Use of anti-factor XII antibodies for the treatment or prevention of hereditary angioedema

Abstract

The present invention relates to anti-FXII antibodies for use in a method of treating or preventing hereditary angioedema (HAE) in a subject, administered subcutaneously to the subject.

Description

Technical Field

[0001] The present invention relates to an anti-FXII antibody for use in a method of treating or preventing hereditary angioedema (HAE) in a subject, wherein the antibody is administered subcutaneously to the subject.

Background Art

[0002] Factor XII (Hageman factor, FXII) is a serum glycoprotein with a molecular weight of approximately 80 kDa. In addition to autoactivation by exposure to negatively charged surfaces, Factor XII is further activated by kallikrein by proteolytic cleavage to form alpha Factor XIIa, which is then further converted to beta Factor XIIa (FXIIa-β) by, for example, trypsin. Alpha Factor XIIa is composed of an approximately 50 kDa N-terminal heavy chain containing a contact-binding domain and an approximately 28 kDa C-terminal light chain containing a catalytic center. The heavy and light chains are connected by disulfide bonds. FXIIa-β is the active form of FXII, consisting of a complete light chain and a 2000 Da fragment of the heavy chain linked by a disulfide bond.

[0003] Hereditary angioedema is a rare genetic disorder classified into three disease types, including type 1 HAE, type 2 HAE, and HAE with normal C1-esterase inhibitor (nC1-INH) [Non-Patent Document 1; Non-Patent Document 2]. Type 1 HAE and type 2 HAE are caused by mutations in the SERPING1 gene and are characterized by a quantitative decrease in C1-esterase inhibitor (C1-INH) plasma concentration (type 1) and dysfunctional C1-INH present at normal plasma concentrations (type 2) [Non-Patent Document 3; Non-Patent Document 4]. Together, type 1 HAE and type 2 HAE are grouped as HAE with C1-INH deficiency (C1-INH HAE). C1-esterase inhibitor is a serine protease inhibitor that regulates the generation of BK by the plasma contact system and is the main inhibitor of many plasma contact system proteases, including FXII and kallikrein [Non-Patent Document 5]. Excessive BK formation due to pathological activation of the FXII-driven plasma contact system is a consistent finding in acute episodes of HAE [Non-Patent Document 6] (see Figure 1).

[0004] HAE with normal C1-INH (nC1-INH) is a genetic disorder associated with missense mutations, deletions, or insertions of base pairs in the FXII gene [Non-Patent Document 4], missense mutations in the plasminogen gene [Non-Patent Document 7], [Non-Patent Document 8], or caused by unknown genetic defects [Non-Patent Document 4].

[0005] Clinically, HAE attacks occurring in patients with HAE are characterized by local swelling of the skin (i.e., limb edema, facial edema, genital edema), abdominal pain, and sometimes life-threatening laryngeal edema attacks [Non-Patent Document 9]. The estimated prevalence of C1-INH HAE is generally reported to be 1:50,000, but the prevalence of nC1-INH HAE is unknown [Non-Patent Document 10; Non-Patent Document 11].

[0006] The current treatment options for HAE can be subdivided into acute attack treatment and prophylaxis. The acute and prophylactic treatments of HAE are based on inhibiting BK production by targeting various proteins of the kallikrein-kinin pathway. The treatment selected for the event of an acute HAE attack is the rapid intravenous (IV) administration of C1-INH concentrate [Non-Patent Document 9; Non-Patent Document 12; Non-Patent Document 13]. Recently, compounds including kallikrein inhibitors and bradykinin B2 receptor antagonists have been added to the range of drugs available for the treatment of acute HAE attacks [Non-Patent Document 14; Non-Patent Document 10].

[0007] The C1-INH concentrates currently approved for treating acute HAE attacks by intravenous administration are plasma-derived Berinert® and recombinant Ruconest®. Alternatively, the kallikrein inhibitor Kalbitor® (icatibant), or the bradykinin B2 receptor antagonist Firazyr® (ecallantide), can be administered subcutaneously in the case of acute HAE attacks. The treatment options for prophylactic treatment of HAE are limited to plasma-derived Cinryze® (IV) HAEGARDA / Berinert 2000 / 3000 (SC). Very recently, the kallikrein antibody product Takhzyro® (lanadelumab, SC) has been approved as an alternative option for prophylaxis.

[0008] Despite the existing treatment options for acute HAE attacks and prophylactic treatment of HAE, there are areas of unmet medical need, particularly in the area of prophylaxis. The limitations of current prophylactic treatments are an unfavorable side effect profile (attenuation of androgens), lack of efficacy (antifibrinolytics), or frequency of administration (IV or SC C1-INH). Furthermore, plasma-derived C1-INH products can sometimes have supply problems, and for this reason, alternative treatment options are still needed.

[0009] Patent Document 1 and Patent Document 2 disclose various anti-FXII antibodies and their use in the treatment of various diseases including, but not limited to, HAE. Regarding HAE, no in vivo experimental data, patient safety data, or data regarding clinical trials have been provided.

[0010] Patent Document 3 discloses additional anti-FXII antibodies including, but not limited to, the antibodies used in the context of the present invention. In Patent Document 3, HAE is not mentioned.

[0011] Finally, it remained unclear whether the anti-factor XII mAb is effective in the treatment or prevention of HAE.

Prior Art Documents

Patent Documents

[0012]

Patent Document 1

Patent Document 2

Patent Document 3

Non-Patent Documents

[0013]

Non-Patent Document 1

Non-Patent Document 2

Non-Patent Document 3

Non-Patent Document 4

Non-Patent Document 5

[0014] Overall, while the new treatment provides an improvement in preventive clinical outcomes, there is a need for preventive management of HAE, particularly additional modalities targeting novel pharmacological pathways. [Means for Solving the Problems]

[0015] The present invention relates to (i) a V comprising CDRH1 comprising the sequence set forth in SEQ ID NO: 1; CDRH2 comprising the sequence set forth in SEQ ID NO: 2; and CDRH3 comprising the sequence set forth in SEQ ID NO: 3 H ; and (ii) a V comprising CDRL1 comprising the sequence set forth in SEQ ID NO: 4; CDRL2 comprising the sequence set forth in SEQ ID NO: 5; and CDRL3 comprising the sequence set forth in SEQ ID NO: 6 L and is for use in a method of treating or preventing hereditary angioedema (HAE) in a subject, administered subcutaneously to the subject. It relates to an anti-FXII antibody.

[0016] In a preferred embodiment, the anti-FXII antibody comprises a V H comprising the sequence set forth in SEQ ID NO: 7 L and a V comprising the sequence set forth in SEQ ID NO: 8.

[0017] In a preferred embodiment, the anti-FXII antibody is an IgG, preferably an IgG4 antibody.

[0018] In a preferred embodiment, the anti-FXII antibody comprises a heavy chain sequence set forth in SEQ ID NO: 9 and a light chain sequence set forth in SEQ ID NO: 10.

[0019] In a preferred embodiment, the heavy chain comprises an additional lysine linked to the last amino acid of SEQ ID NO: 9.

[0020] In a preferred embodiment, the anti-FXII antibody is administered in an amount that maintains a concentration of at least 5 μg / mL of the antibody between two successive administrations of the antibody.

[0021] In a preferred embodiment, the antibody is administered at a dosage of 70 mg to 700 mg, once every 1 to 3 months, preferably once every 1 to 2 months.

[0022] In a preferred embodiment, the antibody is administered at a dosage of 150 mg to 250 mg, preferably 170 mg to 220 mg, more preferably 200 mg.

[0023] In a preferred embodiment, the antibody is administered at a dosage of from 50 mg to 150 mg, preferably from 70 mg to 130 mg, more preferably 100 mg.

[0024] In a preferred embodiment, the antibody is administered once every 1 to 2 months, preferably once every month.

[0025] In a preferred embodiment, the subject is a human patient having HAE, suspected of having HAE, or at risk of HAE.

[0026] In a preferred embodiment, the method comprises administration of a loading dose of an anti-FXII antibody.

[0027] In a preferred embodiment, the administration of the loading dose is intravenous administration of the anti-FXII antibody at a dosage between 30 mg and 400 mg, preferably between 100 and 300 mg, more preferably about 200 mg.

[0028] In a preferred embodiment, the administration of the loading dose is subcutaneous administration of the anti-FXII antibody at a dosage between 70 mg and 700 mg, preferably between 200 and 500 mg, more preferably about 400 mg.

[0029] In a preferred embodiment, the anti-FXII antibody is administered only subcutaneously to the subject.

[0030] In a preferred embodiment, the administration of the anti-FXII antibody reduces the risk of HAE attacks by preferably more than 85%, more preferably more than 90%, even more preferably more than 95% or more than 98%.

Mode for Carrying Out the Invention

[0031] According to the present invention, the "anti-FXII antibody" binds to and inhibits the activated form of FXII, i.e., FXIIa-beta (factor XIIa beta), but also binds to FXII and FXIIa (factor XIIa alpha).

[0032] In the broadest sense, an "antibody" is a polypeptide containing an immunoglobulin variable region that specifically recognizes an epitope on an antigen. The term "antibody" also includes antibody fragments that retain the ability to bind to FXIIa and FXII. Preferred antigen-binding fragments are Fab fragments, Fab' fragments, F(ab')2 fragments, Fv fragments, single-chain antibodies, single-chain Fv fragments, disulfide-stabilized Fv proteins, or dimers of single-chain Fv fragments. The antibodies included in the present invention are chimeric antibodies, humanized antibodies, murine antibodies or bispecific antibodies. Methods for producing these fragments and antibodies are well known in the art (see, for example, Harlow & Lane: Antibodies, A Laboratory Manual, Cold Spring Harbor Laboratory, 1988).

[0033] Antibodies typically consist of two identical heavy chains and two identical light chains, each having a variable region (V H and V L region) at each N-terminus. Usually, the V H and V L regions bind to form an antigen-binding site. However, single-domain antibodies that have only one variable region and bind to an antigen have also been described.

[0034] Typically, an antibody contains two heavy chains and two light chains connected by disulfide bonds. There are five major isotypes (IgG, IgM, IgE, IgA, IgD) of antibodies, some of which occur as multimers of the basic antibody structure. The isotype is determined by the constant region of the heavy chain. There are two types of light chains, lambda and kappa.

[0035] As used herein, the term "antibody" includes intact antibodies (also known as full-length antibodies or antibodies that include both the variable and constant domains of the heavy and light chains), as well as variants and portions thereof that retain antigen binding. This includes fragments of antibodies such as Fab fragments, F(ab’)2 fragments, Fab’ fragments, single-chain Fv fragments, or disulfide-stabilized Fv fragments. Thus, the term "antibody or antigen-binding fragment thereof" as used herein is merely precautionary and the term "antibody" alone is already intended to encompass antibodies and their antigen-binding fragments.

[0036] The terms "full-length antibody", "intact antibody" or "whole antibody" are used interchangeably to refer to an antibody in a substantially intact form, as opposed to an antigen-binding fragment of an antibody. In particular, whole antibodies include antibodies having heavy and light chains that include an Fc region. The constant domain may be a wild-type sequence constant domain (e.g., a human wild-type sequence constant domain) or an amino acid sequence variant thereof.

[0037] Each heavy and light chain consists of a variable region and a constant region. The variable region includes framework residues and hypervariable regions, which are also called complementarity-determining regions or CDRs.

[0038] As used herein, "variable region" refers to the portion of the light and / or heavy chains of an antibody as defined herein that can specifically bind to an antigen and includes the amino acid sequences of the complementarity-determining regions (CDRs); i.e., CDR1, CDR2, and CDR3, as well as the framework regions (FRs). Exemplary variable regions include three or four FRs (e.g., FR1, FR2, FR3 and optionally FR4) together with the three CDRs.

