflexes The principal investigator (subinvestigator) or clinical trial collaborator evaluated the subjects' locations (patellar tendon, Achilles tendon) to see if the reflexes were functioning normally.

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

[0110] 1.5.1.2.9 12-lead electrocardiogram ECGs were performed at screening and 24 hours after dosing. If any significant abnormalities were detected by ECG after study drug administration, additional testing was to be performed and the clinical significance and diagnosis recorded.

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

[0112] 2) Pregnancy test Pregnancy tests were performed only on female subjects, and were not required for male subjects. Serum human chorionic gonadotropin β subunit (βHCG) tests were performed at screening and at the visit 13 weeks after administration. Urinary βHCG tests were performed at least 0 hours before administration and at the visit 24 weeks after administration, or at the time of discontinuation of the clinical trial if the trial was to be discontinued during the trial. Urine pregnancy tests were performed at appropriate times, referring to the description in Note e of Tables 4 and 5 (observation and examination schedule). If pregnancy was found after administration of the investigational drug, the trial could be continued after ensuring the safety of the subject. However, if the trial was continued, X-ray imaging could not be continued. In addition, efforts were made to collect information in accordance with "Regarding pregnancy during the clinical trial period" in the clinical trial implementation protocol.

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

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

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

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

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

[0118] 2) Use of auxiliary medications (analgesics) This was checked at screening, pre-dose, 24 hours post-dose, and on scheduled visits.

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

[0120] 1.5.1.2.15 Physical function assessment The subjects were asked to complete questionnaires at screening, before administration, 24 hours after administration, and on the designated visit day. The degree to which low back or leg pain interfered with the subjects' ability to manage their daily tasks was measured using the ODI (version 2.0). Functional level was assessed as improvement, no change, or deterioration based on the change in score from baseline. The ODI measured nine domains of daily functioning: pain intensity, self-care, lifting, walking, sitting, standing, sleep, social life, and transportation. The question on sex life was omitted in this study. Items were scored from 0 to 5, with 0 being the best level of functioning and 5 being the worst level of functioning. A percentage was then derived from these responses (subject score / maximum total score: 45 points x 100) and recorded as the ODI for that day. Scores were then categorized into disability levels as shown in Table 8 below. [Table 8]

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

[0122] 1.5.1.2.17 Provision, collection and review of patient diary At the time of screening, the principal investigator (subinvestigator) or clinical trial collaborator handed the patient diary to the subject and instructed them to fill in the following items under "12) Pain Assessment": "i) Lower back pain and leg pain (NRS)" and "ii) Use of supplementary medications (analgesics)." The principal investigator (subinvestigator) collected and checked the patient diary according to the prescribed schedule, and then recorded it in the eCRF.

[0123] 1.5.1.2.18 Adverse Events

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

[0125] 1.5.1.2.18.1.1 Definition of Serious Adverse Events Serious adverse events are defined as follows among the adverse events defined in "1.5.1.2.18.1 Definition of Adverse Events": 1) death 2) Anything that may lead to death 3) Those who require hospitalization or an extension of hospitalization for treatment 4) Disability 5) Anything that may cause injury 6) Cases that are serious similar to those listed in 1) to 5). 7) Congenital diseases or abnormalities in later generations

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

[0127] 1.5.1.2.18.2 Evaluation of Adverse Events

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

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

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

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

[0132] 1.5.1.2.18.4 Anticipated Adverse Events Adverse events that the responsible (sub-) physician judged to be "expected" were defined as "expected adverse events."

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

[0134] 1.5.1.3 Evaluation Contents

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

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

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

[0138] 1.5.2 Appropriateness of Measurements

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

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

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

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

[0143] 1.6 Data Quality Assurance

[0144] 1.6.1 Quality Control and Quality Assurance of Clinical Trials The coordinating investigator set quality objectives, prepared a quality management plan that described the plan for achieving the quality objectives, and shared it with the personnel involved in the clinical trial. No risks anticipated in the quality management plan were observed in this clinical trial, and no new risks were observed during the conduct of the clinical trial. In order to ensure the appropriate implementation of the following quality control and quality assurance activities, the principal investigator and the head of the medical institution conducting the clinical trial will ensure that monitors, auditors, and regulatory authorities have direct access to source documents, and will be present and take action during monitoring, audits, and inspections, if necessary.

