Dosage regimens for treating or preventing C5-associated disease

Abstract

The present invention provides dosing regimens for anti-C5 antibodies, such as pozelimab, for treating or preventing C5-related diseases, such as paroxysmal nocturnal hemoglobinuria or CHAPLE disease.

Description

[Technical Field]

[0001] This application claims the benefit of U.S. Provisional Patent Application No. 62 / 926,213, filed October 25, 2019; U.S. Provisional Patent Application No. 62 / 992,330, filed March 20, 2020; and U.S. Provisional Patent Application No. 63 / 019,533, filed May 4, 2020; each of which is incorporated by reference herein in its entirety for all purposes.

[0002] The Sequence Listing of the present application is submitted electronically as an ASCII sequence listing with the file name "seqlist10673P2", created on March 20, 2020, and 165 Kb in size. This submitted Sequence Listing is a part of the present specification and is incorporated herein by reference in its entirety.

[0003] The present invention relates to methods of administering antagonist anti-C5 antibodies to treat or prevent C5-associated disorders. [Background technology]

[0004] Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, chronic, progressive, and fatal multisystem disorder. It is typically characterized by uncontrolled complement activation, leading to intravascular hemolysis of red blood cells (RBCs) (Non-Patent Document 1) and an increased risk of thrombosis of white blood cells (WBCs) and platelets. The estimated incidence of PNH is 1.3 cases per million people per year, and the estimated prevalence is 15.9 cases per million people per year (Non-Patent Document 2).

[0005] Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired, fatal blood disorder. Defective red blood cells in PNH are highly susceptible to premature destruction by a specific part of the person's own immune system called the complement system. The disease is characterized by destruction of red blood cells (hemolytic anemia), blood clots (thrombi), and bone marrow dysfunction.

[0006] CD55-deficient protein-losing enteropathy (CD55-deficient PLE), also known as complement hyperactivation, angiopathic thrombosis, or protein-losing enteropathy (CHAPLE disease), is a rare disease that can be treated with C5 blockade (Non-Patent Document 3; Non-Patent Document 4). CD55-deficient PLE / CHAPLE disease is caused by biallelic loss-of-function mutations in the CD55 gene. Lack of CD55 leads to hyperactivation of the complement system, resulting in the production of various complement products, including anaphylatoxins and the membrane attack complex. In CD55-deficient PLE, isolated germline loss of CD55 expression in any tissue manifests in the GI tract, similar to primary intestinal lymphangiectasia, and causes PLE. The majority of patients suffer from early-onset GI symptoms including bloody diarrhea, vomiting, and abdominal pain, occasionally developing partial or complete bowel obstruction and intestinal failure. [Prior art documents] [Non-patent literature]

[0007] [Non-Patent Document 1] Sahin et al. Pesg PNH diagnosis, follow-up and treatment guidelines. Am J Blood Res 2016;6(2):19-27 [Non-patent document 2] Preis & Lowrey, Laboratory tests for paroxysmal nocturnal hemoglobinuria. Am J Hematol 2014;89(3):339~41 [Non-patent document 3] Kurolap et al., Loss of CD55 in Eculizumab-Responsive Protein-Losing Enteropathy. N Engl J Med., 377(1):87-89 (2017) [Non-patent document 4] Ozen et al., CD55 Deficiency and Protein-Losing Enteropathy. N Engl J Med., 377(15):1499~500 (2017) Summary of the Invention [Problem to be solved by the invention]

[0008] Eculizumab, an antibody against C5, blocks the formation of MAC-C5b-9 and thus protects PNH RBCs from complement-mediated intravascular hemolysis. However, not all patients receive optimal therapeutic benefit. For example, 25% of patients still require repeated transfusions, albeit less frequently. Up to 20% of patients on eculizumab therapy require a significant increase in dose or dosing frequency due to breakthrough hemolysis secondary to incomplete C5 inhibition (Nakayama et al., Eculizumab Dosing Intervals Longer than 17 Days May Be Associated with Greater Risk of Breakthrough Hemolysis in Patients with Paroxysmal Nocturnal Hemoglobinuria. Biol Pharm Bull 2016;39(2):285-8) (Hill et al., Thrombosis in paroxysmal nocturnal hemoglobinuria. Blood 2013;121(25):4985-96) (Peffault de Latour et al., Assessing complement blockade in patients with paroxysmal nocturnal hemoglobinuria receiving eculizumab. Blood 2015;125(5):775-83). Additionally, eculizumab administration via intravenous (IV) infusion every two weeks (Q2W) has been described as a burden for patients. Ravulizumab is also an anti-C5 antibody used to treat diseases such as PNH. However, some patients using ravulizumab still experience some degree of hemolytic breakthrough. Furthermore, IV-administered ravulizumab does not offer the significant convenience and burden reduction of subcutaneous (SC) self-administration (originally approved by the US FDA). The SC ravulizumab dosing regimen requires the infusion of 7 ml in two separate injections over 10 minutes. Alexion: Investor Presentation (Slide Presentation), March 20, 2019. [Means for solving the problem]

[0009] The present invention provides a method of administering an antagonist antigen binding protein that specifically binds C5 (e.g., REGN3918) or a pharmaceutical formulation thereof to a subject suffering from a C5-related disease (e.g., PNH, aHUS, MG or CHAPLE), the method comprising the steps of intravenously introducing into the subject's body one or more times about 30 mg / kg of the antagonist antigen binding protein that specifically binds C5; and, optionally, subcutaneously introducing into the subject's body one or more times the antagonist antigen binding protein that specifically binds C5 or a pharmaceutical formulation thereof.

[0010] The present invention also provides a dosing regimen for administering to a subject (e.g., a human) an antagonist antigen binding protein that specifically binds to C5 (e.g., REGN3918), comprising administering to the subject (i) one or more doses of about 30 mg / kg of anti-C5 antigen binding protein intravenously (IV), followed by (ii) one or more doses of about 800 mg of anti-C5 antigen binding protein subcutaneously (SC) (e.g., given weekly starting about 7 days after the first dose); or Also provided is a dosing regimen comprising: (a) administering about 30 mg / kg of anti-C5 antigen-binding protein intravenously (IV) in one or more doses; and (b) administering one or more subcutaneous doses based on body weight as follows: 125 mg for body weight (BW) < 10 kg, 200 mg for BW > 10 kg and < 20 kg, 350 mg for BW > 20 kg and < 40 kg, 500 mg for BW > 40 kg and < 60 kg, and 800 mg for BW > 60 kg. For example, in one embodiment of the present invention, subcutaneous administration is administered once a week (weekly, q1w, or qw). Weekly administrations, in one embodiment of the present invention, are administered about every 7 days, every 7 days (+1 day), every 7 days (+2 days), or every 7 days (+3 days) after the immediately preceding administration. For example, if the first administration is administered on day 1, the next weekly administration is administered on about day 8, and so on, about every 7 days thereafter. In one embodiment of the present invention, the subject has a C5-associated disease (eg, PNH, CHAPLE, aHUS, or MG).

[0011] The present invention further provides methods of treating or preventing CHAPLE disease in a subject by administering to the subject an antagonist antigen binding protein that specifically binds to C5 described herein, e.g., REGN3918 (a therapeutically effective amount of the antigen binding protein).

[0012] The present invention also provides a method of treating or preventing a C5-associated disease or reducing C5 complement activity (e.g., by about 99 or 100%, as measured, e.g., by a CH50 assay, e.g., a CH50 assay that measures the lysis of sheep red blood cells) in a subject (e.g., a human subject), comprising administering to the subject an antagonist antigen binding protein that specifically binds C5 (e.g., REGN3918) via a dosing regimen discussed herein. In one embodiment of the present invention, the C5-related disease is selected from the group consisting of adult respiratory distress syndrome, age-related macular degeneration (AMD), allergies, Alport syndrome, Alzheimer's disease, amyotrophic lateral sclerosis (ALS), antiphospholipid syndrome (APS), asthma, atherosclerosis, atypical hemolytic uremic syndrome (aHUS), autoimmune diseases, autoimmune hemolytic anemia (AIHA), balloon angioplasty, bronchoconstriction, bullous pemphigoid, burns, C3 glomerulopathy, capillary leak syndrome, cardiovascular disorders, fulminant antiphospholipid syndrome (CAPS), cerebrovascular disorders, and CHAPLE disease (complement CD55 deficiency with hyperactivation of CD55, vasculopathic thrombosis, and protein-losing enteropathy); chemical injury; chronic obstructive pulmonary disease (COPD); cold agglutinin disease (CAD); corneal and / or retinal tissue; Crohn's disease; Degos disease; dense deposit disease (DDD); dermatomyositis; diabetes; diabetic vasculopathy; diabetic macular edema (DME); diabetic nephropathy; diabetic retinopathy; dilated cardiomyopathy; disorders of inappropriate or unwanted complement activation; respiratory distress; eclampsia; emphysema; epidermolysis bullosa; epilepsy; fibrosing pneumoconiosis dust disease); frostbite; geographic atrophy (GA); glomerulonephritis; glomerulopathy; Goodpasture's syndrome; Graves' disease; Guillain-Barré syndrome; Hashimoto's thyroiditis; hemodialysis complications; hemolysis, elevated liver enzymes, and thrombocytopenia (HELLP) syndrome; hemolytic anemia; hemoptysis; Henoch-Schönlein purpura nephritis; hereditary angioedema; hyperacute allograft rejection; hypersensitivity pneumonitis; idiopathic thrombocytopenic purpura (ITP); IgA nephropathy; immune complex disorders; immune complex vasculitis; immune complex-associated inflammation; infection; inflammation due to autoimmune disease; inflammatory disorders; hereditary CD59 deficiency; injury due to inert dust and / or inorganic particles; interleukin-2-induced toxicity during IL-2 therapy; ischemia-reperfusion injury; Kawasaki disease; pulmonary disease or injury; lupus nephritis;Membranoproliferative glomerulonephritis; Membranoproliferative nephritis; Mesenteric artery reperfusion after aortic reconstruction; Mesenteric / intestinal vascular disorders; Multifocal motor neuropathy (MMN); Multiple sclerosis; Myasthenia gravis; Myocardial infarction; Myocarditis; Neuropathy; Neuromyelitis optica; Obesity; Intraocular neovascularization; Intraocular neovascularization affecting the choroid; Organic pneumoconiosis; Parasitic diseases; Parkinson's disease; Paroxysmal nocturnal hemoglobinuria (PNH); Microimmune vasculitis; Pemphigus; Percutaneous transluminal coronary angioplasty (PTCA); Peripheral (e.g., musculoskeletal) vascular disorders; Pneumonia; Postischemic reperfusion state; Post-pump syndrome in cardiopulmonary bypass; Post-pump syndrome in renal bypass; Preeclampsia; Progressive renal failure; Proliferative nephritis; Proteinuric kidney disease psoriasis; pulmonary embolism; pulmonary fibrosis; pulmonary infarction; pulmonary vasculitis; recurrent abortion; renal damage; renal ischemia; renal ischemia-reperfusion injury; renal vascular disease; restenosis after stent placement; rheumatoid arthritis (RA); rotational atherectomy; schizophrenia; sepsis; septic shock; SLE nephritis; smoke poisoning; spinal cord injury; spontaneous abortion; stroke; systemic inflammatory response to sepsis; systemic lupus erythematosus (SLE); systemic lupus erythematosus-associated vasculitis; Takayasu's disease; burns; thrombotic thrombocytopenic purpura (TTP); traumatic brain injury; type 1 diabetes; typical hemolytic uremic syndrome (tHUS); uveitis; vasculitis; vasculitis associated with rheumatoid arthritis; venous gas embolism (VGE); and / or xenograft rejection.

[0013] The present invention also provides methods of establishing and / or maintaining a concentration (e.g., trough concentration) of at least about 100 mg / L, 150 mg / L, 400 mg / L, 600 mg / L, 700 mg / L, or 600-700 mg / L over time in the serum of a subject (e.g., a human) of an antagonist antigen binding protein that specifically binds C5 (e.g., REGN3918), and / or achieving at least 80% (e.g., 81, 82, 93, 84, 85, 90, 95% or more) suppression of hemolysis in the serum of the subject (e.g., as measured by AH50 and / or CH50 assays), comprising administering to the subject an anti-C5 antigen binding protein according to a dosing regimen discussed herein.