[0039] As used herein, the term "complementary determining region" (CDR; synonymous with CDR1, CDR2, and CDR3) refers to the amino acid residues of an antibody variable domain whose presence is necessary for antigen binding. Each variable domain typically has three CDR regions, identified as CDR1, CDR2, and CDR3. The framework residues and the scope of the CDRs are determined according to Kabat; the Kabat database is available online (Kabat EA, Wu TT, Perry HM, Gottesman KS, Foeller C (1991) Sequences of proteins of immunological interest, 5th edition, US Department of Health and Human Services, NIH, Bethesda, MD). The CDR regions are important for binding to the epitope and thus determine the specificity of the antibody.

[0040] The "framework region" (FR) is the variable domain residue other than the CDR residues.

[0041] A "monoclonal antibody" is an antibody produced by a single clone of B lymphocytes or by a cell line engineered to express a single antibody.

[0042] A "chimeric antibody" is an antibody in which a variable region of one species has been grafted onto a constant region of a different species. A "humanized" antibody is an antibody in which the CDR regions from a different species, such as a murine monoclonal antibody, have been grafted onto the framework of a human antibody. Similarly, a "murinized" antibody is an antibody in which the CDR regions from a different species, such as a human monoclonal antibody, have been grafted onto the framework of a murine antibody. A human antibody is an antibody that is fully of human origin, i.e., human CDRs in a human framework and any constant region suitable for administration to humans.

[0043] A "germline" antibody is an antibody in which somatic mutations that introduced changes in the framework residues have been reverted to the original sequences present in the genome.

[0044] "Antigen-binding fragment" refers to any fragment of an antibody that retains the ability to specifically bind to the epitope of an antigen to which the antibody binds. These include, but are not limited to, Fab, F(ab’)2, or single-chain Fv fragments.

[0045] "Binding affinity" refers to the affinity of an antibody for its antigen. It can be measured by various techniques, such as techniques based on surface plasmon resonance (BiaCore®).

[0046] "Epitope" is an antigenic determinant, defined by the residues or specific chemical structures that an antibody contacts on an antigen.

[0047] "Sequence identity" is related to the similarity of amino acid sequences. The best possible alignment of two sequences is prepared, and sequence identity is determined by the percentage of identical residues. Standard methods for sequence alignment are available, such as those of Needleman and Wunsch (J Mol Biol (1970) 48:443), Smith and Waterman (Adv Appl Math (1981) 2:482), Pearson and Lipman (Proc Natl Acad Sci USA (1988) 85:2444). For example, alignments can be created using GAP or BESTFIT with default parameters, or their successors, and appropriate software is commercially available, such as the software of the GCG suite (Devereux et al. (1984), Nucl Acids Res 12:387). The Blast algorithm, originally described by Altschul et al. (J Mol Biol (1990) 215:403) and further refined to include gapped alignments (Blast 2) available from various sources such as EBI, NCBI, also generates alignments and calculates the % identity between two sequences.

[0048] "Specific binding" refers to binding to substantially only a single antigen.

[0049] "FXII / FXIIa" refers to either or both of factor XII and activated factor XII (FXIIa). Thus, an "FXII / FXIIa inhibitor" includes an inhibitor of either or both of FXII and FXIIa. Further, anti-FXII / FXIIa antibodies include antibodies that bind to and inhibit either or both of FXII and FXIIa.

[0050] "To treat" or "treatment" means the reduction of any symptoms associated with HAE, particularly the reduction in the severity and / or frequency of HAE attacks.

[0051] "To prevent" or "prevention" means the prevention of any symptoms associated with HAE, including the worsening of the disease.

[0052] As described in more detail in the attached examples, the inventors have surprisingly been able to show for the first time that the anti-FXII antibodies used in the context of the present invention are highly active in reducing the number of attacks in patients with hereditary angioedema (HAE). Indeed, the antibodies used in the context of the present invention can almost completely prevent such HAE attacks even when administered subcutaneously. By repeatedly administering the anti-FXII antibodies of the present invention over time and thereby maintaining the antibody concentration in the blood, a significant reduction in the number of HAE attacks is brought about. Thus, the antibodies used in the context of the present invention represent a useful agent for the prevention or treatment of HAE.

[0053] Thus, in one aspect, the present invention is (i) a V comprising CDRH1 comprising the sequence set forth in SEQ ID NO: 1; CDRH2 comprising the sequence set forth in SEQ ID NO: 2; and CDRH3 comprising the sequence set forth in SEQ ID NO: 3 H ; and (ii) a V comprising CDRL1 comprising the sequence set forth in SEQ ID NO: 4; CDRL2 comprising the sequence set forth in SEQ ID NO: 5; and CDRL3 comprising the sequence set forth in SEQ ID NO: 6 L ; comprising administered subcutaneously to a subject, Relates to an anti-FXII antibody for use in a method of treating or preventing HAE in a subject.

[0054] The CDR sequences are also shown in Figure 10.

[0055] Preferably, the antibody used in the context of the present invention has a K -7 better than 10 -8 M, more preferably better than 3×10 -8 M, more preferably better than 10 -9 M, even more preferably better than 3×10 -9 M, most preferably better than 10 -10 M or 5×10 D and binds to human factor XIIa-β.

[0056] The antibody or its antigen-binding fragment may be of any isotype including IgG, IgM, IgE, IgD, or IgA and any subtype thereof. Preferably, the antibody or its antigen-binding fragment of the present invention is a human IgG or a variant thereof, preferably human IgG4 or a variant thereof. Methods for switching the type of antibody are well known in the art. The nucleic acid molecule encoding the V H or V L region is isolated and operably linked to a nucleic acid sequence encoding a different constant region of an immunoglobulin molecule, either c H or c L .

[0057] The present disclosure encompasses the proteins and / or antibodies described herein, including the constant regions of the antibodies. This includes antigen-binding fragments of antibodies fused to Fc.

[0058] The sequences of the constant regions useful for producing the proteins of the present disclosure may be obtained from several different sources. In some examples, the constant region of the protein or a portion thereof is derived from a human antibody. The constant region or a portion thereof may be derived from any antibody class including IgM, IgG, IgD, IgA, and IgE, as well as any antibody isotype including IgG1, IgG2, IgG3, and IgG4.

[0059] In one embodiment, the constant region is a human isotype IgG4 or a stabilized IgG4 constant region.

[0060] In one embodiment, the Fc region of the constant region has a reduced ability to induce effector functions as compared to, for example, a native or wild-type human IgG1 or IgG3 Fc region. In one embodiment, the effector functions are antibody-dependent cell-mediated cytotoxicity (ADCC) and / or antibody-dependent cell-mediated phagocytosis (ADCP) and / or complement-dependent cytotoxicity (CDC). Methods for assessing the level of effector function of an Fc region containing a protein are well known in the art.

[0061] In one embodiment, the Fc region is an IgG4 Fc region (i.e., from an IgG4 constant region), for example, a human IgG4 Fc region. Suitable sequences of the IgG4 Fc region will be apparent to those skilled in the art and / or are available in publicly accessible databases (e.g., available from the National Center for Biotechnology Information).

[0062] In one embodiment, the constant region is a stabilized IgG4 constant region. The term "stabilized IgG4 constant region" is understood to mean an IgG4 constant region that has been modified to reduce the tendency to undergo Fab arm exchange or to form half antibodies. "Fab arm exchange" refers to a type of protein modification of human IgG4 in which the IgG4 heavy chain and attached light chain (half molecule) are exchanged for a heavy chain-light chain pair from another IgG4 molecule. Thus, an IgG4 molecule may acquire two different Fab arms that recognize two different antigens (resulting in a bispecific molecule). Fab arm exchange occurs spontaneously in vivo and can be induced in vitro by reducing agents such as purified blood cells or reduced glutathione. A "half antibody" is formed when an IgG4 antibody dissociates to form two molecules each containing a single heavy chain and a single light chain.

[0063] In one embodiment, the stabilized IgG4 constant region contains a proline at position 241 of the hinge region according to the Kabat system (Kabat et al., Sequences of Proteins of Immunological Interest Washington DC United States Department of Health and Human Services, 1987 and / or 1991). This position corresponds to position 228 of the hinge region according to the EU numbering system (Kabat et al., Sequences of Proteins of Immunological Interest Washington DC United States Department of Health and Human Services, 2001 and Edelman et al., Proc. Natl. Acad. Sci USA, 63, 78-85, 1969). In human IgG4, this residue is generally serine. After substituting serine with proline, the IgG4 hinge region contains the sequence CPPC. In this regard, one of ordinary skill in the art will recognize that the "hinge region" is the proline-rich portion of the antibody heavy chain constant region that links the Fc region and the Fab region, giving mobility to the two Fab arms of the antibody. The hinge region contains cysteine residues involved in inter-heavy chain disulfide bonds. This is generally defined as the stretch from Glu226 to Pro243 of human IgG1 according to the Kabat numbering system. The hinge regions of other IgG isotypes can be aligned with the IgG1 sequence by placing the first and last cysteine residues that form the inter-heavy chain disulfide (S-S) bond at the same positions (see, for example, WO 2010 / 080538).

[0064] Additional embodiments of the stabilized IgG4 antibody are antibodies in which arginine at position 409 of the heavy chain constant region of human IgG4 (according to the EU numbering system) is replaced with lysine, threonine, methionine, or leucine (for example, as described in WO 2006 / 033386). The Fc region of the constant region may additionally or alternatively contain a residue selected from the group consisting of alanine, valine, glycine, isoleucine, and leucine at a position corresponding to 405 (according to the EU numbering system). Optionally, the hinge region contains proline at position 241 (i.e., the CPPC sequence) (as described above).

[0065] In another embodiment, the Fc region is a region modified to have reduced effector function, i.e., a "non-immunostimulatory Fc region". For example, the Fc region is an IgG1 Fc region that includes substitutions at one or more positions selected from the group consisting of 268, 309, 330, and 331. In another embodiment, the Fc region is an IgG1 Fc region that includes one or more of the following changes: E233P, L234V, L235A, and deletion of G236 and / or one or more of the following changes: A327G, A330S, and P331S (Armour et al., Eur J Immunol. 29:2613-2624, 1999; Shields et al., J Biol Chem. 276(9):6591-604, 2001). Additional examples of non-immunostimulatory Fc regions are described, for example, in Dall’Acqua et al., J Immunol. 177:1129-1138, 2006; and / or Hezareh J Virol; 75:12161-12168, 2001.

[0066] In another embodiment, the Fc region is, for example, at least one C H 2 domain from an IgG4 antibody and at least one C HA chimeric Fc region comprising 3 domains, wherein the Fc region comprises one or more substitutions at amino acid positions selected from the group consisting of 240, 262, 264, 266, 297, 299, 307, 309, 323, 399, 409 and 427 (EU numbering) (e.g., as described in International Publication No. WO 2010 / 085682). Exemplary substitutions include 240F, 262L, 264T, 266F, 297Q, 299A, 299K, 307P, 309K, 309M, 309P, 323F, 399S, and 427F.

[0067] The present disclosure also contemplates additional modifications to the antibody.

[0068] For example, the antibody comprises one or more amino acid substitutions that increase the half-life of the protein. For example, the antibody comprises an Fc region that comprises one or more amino acid substitutions that increase the affinity of the Fc region for the neonatal Fc receptor (FcRn). For example, the Fc region has increased affinity for FcRn at a lower pH, e.g., about pH 6.0, to facilitate Fc / FcRn binding in the endosome. In one example, the Fc region has increased affinity for FcRn at about pH 6 compared to its affinity at about pH 7.4, which promotes the re-release of Fc (and thus molecules comprising the Fc region) into the blood after cellular recycling. These amino acid substitutions serve to extend the half-life of the protein by reducing clearance from the blood.