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

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

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

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

[0149] 1.7.1.1 Statistical Analysis Plan

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

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

[0152] 1.7.1.1.3 Safety Analysis

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

[0154] 1.7.1.1.3.2 Handling Adverse Events and Side Effects

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

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

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

[0158] 1.7.1.1.4 Efficacy Analysis For each efficacy endpoint, the following statistics were calculated for each group:

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

[0160] 1.7.1.1.4.2 Exploratory Endpoints 1) Pain assessment (pain intensity) *ODI Summary statistics were calculated for the values ​​observed at each time point from baseline to 24 weeks after administration. Summary statistics were also calculated for the change from baseline at each time point. * Use of auxiliary drugs (analgesics) The number and percentage of subjects who used adjunctive medications (analgesics) were calculated for each measurement period from Day 1 0 hr to 24 weeks after administration and for the entire period. 2) Pain assessment (type of pain) * Pain Detect Summary statistics were calculated for the scores of the nine questions, and for the results observed from baseline to 24 weeks after administration at each time point. Summary statistics were also calculated for the change from baseline at each time point. 3) Physical function evaluation * EQ-5D-5L For the results observed at each evaluation point from baseline to 24 weeks after administration, summary statistics of QOL scores and their changes using the EQ-5D-5L questionnaire were calculated. 4) Neurological Examination * Neurological findings The manual muscle testing, sensory testing, and deep tendon reflex evaluations and their findings were assessed comprehensively, and the neurological findings from baseline to 24 weeks after administration were compared with baseline to calculate the number and percentage of cases that fell into each diagnostic result (0: worsening, 1: no change, 2: improvement, 3: normalization). 5) Additional treatment, its contents, and the period until its initiation The occurrence of additional treatment was designated an "event," and the number of days until the event was compared between groups using the Log-rank test. In addition, the time-point event rate and its 95% confidence interval were calculated for each group using the Kaplan-Meier method, and a Kaplan-Meier plot of the time-point event rate was drawn. For subjects who were lost to follow-up and the reason for discontinuation was an adverse event, these were treated as competing risks, and the time-point event rate and its 95% confidence interval were calculated using the Cumulative Incidence Function method as a supplementary analysis. 6) MRI images (changes in size of herniated disc) The MRI evaluators evaluated the MRI images in the following order: (a) to (c). (a) For each case number (Y-001, etc.), a table containing the following information was prepared and submitted to the Secretariat. * Presence or absence of changes in the endplate (Modic change, etc.) or intervertebral disc by MRI, and their extent (whether there are any inconsistencies with the natural course of herniation, etc.). * MRI herniated disc volume was evaluated for each case using two methods: whether there was a tendency for reduction or not. (b) The secretariat then disclosed to the MRI evaluator which group the case number was assigned to (allocation list). (c) After evaluation, group information was obtained. Changes in each case were observed while ensuring blinding using the above flow. Finally, the MRI evaluators conferred together and qualitatively evaluated each group in comparison with the other groups.

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

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

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

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

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

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

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

[0168] 3. Evaluation of efficacy

[0169] 3.1 Analyzed Dataset The analyzed datasets in this clinical trial are shown in Table 15 (Analyzed Datasets). [Table 15] Of the 24 subjects who provided consent, 3 subjects who were ineligible at screening, 1 subject who requested participation, and 1 subject who the investigator (subinvestigator) deemed difficult to administer the investigational drug were excluded, leaving 19 subjects for the SAF, FAS, and PPS. Note that the number of subjects employed in the FAS and PPS was the same, but the period of analysis differed depending on the subject.