[0014] The present invention also provides methods of reducing serum lactate dehydrogenase (LDH) levels, intravascular hemolysis, and / or the need for red blood cell transfusions in a subject (e.g., a human) suffering from paroxysmal nocturnal hemoglobinuria (PNH), comprising administering to the subject an antagonist antigen binding protein that specifically binds C5 (e.g., REGN3918) via a dosing regimen discussed herein (e.g., (i) one or more intravenous (IV) administrations of about 30 mg / kg of the antigen binding protein; followed by (ii) subcutaneous (SC) administrations of about 800 mg of the antigen binding protein one or more times per week).

[0015] In one embodiment of the present invention, in a subject (e.g., suffering from PNH) taking an antagonist antigen binding protein that specifically binds C5 (e.g., REGN3918) discussed herein, (i) the subject has a serum lactate dehydrogenase (LDH) level ≥ 2 x the upper limit of normal (ULN); (ii) the subject has > 10% PNH granulocytes (polymorphonuclear [PMN]); (iii) the subject has hypoalbuminemia of 3.2 g / dL or less; (iv) the subject is suffering from diarrhea; (v) the subject is suffering from vomiting; (vi) the subject is suffering from abdominal pain. (vii) the subject suffers from peripheral or facial edema; (viii) the subject suffers from an episode of infection complicated by hypogammaglobulinemia or a thromboembolic event; (ix) the subject suffers from fatigue; (x) the subject suffers from hemoglobinuria; (xi) the subject suffers from shortness of breath (dyspnea); (xii) the subject suffers from anemia; (xiii) the subject suffers from a history of a major adverse vascular event; (xiv) the subject suffers from dysphagia; and / or (xv) the subject suffers from erectile dysfunction.

[0016] The present invention also provides methods of normalizing and / or increasing serum albumin or reducing therapeutic intervention in a subject suffering from CD55-deficient protein-losing enteropathy, comprising administering to the subject an antagonist antigen binding protein that specifically binds C5 (e.g., REGN3918) by a dosing regimen described herein, wherein the therapeutic intervention is one or more selected from the group consisting of: (i) administration of a corticosteroid; (ii) administration of an immunoglobulin; (iii) administration of albumin; (iv) administration of an anti-tumor necrosis factor alpha therapeutic agent; (v) administration of an immunomodulatory agent; (vi) administration of a micronutrient; (vii) administration of enteral or parenteral supplementation; (viii) administration of an anticoagulant; (ix) administration of an antibiotic; and (x) administration of an antiplatelet agent.

[0017] In one embodiment of the present invention, in a subject (e.g., suffering from CHAPLE) taking an antagonist antigen binding protein that specifically binds C5 discussed herein (e.g., REGN3918), (i) the subject has biallelic loss-of-function mutations in CD55; (ii) the subject has biallelic loss-of-function mutations in CD55 that are frameshift mutations; missense mutations, splice site mutations, or nonsense mutations; (iii) the subject has hypoalbuminemia with serum albumin of 3.2 g / dL or less; (iv) the subject is suffering from diarrhea; (v) the subject is suffering from vomiting; (vi) the subject is suffering from abdominal pain; (vii) the subject is suffering from peripheral edema or facial edema; (viii) the subject is suffering from an episode of infection complicated by hypogammaglobulinemia; and / or (ix) the subject is suffering from a thrombotic event.

[0018] In one embodiment of the present invention, the antagonist antigen binding protein that specifically binds to C5 discussed herein is an antibody or antigen-binding fragment thereof, such as REGN3918 (pozelimab). In one embodiment of the present invention, the antagonist antigen-binding protein (e.g., an antibody or antigen-binding fragment thereof) that specifically binds to C5 discussed herein is selected from the group consisting of: (1) a heavy chain variable region (HCVR) comprising the amino acid sequence set forth in SEQ ID NO:2 or an HCDR1, HCDR2, and HCDR3 thereof, and a light chain variable region (LCVR) comprising the amino acid sequence set forth in SEQ ID NO:10 or an LCDR1, LCDR2, and LCDR3 thereof; (2) a HCVR comprising the amino acid sequence set forth in SEQ ID NO:18 or an HCDR1, HCDR2, and HCDR3 thereof, and a LCVR comprising the amino acid sequence set forth in SEQ ID NO:26 or an LCDR1, LCDR2, and LCDR3 thereof; (3) a HCVR comprising the amino acid sequence set forth in SEQ ID NO:34 or an HCDR1, HCDR2, and HCDR3 thereof, and a LCVR comprising the amino acid sequence set forth in SEQ ID NO:42 or an LCDR1, LCDR2, and LCDR3 thereof; (4) a HCVR comprising the amino acid sequence set forth in SEQ ID NO:50 or an LCVR comprising the amino acid sequence set forth in SEQ ID NO:51; (5) an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 66 or HCDR1, HCDR2 and HCDR3 thereof, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 74 or LCDR1, LCDR2 and LCDR3 thereof; (6) an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 82 or HCDR1, HCDR2 and HCDR3 thereof, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 90 or LCDR1, LCDR2 and LCDR3 thereof; (7) an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 98 or HCDR1, HCDR2 and HCDR3 thereof, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 106 or LCDR1, LCDR2 and LCDR3 thereof;(8) HCVR having the amino acid sequence set forth in SEQ ID NO: 98 or its HCDR1, HCDR2, and HCDR3, and LCVR having the amino acid sequence set forth in SEQ ID NO: 114 or its LCDR1, LCDR2, and LCDR3; (9) HCVR having the amino acid sequence set forth in SEQ ID NO: 122 or its HCDR1, HCDR2, and HCDR3, and LCVR having the amino acid sequence set forth in SEQ ID NO: 106 or its LCDR1, LCDR2, and LCDR3; (10) HCVR having the amino acid sequence set forth in SEQ ID NO: 98 or its HCDR1, HCDR2, and HCDR3, and LCVR having the amino acid sequence set forth in SEQ ID NO: 130 or its LCDR1, LCDR2, and LCDR3; (11) HCVR having the amino acid sequence set forth in SEQ ID NO: 138 or its HCDR1, HCDR2, and HCDR3, and LCVR having the amino acid sequence set forth in SEQ ID NO: 106 or its LCDR1, LCDR2, and LCDR3; (1 (2) an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 146 or its HCDR1, HCDR2, and HCDR3, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 106 or its LCDR1, LCDR2, and LCDR3; (13) an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 122 or its HCDR1, HCDR2, and HCDR3, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 130 or its LCDR1, LCDR2, and LCDR3; (14) an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 146 or its HCDR1, HCDR2, and HCDR3, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 114 or its LCDR1, LCDR2, and LCDR3; (15) an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 146 or its HCDR1, HCDR2, and HCDR3, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 130 or its LCDR1, LCDR2, and LCDR3;(16) HCVR comprising the amino acid sequence set forth in SEQ ID NO: 138 or its HCDR1, HCDR2, and HCDR3, and LCVR comprising the amino acid sequence set forth in SEQ ID NO: 130 or its LCDR1, LCDR2, and LCDR3; (17) HCVR comprising the amino acid sequence set forth in SEQ ID NO: 154 or its HCDR1, HCDR2, and HCDR3, and LCVR comprising the amino acid sequence set forth in SEQ ID NO: 162 or its LCDR1, LCDR2, and LCDR3; (18) HCVR comprising the amino acid sequence set forth in SEQ ID NO: 170 or its HCDR1, HCDR2, and HCDR3, and LCVR comprising the amino acid sequence set forth in SEQ ID NO: 178 or its LCDR1, LCDR2, and LCDR3; (19) HCVR comprising the amino acid sequence set forth in SEQ ID NO: 186 or its HCDR1, HCDR2, and HCDR3, and LCVR comprising the amino acid sequence set forth in SEQ ID NO: 194 or its LCDR1, LCDR2, and LCDR3; (20) HCVR having the amino acid sequence set forth in SEQ ID NO: 202 or its HCDR1, HCDR2, and HCDR3, and LCVR having the amino acid sequence set forth in SEQ ID NO: 210 or its LCDR1, LCDR2, and LCDR3; (21) HCVR having the amino acid sequence set forth in SEQ ID NO: 218 or its HCDR1, HCDR2, and HCDR3, and LCVR having the amino acid sequence set forth in SEQ ID NO: 226 or its LCDR1, LCDR2, and LCDR3; (22) HCVR having the amino acid sequence set forth in SEQ ID NO: 234 or its HCDR1, HCDR2, and HCDR3, and LCVR having the amino acid sequence set forth in SEQ ID NO: 242 or its LCDR1, LCDR2, and LCDR3; (23) HCVR having the amino acid sequence set forth in SEQ ID NO: 250 or its HCDR1, HCDR2, and HCDR3, and LCVR having the amino acid sequence set forth in SEQ ID NO: 258 or its LCDR1, LCDR2, and LCDR3;(24) HCVR comprising the amino acid sequence set forth in SEQ ID NO: 266 or its HCDR1, HCDR2 and HCDR3, and LCVR comprising the amino acid sequence set forth in SEQ ID NO: 258 or its LCDR1, LCDR2 and LCDR3; (25) HCVR comprising the amino acid sequence set forth in SEQ ID NO: 274 or its HCDR1, HCDR2 and HCDR3, and LCVR comprising the amino acid sequence set forth in SEQ ID NO: 282 or its LCDR1, LCDR2 and LCDR3; (26) HCVR comprising the amino acid sequence set forth in SEQ ID NO: 290 or its HCDR1, HCDR2 and HCDR3, and LCVR comprising the amino acid sequence set forth in SEQ ID NO: 298 or its LCDR1, LCDR2 and LCDR3; (27) HCVR comprising the amino acid sequence set forth in SEQ ID NO: 306 or its HCDR1, HCDR2 and HCDR3, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 314 or an LCDR1, LCDR2, and LCDR3 thereof; (28) an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 322 or an HCDR1, HCDR2, and HCDR3 thereof, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 330 or an LCDR1, LCDR2, and LCDR3 thereof; and / or (29) an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 338 or an HCDR1, HCDR2, and HCDR3 thereof, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 346 or an LCDR1, LCDR2, and LCDR3 thereof; or competes for binding to C5 with an antigen-binding protein selected from the group consisting of (1) to (29); or binds to the same epitope on C5 as an antigen-binding protein selected from the group consisting of (1) to (29).

[0019] In one embodiment of the present invention, a subject receiving an antagonist antigen binding protein that specifically binds C5 described herein has previously received tesidolumab, eculizumab, or ravulizumab. In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds C5 described herein is administered in combination with an additional therapeutic agent; for example, cemdisiran, an oligonucleotide, an anticoagulant, warfarin, aspirin, heparin, phenindione, fondaparinux, idraparinux, a thrombin inhibitor, argatroban, lepirudin, bivalirudin, dabigatran, an anti-inflammatory drug, a corticosteroid, a nonsteroidal anti-inflammatory drug (NSAID), an antihypertensive drug, angiotensin-converting enzyme inhibitor, an immunosuppressant, vincristine, cyclosporine A, or methotrexate, a fibrinolytic agent. In one embodiment of the present invention, the additional therapeutic agent is an oligonucleotide, which is a DNA oligonucleotide, an RNA oligonucleotide, a single-stranded DNA oligonucleotide, a single-stranded RNA oligonucleotide, a double-stranded DNA oligonucleotide, or a double-stranded RNA oligonucleotide; and optionally, the oligonucleotide is conjugated to a sugar.