[0069] Exemplary amino acid substitutions include T250Q and / or M428L or T252A, T254S and T266F or M252Y, S254T and T256E or H433K and N434F according to the EU numbering system. Additional or alternative amino acid substitutions are described, e.g., in US Patent Application Publication No. US 2007 / 0135620 or US Patent No. US 7083784.

[0070] More preferably, the antibody of the present invention is a human IgG1 or human IgG4 engineered to enhance binding to the human neonatal Fc receptor FcRn at a lower pH, such as pH 6, thereby increasing the half-life of the antibody in human serum. Methods for screening for optimal Fc variants to optimize FcRn binding have been described (e.g., Zalevsky et al. (2010) Nature Biotech 28, 157-159).

[0071] In a preferred embodiment, the antibody used in the context of the present invention is a germline antibody as defined above.

[0072] Other preferred antibodies or antigen-binding fragments thereof of the present invention include mammalian immunoglobulin constant regions, such as those of IgG, IgM, IgE, IgD, or IgA and any subtypes thereof. Preferably, the antibody is a mammalian IgG including mouse IgG, porcine IgG, bovine IgG, equine IgG, feline IgG, canine IgG, and primate IgG or variants thereof. These antibodies may be chimeric antibodies in which the human variable regions of the present invention are combined with the constant regions of immunoglobulins of the selected species. Alternatively, the antibody or antigen-binding fragment thereof is produced by grafting the human CDR regions described herein onto framework residues from immunoglobulins of the selected species.

[0073] Preferably, the antibody or antigen-binding fragment thereof of the present invention is in its mature form, i.e., without the signal peptide; however, antibodies or antigen-binding fragments thereof containing the signal peptide are also included in the present invention.

[0074] In a more preferred embodiment, the anti-FXII antibody comprises a V H comprising the sequence set forth in SEQ ID NO: 7 and a V L comprising the sequence set forth in SEQ ID NO: 8. Preferably, the anti-FXII antibody is a germline antibody.

[0075] In a further preferred embodiment, the anti-FXII antibody comprises the heavy chain sequence set forth in SEQ ID NO: 9 and the light chain sequence set forth in SEQ ID NO: 10. These sequences represent the full-length heavy and light chains of the germline antibody CSL312 antibody as defined above. It is particularly included in the present invention that the constant regions of these heavy and light chains contain the modifications disclosed above.

[0076] The amino acid sequence of this particularly preferred antibody is also shown in FIG. 10.

[0077] Depending on the production method, it is often known in the art that the terminal lysine of the heavy chain is cleaved from at least some of the arms of the antibody. Thus, the present invention includes both that the heavy chain sequence of the antibody does not contain a terminal lysine as shown in SEQ ID NO: 9 and that the heavy chain sequence of the antibody contains an additional lysine linked to the last amino acid of SEQ ID NO: 9, and includes a population of antibodies containing uncleaved, partially cleaved, and fully cleaved species.

[0078] Any discussion of the antibodies herein is understood to include any variants of the antibodies produced during manufacture and / or storage. For example, during manufacture or storage, the antibody can be deamidated (e.g., at asparagine or glutamine residues), and / or the glycosylation can be changed, and / or the glutamine residues can be converted to pyroglutamine, and / or the N-terminal or C-terminal residues can be removed or "clipped", and / or part or all of the signal sequence can be incompletely processed, resulting in remaining at the ends of the antibody. It is understood that a composition containing a specific amino acid sequence can be a heterogeneous mixture of the described or encoded sequence and / or variants of the described or encoded sequence.

[0079] The antibodies used in the context of the present invention are produced by any method well known in the art. For example, antibodies can be produced by introducing nucleic acids encoding the antibodies into suitable cells, such as mammalian cell lines like CHO, HEK293, MDCK, COS, HeLa, or myeloma cell lines like NS0. Another suitable cell line is an insect cell line for use with baculovirus, such as SF9 cells, SF21 cells, or HighFive™ cells. Yet another cell is a yeast cell, such as Saccharomyces, e.g., S. cerevisiae, or Pichia pastoris. Bacterial host cells such as Escherichia coli are also possible. Methods for introducing DNA into each host cell are well known in the art. For example, when the host cell is a mammalian cell line, techniques such as lipofection or electroporation may be used.

[0080] Methods for producing antibodies may include culturing host cells, such as the cell lines or yeast cells of the present invention, under suitable conditions for expressing the antibodies. Thereafter, the antibodies may be purified. The antibodies are secreted by the host cells and can then be easily purified from the culture supernatant. Techniques for purifying antibodies are well known in the art and include techniques such as ammonium sulfate precipitation, size exclusion chromatography, affinity chromatography, and ion exchange chromatography.

[0081] When expressed in Escherichia coli, the antibody or its antigen-binding fragment is produced as inclusion bodies. Methods for isolating the inclusion bodies and refolding the expressed protein are well known in the art.

[0082] Accordingly, the present invention also relates to anti-FXII antibodies for use in a method of treating or preventing hereditary angioedema (HAE) in a subject, wherein the antibody is administered subcutaneously to the subject and the anti-FXII antibody is obtained by introducing a nucleic acid encoding the above anti-FXII antibody, preferably the nucleic acids set forth in SEQ ID NOs: 11 and 12, into a cell, and the anti-FXII antibody is produced intracellularly and subsequently purified.

[0083] The nucleic acids according to SEQ ID NOs: 11 and 12 encode the polypeptides according to SEQ ID NOs: 9 and 10.

[0084] According to the present invention, the antibody is administered subcutaneously to a subject. Methods for formulating an antibody for subcutaneous administration are well known in the art and include the preparation of a pharmaceutical composition containing the antibody.

[0085] For example, for the preparation of a pharmaceutical composition for subcutaneous administration, the antibody can be mixed with one or more pharmaceutically acceptable carriers, diluents or excipients. For example, sterile water or physiological saline may be used. Other substances such as pH buffers, viscosity reducing agents, or stabilizers may also be included.

[0086] A variety of pharmaceutically acceptable excipients and carriers are well known in the art. Such pharmaceutical carriers and excipients, as well as suitable formulations, are well described in various publications (e.g., "Pharmaceutical Formulation Development of Peptides and Proteins", Frokjaer et al., Taylor & Francis (2000) or "Handbook of Pharmaceutical Excipients", 3rd Edition, Kibbe et al., Pharmaceutical Press (2000) A. Gennaro (2000) "Remington: The Science and Practice of Pharmacy", 20th Edition, Lippincott, Williams, & Wilkins; Pharmaceutical Dosage Forms and Drug Delivery Systems (1999) H.C. Ansel et al., 7th Edition, Lippincott, Williams, & Wilkins; and Handbook of Pharmaceutical Excipients (2000) A.H. Kibbe et al., 3rd Edition, Amer. Pharmaceutical Assoc). In particular, the pharmaceutical composition containing the antibody of the present invention is formulated in a lyophilized or stable soluble form. The polypeptide may be lyophilized by various procedures known in the art. The lyophilized formulation is reconstituted prior to use by adding one or more pharmaceutically acceptable diluents such as sterile water for injection or sterile saline.

[0087] For subcutaneous administration, the pharmaceutical composition containing the antibody can be administered by dosages and techniques well known in the art. The amount and timing of administration are determined by the treating physician or veterinarian in order to achieve the desired objective and should ensure delivery of a safe and therapeutically effective dose to the blood of the subject being treated.

[0088] In one embodiment, the anti-FXII antibody is administered in an amount that maintains the concentration of the antibody in the blood at at least about 3, 5, 7, or 10 μg / mL, preferably about 5 μg / mL, between two successive administrations of the antibody.

[0089] As can be understood from the examples, particularly from FIG. 5, administration of 75 mg, 200 mg, or 600 mg of the anti-FXII antibody results in a blood concentration of the antibody of at least about 3 μg / mL during one treatment cycle, i.e., the period between two administrations of the antibody. Even when the blood antibody concentration is as low as in the steady state, a significant reduction in the number of HAE attacks is observed. Also, as can be seen from FIG. 5, the peak concentration of the anti-FXII antibody in the blood after administration of 75 mg or 200 mg need not be higher than about 20 μg / mL.

[0090] As a result, in embodiments of the present invention, the anti-FXII antibody is administered in an amount that achieves a maximum concentration of the antibody in the blood of about 20 μg / mL.

[0091] In a further embodiment, the anti-FXII antibody is administered in an amount that reduces the activity of FXII, including its activated form, to a level observed in healthy subjects. Thus, the anti-FXII antibody is administered in an amount that normalizes the activity of FXII, including its activated form.

[0092] In a further aspect, the present invention also relates to an anti-FXII antibody for use in a method of treating or preventing hereditary angioedema (HAE) in a subject, wherein the antibody is administered subcutaneously to the subject and the anti-FXII antibody is administered in an amount that reduces the activity of FXII, including its activated form, to a level observed in healthy subjects.

[0093] According to the present invention, moderate inhibition of FXII-mediated kallikrein activity at the end of the dosing cycle in the steady state promotes effective results. As a result, in a further embodiment, the anti-FXII antibody is administered in an amount sufficient to inhibit FXII-mediated kallikrein activity by less than about 60%, less than about 50%, less than about 40%, or less than about 30% between two successive administrations of the antibody.

[0094] The anti-FXII antibody may be administered at a dosage of about 70 mg to 700 mg, about 75 mg to 150 mg, about 150 mg to 250 mg, about 300 mg to 350 mg, about 350 mg to 700 mg, about 170 mg to 220 mg, preferably at a dosage of about 75 mg, about 100 mg, about 150 mg, about 170 mg, about 200 mg, about 300 mg, about 340 mg or about 600 mg, and preferably at a dosage of about 100 mg or about 200 mg.

[0095] The anti-FXII antibody may be administered once every 1 to 3 months, once every 1 to 2 months, or once a month. It may also be administered once every 2, 3, 4, 5, 6, 7, or 8 weeks.

[0096] According to the present invention, the anti-FXII antibody may be administered at a dosage of 70 mg to 700 mg once every 1 to 3 months, 70 mg to 700 mg once every 1 to 2 months, 70 mg to 700 mg once every 2 months, 70 mg to 700 mg once every 6 weeks, 70 mg to 700 mg once a month, 75 mg to 150 mg once every 1 to 3 months, 75 mg to 150 mg once every 1 to 2 months, 75 mg to 150 mg once every 2 months, 75 mg to 150 mg once every 6 weeks, 75 mg to 150 mg once a month, 150 mg to 250 mg once every 1 to 2 months, 150 mg to 250 mg once every 2 months, 150 mg to 250 mg once every 6 weeks, 150 mg to 250 mg once a month, 170 mg to 220 mg once every 1 to 2 months, 170 mg to 220 mg once every 2 months, 170 mg to 220 mg once every 6 weeks, 170 mg to 220 mg once a month, 75 mg once every 1 to 2 months, 75 mg once every 2 months, 75 mg once every 6 weeks, 75 mg once a month, 100 mg once every 1 to 2 months, 100 mg once every 2 months, 100 mg once every 6 weeks, 100 mg once a month, 200 mg once every 1 to 2 months, 200 mg once every 2 months, 200 mg once every 6 weeks, 200 mg once a month.

[0097] In a preferred embodiment, the antibody is administered at a dosage of about 150 mg to 250 mg, preferably about 170 mg to 220 mg, more preferably about 200 mg, once every 1 to 3 months, preferably once every 1 to 2 months, preferably once a month.

[0098] In an alternative preferred embodiment, the antibody is administered at a dosage of about 50 mg to 150 mg, preferably about 70 mg to 130 mg, more preferably about 100 mg, once every 1 to 3 months, preferably once every 1 to 2 months, preferably once a month.