[0170] 3.2 Demographic and other baseline characteristics

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

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

[0173] 3.3 Measuring adherence to treatment The status of administration of investigational drugs in the FAS is shown in Table 18 (Status of Administration of Investigational Drugs (FAS)). [Table 18] The mean total dose of the investigational drug was 150 μg in the 150 μg group, 300 μg in the 300 μg group, and 600 μg in the 600 μg group, which was the planned dose in all treatment groups. All patients in the FAS (3 in the sham group, 3 in the 150 μg group, 11 in the 300 μg group, and 2 in the 600 μg group) received a single injection of the investigational drug into the intervertebral disc (only puncture in the sham group).

[0174] 3.4 Efficacy Results and Individual Patient Data Tabulations

[0175] 3.4.1 Efficacy Analysis

[0176] 3.4.1.1 Secondary endpoints

[0177] 3.4.1.1.1 Pain assessment (pain intensity)

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

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

[0180] 3.4.1.1.2 Neurological examination

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

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

[0183] 3.4.1.2 Exploratory Endpoints

[0184] 3.4.1.2.1 Pain assessment

[0185] 3.4.1.2.1.1 Pain intensity

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

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

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

[0189] 3.4.1.2.2 Physical Function Assessment (EQ-5D-5L) The changes in EQ-5D-5L in the FAS are shown in Tables 27 to 28 (Changes in EQ-5D-5L (FAS)). [Table 27] [Table 28] The mean EQ-5D-5L score in the FAS increased over time from baseline in all groups except the 600 μg group, in which it decreased from baseline until 1 week after administration and then increased over time. Similar results were observed in the PPS.

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

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

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

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

[0194] 3.4.1.2.6.1 Presence and severity of changes in the intervertebral disc and endplate The presence and extent of changes in the intervertebral disc and endplate were evaluated using FAS and PPS. MRI of one patient in the 300 μg group (subject number: Y-010) showed Type 1 Modic changes that progressed both 6 and 13 weeks after administration, but this finding was not inconsistent with the natural course of hernia. Three patients in the 300 μg group (subject numbers: Y-018, K-004, and K-006) showed Type 3 Modic changes from the first MRI, but no tendency for these to increase or decrease during follow-up was observed. Based on the above, no changes in the intervertebral discs or endplates were found that were strongly suspected to have been caused by administration of this drug.

[0195] 3.4.1.2.6.2 Assessment of disc herniation volume The evaluation results of the disc herniation volume by MRI are shown in Table 30 (Evaluation results of disc herniation volume). In this clinical trial, some cases in the sham group showed a decrease in hernia size over time (33.3% at 6 weeks and 66.7% at 13 weeks after administration), but this was considered appropriate as a natural decrease in hernia size. Also, it is worth noting that although there was no significant difference because the purpose of this clinical trial was not to test for significant differences, at 13 weeks after administration, there was a tendency for the lesions to decrease by 81.8% in the 300 μg group and 100% in the 600 μg group, which may represent a certain degree of the efficacy of this drug. [Table 30] *Fisher's exact test was used to compare the three pairs of groups: the sham group and the other three groups; no significant differences were found in any of the three pairs.

[0196] 3.4.2 Pharmacodynamics

[0197] 3.4.2.1 Serum keratan sulfate concentration The time course of serum keratan sulfate concentrations in PPS patients is shown in FIG. Serum keratan sulfate concentrations increased in a dose-dependent manner at each time point. In terms of the time course of serum keratan sulfate concentration, no clear change was observed over time in the sham group and the 150 μg group. In the 300 μg group, serum keratan sulfate concentration increased from 24 hours after administration, reached a maximum at 1 week after administration (mean change from baseline in serum keratan sulfate concentration: 265.300 ng / mL), and then decreased. In the 600 μg group, serum keratan sulfate concentration increased from 24 hours after administration, reaching a maximum at 2 weeks after administration (mean change from baseline in serum keratan sulfate concentration: 710.000 ng / mL).

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

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

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

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

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

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

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

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

[0206] 3.4.3.8 Consideration of subgroups Not applicable

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

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

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

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

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

[0212] 4. Safety Assessment

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

[0214] 4.2 Adverse Events Adverse events in this clinical trial were compiled by translating the names of symptoms and events listed on the eCRF using the ICH International Medical Dictionary Japanese version (MedDRA / J) Ver. 26.1.