[0020] The present invention also provides an administration regimen for administering to a subject (e.g., a human) an antagonist antigen binding protein that specifically binds to C5 (e.g., REGN3918), wherein the administration regimen induces the following in the subject's body: (i) administering one or more doses of about 30 mg / kg of anti-C5 antigen binding protein intravenously (IV); and / or (ii) administering one or more subcutaneous (SC) doses of about 800 mg of anti-C5 antigen binding protein (e.g., given weekly starting about 7 days after the first dose); or (a) administering one or more doses of about 30 mg / kg of anti-C5 antigen binding protein intravenously (IV); and / or (b) The dosing regimen also includes one or more subcutaneous doses based on body weight (e.g., given weekly, starting about 7 days after the first dose) as follows: 125 mg for body weight (BW) < 10 kg, 200 mg for BW > 10 kg and < 20 kg, 350 mg for BW > 20 kg and < 40 kg, 500 mg for BW > 40 kg and < 60 kg, and 800 mg for BW > 60 kg. As noted above, (i) and (ii) can be in either order, and (a) and (b) can be in either order. For example, in one embodiment of the present invention, subcutaneous administration is administered weekly (weekly, q1w or qw). In one embodiment of the present invention, weekly administration is administered about every 7 days, every 7 days (+1 day), every 7 days (+2 days), or every 7 days (+3 days) after the immediately preceding dose. For example, if the first administration is given on day 1, the next weekly administration is given on about day 8, and so on, every 7 days thereafter. In one embodiment of the present invention, the subject suffers from a C5-related disease (e.g., PNH, CHAPLE, aHUS, or MG). Methods for treating or preventing C5-related disorders, including the above administration methods, are within the scope of the present invention. [Brief explanation of the drawings]

[0021] [Figure 1] FIG. 1 illustrates cohorts in a clinical trial of REGN3918 in patients with paroxysmal nocturnal hemoglobinuria (PNH). [Figure 2]Graph showing mean (±SE) serum concentrations of total REGN3918 over nominal time in healthy human volunteers for each treatment group (1 mg / kg IV, single dose; 3 mg / kg IV, single dose; 300 mg SC, single dose; 10 mg / kg IV, single dose; 600 mg SC, single dose; 30 mg / kg IV, single dose; or 15 mg / kg IV followed by 400 mg q1w x 4 weeks of SC dosing repeated four times). [Figure 3] Graph showing the mean (±SE) % change from baseline in CH50 over nominal time for each treatment group (1 mg / kg IV, single dose; 3 mg / kg IV, single dose; 300 mg SC, single dose; 10 mg / kg IV, single dose; 600 mg SC, single dose; 30 mg / kg IV, single dose; or 15 mg / kg IV followed by 400 mg q1w x 4 weeks of SC dose repeated four times) in healthy human volunteers. [Figure 4-1] Figures 4 (A-I) are graphs showing in vitro alternative pathway (AP) and classical pathway (CP) hemolysis in the presence of various concentrations of pozelimab (REGN3918), eculizumab, ravulizumab, or an isotype control antibody (REGN1945). Figure 4A shows an AP hemolysis assay in the presence of 10% normal human serum (NHS). Figure 4B shows an AP hemolysis assay in the presence of 25% NHS. Figure 4C shows an AP hemolysis assay in the presence of 48% NHS. Figure 4D shows a CP hemolysis assay in the presence of 5% NHS. Figure 4E shows a CP hemolysis assay in the presence of 10% NHS. Figure 4F shows a CP hemolysis assay in the presence of 25% NHS. Figure 4G shows an AP hemolysis assay in the presence of 25% NHS and 1 mM MgCl. Figure 4H is a graph showing the AP hemolysis assay in the presence of 25% NHS and 1.5 mM MgCl2. Figure 4I is a graph showing the AP hemolysis assay in the presence of 25% NHS and 2 mM MgCl2. [Figure 4-2] Continued from Figure 4-1. [Figure 5] 1 is a graph showing lactate dehydrogenase (LDH) (× ULN) over time for six patients (410001001F; 410001002F; 410004001F; 410004002M; 410005001F, and 410005002M) on a normal scale. LDH upper limit of normal (ULN) and 1.5×ULN are displayed. [Figure 6] 1 is a graph showing lactate dehydrogenase (LDH) (× ULN) over time for six patients on a semi-log scale. LDH upper limit of normal (ULN) and 1.5×ULN are displayed. [Figure 7] 1 is a graph showing mean lactate dehydrogenase (LDH) (× ULN) over time for six patients on a normal scale. LDH upper limit of normal (ULN) and 1.5×ULN are displayed. [Figure 8] 1 is a graph showing mean lactate dehydrogenase (LDH) (× ULN) over time for six patients on a semi-log scale. LDH upper limit of normal (ULN) and 1.5×ULN are displayed. [Figure 9A] FIG. 9A is a graph showing individual normal-scale concentrations (mg / L) of total serum REGN3918 versus nominal time observed in six patients with initial PNH treatment naive. [Figure 9B] FIG. 9B is a graph showing individual semi-logarithmic scale concentrations (mg / L) of total serum REGN3918 versus nominal time observed in six patients with initial PNH treatment naive. [Figure 9C] Figure 9C is a graph showing the median normal-scaled serum total REGN3918 concentrations (mg / L) versus nominal time observed in six first-time treatment-naive patients with PNH. Figure 9D is a graph showing the median semi-logarithmic scaled serum total REGN3918 concentrations (mg / L) versus nominal time observed in six first-time treatment-naive patients with PNH. [Figure 9D] FIG. 9D is a graph showing the median semi-logarithmic scale concentration of total serum REGN3918 (mg / L) versus nominal time observed in six first-time treatment-naive patients with PNH. [Figure 10A]FIG. 10A is a graph showing individual normal-scale concentrations (mg / L) of total serum REGN3918 by sex versus nominal time observed in six first-time treatment-naive patients with PNH. [Figure 10B] FIG. 10B is a graph showing individual semi-logarithmic scale concentrations (mg / L) of total serum REGN3918 by sex versus nominal time observed in six first-time treatment-naive patients with PNH. [Figure 10C] FIG. 10C is a graph showing the median normal-scaled serum total REGN3918 concentrations (mg / L) by sex versus nominal time observed in six first-time treatment-naive patients with PNH. [Figure 10D] FIG. 10D is a graph showing the median semi-logarithmic scale concentration (mg / L) of serum total REGN3918 by sex versus nominal time observed in six first-time treatment-naive patients with PNH. [Figure 11A] FIG. 11A is a graph showing the individual concentrations (mg / L) of plasma total C5 versus nominal time observed in six patients initially naive to treatment for PNH. [Figure 11B] FIG. 11B is a graph showing the median plasma total C5 concentration (mg / L) versus nominal time observed in six patients with initial PNH treatment naive. [Figure 12A] FIG. 12A is a graph showing individual concentrations (mg / L) of plasma total C5 by sex versus nominal time observed in six first-time treatment-naive patients with PNH. [Figure 12B] FIG. 12B is a graph showing median plasma C5 concentrations (mg / L) by sex versus nominal time observed in six first-time treatment-naive patients with PNH. [Figure 13A] FIG. 13A is a graph showing individual fold changes over baseline plasma total C5 by nominal time observed in six first-time treatment-naive patients with PNH. [Figure 13B] FIG. 13B is a graph showing the median fold increase over baseline plasma total C5 by nominal time in six first-time treatment-naive patients with PNH. [Figure 14A]FIG. 14A is a graph showing the individual fold changes over baseline plasma total C5 by nominal time and by sex observed in six first-time treatment-naive patients with PNH. [Figure 14B] FIG. 14B is a graph showing the median fold increase in baseline plasma total C5 by nominal time and by sex observed in six first-time PNH treatment-naive patients. [Figure 15] 1 is a graph showing the mean (±SD) plasma total C5 concentrations (mg / L) versus nominal time observed in six patients with initial PNH treatment naive. [Figure 16] Graphs showing individual concentrations of total REGN3918 (TOR3918; triangles) and total C5 (TOC5; circles) versus nominal time in six patients (A, B, C, D, E, and F). [Figure 17] Graph showing LDH (x ULN) for 6 patients, including those from day 57 onwards (female LDH ULN=330 U / L and male LDH ULN=281 U / L). [Figure 18] Graph showing semi-logarithmic scale LDH (x ULN) for 6 patients, including those from day 57 onwards (female LDH ULN=330 U / L and male LDH ULN=281 U / L). [Figure 19] Graph showing mean LDH (x ULN) for 6 patients, including those from day 57 onwards (female LDH ULN=330 U / L and male LDH ULN=281 U / L). [Figure 20] Graph showing mean LDH (x ULN) on a semi-log scale for 6 patients, including days 57 and above (female LDH ULN=330 U / L and male LDH ULN=281 U / L). [Figure 21] Graph showing LDH (x ULN) for 9 patients, including those from day 57 onwards (female LDH ULN=330 U / L and male LDH ULN=281 U / L). [Figure 22]Graph showing LDH (x ULN) on a semi-logarithmic scale for nine patients, including those from day 57 onwards (female LDH ULN=330 U / L and male LDH ULN=281 U / L). [Figure 23] Graph showing mean LDH (x ULN) for 9 patients, including those from day 57 onwards (female LDH ULN=330 U / L and male LDH ULN=281 U / L). [Figure 24] Graph showing mean LDH (x ULN) on a semi-log scale for 9 patients, including days 57 and beyond. [Figure 25] FIG. 1 shows an overview of a clinical trial treating naive PNH patients with ALXN1210 (ravulizumab) or eculizumab. [Figure 26A] Figure 26A shows graphs demonstrating that switching administration from eculizumab to REGN3918 results in normalization of serum C5 concentrations and sustained suppression of hemolytic activity. Figure 26B shows graphs demonstrating that total hIgG concentrations were measured by Gyros in serum collected from C5 hu / hu mice administered three doses of REGN3918 alone (filled circles), three doses of eculizumab alone (squares), or one dose of eculizumab followed by two doses of REGN3918 (switch, open circles). The arrows on the y-axis and the vertical gray dashed lines indicate the time of administration. [Figure 26B] Figure 26B shows that switching from eculizumab to REGN3918 results in normalization of serum C5 concentrations and sustained suppression of hemolytic activity. Figure 26B shows total C5 serum concentrations measured from bled mice throughout the trial in C5hu / hu mice treated with REGN3918 alone (filled circles), eculizumab alone (squares), or eculizumab switched to REGN3918 (switch, open circles). [Figure 26C]Figure 26C is a graph showing that switching from eculizumab to REGN3918 results in normalization of serum C5 concentrations and sustained suppression of hemolytic activity. Figure 26D is a graph showing that serum collected from the terminal bleed of C5hu / hu mice treated with REGN3918 alone (filled circles), eculizumab alone (squares), or an eculizumab / REGN3918 switch (open circles) was supplemented with hC3, and the percent CP-mediated hemolysis was assessed using an ex vivo assay. [Figure 26D] Figure 26A shows that switching from eculizumab to REGN3918 resulted in normalization of serum C5 concentrations and maintained suppression of hemolytic activity. Figure 26B shows that serum concentrations of total C5 and hIgG were used to calculate the C5:mAb ratio at the indicated time points. Data are plotted as mean ± SEM. [Figure 27] This graph shows that REGN3918 and eculizumab bind to different sites on C5 and form a complex containing primarily one to two molecules of C5 when all three are present under conditions designed to mimic dose switching. The eculizumab:C5 complex was analyzed by asymmetric flow field-flow fractionation coupled with multi-angle laser light scattering (A4F-MALLS). Fractograms obtained from individual samples of eculizumab, C5, and REGN3918 are also overlaid. The relative UV absorbance at 215 nm as a function of retention time is shown for each sample, and molar mass measurements of the resolved peaks are shown. [Figure 28A] Figure 28A shows a plot of serum albumin levels over time for each of four CHAPLE patients.Figure 28A is a graph showing serum albumin levels for four CHAPLE patients over the course of treatment. [Figure 28B] Figure 28A shows a plot of serum albumin levels over time for each of four CHAPLE patients. Figure 28B shows a graph showing serum albumin levels for the first of four CHAPLE patients before treatment. [Figure 28C]Figure 28C shows a plot of serum albumin levels over time for each of the four CHAPLE patients. Figure 28C is a graph showing serum albumin levels for the second of the four CHAPLE patients before treatment. [Figure 28D] Figures 28A and 28B show plots of serum albumin levels over time for each of four CHAPLE patients.Figure 28D is a graph showing serum albumin levels for the third of four CHAPLE patients before treatment. [Figure 28E] Figure 28A shows a plot of serum albumin levels over time for each of four CHAPLE patients. Figure 28B shows a graph of serum albumin levels for the fourth of four CHAPLE patients before treatment. The lower limit of normal (LLN) is displayed for male and female patients. [Figure 29] 1 is a graph showing plots of total serum protein over time, starting from baseline, in each of four patients with CHAPLE. The lower limit of normal (LLN) and upper limit of normal (ULN) are displayed. [Figure 30] 1 is a graph showing plots of vitamin B12 levels over time in each of four CHAPLE patients, from baseline, during the treatment period. [Figure 31] 1 is a graph showing a plot of platelet counts over time in each of four CHAPLE patients over the course of treatment, from baseline. [Figure 32] 1 is a graph showing a plot of fecal alpha-1-antitrypsin concentrations over time in each of four CHAPLE patients over the course of treatment, from baseline. The upper limit of normal (ULN) is displayed. [Figure 33] 1 is a graph showing a plot of facial edema grade over time in each of four CHAPLE patients before and during treatment. [Figure 34] 1 is a graph showing plots of peripheral edema grade over time in each of four CHAPLE patients before and during treatment. [Figure 35] 1 is a graph showing a plot of the average number of bowel movements per day by week for each of the four CHAPLE patients. DETAILED DESCRIPTION OF THE INVENTION