[0099] In another alternative preferred embodiment, the antibody is administered at a dosage of about 300 mg to 350 mg, preferably about 300 mg or 340 mg, once every 1 to 3 months, preferably once every 2 months.

[0100] According to a preferred embodiment, the subject is a human subject, preferably a human patient having HAE, or suspected of having HAE, or at risk of HAE.

[0101] According to the present invention, the anti-FXII antibody is administered subcutaneously to a subject during a method of treating or preventing HAE. Preferably, this includes only that the anti-FXII antibody is administered subcutaneously to the subject. Alternatively, the method may also include another administration such as intravenous, intraarterial, intradermal, intraperitoneal, oral, transmucosal, epidural, or intrathecal administration, preferably intravenous administration.

[0102] In one embodiment, the method includes administration of a loading dose of an anti-FXII antibody. This loading dose may be the same dose as the next administration, or may be a higher or lower dose. Further, the loading dose is administered subcutaneously or, as described above, preferably intravenously. The loading dose may be administered simultaneously with the start of the next administration or immediately prior thereto (i.e., within about one week). In the case of subcutaneous administration of the loading dose, such a loading dose is preferably the same amount as the first subsequent dose and is administered simultaneously. Thereby, a first dosing that is twice as much as subsequent dosing is performed. In the case of intravenous administration of the loading dose, the initial dose is usually lower than the subsequent doses, for example, about 25%, 50% or 75% of the subsequent doses. Preferably, the loading dose is administered immediately prior to the subsequent dose.

[0103] In a preferred embodiment, the administration of the loading dose is intravenous administration of the anti-FXII antibody at a dose between about 30 mg and 400 mg, preferably between 100 and 300 mg, more preferably 200 mg. For example, in the case of a subsequent subcutaneous administration of about 75 mg, the loading dose may be between about 30 mg and 60 mg, and in the case of a subsequent subcutaneous administration of 100 mg, the loading dose may be between about 40 mg and 70 mg, and in the case of a subsequent subcutaneous administration of 200 mg, the loading dose may be between about 80 mg and 130 mg, and in the case of a subsequent subcutaneous administration of about 600 mg, the loading dose may be between about 240 mg and 700 mg.

[0104] In a more preferred embodiment, the administration of the loading dose is subcutaneous administration of the anti-FXII antibody at a dose between about 70 mg and 700 mg, preferably between 200 and 500 mg, more preferably 400 mg. For example, in the case of a subsequent subcutaneous administration of about 75 mg, the simultaneous loading dose may be about 75 mg (i.e., in the first administration, a total dose of 150 mg is administered subcutaneously). In the case of a subsequent subcutaneous administration of about 100 mg, the simultaneous loading dose may be about 100 mg, and in the case of a subsequent subcutaneous administration of 200 mg, the simultaneous loading dose may be about 200 mg, and in the case of a subsequent subcutaneous administration of about 600 mg, the simultaneous loading dose may be about 600 mg.

[0105] In the context of the present invention, and as shown in the examples, the inventors were able to demonstrate that administration of the antibodies used in the context of the present invention can significantly reduce the number of HAE attacks.

[0106] As a result, in a preferred embodiment of the present invention, administration of the anti-FXII antibody reduces the risk of HAE attacks, preferably by more than 85%, preferably by more than 90%, even more preferably by more than 95% or by more than 98%. Preferably, said reduction is applied as compared to an untreated subject.

[0107] In a further aspect, the present invention also relates to a method of treating or preventing hereditary angioedema (HAE) in a subject, said method comprising subcutaneous administration to said subject of an anti-FXII antibody comprising CDRH1 comprising the sequence set forth in SEQ ID NO: 1; CDRH2 comprising the sequence set forth in SEQ ID NO: 2; and CDRH3 comprising the sequence set forth in SEQ ID NO: 3 H ; and (ii) VL comprising CDRL1 comprising the sequence set forth in SEQ ID NO: 4; CDRL2 comprising the sequence set forth in SEQ ID NO: 5; CDRL3 comprising the sequence set forth in SEQ ID NO: 6 L The anti-FXII antibody is preferably administered to the subject in a therapeutically active amount.

[0108] All embodiments disclosed above with respect to other aspects of the present invention are also applicable to this aspect of the present invention.

[0109] The present invention is further illustrated with the aid of the following figures and examples, which are for illustrative purposes only and not for limiting purposes. BRIEF DESCRIPTION OF THE DRAWINGS

[0110]

Figure 1

Figure 2

Figure 3-1

Figure 3-2

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11

[0111] Key to the sequence table SEQ ID NO:1 is the amino acid sequence from the CDR1 variable domain of the anti-FXII antibody CSL312.

[0112] SEQ ID NO:2 is the amino acid sequence from the CDR2 variable domain of the anti-FXII antibody CSL312.

[0113] SEQ ID NO:3 is the amino acid sequence from the CDR3 variable domain of the anti-FXII antibody CSL312.

[0114] SEQ ID NO:4 is the amino acid sequence from the CDR1 variable domain of the anti-FXII antibody CSL312.

[0115] SEQ ID NO:5 is the amino acid sequence from the CDR2 variable domain of the anti-FXII antibody CSL312.

[0116] SEQ ID NO:6 is the amino acid sequence from the CDR3 variable domain of the anti-FXII antibody CSL312.

[0117] SEQ ID NO:7 is the amino acid sequence from the heavy region variable domain of anti-FXII antibody CSL312.

[0118] SEQ ID NO:8 is the amino acid sequence from the light region variable domain of anti-FXII antibody CSL312.

[0119] SEQ ID NO: 9 is the amino acid sequence from the heavy chain variable domain of anti-FXII antibody CSL312.

[0120] SEQ ID NO: 10 is the amino acid sequence from the light chain variable domain of the anti-FXII antibody CSL312.

[0121] SEQ ID NO: 11 is the nucleic acid sequence encoding the heavy chain of the anti-FXII antibody CSL312.

[0122] SEQ ID NO: 12 is the nucleic acid sequence encoding the heavy chain of the anti-FXII antibody CSL312.

Example 1

[0123] A single-site, randomized, double-blind, placebo-controlled, single ascending dose, Phase 1 trial was conducted to investigate the safety, tolerability, and PK of escalating doses of CSL312 following a single IV infusion or SC injection in healthy subjects. The heavy and light chains of CSL312 are provided in Figure 10.

[0124] Study Design CSL312 is a fully human IgG4 / lambda recombinant monoclonal antibody that specifically binds to the catalytic domain of activated FXII (FXIIa and βFXIIa) and potently inhibits its catalytic activity. CSL312 inhibits bradykinin (BK) production in vitro and suppresses the formation of edema in a BK-mediated edema model in vivo. CSL312 suppresses the expression of inflammatory mediators.

[0125] A total of 48 subjects were randomized into one of eight cohorts (five IV cohorts and three SC cohorts) (Figure 1). Each cohort consisted of six subjects (four active and two placebo). Subjects in each of the five IV cohorts were administered a single IV dose of CSL312 at 0.1, 0.3, 1, 3, or 10 mg / kg, or placebo (formulation buffer). Subjects in each of the three SC cohorts were administered a single SC injection of CSL312 at 1, 3, or 10 mg / kg, or placebo (formulation buffer). (Figure 2: Dosing and dose escalation scheme)

[0126] Sentinel dosing was performed for each IV cohort and the first SC cohort. The first two enrolled subjects (sentinel subjects) were randomized to receive either CSL312 (one subject) or placebo (one subject) and were monitored for 48 hours. Next, the principal investigator and the medical monitor evaluated the safety data from the 48-hour monitoring period. After no safety issues were identified, an additional four subjects were randomized and received either CSL312 or placebo (in a 3:1 ratio); dosing of these four subjects was initiated at least 48 hours after dosing of the second sentinel subject.

[0127] Safety analysis and results: The summary of all AEs was limited to treatment-emergent AEs (TEAEs) only. Subjects who experienced the same TEAE (in preferred terms) more than once were counted only once for that event in terms of the number of subjects, but all occurrences of the same event were counted in terms of the number of events.

[0128] Hematology, biochemistry, and coagulation data were summarized at each scheduled visit along with the actual values and changes from baseline. For all subjects who received CSL312, the incidence of anti-drug antibodies (ADA) was summarized by time point. Descriptive summaries were provided for the observed values and changes from baseline for 12 electrocardiogram parameters and vital sign evaluations.

[0129] Overall, 43 / 48 subjects (89.6%) in the cohort experienced at least one TEAE. More subjects experienced TEAE with CSL312 (30 / 32 subjects [93.8%] in 106 events) than with placebo (13 / 16 subjects [81.3%] in 50 events). Most of the TEAEs reported after treatment with CSL312 or placebo were of severity grade 1 (100 / 106 events [94.3%] with CSL312 and 45 / 50 events [90.0%] with placebo). Less than one-third of all TEAEs were evaluated as related to CSL312 or placebo (31 / 106 events [29.2%] with CSL312 and 14 / 50 events [28.0%] with placebo). All TEAEs, except for three ongoing TEAEs in three subjects who received placebo, had an outcome of recovery or resolution.

[0130] No dose-dependent trends were seen in the frequency or severity of TEAEs. No deaths, serious AEs, or AEs leading to discontinuation were reported.

[0131] Infusion / injection site reactions were reported to be more frequent in subjects who received CSL312 (18 / 32 subjects [56.3%], 21 events) than in subjects who received placebo (5 / 16 subjects [31.3%], 9 events), mainly due to events reported in the SC cohort. Overall, in the IV cohort, the percentage of subjects with infusion site reactions was similar for CSL312 and placebo (30.0% for both treatments). In the SC cohort, all subjects who received SC CSL312 experienced at least one injection site reaction, compared to 33.3% of subjects who received SC placebo. All infusion / injection site reactions were grade 1 and had an outcome of recovery or resolution.

[0132] There were no thromboembolic events, bleeding, or anaphylactic events.

[0133] There were no clinically relevant trends in the results of hematology, biochemistry, urinalysis, coagulation, or complement activity. Abnormal test values were observed in individual subjects, but no safety concerns were identified.

[0134] At baseline or at any point during the study, no subjects were tested positive for anti-CSL312 antibody.

[0135] No clinically relevant trends were reported for electrocardiogram or vital sign evaluations.

[0136] Pharmacokinetic analysis and results: PK parameters and CSL312 plasma concentrations were descriptively summarized by active treatment. All PK parameters were calculated using the actual sampling times. Summary statistics for the concentration-time data included the number of subjects in the analysis population, the number of actual observations, and the percentage of observations below the lower limit of quantification (BLQ) value relative to the total number of observations.

[0137] Dose proportionality was evaluated separately for IV and SC doses for PK parameters C max , AUC 0-inf and AUC 0-t . Exploratory dose proportionality was analyzed using a power model. A linear proportionality between the PK parameter and the dose was considered demonstrated if the 90% confidence interval (CI) was within the pre-defined critical interval of 0.85 - 1.15 for IV infusion or 0.7 - 1.3 for SC injection.

[0138] The PK parameters AUC 0-inf and AUC from time 0 to the last quantifiable time point after dosing (AUC 0-last ) for subjects receiving IV infusion of CSL312 were compared to the AUC 0-inf and AUC 0-last for subjects receiving SC injection of CSL312. A one-way analysis of variance (ANOVA) model was used to compare between the same doses of IV and SC (i.e., 1 mg / kg IV and 1 mg / kg SC, etc.), as well as between pooled IV and pooled SC doses.