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

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

[0217] 4.2.3 Analysis of Adverse Events

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

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

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

[0221] 4.3 Deaths, Other Serious Adverse Events, and Other Significant Adverse Events

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

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

[0224] 4.3.1.2 Other serious adverse events In this clinical trial, a serious adverse event, hypoesthesia, was observed in 1 of 11 patients (9.1%) in the 300 μg group. Details of this case are described in Section 4.3.2.

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

[0226] 4.3.1.3.1 Adverse events leading to discontinuation No adverse events leading to discontinuation of study drug were reported in this study.

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

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

[0229] 4.3.2 Description of deaths, other serious adverse events, and selected other significant adverse events Hypoesthesia (Subject number: Y-007) The subject was male, 30 years old at the time of consent, and the level of herniated disc was L4-L5. His medical history included surgery for deviated nasal septum, bilateral maxillary wisdom tooth extraction, and bilateral mandibular wisdom tooth extraction, as well as complications such as contact dermatitis and tinea pedis. Twelve days after administration of 300 μg of this drug, the subject developed severe hypoesthesia and non-severe back pain. Both events were Grade 2 in severity, and the subject recovered 79 days after onset. As a result of detailed examination using MRI, computed tomography (CT), X-ray, etc., no test findings were found that could be determined to be clearly caused by the administration of KTP-001 into the intervertebral disc (changes in brightness on MRI of the administered intervertebral disc and the adjacent end plate, morphological changes such as narrowing of the intervertebral disc space by CT or X-ray), and it was determined that the influence of COVID-19 infection that appeared 6 days after administration of this drug was significant, and a causal relationship with the administration of the investigational drug was denied.

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

[0231] 4.4 Laboratory evaluation

[0232] 4.4.1 Listing of individual laboratory values ​​for each patient Specific laboratory values ​​were tabulated.

[0233] 4.4.2 Evaluation of each clinical test item

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

[0235] 4.4.2.1.1 Hematology No clear or clinically meaningful differences were observed in the mean and median values ​​of hematological parameters between the groups, and no clinically significant changes were observed in the mean and median values ​​of any of the parameters over time.

[0236] 4.4.2.1.2 Blood chemistry tests

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

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

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

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

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

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

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

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

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

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

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

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

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

[0250] 5. Discussion and general conclusions

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

[0252] 5.2 General conclusions KTP-001 was safe and well tolerated when administered intradiscally in a single dose of up to 600 μg in patients with lumbar disc herniation. Serum KTP-001 concentrations were below the lower limit of quantification in all subjects throughout the study period, and anti-KTP-001 antibodies were negative. Efficacy evaluation showed that lower limb pain and lower back pain were reduced from baseline in all groups. Leg-raising tests and neurological findings showed early improvement in the drug group. Serum keratan sulfate concentrations increased in a dose-dependent manner. These results demonstrate that KTP-001 has a favorable safety and tolerability profile, improves neurological findings due to herniated discs early after administration, and reduces lower back pain and lower limb pain over time.

Claims

1. A treatment for human intervertebral disc herniation, comprising MMP-7 as an active ingredient, the treatment comprising a single dose of MMP-7 ranging from 300 μg to 600 μg.

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

3. The treatment according to claim 1, for direct administration to the affected area of ​​a human herniated disc.

4. The treatment of claim 1, for multiple administration to a human patient with a herniated disc.

5. The treatment according to claim 1, for administration to a patient with a herniated human disc who is not undergoing conservative treatment for the herniated human disc.

6. The treatment of claim 1 for administration to a patient with a human herniated disc, the patient immediately following a diagnosis confirming the presence of the herniated disc.

7. The method according to claim 6, wherein the diagnosis for confirming the human herniated disc is performed using MRI.

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

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

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

11. The treatment of claim 1, for administration once daily to a human patient with herniated disc.

Images