[0022] A convenient REGN3918 (pozelimab) dosing regimen containing a subcutaneous component has been developed for treating C5-related disorders, such as PNH, in humans. Subcutaneous administration offers patients the option of home administration and, therefore, the advantage of better patient compliance compared with the IV dosing regimens of eculizumab and ravulizumab. This dosing regimen has been shown to be highly effective in controlling hemolysis and reducing breakthrough hemolysis in human patients receiving the antibody. REGN3918 administered 30 mg / kg IV followed by 800 mg SC once weekly (REGN3918-30+800 dosing regimen) demonstrated robust inhibition of intravascular hemolysis and normalization of LDH in human patients with PNH. REGN3918, known to bind C5(R885H / C) with high affinity, was shown to effectively normalize LDH in human PNH patients receiving the REGN3918-30+800 dosing regimen. The data presented herein demonstrated the efficacy of the REGN3918-30 + 800 dosing regimen in human patients with C5 mutations who were resistant to prior eculizumab therapy. The REGN3918-30 + 800 dosing regimen also demonstrated clinical advantages over eculizumab and ravulizumab. Treatment with REGN3918 resulted in rapid, robust, and sustained reductions in LDH levels through study day 57; all six patients had LDH reductions by day 3 (48 hours after the first dose), LDH levels ≤ 1.5 × ULN (upper limit of normal) by day 14, and normalized LDH levels (≤ 1.0 × ULN) by day 29, achieving control of intravascular hemolysis. In contrast, evidence suggests that only approximately half of patients treated with ravulizumab and eculizumab achieved LDH normalization. Indeed, 25% of PNH patients receiving eculizumab still require repeated transfusions, albeit less frequently; up to 20% of patients require a significant increase in dose or frequency of administration due to breakthrough hemolysis secondary to incomplete inhibition of C5.See Nakayama et al., Eculizumab Dosing Intervals Longer than 17 Days May Be Associated with Greater Risk of Breakthrough Hemolysis in Patients with Paroxysmal Nocturnal Hemoglobinuria. Biol Pharm Bull 2016;39(2):285-8; Hil et al., Thrombosis in paroxysmal nocturnal hemoglobinuria. Blood 2013;121(25):4985-96; and Peffault de Latour et al., Assessing complement blockade in patients with paroxysmal nocturnal hemoglobinuria receiving eculizumab. Blood 2015;125(5):775-83. The comparative ex vivo hemolysis assays presented herein suggest that pozelimuab is more effective than ravulizumab and eculizumab in inhibiting AP complement-mediated hemolysis and is superior to ravulizumab in inhibiting CP complement-mediated hemolysis.

[0023] Discussion of a dosing regimen involving administration of A and then optionally B refers to a regimen involving administration of A only, as well as a regimen involving administration of A and then B.

[0024] Antagonist antigen-binding protein that specifically binds to C5 The present invention provides methods of using the antagonist antigen-binding proteins (e.g., antibodies and antigen-binding fragments thereof) that specifically bind to C5 as defined herein and pharmaceutical formulations thereof comprising a pharmaceutically acceptable carrier.

[0025] In one embodiment of the invention, the antagonist antigen binding protein that specifically binds to C5 binds to the beta chain or the alpha chain or both of C5, e.g., at residues 591-599 and / or 775-794, e.g., NMATGMDSW (SEQ ID NO: 353) and / or WEVHLVPRRKQLQFALPDSL (SEQ ID NO: 354). In one embodiment of the invention, the anti-C5 antigen binding protein does not bind C5a.

[0026] In one embodiment of the invention, the antagonist antigen binding protein that specifically binds to C5 binds at residues KDMQLGRLHMKTLLPVSK (SEQ ID NO: 355).

[0027] In one embodiment of the invention, an antagonist antigen binding protein that specifically binds C5 binds the beta chain of C5, for example, at residues 332-398, 332-378, 332-364, 332-348, 350-420, 369-409, 379-398 and / or 386-392.

[0028] In one embodiment of the invention, the antagonist antigen binding protein that specifically binds C5 binds C5a, for example, at residues NDETCEQRA (SEQ ID NO: 356) and / or SHKDMQL (SEQ ID NO: 357).

[0029] In one embodiment of the invention, the antagonist antigen binding protein that specifically binds C5 binds the beta chain of C5, e.g., residues 19 to 180. In one embodiment of the invention, binding to C5 is achieved by: Reduced by E48A, D51A and / or K109A C5 mutations.

[0030] Immunoglobulin polypeptides of antagonist antigen binding proteins (eg, antibodies or antigen-binding fragments thereof) that specifically bind to C5 for use in the methods of the present invention are set forth in Table A.

[0031] [Table 1]

[0032] Polynucleotides encoding the chains set forth in Table A are set forth in Table B below.

[0033] [Table 2]

[0034] H2M11683N HCVR Gln Val Gln Leu Val Glu Ser Gly Gly Gly Val Val Gln Pro Gly Arg 1 5 10 15 Ser Leu Arg Leu Ser Cys Val Ala Ser Gly Phe Thr Phe Ser Ser Tyr 20 25 30 Gly Ile His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ala Val Ile Trp Asp Asp Gly Asn Asn Ile Asn Tyr Ser Asp Ser Val 50 55 60 Lys Gly Arg Phe Ile Ile Ser Arg Asp Asn Ser Arg Lys Thr Val Tyr 65 70 75 80 Leu Gln Met Asn Ser Leu Arg Gly Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Asp Ala Pro Ile Ala Pro Val Pro Asp Tyr Trp Gly Gln Gly 100 105 110 Thr Leu Val Thr Val Ser Ser 115 (SEQ ID NO:2)

[0035] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Thr Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Ser Ile Ser Ser Trp 20 25 30 Leu Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Lys Ala Ser Ser Leu Asp Thr Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Glu Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Asp Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Tyr Asn Thr Tyr Ser Tyr 85 90 95 Thr Phe Gly Leu Gly Thr Lys Leu Glu Ile Lys 100 105 (SEQ ID NO:10)

[0036] H2M11686N HCVR Gln Val Gln Leu Val Glu Ser Gly Gly Gly Leu Val Lys Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Ser Asp Tyr 20 25 30 Tyr Met Ser Trp Ile Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ser Tyr Ile Ser Ser Ser Gly Asn Thr Ile Lys Tyr Ala Asp Ser Met 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ala Lys Lys Ser Leu Phe 65 70 75 80 Val Glu Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Tyr Lys Ser Ser Ser Asp Tyr Phe Asp His Trp Gly Gln Gly 100 105 110 Thr Leu Val Thr Val Ser Ser 115 (SEQ ID NO: 18)

[0037] LCVR Glu Ile Val Leu Thr Gln Ser Pro Ala Thr Leu Ser Leu Ser Pro Gly 1 5 10 15 Glu Arg Ala Thr Leu Ser Cys Arg Ala Ser Gln Ser Val Arg Ser Tyr 20 25 30 Leu Ala Trp Tyr Gln Gln Lys Pro Gly Gln Ala Pro Arg Leu Leu Ile 35 40 45 Tyr Asp Ala Ser Asn Arg Ala Thr Ala Ile Pro Ala Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Glu Pro 65 70 75 80 Glu Asp Leu Ala Val Tyr Tyr Cys Gln Gln Ser Gly Asn Trp Pro Leu 85 90 95 Thr Phe Gly Gly Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 26)

[0038] H4H12159P HCVR Gln Val Gln Leu Val Glu Ser Gly Gly Gly Val Val Gln Pro Gly Arg 1 5 10 15 Ser Leu Arg Leu Ser Cys Gly Ala Ser Gly Phe Thr Phe Ser Thr Tyr 20 25 30 Gly Met His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ala Val Ile Trp Asp Asp Gly Asn Asn Lys Tyr Tyr Ala Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Tyr 65 70 75 80 Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Asp Ser Glu Val Ala Pro Val Gly Asp Tyr Trp Gly Gln Gly 100 105 110 Thr Leu Val Thr Val Ser Ser 115 (SEQ ID NO: 34)

[0039] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Thr Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Ile Cys Arg Ala Ser Gln Ser Ile Asn Arg Trp 20 25 30 Leu Ala Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Lys Ala Ser Ser Leu Glu Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Glu Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Asp Asp Phe Ala Ala Tyr Tyr Cys Gln Gln Tyr Asn Asp Tyr Ser Tyr 85 90 95 Thr Phe Gly Gln Gly Thr Lys Leu Glu Ile Lys 100 105 (SEQ ID NO: 42)

[0040] H4H12161P HCVR Glu Val Gln Leu Val Glu Ser Gly Gly Asp Leu Val Gln Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Ser Asp His 20 25 30 Tyr Met Asp Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Asp Trp Ile 35 40 45 Gly Arg Ile Arg Asn Lys Ala Asn Ala Tyr Asn Thr Glu Tyr Ala Ala 50 55 60 Ser Val Arg Gly Arg Phe Thr Ile Ser Arg Asp Asp Ser Gln Asn Leu 65 70 75 80 Leu Tyr Leu Gln Met Asn Ser Leu Lys Thr Asp Asp Thr Ala Val Tyr 85 90 95 Tyr Cys Val Arg Val Trp Asn Tyr Ala Tyr Phe Ala Met Asp Val Trp 100 105 110 Gly Gln Gly Thr Thr Val Thr Val Ser Ser 115 120 (SEQ ID NO: 50)[[ID=四十]]

[0041] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ser Ser Gln Asn Ile Gly Ile Phe 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Glu Ala Pro Asn Leu Leu Ile 35 40 45 Ser Ala Ala Ser Ser Leu His Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Gly Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Thr Tyr Asn Thr Ile Phe 85 90 95 Thr Phe Gly Pro Gly Thr Lys Val Asp Ile Lys 100 105 (SEQ ID NO: 58)

[0042] H4H12163P HCVR Glu Val Gln Leu Val Glu Ser Gly Gly Asp Leu Val Gln Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Ser Ser Tyr 20 25 30 Ala Met Asn Trp Val Arg Gln Gly Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ser Ala Ile Ser Gly Arg Gly Asp Ser Thr Tyr Tyr Ala Asp Ser Val 50 55 60 Lys Gly Arg Leu Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Tyr 65 70 75 80 Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Val Lys Glu Gly Glu Gln Leu Val Tyr Trp Tyr Phe Asp Leu Trp Gly 100 105 110 [[ID=?]]Arg Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 66)

[0043] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Thr Ile Ser Asn Phe 20 25 30 Leu His Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro It seems there is a typo in your original text where "" has "Arg Gly Thr Leu Val Thr Val Ser Ser" and in the translation you provided it has "Arg Gly Thr Leu Val Thr Val Ser Ser " which is incorrect. I've corrected it in the translation above. Also, the "" has a wrong Chinese character "配列番号" which should be "SEQ ID NO:". I've corrected that as well.65 70 75 80 Glu Asp Phe Ser Thr Tyr Phe Cys Gln Gln Ser Tyr Thr Thr Pro Leu 85 90 95 Thr Phe Gly Gly Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 74)

[0044] H4H12164P HCVR Glu Val Gln Leu Val Glu Ser Gly Gly Gly Leu Val Arg Ser Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Asn Arg Tyr 20 25 30 Ala Met Thr Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ser Ala Ile Ser Gly Ser Gly Ser Ser Thr Tyr Tyr Thr Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ser Lys Asn Ser Val Asp 65 70 75 80 Leu Gln Met His Ser Leu Arg Val Glu Asp Thr Ala Ile Tyr Tyr Cys 85 90 95 Ala Arg Gly Thr Thr Val Thr Thr Gly Tyr Gly Met Asp Val Trp Gly 100 105 110 Gln Gly Thr Thr Val Thr Val Ser Ser 115 120 (SEQ ID NO: 82)