[0139] After a single IV injection of CSL312, plasma concentrations generally reached their peak at the end of the injection (1 hour), except for a dose of 0.1 mg / kg that reached its peak at approximately 4 hours. The mean t 1 / 2 was in the range of approximately 14 to 20 days over IV administration (see Figure 3A).

[0140] After a single SC injection of 1, 3, or 10 mg / kg CSL312, plasma concentrations reached their peak at approximately 7 days (168 hours), 5 days (120 hours), and 7 days (168 hours), respectively. The mean t 1 / 2 was in the range of approximately 18 to 20 days over SC administration (see Figure 3B).

[0141] In a single administration of CSL312, when administered as an IV injection at doses of 0.1, 0.3, 1, 3, 10 mg / kg or as an SC injection at doses of 1, 3, 10 mg / kg, CSL312 showed a dose-dependent increase in C max and AUC.

[0142] Overall comparison of pooled IV doses to pooled SC doses showed that the bioavailability of dose-normalized AUC 0-inf was estimated to be 49.7%.

[0143] In conclusion, CSL312 was safe and well tolerated when administered as a single IV injection or single subcutaneous injection up to 10 mg / kg in healthy male subjects. CSL312 showed linear PK with an absolute bioavailability of approximately 50% after SC injection and a t 1 / 2 of approximately 18 days when administered as a single IV injection or SC injection.

Example 2

[0144] A multi-center, randomized, placebo-controlled, parallel-group, Phase 2 trial was conducted to investigate the clinical efficacy, pharmacokinetics, pharmacodynamics, and safety of CSL312 as a prophylactic method for preventing attacks of hereditary angioedema (HAE) in C1-INH HAE subjects.

[0145] Study Design Multiple subcutaneous doses of CSL312 were administered to HAE patients at the following doses: 75 mg, 200 mg, or 600 mg. This study consisted of a screening period (≤4 weeks), a ramp-up period (≤8 weeks), treatment period 1 (≤13 weeks), treatment period 2 (≤44 weeks), and a follow-up period (≤14 weeks). An overview of the main study design including the ramp-up period and randomized treatment period 1 is presented in Figure 4.

[0146] After screening, eligible subjects entered an initial ramp-up period that lasted at least 4 weeks and up to 8 weeks to confirm the status of their underlying diseases and evaluate their eligibility to participate in treatment period 1. Subjects with C1-INH HAE discontinued participation in the ramp-up period and initiated treatment period 1 when they met pre-specified criteria, including experiencing ≥2 HAE attacks within 4 consecutive weeks during the ramp-up period.

[0147] A total of 32 subjects with C1-INH HAE eligible to participate in blinded treatment period 1 were randomly assigned in a blinded manner to treatment with one of the following treatment regimens: · A single intravenous (IV) loading dose of 40 mg CSL312, followed by 75 mg CSL312 subcutaneously [SC] every 4 weeks [q4wk] for 12 weeks (9 patients) approximately 1 week later; · A single IV loading dose of 100 mg CSL312, followed by 200 mg CSL312 SC q4wk for 12 weeks (8 patients) approximately 1 week later; · A single IV loading dose of 300 mg CSL312, followed by 600 mg CSL312 SC q4wk for 12 weeks (7 patients) approximately 1 week later; · A single IV loading dose of placebo, followed by placebo SC q4wk for 12 weeks (8 patients) approximately 1 week later.

[0148] All 32 patients completed Treatment Period 1 and initiated treatment in Treatment Period 2. The physicians evaluated and documented the occurrence of HAE attacks based on data reported by the subjects in the electronic diary (eDiary). Safety, PK / PD parameters, and the use of on-demand HAE medications were also evaluated.

[0149] Subjects who completed the 13-week Treatment Period 1 were eligible to participate in Treatment Period 2. Subjects who continued to participate in the open-label Treatment Period 2 were administered CSL312 (200 mg or 600 mg) q4wk SC as assigned. The physicians continued to evaluate and document the occurrence of HAE attacks based on data reported by the subjects in the eDiary. Safety and PK parameters were also continuously evaluated. Treatment Period 2 was conducted in an open-label manner for all subjects.

[0150] All subjects, including those who discontinued participation, attended a follow-up visit approximately 14 weeks after the last visit of each subject during the treatment period.

[0151] Dose Selection The dose selection for the second phase was based on the safety, PK, and PD data obtained from a first-phase single ascending dose study following administration to healthy volunteers (Example 1). The primary PD assessment used for dose selection was FXIIa-mediated kallikrein activity. The inhibitory capacity of CSL312 was investigated using biomarkers of the kallikrein-kinin system. Kallikrein activity informs how CSL312 contributes to the pathophysiology of HAE. Plasma samples were activated ex vivo to mimic an HAE attack, resulting in FXII-mediated amplification of the kallikrein-kinin pathway. FXIIa cleaves prekallikrein to generate kallikrein, and its activity can be measured using a chromogenic peptide substrate. A hypothesis was established that protection from HAE attacks could be expected by consistently inhibiting FXIIa-mediated kallikrein activity to a specific % target inhibition. The exact % target FXIIa-mediated kallikrein inhibition for preventing HAE attacks was unknown. A PK / PD model was developed to quantify the relationship between CSL312 plasma concentration and FXIIa-mediated kallikrein activity in a first-phase single ascending dose study following administration to healthy volunteers. The modeled relationship showed an increase in the inhibition of FXIIa-mediated kallikrein activity with an increase in the concentration of CSL312. To provide information along the full spectrum of the curve from the relationship between the plasma concentration of CSL312 and FXIIa-mediated kallikrein activity, selected % target inhibition levels included ≥30, ≥50, and ≥90%, strengthening the evaluation of doses in this study. Simulations using the final PK / PD model showed that when administered fixed doses of 75 mg, 200 mg, and 600 mg every 4 weeks, at least 75% of patients reached ≥30, ≥50, and ≥90% % target inhibition of FXIIa-mediated kallikrein activity, respectively.

[0152] Study population To enter the acclimatization period, subjects must meet all of the following inclusion criteria: 1. Submitted written informed consent. 2. Male or female. 3. 18 years of age or older and 65 years of age or younger at the time of submission of written informed consent. 4. Clinical diagnosis of C1-INH HAE based on the following criteria: · In the case of C1-INH HAE (type 1): - Documented medical history consistent with HAE (subcutaneous or mucosal non-itchy swelling episodes without urticaria). - C1-INH antigen concentration or functional activity less than 50% of the lower limit of the reference range as recorded in the subject's medical record. - C4 antigen concentration below the lower limit of the reference range as recorded in the subject's medical record. · In the case of C1-INH HAE (type 2): - Documented medical history consistent with HAE (subcutaneous or mucosal non-itchy swelling episodes without urticaria). - C1-INH functional activity less than 50% of the lower limit of the reference range as recorded in the subject's medical record. - C4 antigen concentration below the lower limit of the reference range as recorded in the subject's medical record. 5. In the case of subjects with C1-INH HAE: Four or more HAE attacks during two consecutive months within the three months prior to screening as recorded in the subject's medical record. Note: In the case of subjects who have received prophylactic HAE therapy within the three months prior to screening, there may be a record of four or more HAE attacks during two consecutive months within the three months prior to the start of prophylactic treatment. 6. After being evaluated by a physician as being able to appropriately manage on-demand treatment of HAE attacks without assistance, on the first day of the run-in period, desire to discontinue the use of C1-INH products, androgens, or antifibrinolytics for daily prevention of HAE attacks. 7. The physician is convinced that the subject understands the nature, scope, and possible results of the study.

[0153] A subject must not enter the run-in period if they meet any of the following exclusion criteria: 1. History of clinically significant arterial or venous thrombosis, or current clinically significant thrombosis-promoting risk (including the presence of a central venous access device). 2. History of uncontrollable abnormal bleeding events due to coagulation disorders, or current clinically significant coagulation disorders or risk of clinically significant bleeding events. 3. Planned surgery during the trial with an inherent clinically significant risk of thrombotic events or bleeding. 4. Known incurable malignancy at screening. 5. For subjects who have received a clinical diagnosis of C1-INH HAE, a clinically important history of poor response to C1-INH therapy for the management of HAE. 6. Female subjects with C1-INH HAE who initiated taking or changing the dose of any hormonal contraceptive regimen or hormone replacement therapy (i.e., estrogen / progesterone-containing products) within 3 months prior to screening. 7. Participation in another interventional clinical study during either the 30 days prior to screening or the longer of the two periods: within the five half-lives of the final dose of the investigational medicinal product administered during a previous interventional study. 8. Previous treatment with monoclonal antibodies, recombinant proteins with an Fc domain, RNA silencing, or gene transfer technology. 9. Receiving any other treatment not permitted during the study at the time of screening. 10. Male or female subjects of childbearing potential who are not using, or have no intention of using, a highly effective method of contraception, or are not sexually abstinent, or are not surgically sterile, at any time during Treatment Period 1 or Treatment Period 2 and during the follow-up period. 11. Intending to become pregnant or father a child at any time during the study. 12. Mothers who are pregnant or breastfeeding. 13. Known or suspected hypersensitivity to the investigational medicinal product or an additive of the investigational medicinal product. 14. Employees of the study facility, or spouses / partners or relatives of physicians or their subordinates. 15. Other issues that, in the opinion of the physician, render the subject ineligible to participate in the study.

[0154] When the subject meets the following criteria, for the end of the acclimation period and the start of Treatment Period 1: 1. The subject participated in the acclimation period for at least 4 weeks (28 days). 2. For subjects with C1-INH HAE, confirmation of diagnosis by central laboratory testing: · For subjects with C1-INH HAE (type 1): - C1-INH antigen concentration or functional activity < 50% of the lower limit of the reference range. - C4 antigen concentration below the lower limit of the reference range. · For subjects with C1-INH HAE (type 2): - C1-INH functional activity < 50% of the lower limit of the reference range. - C4 antigen concentration below the lower limit of the reference range. 3. For subjects with C1-INH HAE: Two or more HAE attacks occurred within a continuous 4-week period during the acclimation period. 4. There were no clinically significant clinical abnormalities as evaluated by the physician for the results of the hematology, chemistry, or urine test evaluations conducted during screening. Note: Subjects with an aspartate aminotransferase and / or alanine aminotransferase above twice the upper limit of normal may be eligible to participate if there is an explanation for this test result and the result is not clinically significant.

[0155] Study Objectives The primary objective of this study is to evaluate the efficacy of CSL312 in the prevention of HAE attacks in subjects with C1-INH HAE. The primary endpoint is the time-normalized number of HAE attacks (per month) in subjects with C1-INH HAE treated with CSL312 or placebo q4wk during Treatment Period 1.

[0156] The secondary objectives of the study are: · To further evaluate the efficacy of CSL312 in subjects with C1-INH HAE. · To evaluate the PK of CSL312 in subjects with C1-INH HAE. · To evaluate the safety and tolerability of CSL312 in subjects with C1-INH HAE.

[0157] Safety: CSL312 was safe and well tolerated at all doses. There were no concerns about dose-dependent safety. The percentage of subjects who experienced at least one AE during treatment at any dose of CSL312 was similar to that of placebo. All AEs were not severe and were evaluated as mild or moderate in intensity. Subjects with C1-INH HAE did not experience SAE (serious adverse event), AEs of particular interest (anaphylaxis, thromboembolic events or bleeding events), or AEs leading to discontinuation during blinded treatment with CSL312. No deaths were reported.

[0158] Pharmacokinetics, pharmacodynamics and efficacy: All 32 randomized patients (mean age 40 years [range 20 - 65]; 56% female; 91% white; 94% HAE type 1) completed treatment period 1. Treatment with CSL312 SC every 4 weeks achieved statistical significance in reducing the HAE attack rate compared to placebo. This study also demonstrated clinically meaningful results in preventing HAE attacks for secondary endpoints.