[0045] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Phe Thr Cys Gln Ala Ser Gln Asp Ile Thr Asn Ser 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Arg Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Asp Ala Ser Tyr Leu Lys Ala Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Phe Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Ile Ala Thr Tyr Tyr Cys Gln Gln Tyr Asp Asp Leu Pro Tyr 85 90 95 Thr Phe Gly Gln Gly Thr Lys Leu Glu Ile Lys 100 105 (SEQ ID NO: 90)

[0046] H4H12166P<0000�53> HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu Gly Asn Val Asp Thr Thr Met Ile Phe Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 98)

[0047] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Leu Gln Asp Phe Asn Tyr Pro Trp 85 90 95 Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 106)

[0048] H4H12166P2 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 [[ID=]Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu Gly Asn Val Asp Thr Thr Met Ile Phe Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 98)

[0049] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys His Gln Asp Phe Asn Tyr Pro Trp 85 90 95 Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 114)

[0050] H4H12166P3 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu His Asn Val Asp Thr Thr Met Ile Phe Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 122)

[0051] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Leu Gln Asp Phe Asn Tyr Pro Trp 85 90 95 Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 106)

[0052] H4H12166P4 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu Gly Asn Val Asp Thr Thr Met Ile Phe Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 98)

[0053] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Leu Gln Asp Phe Asn Tyr Pro Trp 85 90 95 His Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 130)

[0054] H4H12166P5 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu[[ID=X]] 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu Gly Asn Val Asp Thr Thr Met Ile His Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 138)

[0055] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Leu Gln Asp Phe Asn Tyr Pro Trp 85 90 95 Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 106)

[0056] H4H12166P6 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu Gly Asn Val Asp His Thr Met Ile Phe Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 146)

[0057] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Leu Gln Asp Phe Asn Tyr Pro Trp 85 90 95 Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 106)

[0058] H4H12166P7 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu His Asn Val Asp Thr Thr Met Ile Phe Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 122)

[0059] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Leu Gln Asp Phe Asn Tyr Pro Trp 85 90 95 His Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 130)

[0060] H4H12166P8 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu Gly Asn Val Asp His Thr Met Ile Phe Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 146)

[0061] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys His Gln Asp Phe Asn Tyr Pro Trp 85 90 95 Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 114)

[0062] H4H12166P9 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu Gly Asn Val Asp His Thr Met Ile Phe Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 146)

[0063] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Leu Gln Asp Phe Asn Tyr Pro Trp 85 90 95 His Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 130)

[0064] H4H12166P10 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Glu 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Asp Ser Val Ser Ser Ser 20 25 30 Tyr Trp Thr Trp Ile Arg Gln Pro Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Gly Tyr Ile Tyr Tyr Ser Gly Ser Ser Asn Tyr Asn Pro Ser Leu Lys 50 55 60 Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe Ser Leu 65 70 75 80 Lys Leu Ser Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr Cys Ala 85 90 95 Arg Glu Gly Asn Val Asp Thr Thr Met Ile His Asp Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 138)

[0065] LCVR Ala Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ala Gly 50 55 60 Arg Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Leu Gln Asp Phe Asn Tyr Pro Trp 85 90 95 His Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 130)

[0066] H4H12167P HCVR Gln Val Gln Leu Val Glu Ser Gly Gly Gly Leu Val Lys Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Ser Asp Ser 20 25 30 Tyr Met Ser Trp Ile Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Ser Tyr Ile Gly Ser Ser Gly Asn Thr Phe Tyr Tyr Ala Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ala Asn Asn Leu Leu Tyr 65 70 75 80 Leu Gln Met Thr Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Glu Glu Gly Asp Phe Trp Ser Ala Val Asp Ser Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 154)

[0067] LCVR Asp Ile Gln Leu Thr Gln Ser Pro Ser Phe Leu Ser Ala Ser Val Gly 1 5 10 15 ​​​​​​35 40 45 他的苏氨酸、丙氨酸、丝氨酸、苏氨酸、亮氨酸、谷氨酰胺、丝氨酸、甘氨酸、缬氨酸、脯氨酸、丝氨酸、精氨酸、苯丙氨酸、丝氨酸、甘氨酸 50 55 60 丝氨酸、甘氨酸、丝氨酸、甘氨酸、苏氨酸、谷氨酸、苯丙氨酸、苏氨酸、亮氨酸、苏氨酸、异亮氨酸、丝氨酸、天冬酰胺、亮氨酸、谷氨酰胺、脯氨酸 65 70 75 80 谷氨酸、天冬氨酸、苯丙氨酸、丙氨酸、苏氨酸、酪氨酸、酪氨酸、半胱氨酸、谷氨酰胺、谷氨酰胺、亮氨酸、天冬酰胺、丝氨酸、酪氨酸、脯氨酸、苯丙氨酸 85 90 95 苏氨酸、苯丙氨酸、甘氨酸、脯氨酸、甘氨酸、苏氨酸、赖氨酸、缬氨酸、天冬氨酸、异亮氨酸、赖氨酸 100 105 (SEQ ID NO: 162)

[0068] H4H12168P HCVR 谷氨酰胺、缬氨酸、谷氨酰胺、亮氨酸、缬氨酸、谷氨酸、丝氨酸、甘氨酸、甘氨酸、甘氨酸、缬氨酸、缬氨酸,谷氨酰胺、脯氨酸、甘氨酸、甘氨酸 1 5 10 15 丝氨酸、亮氨酸、精氨酸、亮氨酸、丝氨酸、半胱氨酸、丙氨酸、丙氨酸、丝氨酸、甘氨酸、苯丙氨酸、苏氨酸、苯丙氨酸、甘氨酸、甘氨酸、组氨酸 20 25 30 丙氨酸、甲硫氨酸、组氨酸、色氨酸、缬氨酸、精氨酸、谷氨酰胺、丙氨酸、脯氨酸、甘氨酸、赖氨酸、甘氨酸、亮氨酸、谷氨酸、色氨酸、亮氨酸 35 40 45 丙氨酸、缬氨酸、异亮氨酸、丝氨酸、丝氨酸、天冬氨酸、甘氨酸、丝氨酸、天冬酰胺、赖氨酸、谷氨酰胺、酪氨酸、丙氨酸、天冬氨酸、丝氨酸、缬氨酸 50 55 60 赖氨酸、甘氨酸、精氨酸、苯丙氨酸、苏氨酸、异亮氨酸、丝氨酸、精氨酸、天冬酰胺、脯氨酸、赖氨酸、天冬酰胺、苏氨酸、亮氨酸、酪氨酸 65 70 75 80 Leu Gln Met Asn Ser Leu Arg Val Gly Asp Thr Ala Ile Tyr Tyr Cys 85 90 95 Ala Lys Glu Val Ala Pro Arg Tyr Tyr Tyr Tyr Gly Leu Asp Val Trp 100 105 110 Gly Gln Gly Thr Thr Val Thr Val Ser Ser 115 120 (SEQ ID NO: 170)

[0069] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Asp Ile Ser Asn Phe 20 25 30 Leu Ala Trp Tyr Gln Gln Lys Pro Gly Lys Val Pro Lys Leu Leu Ile 35 40 45 Tyr Thr Ala Ser Thr Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Val Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Val Ala Thr Tyr Tyr Cys Gln Lys Tyr Ala Gly Ala Leu Thr 85 90 95 Phe Gly Pro Gly Thr Lys Val Asp Ile Lys 100 105 (Accession No. 178)

[0070] H4H12169P HCVR Glu Val Gln Leu Val Glu Ser Gly Gly Gly Leu Ala Gln Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Arg Ser Tyr 20 25 30 Ala Met Ser Trp Val Arg Gln Ala Pro Gly Lys Gly Pro Glu Trp Val 35 40 45 Ser Gly Ile Gly Gly Asn Gly Val Thr Thr Tyr Tyr Ala Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Phe 65 70 75 80 Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Val Gln Gly Gly Leu Gly Gly Tyr Phe Thr Gly Tyr Trp Gly Gln Gly 100 105 110 Thr Leu Val Thr Val Ser Ser 115 (Accession No. 186)

[0071] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Ser Ile Ser Thr Tyr 20 25 30 Leu Asn Trp Tyr Gln Gln Asn Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Phe Asp Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Arg Gly Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Ser Tyr Ser Ala Pro Leu 85 90 95 Thr Phe Gly Gly Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 194)

[0072] H4H12170P HCVR Gln Val Gln Leu Val Glu Ser Gly Gly Gly Val Val Gln Pro Gly Arg 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Ser Gly Tyr 20 25 30 Gly Met His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ala Leu Ile Trp Leu Asp Gly Ser Asn Asp Tyr Tyr Ala Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ser Lys Asn Thr Leu Tyr 65 70 75 80 Leu Gln Met Asn Arg Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Asp Gly Pro Val Ala Ala Ile Pro Asp Tyr Trp Gly Gln Gly 100 105 110 Thr Leu Val Thr Val Ser Ser 115 (SEQ ID NO: 202)

[0073] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Thr Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Ser Ile Ser Arg Trp 20 25 30 Leu Ala Trp Tyr Gln Leu Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Lys Ala Ser Ser Leu Glu Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Asp Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Tyr Asn Thr Tyr Ser Tyr 85 90 95 Thr Phe Gly Gln Gly Thr Lys Leu Glu Ile Lys 100 105 (SEQ ID NO: 210)

[0074] H4H12171P HCVR Glu Val Gln Leu Val Glu Ser Gly Gly Gly Val Val Arg Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Asp Glu Tyr 20 25 30 Gly Met Thr Trp Val Arg Gln Val Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ser Gly Ile Thr Trp Asn Gly Gly Phe Thr Asp Tyr Thr Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ser Ser Arg Asp Asn Ala Lys Asn Ser Leu Tyr 65 70 75 80 Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Leu Tyr Tyr Cys 85 90 95 Ala Arg Asp Gly Tyr Ser Ser Ser Trp Gly Ala Tyr Asp Ile Trp Gly 100 105 110 Gln Gly Thr Met Val Thr Val Ser Ser 115 120 (SEQ ID NO: 218)

[0075] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Ser Ile Ser Thr Tyr 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Leu Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Ser Tyr Phe Cys Gln Gln Ser Tyr Ser Thr Pro Tyr 85 90 95 Thr Phe Gly Gln Gly Thr Lys Leu Glu Ile Lys 100 105 (SEQ ID NO: 226)

[0076] H4H12175P HCVR Glu Val Gln Leu Val Glu Ser Gly Gly Gly Val Val Gln Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Asn Asp Tyr 20 25 30 Ala Met His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ser Leu Ile Ser Gly Asp Gly Gly Asn Thr Tyr Tyr Ala Asp Ser Val 50 55 60 Lys Gly Arg Leu Thr Ile Ser Arg Asp Asn Ser Lys Asn Ser Leu Tyr<( 65 70 75 80 Leu Gln Met Asn Ser Leu Arg Thr Glu Asp Thr Ala Leu Tyr Tyr Cys 85 90 95 Ala Lys Asp Lys Gly Trp Asn Phe Gly Tyr Phe Asp Leu Trp Gly Arg 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 234)

[0077] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Thr Ser Val Gly 1 5 10

[15] Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Asn Ile Asp Thr Tyr 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile Note: There seems to be a formatting issue with the tag <( in the original text which is corrected to in the translation. Also, the "

[15] " in the translation of line 36 is added to match the format in the original text as it's not clear if there's a specific meaning for the brackets there. If it's a mistake in the original, it should be adjusted accordingly.35 40 45 Tyr Asp Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Thr Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Asn Asp Asn Ile Leu His 85 90 95 Pro Leu Thr Phe Gly Gly Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 242)

[0078] H4H12176P2 HCVR Glu Val Gln Leu Val Glu Ser Gly Gly Gly Leu Val Gln Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe His Ser Asn Arg Tyr 20 25 30 Trp Met Asp Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ala Asn Ile Lys Gln Asp Gly Ser Glu Glu Asn Tyr Val Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ala Lys Asn Ser Leu Tyr 65 70 75 80 Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Asp Arg Ser Thr Ser Trp Val Pro Tyr Trp Phe Phe Asp Leu 100 105 110 Trp Gly Arg Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 250)

[0079] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Ser Ile Ser Ser Tyr 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Ser Tyr Ser Thr Pro Pro 85 90 95 Ile Thr Phe Gly Gln Gly Thr Arg Leu Glu Ile Lys 100 105 (SEQ ID NO: 258)

[0080] H4H12177P2 HCVR Glu Val Gln Leu Val Glu Ser Gly Gly Gly Val Val Gln Arg Gly Glu 1 5 10 15 Ser Leu Arg Leu Ser Cys Ser Ala Ser Asp Phe Ile Phe Lys Asp Tyr 20 25 30 Ala Met Tyr Trp Val Arg Gln Ile Pro Gly Lys Gly Leu Glu Trp Ile 35 40 45 Ser Leu Ile Ser Gly Asp Gly Asp Thr Thr Trp Tyr Gly Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Asn Glu Asn Ser Leu Phe 65 70 75 80 Leu Gln Met Asn Asp Leu Arg Thr Glu Asp Thr Ala Met Tyr Tyr Cys 85 90 95 Ala Arg Asp Met Gly Trp Asn Phe Phe Gln Leu Gln Tyr Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 1200] (SEQ ID NO: 266)

[0081] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Ser Ile Ser Ser Tyr 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ser Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Gln Gln Ser Tyr Ser Thr Pro Pro 85 90 95 Ile Thr Phe Gly Gln Gly Thr Arg Leu Glu Ile Lys 100 105 (SEQ ID NO: 258)

[0082] H4H12183P2 HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Ala Leu Val Lys Pro Ser Gln 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Gly Ser Ile Ile Arg Gly 20 25 30 Ser Thr Tyr Trp Ser Trp Val Arg Gln Phe Pro Gly Lys Gly Leu Glu 35 40 45 Trp Ile Gly Tyr Ser Tyr Tyr Ser Gly Thr Ala Tyr Tyr Asn Pro Ser 50 55 60 Leu Glu Ser Arg Ala Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe 65 70 75 80 Ser Leu Asn Leu Lys Ser Val Thr Ala Ala Asp Thr Ala Val Tyr Tyr 85 90 95 Cys Thr Arg Glu Ile Gly Val Ala Gly Leu Phe Asp Ile Trp Gly Gln 100 105 110 Gly Thr Leu Val Thr Val Ser Ser 115 120 (SEQ ID NO: 274) <000131!> LCVR Glu Ile Val Leu Thr Gln Ser Pro Gly Thr Leu Ser Leu Ser Pro Gly 1 5 10 15 Glu Arg Ala Thr Leu Ser Cys Arg Ala Ser Gln Ser Val Ser Ser Ser 20 25 30 Tyr Leu Ala Trp Tyr Gln Gln Lys Pro Gly Gln Ala Pro Arg Leu Leu 35 40 45 Ile Tyr Gly Ala Ser Ser Arg Ala Thr Gly Ile Pro Asp Arg Phe Ser 50 55 60 Gly Ser Gly Ser Gly Thr Asp Phe Thr Leu Thr Ile Ser Arg Leu Glu It should be noted that there seems to be an error in the tag

[0083] which is shown as <000131!> in the translation. Please check and correct if necessary.65 70 75 80 Pro Glu Asp Phe Ala Val Tyr Tyr Cys Gln Gln Tyr Gly Ser Ser Pro 85 90 95 Trp Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 282)

[0084] H2M11682N HCVR Gln Glu Gln Leu Val Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Ala 1 5 10 15 Ser Val Lys Val Ser Cys Lys Ala Ser Gly Tyr Thr Phe Thr Gly Tyr 20 25 30 Tyr Ile His Trp Val Arg Gln Ala Pro Gly Leu Gly Leu Glu Trp Met 35 40 45 Gly Trp Ile Asn Pro Asn Ser Gly Gly Thr Lys Tyr Ala Gln Lys Phe 50 55 60 Gln Gly Arg Val Thr Met Thr Arg Asp Thr Ser Ile Asn Thr Ala Tyr 65 7� 75 80 Met Glu Leu Lys Arg Leu Lys Ser Asp Asp Ser Ala Val Tyr Tyr Cys 85 90 95 Ala Arg Asp Ala Pro Pro His Asp Val Phe Asp Ile Trp Gly Gln Gly 100 105 110 Thr Leu Val Thr Val Ser Ser 115 (SEQ ID NO: 290)

[0085] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Gly Ile Arg Asn Asp 20 25 30 Leu Gly Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Arg Leu Ile 35 40 45 Tyr Ala Ala Ser Ser Leu Gln Ile Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Glu Phe Thr Leu Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Phe Ala Thr Tyr Tyr Cys Leu Gln His Asn Ser Tyr Pro Leu 85 90 95 Thr Phe Gly Gly Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 298)

[0086] H2M11684N HCVR Gln Val Gln Leu Gln Glu Ser Gly Pro Gly Leu Val Lys Pro Ser Gln 1 5 10 15 Thr Leu Ser Leu Thr Cys Thr Val Ser Gly Gly Ser Ile Ser Ser Gly 20 25 30 Ala Tyr His Trp Ser Trp Ile Arg Gln His Pro Gly Lys Gly Leu Glu 35 40 45 Trp Ile Gly Tyr Ile Tyr Tyr Asn Gly Asp Thr Tyr Tyr Asn Pro Ser 50 55 60 Leu Lys Ser Arg Val Thr Ile Ser Val Asp Thr Ser Lys Asn Gln Phe 65 70 75 80 Phe Leu Lys Val Thr Ser Val Thr Ala Ala Asp Thr Ala Met Tyr Tyr 85 90 95 Cys Ala Gly Glu Lys Gln Leu Thr Ala Phe Asp Ile Trp Gly Gln Gly 100 105 110 Thr Leu Val Thr Val Ser Ser 115 (SEQ ID NO: 306)

[0087] LCVR Val Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Arg Ala Ser Gln Asp Ile Asn Asn Phe 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Leu Gly Lys Ala Pro Lys Leu Leu Ile 35 40 45 Ser Asp Ala Ser Asn Leu Gln Thr Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Phe Thr Ile Ser Ser Leu Gln Pro 65 70 75 80 Glu Asp Ile Ala Ala Tyr Tyr Cys Gln Gln Tyr Asp His Phe Pro Tyr 85 90 95 Thr Phe Gly Gln Gly Thr Arg Leu Glu Asn Asn 100 105 (SEQ ID NO: 314)

[0088] H2M11694N HCVR Glu Val Gln Leu Val Glu Ser Gly Gly Gly Val Val Arg Pro Gly Gly 1 5 10 15 Ser Leu Arg Leu Ser Cys Ala Ala Ser Gly Phe Thr Phe Asp Asp Tyr 20 25 30 Gly Met Thr Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Val 35 40 45 Ser Gly Ile Asn Trp Asn Gly Asp Ser Thr Glu Tyr Ser Asp Ser Val 50 55 60 Lys Gly Arg Phe Thr Ile Ser Arg Asp Asn Ala Lys Asn Ser Leu Tyr 65 70 75 80 Leu Gln Met Asn Ser Leu Arg Ala Glu Asp Thr Ala Phe Tyr His Cys 85 90 95 Ala Arg Glu Asn Asn Trp Asn Phe Tyr Phe Asp Tyr Trp Gly Gln Gly 100 105 110 Thr Leu Val Thr Val Ser Ser 115 (SEQ ID NO: 322)

[0089] LCVR Glu Ile Val Met Thr Gln Ser Pro Ala Thr Leu Ser Val Ser Arg Gly 1 5 10 151] Glu Arg Ala Thr Leu Ser Cys Arg Ala Ser Gln Ser Val Ser Ser Asn 20 25 30 Leu Ala Trp Tyr Gln Gln Lys Leu Gly Gln Ala Pro Arg Leu Leu Ile 35 40 45 Tyr Gly Ala Ser Thr Arg Ala Thr Gly Ile Pro Ala Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Glu Phe Thr Leu Thr Ile Ser Ser Leu Gln Ser 65 70 75 80 Glu Asp Phe Ala Val Tyr Tyr Cys Gln Gln Tyr Asn Asn Trp Pro Trp 85 90 95 Thr Phe Gly Gln Gly Thr Lys Val Glu Ile Lys 100 105 (SEQ ID NO: 330)

[0090] H2M11695N HCVR Gln Val His Leu Val Gln Ser Gly Ala Glu Val Lys Lys Pro Gly Ala 1 5 10 15 Ser Val Lys Val Ser Cys Lys Val Ser Gly Asn Thr Leu Thr Glu Leu 20 25 30 Ser Met His Trp Val Arg Gln Ala Pro Gly Lys Gly Leu Glu Trp Met 35 40 45 Gly Gly Phe Asp Pro Glu Asp Gly Asp Thr Ile Tyr Ser Gln Lys Phe 50 55 60 Gln Gly Arg Val Thr Leu Thr Glu Asp Thr Ser Thr Asp Thr Ala Tyr 65 70 75 80 Met Glu Leu Ser Ser Leu Arg Ser Glu Asp Thr Ala Val Tyr Tyr Cys 85 90 95 Ser Thr Val Gly Gly Pro Thr Ser Asp Cys Trp Gly Gln Gly Thr Leu 100 105 110 Val Thr Val Ser Ser 115 (SEQ ID NO: 338)

[0091] LCVR Asp Ile Gln Met Thr Gln Ser Pro Ser Ser Leu Ser Ala Ser Val Gly 1 5 10 15 Asp Arg Val Thr Ile Thr Cys Gln Ala Ser Gln Asp Ile Ser Asn Tyr 20 25 30 Leu Asn Trp Tyr Gln Gln Lys Pro Gly Lys Ala Pro Lys Val Leu Ile 35 40 45 Phe Asp Ala Ser Asn Leu Glu Pro Gly Val Pro Ser Arg Phe Ser Gly 50 55 60 Ser Gly Ser Gly Thr Asp Phe Thr Phe Thr Ile Ile Ser Leu Gln Pro 65 70 75 80 Glu Asp Ile Ala Thr Tyr Tyr Cys Gln Gln Tyr Asp Asn Leu Pro Ile 85 90 95 Thr Phe Gly Gln Gly Thr Arg Leu Asp Ile Lys 100 105 (SEQ ID NO: 346)

[0092] In one embodiment of the present invention, any antigen-binding protein (anti-C5) that specifically binds to C5 discussed herein is an antagonist. Such an antagonist (e.g., an antagonist antigen-binding protein that specifically binds to C5) binds to C5 and inhibits at least one biological activity of C5; for example, preventing or blocking complement-mediated hemolysis via the classical or alternative pathway, and / or inhibiting the cleavage of C5 into C5a and C5b, and / or inhibiting complement-mediated lysis of red blood cells, and / or inhibiting the formation of the membrane attack complex (MAC), and / or inhibiting the formation of the C5b-6 complex.