[0159] After the loading dose and 3 SC administrations, plasma concentrations of CSL312 after day 63 reached a peak approximately 3 - 7 days after the third SC injection for all 3 doses. These data on steady state and the dose-dependent increase in the mean plasma levels of CSL312 are shown in Figure 5 (the graph of plots from top to bottom corresponds to the regimens listed from bottom to top).

[0160] Table 1 presents a summary of the plasma PK parameters after the last SC administration of CSL312 during treatment period 1 (visit day 63). After the last SC administration of CSL312 during treatment period 1 (visit day 63), the mean C maxwas in the range of 10.6 - 56.4 μg / mL. With 2.7-fold and 8-fold increases in dose, at SC doses of CSL312 between 75 mg and 200 mg, and between 75 mg and 600 mg respectively, mean C max increased approximately 1.5-fold and 5-fold. Mean AUC 0-tau was in the range of 4507 - 26,514 h*μg / mL. With 2.7-fold and 8-fold increases in dose, at SC doses of CSL312 between 75 mg and 200 mg and between 75 mg and 600 mg respectively, mean AUC 0-tau increased approximately 1.6-fold and 6-fold. Mean T 1 / 2 was in the range of approximately 16 to 18 days across doses. Overall, after the last SC administration of CSL312 in Treatment Period 1 (Day 63 of visit), CSL312 C max and AUC increased in a dose-dependent manner.

[0161]

Table 1

[0162] Figure 6 represents the mean (SD) percent of the baseline profile of FXIIa-mediated kallikrein activity at steady state due to treatment, i.e., after Day 63. 100% kallikrein activity is the baseline for this plot (pre-treatment kallikrein activity), i.e., all values plotted are values relative to the baseline for each HAE subject. This figure demonstrates a dose-dependent inhibition of FXIIa-mediated kallikrein activity (the graph of the plot from top to bottom corresponds to the regimens listed from top to bottom).

[0163] Generally, a dose-dependent inhibition of FXIIa-mediated kallikrein activity was observed after administration of CSL312. Mean FXIIa-mediated kallikrein activity was higher in the 75 mg treatment group at some sampling points compared to placebo. This may be due to the large variability in the results. Near-complete inhibition of FXIIa-mediated kallikrein activity was observed at the peak concentration of CSL312 after SC administration of the 600 mg dose.

[0164] Figure 7 represents the simulated and observed exposure (CSL312 concentration in blood) - response (FXIIa-mediated kallikrein activity) relationship based on data from healthy and HAE subjects. At CSL312 plasma concentrations above 50 μg / mL, FXIIa-mediated kallikrein activity is completely inhibited.

[0165] The mean HAE attack rates by dose are shown in Figure 8. From these figures, especially Figure 8, it can be seen that there is no clinically significant difference among the three doses used in the second phase.

[0166] The primary efficacy evaluation item in the second-phase trial was the time-normalized number of HAE attacks. Treatment with CSL312 75 mg, 200 mg, or 600 mg resulted in a clinically relevant decrease in the time-normalized number of HAE attacks compared to placebo (Table 2). The mean (SD) time-normalized number of HAE attacks was 4.24 (1.801) in the placebo group, 0.05 (0.127) in the CSL312 200 mg treatment group, and 0.40 (0.514) in the 600 mg CSL312 treatment group. The mean decrease in the time-normalized number of HAE attacks was 98.94% with CSL312 200 mg and 90.50% with CSL312 600 mg compared to placebo. Treatment with 75 mg CSL312 was also evaluated, but no formal statistical comparison was made between CSL312 75 mg and placebo. However, the summary statistics demonstrate the efficacy of treatment at this dose. The mean (SD) time-normalized number of HAE attacks was 0.48 (1.057). The mean decrease in the time-normalized number of HAE attacks was 88.68% with CSL312 75 mg compared to placebo.

[0167] The secondary evaluation items were responder population, subjects without HAE attacks, HAE attacks, HAE attacks treated with on-demand HAE medications, and CSL312 PK in plasma (see C max , T max , T 1 / 2 , AUC, see Table 1).

[0168]

Table 2

[0169] Analysis of the percentage of habituation periods of subjects in which the time-normalized number of HAE attacks (i.e., responders) decreased by 50% or more, 70% or more, or 90% or more using CSL312 was performed (Table 3). The percentage of responders was higher during treatment with CSL312 compared to treatment with placebo. · The number and percentage of responders in whom HAE attacks decreased by 50% or more were 0 in the placebo group, 9 / 9 (100.0%) in the 75 mg group, 8 / 8 (100.0%) in the 200 mg group, and 6 / 7 (85.7%) in the 600 mg group. · The number and percentage of responders in whom HAE attacks decreased by 70% or more were 0 in the placebo group, 8 / 9 (88.9%) in the 75 mg group, 8 / 8 (100.0%) in the 200 mg group, and 6 / 7 (85.7%) in the 600 mg group. · The number and percentage of responders in whom HAE attacks decreased by 90% or more were 0 in the placebo group, 8 / 9 (88.9%) in the 75 mg group, 8 / 8 (100.0%) in the 200 mg group, and 4 / 7 (57.1%) in the 600 mg group.

[0170] Analysis of the percentage of responders in whom the time-normalized number of HAE attacks decreased by 30% or more with CSL312 over the habituation period was also performed, but it was not part of the topline results and is therefore not shown here. The results of this responder analysis were consistent with the above results.

[0171]

Table 3

[0172] The mean reduction rate of the time-normalized number of HAE attacks during treatment with CSL312 compared to placebo was 88.68% at 75 mg, 98.94% at 200 mg, and 90.50% at 600 mg. In contrast, there was no substantial decrease in the time-normalized number of HAE attacks during treatment with placebo when compared to the run-in period (within-group comparison). The mean decrease in the time-normalized number of HAE attacks with placebo was 9.76% compared to the run-in period.

[0173] Of the 24 subjects randomized to treatment with any dose of CSL312, 15 subjects had no HAE attacks during the efficacy evaluation period. Of these 15 subjects with no HAE attacks, 5 / 9 subjects (55.6% [95% CI: 26.67, 81.12]) had no HAE attacks with 75 mg of CSL312, 7 / 8 subjects (87.5% [95% CI: 52.91, 97.76]) had no HAE attacks with 200 mg of CSL312, and 3 / 7 subjects (42.9% [95% CI: 15.82, 74.95]) had no HAE attacks with 600 mg of CSL312. None of the subjects treated with placebo had no HAE attacks during the efficacy evaluation period.

[0174] Subjects treated with CSL312 who had no HAE attacks during treatment period 1 had a period without HAE attacks between 1.7 and 5.1 weeks with 75 mg (4 subjects) and between 1.3 and 9.9 weeks with 600 mg (4 subjects) until the first attack. The only subject who had no HAE attacks with 200 mg had two HAE attacks along with a 2.3-week period without HAE attacks.

[0175] In conclusion, blinded-treatment CSL312 was safe and well-tolerated when administered as three SC injections every 4 weeks up to a maximum of 600 mg after a single IV injection in patients with C1-INH HAE.

[0176] Subjects with C1-INH HAE who participated in the study were randomized to receive placebo or blinded treatment with CSL312 75 mg, 200 mg, or 600 mg SC q4wk. The results demonstrate that CSL312 is safe and effective for the prevention of HAE attacks in this study population.

[0177] Treatment with CSL312 75 mg, 200 mg, or 600 mg SC q4wk resulted in a clinically relevant decrease in the number of time-normalized HAE attacks compared to placebo. Of the 24 subjects randomized to treatment with any dose of CSL312, 15 subjects had no HAE attacks during the efficacy evaluation period, including 5 / 9 (55.6%) of the subjects treated with 75 mg of CSL312, 7 / 8 (87.5%) of the subjects treated with 200 mg of CSL312, and 3 / 7 (42.9%) of the subjects treated with 600 mg of CSL312. None of the subjects treated with placebo had no HAE attacks during the same evaluation period.

[0178] The results demonstrate that CSL312 exhibits dose-dependent PK with a T of ~17 days after SC administration in treatment period 1. 1 / 2 After SC administration of CSL312 in treatment period 1, a concentration-dependent inhibition of FXIIa-mediated kallikrein activity was observed.

[0179] This new method of preventing HAE attacks by normalizing kallikrein activity through partial inhibition of FXIIa activity in HAE patients has been demonstrated to be highly efficient compared to state-of-the-art methods of preventing HAE attacks (based on increasing C1-INH protein levels to normal or complete maximal inhibition of kallikrein or specific bradykinin receptor 2 blockade).

[0180] Phase 3 pilot study design As is evident from the sudden swelling, HAE patients are more vulnerable to contact activation than healthy subjects. To evaluate the clinical efficacy, pharmacokinetics, and safety of prophylactic CSL312 as prophylaxis for HAE attacks, a follow-up study was conducted to evaluate and confirm the efficacy of CSL312 to determine which dosing regimen to use. Figure 9 depicts a virtual scenario of the predicted HAE attack rate for administering CSL312 at different SC doses on a monthly basis, including a partial SC loading dose (Figure 9A represents the treatment effect of the selected dosing regimen versus placebo; Figure 9B highlights the difference in attack rates of the selected dosing regimen; the bars of the plots from left to right for each period correspond from top to bottom to the regimens listed). For the 6-month treatment period, there was no significant difference in efficacy at the selected monthly doses.

[0181] CSL312 plasma concentrations of less than approximately 20 μg / mL were associated with partial kallikrein activity inhibition, revealing a clinically meaningful prophylactic effect, thereby supporting the low-dose hypothesis. Thus, by continuously maintaining CSL312 drug levels above approximately 5 or 10 μg / mL, overactivation of kallikrein in HAE patients is prevented, and thus, HAE attacks are prevented.

Example 3

[0182] Study Overview This is a multicenter, double-blind, randomized, placebo-controlled, parallel-group, phase 3 trial to investigate the clinical efficacy and safety of subcutaneously administered CSL312 as prophylaxis for HAE attacks in subjects with C1-INH HAE type 1 or type 2.

[0183] Potential Risks In the CSL312 development program, the following risks have not been observed, but are potential risks based on the drug class and / or mechanism of action.

[0184] Thrombotic and bleeding events: Blockade of FXIIa with CSL312 may give rise to potential risks of bleeding or thrombotic events (TEEs) due to changes in hemostasis, unstable clot formation, or impaired clot lysis. Furthermore, an increase in aPTT is expected to be observed dose-dependently due to the pharmacological action of CSL312. Clinical experience with CSL312 in healthy volunteers in Phase 1 trials and in HAE patients in ongoing Phase 2 trials has shown no effect on either prothrombin time or abnormal bleeding. This is consistent with the observation that patients with congenital deficiency of FXII do not exhibit a bleeding phenotype despite prolonged aPTT. Furthermore, non-clinical studies in mice and rabbits have shown no impairment of hemostasis after inhibition of FXIIa. During the study, subjects are closely monitored for signs of bleeding or thrombosis.

[0185] Severe hypersensitivity / anaphylactic-type reactions: Administration of therapeutic proteins, including monoclonal antibodies such as CSL312, is potentially associated with the risk of hypersensitivity and anaphylactic reactions, some of which can be severe and life-threatening. When administering CSL312 at the study site, appropriate precautions are taken and potential severe hypersensitivity and anaphylactic reactions are closely monitored. Administration of CSL312 is performed under medical supervision at the site with immediate access to emergency equipment and medications for the treatment of severe hypersensitivity side effects, including anaphylaxis, at least for the first 2 - 3 doses.

[0186] Immunogenicity (anti-drug antibodies): All protein therapeutics are potentially immunogenic. Since CSL312 is a protein, it may cause the generation of neutralizing and non-neutralizing anti-drug antibodies. Subjects are monitored for the development of immunogenicity throughout the study.