[0093] In one embodiment of the invention, the antagonist antigen-binding protein that specifically binds to C5 is eculizumab (sold as Soliris), ravulizumab (ALXN1210; sold as Ultomiris), tesidolumab (see US8241628; WO2010 / 015608; or WO2017 / 212375), or mubodina (see US7999081); or an antigen-binding fragment thereof. In one embodiment of the invention, the antagonist antigen-binding protein that specifically binds to C5 is the pozelimuab (REGN3918; H4H12166P) antibody; or an antigen-binding fragment thereof. The pozelimuab (REGN3918; H4H12166P) antibody has the amino acid sequence: QVQLQESGPG LVKPSETLSL TCTVSGDSVS SSYWTWIRQP PGKGLEWIGY IYYSGSSNYN 60 PSLKSRATIS VDTSKNQFSL KLSSVTAADT AVYYCAREGN VDTTMIFDYW GQGTLVTVSS 120 ASTKGPSVFP LAPCSRSTSE STAALGCLVK DYFPEPVTVS WNSGALTSGV HTFPAVLQSS 180 GLYSLSSVVT VPSSSLGTKT YTCNVDHKPS NTKVDKRVES KYGPPCPPCP APEFLGGPSV 240 FLFPPKPKDT LMISRTPEVT CVVVDVSQED PEVQFNWYVD GVEVHNAKTK PREEQFNSTY 300 RVVSVLTVLH QDWLNGKEYK CKVSNKGLPS SIEKTISKAK GQPREPQVYT LPPSQEEMTK 360 NQVSLTCLVK GFYPSDIAVE WESNGQPENN YKTTPPVLDS DGSFFLYSRL TVDKSRWQEG 420 NVFSCSVMHE ALHNHYTQKS LSLSLGK 447 (SEQ ID NO:368); heavy chain immunoglobulins containing and the amino acid sequence: AIQMTQSPSS LSASVGDRVT ITCRASQGIR NDLGWYQQKP GKAPKLLIYA ASSLQSGVPS 60 RFAGRGSGTD FTLTISSLQP EDFATYYCLQ DFNYPWTFGQ GTKVEIKRTV AAPSVFIFPP 120 SDEQLKSGTA SVVCLLNNFY PREAKVQWKV DNALQSGNSQ ESVTEQDSKD STYSLSSTLT 180 LSKADYEKHK VYACEVTHQG LSSPVTKSFN RGEC 214 (SEQ ID NO: 369) The immunoglobulin comprises a light chain comprising:

[0094] The present invention relates to the variable regions (V) of the polypeptides specifically discussed herein (e.g., of pozeliman). H and V L ) and / or CDR (V including LCDR1, LCDR2 and LCDR3 L and V comprising HCDR1, HCDR2 and HCDR3. H ), as well as methods of using antagonist antigen binding proteins, e.g., antibodies and antigen-binding fragments thereof, that specifically bind to C5, comprising variable regions and CDRs that are variants of those discussed herein.

[0095] Immunoglobulin chains (e.g., H2M11683N; H2M11686N; H4H12159P; H4H12161P; H4H12163P; H4H12164P; H4H12166P; H4H12166P2; H4H12166P3; H4H12166P4; H4H12166P5; H4H12166P6; H4H12166P7; H4H12166P8; H4 H12166P9;H4H12166P10;H4H12167P;H4H12168P;H4H12169P;H4H12170P;H4H12171P;H4H12175P;H4H12176P2;H4H12177P2;H4H12183P2;H2M11682N;H2M11684N;H2M11694N;H2M11695N; ravulizumab, eculizumab, tesidormab, or mubodina V H , V L"Variants" of polypeptides such as the CDRs thereof (HC or LC or CDRs thereof) may be any of the reference amino acid sequences described herein (e.g., SEQ ID NOs: 2; 4; 6; 8; 10; 12; 14; 16; 18; 20; 22; 24; 26; 28; 30; 32; 34; 36; 38; 40; 42; 44; 46; 48; 50; 52; 54; 56; 58; 60; 62; 64; 66; 68; 70; 72; 74; 76; 78; 80; 82; 84; 86; 88; 90; 92; 94; 96; 98; 100; 102; 104; 106; 108; 110; 112; 114; 116; 118; 119; 120; 121; 122; 123; 124; 126; 128; 129; 130; 131; 132; 133; 134; 135; 136; 137; 138; 140; 141; 142; 143; 144; 145; 146; 147; 148; 149; 150; 151; 152; 153; 154; 155; 156; 157; 158; 159; 160; 161; 162; 163; 164; 165; 00;102;104;106;108;110;112;114;116;118;120;122;124;126;128;130;132;134;136;138;140;142;144;146;148;150;152;154;156;158;160;162;164;166;168;170;172;174;176;178;180;182;184;186;188;190;192;194;196;198;200;202;204 ;206;208;210;212;214;216;218;220;222;224;226;228;230;232;234;236;238;240;242;244;246;248;250;252;254;256;258;260;262;264;266;268;270;272;274;276;278;280;282;284;286;288;290;292;294;296;298;300;302;304;306;308;3 10;312;314;316;318;320;322;324;326;328;330;332;334;336;338;340;342;344;346;348;350 and / or 352) and at least about 70 to 99.9% (e.g., at least 70, 72, 74, 75, 76, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 99.5 or 99.9%) refers to polypeptides containing amino acid sequences that are identical or similar; see, e.g., Table A; when the comparison is performed using the BLAST algorithm, with algorithm parameters selected to maximize matches between the respective sequences over the entire length of each reference sequence (e.g., expectation threshold: 10; word size: 3; maximum matches in query range: 0; BLOSUM 62 matrix; gap costs: presence 11, extension 1; conditional composition score matrix adjustment).

[0096] Additionally, variants of the polypeptides may be any of the immunoglobulin chains specifically described herein (e.g., H2M11683N; H2M11686N; H4H12159P; H4H12161P; H4H12163P; H4H12164P; H4H12166P; H4H12166P2; H4H12166P3; H4H12166P4; H4H12166P5; H4H12166P6; H4H12166P7; H4H12166P 8;H4H12166P9;H4H12166P10;H4H12167P;H4H12168P;H4H12169P;H4H12170P;H4H12171P;H4H12175P;H4H12176P2;H4H12177P2;H4H12183P2;H2M11682N;H2M11684N;H2M11694N;H2M11695N;ravulizumab, eculizumab, tesidormab, or mubodina V H , V L , HC or LC or its CDRs); provided that the polypeptides may include polypeptides containing one or more (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10) mutations, e.g., one or more missense mutations (e.g., conservative substitutions), nonsense mutations, deletions, or insertions. For example, the present invention provides an immunoglobulin light chain (or VH chain) comprising the amino acid sequence set forth in SEQ ID NO: 106, but having one or more of such mutations. L ) variants, and / or immunoglobulin heavy chains (or V) comprising the amino acid sequence set forth in SEQ ID NO: 98 but having one or more of such mutations. Hand methods of using antagonist antigen-binding proteins, e.g., antibodies and antigen-binding fragments thereof, that specifically bind to C5, comprising CDR-L1, CDR-L2, and CDR-L3 variants. In one embodiment of the present invention, the antagonist antigen-binding proteins that specifically bind to C5 comprise immunoglobulin light chain variants that comprise CDR-L1, CDR-L2, and CDR-L3, where one or more (e.g., one, two, or three) of such CDRs have one or more of such mutations (e.g., conservative substitutions), and / or immunoglobulin heavy chain variants that comprise CDR-H1, CDR-H2, and CDR-H3, where one or more (e.g., one, two, or three) of such CDRs have one or more of such mutations (e.g., conservative substitutions).

[0097] The following references relate to the BLAST algorithm, which is often used for sequence analysis: BLAST ALGORITHMS: Altschul et al. (2005) FEBS J. 272(20):5101-5109; Altschul, S. F. et al. (1990) J. Mol. Biol. 215:403-410; Gish, W. et al. (1993) Nature Genet. 3:266-272; Madden, T. L. et al. (1996) Meth. Enzymol. 266:131-141; Altschul, S. F. et al. (1997) Nucleic Acids Res. 25:3389-3402; Zhang, J. et al. (1997) Genome Res. 7:649-656; Wootton, J. C. et al. (1993) Comput. Chem. 17:149-163; Hancock, JM et al., (1994) Comput. Appl. Biosci. 10:67-70; Dayhoff, MO et al., "A model of evolutionary change in proteins." in ALIGNMENT SCORING SYSTEMS: Atlas of Protein Sequence and Structure, (1978) Vol. 5, Supplementary Issue 3, MO Dayhoff (ed.), pp. 345-352, Natl. Biomed. Res. Found., Washington, DC; Schwartz, RM et al., "Matrices for detecting distant relationships." in Atlas of Protein Sequence and Structure, (1978) Vol. 5, Supplementary Issue 3, MO Dayhoff (ed.), pp. 353-358, Natl. Biomed. Res. Found., Washington, DC; Altschul, SF, (1991) J. Mol. Biol. 219:555-565; States, DJ et al. (1991) Methods 3:66-70; Henikoff, S. et al. (1992) Proc. Natl. Acad. Sci. USA 89:10915-10919; Altschul, SF et al. (1993) J.Mol. Evol. 36:290-300; ALIGNMENT STATISTICS: Karlin, S. et al., (1990) Proc. Natl. Acad. Sci. USA 87:2264-2268; Karlin, S. et al., (1993) Proc. Natl. Acad. Sci. USA 90:5873-5877; Dembo, A. et al., (1994) Ann. Prob. 22:2022-2039; and Altschul, S. F. "Evaluating the statistical significance of multiple distinct local alignments." in Theoretical and Computational Methods in Genome Research (ed. S. Suhai), (1997) pp. 1-14, Plenum, NY.

[0098] Unless otherwise noted, "H2M11683N"; "H2M11686N"; "H4H12159P"; "H4H12161P"; "H4H12163P"; "H4H12164P"; "H4H12166P"; "H4H12166P2"; "H4H12166P3"; "H4H12166P4"; "H4H12166P5"; "H4H12166P6"; "H4H12166P7"; "H4H12166P8" ;"H4H12166P9";"H4H12166P10";"H4H12167P";"H4H12168P";"H4H12169P";"H4H12170P";"H4H12171P";"H4H12175P";"H4H12176P2";"H4H12177P2";"H4H12183P2";"H2M11682N";"H2M11684N";"H2M11694N" or "H2M116 95N" respectively correspond to H2M11683N;H2M11686N;H4H12159P;H4H12161P;H4H12163P;H4H12164P;H4H12166P;H4H12166P2;H4H12166P3;H4H12166P4;H4H12166P5;H4H12166P6;H4H12166P7;H4H12166P8;H4H12166P9;H4H12166P10; in Table A. an immunoglobulin heavy chain or variable region thereof (V) comprising an amino acid sequence specifically described herein corresponding to H4H12167P; H4H12168P; H4H12169P; H4H12170P; H4H12171P; H4H12175P; H4H12176P2; H4H12177P2; H4H12183P2; H2M11682N; H2M11684N; H2M11694N; or H2M11695N; H) (e.g., SEQ ID NOs: 2; 18; 34; 50; 66; 82; 98; 138; 146; 122; 146; 154; 170; 186; 202; 218; 234; 250; 266; 274; 290; 306; 322 or 338) (or variants thereof), and / or H2M11683N; H2M11686N; H4H12159P; H4H12161P; H4H12163P; H4H12164P; H4H12166P; H4H12166P2; H4H12166P3; H4H12166P4; H4H12166P5; H4H12166P6; an immunoglobulin light chain or variable region thereof (V) comprising an amino acid sequence specifically described herein corresponding to H12166P6; H4H12166P7; H4H12166P8; H4H12166P9; H4H12166P10; H4H12167P; H4H12168P; H4H12169P; H4H12170P; H4H12171P; H4H12175P; H4H12176P2; H4H12177P2; H4H12183P2; H2M11682N; H2M11684N; H2M11694N or H2M11695N; L ) (e.g., SEQ ID NO: 10; 26; 42; 58; 74; 90; 106; 114; 130; 162; 178; 194; 210; 226; 242; 258; 282; 298; 314; 330 or 346) (or a variant thereof); and / or a heavy chain or V comprising its CDRs (CDR-H1 (or a variant thereof), CDR-H2 (or a variant thereof) and CDR-H3 (or a variant thereof)). H , and / or a light chain or V comprising its CDRs (CDR-L1 (or a variant thereof), CDR-L2 (or a variant thereof), and CDR-L3 (or a variant thereof)). L In one embodiment of the present invention, V refers to an antagonist antigen-binding protein that specifically binds to C5, e.g., antibodies and antigen-binding fragments thereof (including multispecific antigen-binding proteins) that specifically bind to C5 (e.g., human C5)—also see International Patent Application Publication No. WO 2017 / 218515. His linked to a constant heavy chain domain, such as a human constant heavy chain domain (e.g., IgG, IgG1, or IgG4 (e.g., IgG4 (S228P mutant, Eu nubbering))), and / or V L is linked to a constant light chain domain, such as a human constant light chain domain (e.g., lambda or kappa). In one embodiment of the invention, the heavy chain constant domain is IgG4 with an S108P mutation.