[0187] No serious adverse events (SAEs) were reported in either the Phase 1 trial (Example 1) or TP1 of the Phase 2 trial (Example 2). Furthermore, no particularly notable adverse events of special interest (AESIs) were reported in the Phase 2 trial. There were no dose-dependent safety concerns in either study.

[0188] Considering the potential benefits of CSL312 in COVID-19 patients and the favorable safety data from the Phase 1 trial and ongoing Phase 2 trial, the associated benefit-risk assessment is considered acceptable.

[0189] Primary Objectives and Evaluation Items of the Study The primary objective of this study is to evaluate the efficacy of subcutaneous administration of CSL312 as a prophylaxis to prevent HAE attacks in subjects with HAE. The number of time-normalized HAE attacks during the treatment period from Day 1 to Day 182 is the primary evaluation item. This is evaluated by the number of time-normalized HAE attacks (monthly and annual) in subjects treated once a month with either CSL312 (active group) or placebo (placebo group) during the period from Day 1 to Day 182 (6 months).

[0190] Secondary Objectives and Evaluation Items of the Study The secondary objectives of the study are: 1. To characterize the clinical efficacy of subcutaneous CSL312 in the prophylactic treatment of HAE 2. To evaluate the safety of subcutaneous CSL312 in the prophylactic treatment of HAE.

[0191] [Table 4]

[0192] Examination Objectives and Evaluation Items The examination objective of this study is to further evaluate the efficacy, pharmacokinetics (PK) / pharmacodynamics (PD), and quality of life (QoL) associated with the use of CSL312 in subjects with HAE.

[0193] The examination evaluation items include the following: 1. The time from after Day 1 until the first attack after Day 15. 2. CSL312 concentration at the scheduled time points. 3. FXII concentration and FXIIa-mediated kallikrein activity at the scheduled time points. 4. The subjects reported the outcome measurement values: · Angioedema Quality of Life (AE-QoL) · EuroQoL Group 5 Dimensions 5 Levels (EQ-5D-5L) · Work Productivity and Activity Impairment: General Health (WPAI:GH). 5. Integrated Global Assessment of Response to Physician Treatment (IGART).

[0194] Study Design This is a multi-center, double-blind, randomized, placebo-controlled, parallel-group, Phase 3 trial to investigate the efficacy and safety of a single administration of SC CSL312 administered once monthly as a prophylactic measure to prevent HAE attacks in subjects with type 1 and type 2 C1-INH HAE, including adolescents (aged 12 - 17 years) and adults. As shown in Figure 11, this study consists of a screening period (up to 1 month), a run-in period (up to 2 months) for confirmation of disease activity and determination of the baseline HAE attack rate of the subjects, a 1-treatment period (6 months) for confirmation of the safety and efficacy of the 200 mg CSL312 dose, and either a 2-month follow-up period (i.e., 3 months after the last administration of the investigational drug) or participation in an open-label Phase 3b trial.

[0195] Screening: Following informed consent, subjects undergo a screening period of up to 1 month to determine their eligibility for enrollment in the study. Screened subjects who meet all inclusion criteria and none of the exclusion criteria enter the run-in period.

[0196] Run-in period: After screening, eligible subjects enter a run-in period that lasts at least 1 month and up to 2 months to confirm the status of underlying diseases and evaluate their eligibility for participation in the treatment period. The first day of the run-in period may occur on the same day as screening.

[0197] The subject must complete at least one month of the acclimation period. Additionally, for eligibility to enter the treatment period, the subject must experience at least two HAE attacks during the acclimation period. A subject who experiences at least two attacks during the first required month of the acclimation period can enter the treatment period. A subject who does not experience an HAE attack during the first month of the acclimation period remains in the acclimation period for an additional month, during which time they must experience at least two attacks to be eligible to enter the treatment period and randomization.

[0198] Subjects are not permitted to use routine prophylaxis to prevent HAE attacks during the acclimation period; however, if the drug has been shown to be effective previously, the subject can use on-demand HAE therapy to treat HAE attacks.

[0199] Subjects who do not meet the minimum HAE attack rate during the acclimation period or are determined ineligible for screening assessment are considered acclimation failures and must not be rescreened for study participation.

[0200] Treatment period: Subjects who meet the eligibility criteria enter the treatment period after the acclimation period.

[0201] Eligible subjects are randomized 3:2 to either the CSL312 active group or the placebo group. The treatment period is six months. Randomization takes into account age (under 17 years, over 17 years), and in the case of adults, the baseline attack rate observed during the acclimation period (less than 3 attacks per month, and 3 or more attacks per month).

[0202] Follow-up period / Open-label Phase 3b trial entry: Subjects who have successfully completed the current Phase 3 trial have the option to roll over to an open-label Phase 3b trial (OLE). Subjects who choose not to participate in the OLE study are required to complete a follow-up visit (Day 242, which is approximately 3 months after the last dose of the investigational drug). For subjects who choose to participate in the OLE study, the assessments collected on Day 182 are used to meet the applicable assessments on Day 1 of the OLE study.

[0203] Dose and dosing regimen The investigational drug in this study is 200 mg of CSL312 and placebo.

[0204] Subjects randomized to the active group receive CSL312 SC once monthly for 6 months. The first dose of CSL312 is a loading dose of 400 mg administered subcutaneously on the same day as two separate injections at the study site (i.e., Month 1). Subsequent doses of CSL312 are 200 mg administered SC once monthly for 5 consecutive months (i.e., Months 2 to 6).

[0205] Subjects randomized to the placebo group receive an equal volume of placebo once monthly for 6 months. The first dose of placebo in the placebo group is an equal volume of placebo administered SC as two separate injections (i.e., Month 1). Thereafter, subjects receive an equal volume of placebo SC once monthly for 5 consecutive months (i.e., Months 2 to 6).

[0206] The proposed 200 mg dose was selected based on the efficacy and safety observed in the Phase 2 trial TP1 (Example 2), CSL312 PK, inhibition of FXIIa-mediated kallikrein activity, and exposure-response (E-R) modeling.

[0207] A 200 mg dose administered once every 28 days (±3 days) was highly effective across various efficacy endpoints and had a favorable safety profile. Furthermore, the 200 mg dose resulted in approximately 50% inhibition of FXIIa-mediated kallikrein activity.

[0208] To support the selection of the Phase 3 dose, an E-R model was used to simulate the HAE attack rates across a wide range of CSL312 concentrations expected after different dosing regimens. Based on the E-R model, the estimated mean daily concentrations to achieve a 50, 75, and 90% reduction in relative attack risk at baseline attack rates were 1.4, 3.3, and 7.8 μg / mL, respectively. The predicted median steady-state minimum mean daily CSL312 concentration after a 200 mg SC dose administered once monthly corresponded to a 90% relative attack risk reduction of the baseline attack rate in 73% of patients.

[0209] Furthermore, the E-R model showed that the cumulative effect of CSL312 concentration was demonstrated by a decrease in the expected number of HAE attacks per month. A regimen of 200 mg SC once monthly is predicted to reduce the mean attack rate by approximately 91% compared to placebo. Increasing the dose beyond 200 mg is not predicted to result in a further substantial decrease in HAE attacks.

[0210] Finally, exposure at a monthly 200 mg SC dose is not expected to cause an aPTT prolongation in the majority of subjects in the Phase 3 trial.

[0211] Based on all factors considered in dose selection, 200 mg of CSL312 SC administered once monthly is expected to achieve a clinically meaningful treatment effect and an optimal benefit / risk ratio in subjects with C1-INH HAE Type 1 and Type 2.

[0212] Eligibility Criteria The study population is selected based on the inclusion and exclusion criteria described in the following sections. Each subject must meet all inclusion criteria and not meet any exclusion criteria of this study. Prior to a subject's inclusion in the study, the subject's eligibility should be reviewed and documented by an appropriate medically qualified member of the physician's study team.

[0213] Inclusion Criteria To be enrolled and randomized, subjects must meet all of the following inclusion criteria: 1. Persons who can provide written informed consent and have the willingness and ability to comply with all protocol requirements, and / or parents or legally acceptable representatives of subjects who can provide written informed consent / assent as appropriate. 2. Male or female. 3. 12 years of age or older at the time of providing written informed consent or consent for minors. 4. Persons diagnosed with clinically confirmed C1-INH HAE: a. Documented medical history consistent with HAE (non-itchy subcutaneous or mucosal swelling episodes without urticaria), and b. C1-INH antigen and / or functional activity of less than 50% of normal documented in the subject's medical record, and c. C4 antigen concentration below the lower limit of the reference range documented in the subject's medical record. 5. Experience of more than 3 HAE attacks during the 3 months prior to screening, documented in the subject's medical record.

[0214] Note: For subjects receiving prophylactic HAE therapy during the 3 months prior to screening, there may be a requirement for documentation of more than 3 HAE attacks occurring consecutively for more than 3 months prior to initiation of prophylactic treatment.

[0215] Exclusion Criteria Subjects must not be enrolled in the study if they meet any of the following exclusion criteria: 1. Concurrent diagnosis of another form of angioedema, such as idiopathic or acquired angioedema, urticaria, or recurrent angioedema associated with HAE type 3. 2. Major planned surgery or medical procedure during the clinical study. 3. For adult subjects: Use of C1-INH products, androgens, antifibrinolytics, or other small molecule drugs for routine prophylaxis of HAE attacks within 2 weeks prior to the run-in period. 4. For subjects aged 12 - 17 years: Use of long-term preventive therapy for HAE before screening. 5. Use of a monoclonal antibody such as lanadelumab (Takhzyro®) within 3 months before the ramp-up period. 6. Use of estrogen-containing drugs with systemic absorption (e.g., oral contraceptives or hormone replacement therapy), angiotensin-converting enzyme (ACE) inhibitors within 4 weeks before the ramp-up period, or receipt of a treatment not currently permitted during the study period. 7. Participation in another interventional clinical study during the longer of 30 days before screening or the period of 5 half-lives of the final dose of an investigational drug administered during a previous interventional study. 8. Known or suspected hypersensitivity to monoclonal antibody therapy, or hypersensitivity to the investigational drug or any excipient of the investigational drug. 9. In the judgment of the physician or CSL, conditions that may compromise the safety or compliance of the control, impede the success of the study, e.g., clinically significant bleeding due to coagulation disorders, thrombotic disorders, serious illness or major co-existing diseases, interfere with the interpretation of the results, or otherwise render the subject unsuitable for participation in the study. 10. CSL312 previously administered in another interventional clinical study. 11. Pregnancy at any time during the study or intention to father a child. 12. Women of childbearing potential, or fertile and sexually active male subjects who are not using and have no intention of using an acceptable method of contraception to avoid pregnancy during the study and for 30 days after the last dose of the investigational drug.

[0216] Note: All female subjects are assumed to be potentially childbearing, except for: - Subjects over 60 years of age. - Subjects aged 45 - 60 years (inclusive) who have been amenorrheic for 1 year or more and for whom documentation exists of follicle-stimulating hormone levels exceeding 30 IU / L. If follicle-stimulating hormone values are not available before randomization, a urine pregnancy test is required. - Subjects with surgical infertility for at least 3 months before providing informed consent.

[0217] Note: All male subjects, except those with surgical infertility for at least 3 months before providing informed consent, are considered fertile. 13. Pregnancy, lactation, or no intention to stop lactation. 14. Involvement in the planning and / or implementation of the study.

[0218] Criteria for entry into the treatment period Subjects are eligible to enter the treatment period after completing the acclimation period if they meet all of the following criteria: 1. Participated in the acclimation period for at least 1 month. 2. Experienced at least an average of 1 HAE attack per month during the acclimation period (e.g., experienced at least 2 HAE attacks in total). 3. No clinically significant test abnormalities evaluated by the physician in the results of hematology, chemistry, or urine test evaluations. 4. The functional activity and antigen of C1-INH, and the concentration levels of C4 antigen have been verified before randomization.

[0219] Note: Subjects with aspartate aminotransferase and / or alanine aminotransferase levels more than twice the upper normal limit may be eligible to participate if there is an explanation for this test result and the result is not clinically significant.

[0220] Study evaluation Details of the time frames for all evaluations are shown in Table 5.

[0221]

Table 5

[0222] Demographic and safety evaluations During this study, demographic and safety evaluations of the subjects (including some laboratory evaluations) are conducted.

[0223] Pharmacokinetic and pharmacodynamic evaluations Plasma samples are collected during the study for the evaluation of CSL312 concentration (pharmacokinetic evaluation) and FXII concentration as well as FXIIa-mediated kallikrein activity (pharmacodynamic evaluation).

[0224] Efficacy evaluation Hereditary angioedema attacks confirmed by a physician or a designee are used for the efficacy analysis and recorded in the electronic case report form (eCRF). All HAE symptoms reported by the subjects are listed for each subject. The physician reviews the symptoms reported by the subject. The physician checks whether the symptoms represent an HAE attack and, if not an HAE attack, records the symptoms as an AE in the eCRF. Prodromal symptoms alone or the use of on-demand medications should not be considered an attack.

[0225] At each study visit and telephone contact during the run-in period, the physician or designee reviews the subject's electronic diary (eDiary) entries. The physician may ask clarifying questions to assist in the confirmation of HAE attacks, taking into account all available medical information.

[0226] The following information is documented in the subject's eDiary: · Date and time of onset of HAE symptoms · Date and time when the HAE symptoms resolved (i.e., the subject no longer experienced the symptoms of the attack) · Location of HAE symptoms · Confirmation that the symptoms are interfering with the subject's daily life · If on-demand medications were used to treat HAE symptoms: - Name of the medication - Date and time of administration · Confirmation of medical assistance received for HAE symptoms

[0227] The physician checks for additional details regarding the subject related to the symptoms: · Location of HAE symptoms · Start / end date and time of symptoms · Dosage of on-demand medication used · Route of administration of on-demand medication used · Self-administered on-demand medication? (Yes / No) · Administration of on-demand medication at the research facility, at home, or in the emergency treatment room · Types of medical support or intervention provided by medical professionals during HAE symptoms, including hospitalization or visits to the emergency department · Severity of attacks (based on the degree of interference with daily life and whether the use of on-demand medication and / or medical support was required)

[0228] Efficacy analysis The primary evaluation item, "the number of time-normalized HAE attacks per month during treatment from day 1 to day 182," is calculated for each subject as follows: [Number of HAE attacks / Length of the treatment period for the subject] * 30.4375 Here, the length of the treatment period for the subject is calculated as follows: [Date of the 182nd day of the research visit or the date of study termination [whichever comes first] - Date of the 1st day of the research visit + 1].

[0229] To test the difference in the primary efficacy evaluation item between CSL312 and placebo, a comparison of the number of time-normalized HAE attacks during the 6-month active group and the 6-month placebo arm period is performed using the two-sided Wilcoxon test (alpha = 5%).

[0230] The time-normalized number of HAE attacks per month and per year is descriptively summarized by the median and mean with the corresponding 95% confidence interval (CI) for each treatment for the 6-month active group and the 6-month placebo arm period.

[0231] For the sensitivity analysis, a Poisson regression model is used to compare the time-normalized HAE attack counts at 6 months for the active group and at 6 months for the placebo group. The time-normalized HAE attack count during the run-in period and age as covariates, as well as the logarithm of the length of treatment of the subject as an offset variable, are included. The model accounts for overdispersion.

[0232] The secondary efficacy evaluation item of the percentage decrease in the time-normalized HAE attack count is calculated within the subject as follows: 100 * [1 - (time-normalized HAE attack count per month during treatment / time-normalized HAE attack count per month during run-in)] For the entire 6 months of the active group and for the 6-month placebo group period, it is tested by a two-sided Wilcoxon test using the individual percentage decreases between the treatment groups.

[0233] The number and percentage of responders and non-responders are presented with the corresponding 95% CI. If the percentage decrease in HAE attacks is 50% or more, the subject is classified as a responder. Additionally, the number and percentage of subjects with percentage decreases of 70% or more and 90% or more are presented with the corresponding 95% CI.

[0234] The number and percentage of subjects with a 100% percentage decrease, i.e., subjects who have not experienced HAE attacks and have no attacks, are presented and summarized with the corresponding 95% CI for the 6-month active group period and the 6-month placebo group period, and a Fisher's test is performed to evaluate the difference between the treatments.

[0235] The percentage decrease in the time-normalized HAE attack count during the 6 months of the active group is also: 100 * [1 - (median time-normalized HAE attack count per month during the 6 months of the active group / median time-normalized HAE attack count per month during the 6-month placebo group period)] Calculated as the percentage decrease compared to 6 months in the placebo group (between subjects), and explored via a two-sided Wilcoxon test using the individual percentage decreases between treatment groups.

[0236] The secondary efficacy assessment item of the time-normalized number of HAE attacks per month requiring on-demand treatment is calculated as follows: 100 * [1 - (number of HAE attacks requiring on-demand treatment during treatment / number of treatment days of the subject)] * 30.4375

[0237] HAE attacks requiring on-demand treatment are defined as attacks where the date of administration of on-demand treatment is between the start date (inclusive) and end date (inclusive) of the HAE attack. The differences between the 6-month active group and the 6-month placebo group period are explored via a two-sided Wilcoxon test.

[0238] For the analysis of the time-normalized number of moderate and / or severe HAE attacks, an analog calculation is performed using all HAE attacks classified as moderate or severe.

[0239] Safety analysis Adverse events starting from the start time after the first administration of the investigational drug are considered treatment-emergent adverse events (TEAEs). Adverse events that are not at the start time or are partial are also considered TEAEs according to the worst-case principle, unless partial data clearly show that the AE started before the first administration time. Treatment-emergent AEs occurring until the follow-up visit are summarized. Only TEAEs are included in the analysis, but all AEs are listed.

[0240] Pharmacokinetic analysis PK analysis is performed using the PK population. Plasma concentrations of CSL312 are listed for each individual subject and summarized for nominal time points. Individual mean CSL312 plasma concentration vs. time are plotted on linear and semi-logarithmic scales. Plasma CSL312 concentrations are summarized by descriptive statistics: mean, SD, percent coefficient of variation, median, minimum, maximum, and the 1st and 3rd quartiles of continuous variables, geometric mean, and their respective 90% CIs.

[0241] Pharmacodynamic analysis Pharmacodynamic data are summarized using the PD population. FXIIa-mediated kallikrein activity and FXII concentration are evaluated for the pharmacodynamics of CSL312 as described above. FXIIa-mediated kallikrein activity and FXII concentration are listed for each individual subject and summarized for nominal time points and treatments.

Claims

1. A pharmaceutical composition comprising an anti-FXII antibody for use in a method of treating or preventing hereditary angioedema (HAE) in a subject, wherein the antibody is (i) a CDRH1 comprising the sequence set forth in SEQ ID NO: 1; a CDRH2 comprising the sequence set forth in SEQ ID NO: 2; and a CDRH3 comprising the sequence set forth in SEQ ID NO: 3 of V H ; and (ii)a V comprising CDRL1 comprising the sequence set forth in SEQ ID NO: 4; CDRL2 comprising the sequence set forth in SEQ ID NO: 5; and CDRL3 comprising the sequence set forth in SEQ ID NO: 6 L comprising administered subcutaneously to the subject at a dose of 70 mg to 700 mg of the antibody once every 1 to 3 months.

2. The anti-FXII antibody V contains the sequence set forth in SEQ ID NO: 7 H and the sequence set forth in SEQ ID NO: 8 V containing columns L The pharmaceutical composition according to claim 1, comprising

3. The pharmaceutical composition according to claim 1 or 2, wherein the anti-FXII antibody is an IgG4 antibody.

4. The pharmaceutical composition according to claim 3, wherein the anti-FXII antibody comprises a mutation to proline at position 228 in the hinge region according to the EU numbering system.

5. The pharmaceutical composition according to any one of claims 1 to 4, wherein the anti-FXII antibody comprises the heavy chain sequence set forth in SEQ ID NO: 9 and the light chain sequence set forth in SEQ ID NO:

10.

6. The pharmaceutical composition according to claim 5, wherein the heavy chain of the anti-FXII antibody comprises an additional lysine linked to the last amino acid of SEQ ID NO:

9.

7. The pharmaceutical composition according to any one of claims 1 to 6, wherein the anti-FXII antibody is administered in an amount that maintains an antibody concentration of at least 5 μg / ml between two successive antibody administrations.

8. The pharmaceutical composition according to any one of claims 1 to 7, which is administered once every 1 to 2 months.

9. The pharmaceutical composition according to any one of claims 1 to 8, wherein the antibody is administered at a dose of 150 mg to 250 mg.

10. The pharmaceutical composition according to claim 9, wherein the antibody is administered at a dose of 170 mg to 220 mg.

11. The pharmaceutical composition according to claim 10, wherein the antibody is administered at a dose of 200 mg.

12. The pharmaceutical composition according to any one of claims 1 to 8, wherein the antibody is administered at a dose of 50 mg to 150 mg.

13. The pharmaceutical composition according to claim 12, wherein the antibody is administered at a dose of 70 mg to 130 mg.

14. The pharmaceutical composition according to claim 13, wherein the antibody is administered at a dose of 100 mg.

15. The pharmaceutical composition according to any one of claims 1 to 14, which is administered every 1 to 2 months.

16. The pharmaceutical composition according to claim 15, which is administered once a month.

17. The pharmaceutical composition according to any one of claims 1 to 16, wherein the subject is a human patient having HAE, suspected of having HAE, or at risk of HAE.

18. The pharmaceutical composition according to any one of claims 1 to 17, wherein the method comprises administration of a loading dose of an anti-FXII antibody.

19. The pharmaceutical composition according to claim 18, wherein the administration of the loading dose is intravenous administration of an anti-FXII antibody at a dose between 30 mg and 400 mg.

20. The pharmaceutical composition according to claim 19, wherein the administration of the loading dose is intravenous administration of an anti-FXII antibody at a dose between 100 and 300 mg.

21. The pharmaceutical composition according to claim 20, wherein the administration of the loading dose is intravenous administration of an anti-FXII antibody at a dose of 200 mg.

22. The pharmaceutical composition according to claim 18, wherein the administration of the loading dose is subcutaneous administration of an anti-FXII antibody at a dose between 70 mg and 700 mg.

23. The pharmaceutical composition according to claim 22, wherein the administration of the loading dose is subcutaneous administration of an anti-FXII antibody at a dose between 200 and 500 mg.

24. The pharmaceutical composition according to claim 23, wherein the administration of the loading dose is subcutaneous administration of an anti-FXII antibody at a dose of 400 mg.

25. The pharmaceutical composition according to any one of claims 1 to 18 and 22 to 24, which is administered only subcutaneously to a subject.

26. The pharmaceutical composition according to any one of claims 1 to 25, wherein the administration of the anti-FXII antibody reduces the risk of HAE attacks by more than 85%.

27. The pharmaceutical composition according to claim 26, wherein the administration of the anti-FXII antibody reduces the risk of HAE attacks by more than 90%.

28. The pharmaceutical composition according to claim 27, wherein the administration of the anti-FXII antibody reduces the risk of HAE attacks by more than 95%.

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