[0099] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H2M11683N, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO:2, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO:10 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0100] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H2M11686N, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 18, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 26 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0101] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12159P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 34, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 42 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0102] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12161P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 50, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 58 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0103] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12163P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 66, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 74 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0104] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12164P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 82, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 90 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0105] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 98, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 106 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0106] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P2, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 98, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 114 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0107] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P3, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 122, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 106 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0108] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P4, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 98, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 130 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0109] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P5, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 138, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 106 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0110] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P6, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 146, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 106 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0111] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P7, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 122, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 130 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0112] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P8, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 146, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 114 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0113] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P9, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 146, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 130 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0114] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12166P10, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 138, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 130 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0115] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12167P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 154, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 162 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0116] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12168P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 170, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 178 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0117] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12169P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 186, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 194 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0118] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12170P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 202 and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 210 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0119] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12171P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 218, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 226 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0120] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12175P, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 234, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 242 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0121] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12176P2, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 250, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 258 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0122] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12177P2, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 266, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 258 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0123] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H4H12183P2, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 274, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 282 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0124] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H2M11682N, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 290 and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 298 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0125] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H2M11684N, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 306, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 314 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0126] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H2M11694N, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 322 and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 330 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0127] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds to C5, H2M11695N, comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 338, and an LCVR comprising the amino acid sequence set forth in SEQ ID NO: 346 (e.g., the antigen binding protein is an antibody or antigen-binding fragment thereof).

[0128] Thus, the present invention provides a method for the production of a VH1-dependent agonist comprising administering to a subject a VH1-dependent agonist a VH1-dependent agonist a VH1-dependent agonist a VH1-dependent agonist b VH1-dependent agonist b VH1-dependent agonist b VH1-dependent agonist b VH1-dependent agonist c ...H and V L variable domain (e.g., V linked to a human IgG4 heavy chain constant region) H , and V linked to the human kappa light chain constant region L ), including antigen-binding proteins (e.g., H2M11683N; H2M11686N; H4H12159P; H4H12161P; H4H12163P; H4H12164P; H4H12166P; H4H12166P2; H4H12166P3; H4H12166P4; H4H12166P5; H4H12166P6; H4H12166P7; H4H12166P8; H4H12166P9; H4 H12166P10;H4H12167P;H4H12168P;H4H12169P;H4H12170P;H4H12171P;H4H12175P;H4H12176P2;H4H12177P2;H4H12183P2;H2M11682N;H2M11684N;H2M11694N;H2M11695N; including ravulizumab, eculizumab, tesidormab or mubodina).

[0129] The term "antibody," as used herein, refers to an immunoglobulin molecule comprising four polypeptide chains (e.g., IgG4), two heavy chains (HC) comprising three H-CDRs and two light chains (LC) comprising three L-CDRs, interconnected by disulfide bonds—e.g., H2M11683N; H2M11686N; H4H12159P; H4H12161P; H4H12163P; H4H12164P; H4H12166P; H4H12166P2; H4H12166P3; H4H12166P4; H4H12166P5; H4H12166P6; H4H12166P7; H4H12166P8; H4H1216 6P9;H4H12166P10;H4H12167P;H4H12168P;H4H12169P;H4H12170P;H4H12171P;H4H12175P;H4H12176P2;H4H12177P2;H4H12183P2;H2M11682N;H2M11684N;H2M11694N;or H2M11695N. In one embodiment of the present invention, the amino acid assignments for each CDR domain in an immunoglobulin chain are according to the definitions in Sequences of Proteins of Immunological Interest, Kabat et al.; National Institutes of Health, Bethesda, Md.; 5th ed.; NIH Publ. No. 91-3242 (1991); Kabat (1978) Adv. Prot. Chem. 32:1-75; Kabat et al. (1977) J. Biol. Chem. 252:6609-6616; Chothia et al. (1987) J Mol. Biol. 196:901-917 or Chothia et al. (1989) Nature 342:878-883. Thus, the present invention provides a method for the preparation of V H and V L comprises the amino acid sequence described herein (or a variant thereof), and the CDRs are defined by Kabat and / or Chothia, H CDR and V L and antibodies and antigen-binding fragments comprising the CDRs of

[0130] The term "antigen-binding portion" or "antigen-binding fragment" of an antibody or antigen-binding protein, etc., as used herein, does not include the entire sequence of an antibody, but includes any naturally occurring, enzymatically obtainable, synthetic, or genetically engineered polypeptide or glycoprotein that specifically binds an antigen (e.g., C5). Non-limiting examples of antigen-binding fragments include: (i) F(ab) and F(ab') fragments; (ii) F(ab')2 fragments; (iii) Fd fragments (the heavy chain portion of the Fab fragment cleaved with papain); (iv) Fv fragments (V H or V L and (v) single-chain Fv (scFv) molecules; FR3-CDR3-FR4 peptides having amino acid residues that mimic the hypervariable regions of an antibody (e.g., isolated complementarity-determining regions (CDRs), such as CDR3 peptides), or constrained. Other engineered molecules, such as single-domain antibodies, domain-deleted antibodies, minibodies, and small modular immunopharmaceuticals (SMIPs), are also encompassed within the term "antigen-binding fragment" as used herein. In one embodiment of the invention, the antigen-binding fragment comprises one of the following: H2M11683N;H2M11686N;H4H12159P;H4H12161P;H4H12163P;H4H12164P;H4H12166P;H4H12166P2;H4H12166P3;H4H12166P4;H4H12166P5;H4H12166P6;H4H12166P7;H4H12166P8;H4H12166P9;H4H12166P10;H4H12167 P; H4H12168P; H4H12169P; H4H12170P; H4H12171P; H4H12175P; H4H12176P2; H4H12177P2; H4H12183P2; H2M11682N; H2M11684N; H2M11694N; or H2M11695N (e.g., CDR-H1, CDR-H2 and CDR-H3; and / or CDR-L1, CDR-L2 and CDR-L3).

[0131] The term "recombinant" antigen-binding protein, such as an antibody or antigen-binding fragment thereof, refers to such molecules that are made, expressed, isolated, or obtained by techniques or methods known in the art as recombinant DNA technology, including, for example, DNA splicing and transgenic expression. The term includes antibodies expressed in non-human mammals (including transgenic non-human mammals, e.g., transgenic mice), or host cells (e.g., Chinese hamster ovary (CHO) cells) or cellular expression systems, or antibodies isolated from recombinant combinatorial human antibody libraries. The present invention relates to recombinant antigen binding proteins described herein (e.g., H2M11683N; H2M11686N; H4H12159P; H4H12161P; H4H12163P; H4H12164P; H4H12166P; H4H12166P2; H4H12166P3; H4H12166P4; H4H12166P5; H4H12166P6; H4H12166P7; H4H121 66P8; H4H12166P9; H4H12166P10; H4H12167P; H4H12168P; H4H12169P; H4H12170P; H4H12171P; H4H12175P; H4H12176P2; H4H12177P2; H4H12183P2; H2M11682N; H2M11684N; H2M11694N; or H2M11695N).

[0132] The present invention includes methods using monoclonal antagonist antigen-binding proteins (e.g., antibodies and antigen-binding fragments thereof) that specifically bind to C5. The term "monoclonal antibody" or "mAb," as used herein, refers to an antibody derived from a population of substantially homogeneous antibodies, i.e., the antibody molecules comprising the population are identical in amino acid sequence except for naturally occurring mutations that may be present in minor amounts. The modifier "monoclonal" is not to be construed as requiring production of the antibody by any particular method. Monoclonal antibodies can be made by the hybridoma method of Kohler et al. (1975) Nature 256:495, or can be made by recombinant DNA methods (see, e.g., U.S. Pat. No. 4,816,567).

[0133] "Isolated" antagonist antigen-binding proteins (e.g., antibodies or antigen-binding fragments thereof), polypeptides, polynucleotides, and vectors that specifically bind to C5 are at least partially free from other biological molecules from the system, cell, or cell culture in which they are produced. Such biological molecules include nucleic acids, proteins, other antibodies or antigen-binding fragments, lipids, carbohydrates, or other substances such as cell debris and growth medium. Isolated antigen-binding proteins may also be at least partially free from the growth medium in which host cells expressing the antigen-binding protein are grown. In general, the term "isolated" is not limited to the complete absence of such biological molecules (e.g., small or trace amounts of impurities may remain), or to the absence of water, buffers, or salts, or components of pharmaceutical formulations that include the antigen-binding protein (e.g., antibody or antigen-binding fragment).

[0134] An "anti-C5" antigen binding protein specifically binds to C5 (e.g., human C5 or cynomolgus monkey C5). The term "specifically binds" means to bind to C5 with an affinity of at least about 10 as measured by a real-time, label-free biolayer interference assay, such as an Octet® HTX biosensor, or surface plasmon resonance, such as BIACORE™, or solution affinity ELISA. -9 M or less (lower number) (e.g., about 10 -10 M, about 10 -11 M or about 10 -12 M)'s K D In one embodiment of the present invention, the K for binding to human C5 at 25° C., pH 7.4 by surface plasmon resonance assay is used. D is approximately 189 pM; K for binding to human C5 (R885C or R885H) D The K for binding to cynomolgus monkey C5 was approximately 400–500 pM; D is about 2-3 nM. In one embodiment of the present invention, human C5 (including the signal sequence) comprises the amino acid sequence set forth in SEQ ID NO: 362; mature human C5 containing the mutation R885H comprises the amino acid sequence set forth in SEQ ID NO: 363.

[0135] dosage The present invention includes methods of treating or preventing a C5-related disease in a subject and / or ameliorating at least one sign or symptom associated with such a C5-related disease by administering to the subject an antagonist antigen binding protein that specifically binds to C5 (e.g., REGN3918) as follows: (i) about 30 mg / kg (body weight (BW)) of antigen binding protein administered intravenously (IV) in one or more doses (e.g., one dose); followed by (ii) about 800 mg of antigen binding protein administered subcutaneously (SC) in one or more doses (e.g., two or more doses) (this is referred to herein as a 30+800 dose regimen), or one or more SC doses according to body weight as follows: for body weight (BW) < 10 kg: about 125 mg; for BW > 10 kg and < 20 kg: about 200 mg; for BW > 20 kg and < 40 kg: about 350 mg; for BW > 40 kg and < 60 kg: about 500 mg; and for BW > 60 kg: about 800 mg. Such SC dose(s) are given on a weekly basis after the initial IV dose(s). Weekly administration can be continued indefinitely, for example, as long as therapeutic benefit or prevention of undesirable outcomes (e.g., loss of serum albumin or increased serum LDH levels) is desired. Optionally, the subject receives one or more doses of an oligonucleotide (e.g., semdisirane) in conjunction with an antigen-binding protein.

[0136] In one embodiment of the present invention, an antagonist antigen binding protein that specifically binds C5 (e.g., pozelimab) is administered to a patient in the methods described herein (e.g., to treat or prevent PNH or CHAPLE), provided that other agents that reduce complement activity (e.g., reduce C5 activity), e.g., oligonucleotides such as semdisirane (e.g., reduce C5 expression), or antibodies or antigen-binding fragments thereof that specifically bind C5 are not administered to the patient.

[0137] The present invention also includes a method for treating or preventing a C5-related disease (e.g., PNH or CHAPLE) by administering approximately 30 mg / kg (body weight (BW)) of an antagonist antigen-binding protein that specifically binds to C5 (e.g., REGN3918) or a pharmaceutical formulation thereof intravenously (IV) one or more times (e.g., one or more times). Intravenous administration of 30 mg / kg has been demonstrated to rapidly achieve the steady-state trough concentration of the antigen-binding protein (e.g., antibody) required for sustained maximum CH50 inhibition, and thus help to provide a therapeutic effect in the subject. Optionally, further subcutaneous administration of the antigen-binding protein may be given to the subject, e.g., weekly, e.g., after the IV administration(s).

[0138] In one embodiment of the invention, a subject (e.g., suffering from PNH) is administered: (i) about 30 mg / kg of an antagonist antigen binding protein that specifically binds C5 intravenously (IV) initially (day 1); then (ii) about 800 mg of the antigen binding protein once a week (e.g., on days +1, +2 or +3), for example, on about day 8 (e.g., days +1, +2 or +3), day 15 (e.g., days +1, +2 or +3), day 22 (e.g., days +1, +2 or +3), etc., and weekly thereafter (e.g., on days +1, +2 or +3) (e.g., subcutaneously (SC)).

[0139] The present invention relates to a method for producing a compound having the following properties: H2M11683N;H2M11686N;H4H12159P;H4H12161P;H4H12163P;H4H12164P;H4H12166P;H4H12166P2;H4H12166P3;H4H12166P4;H4H12166P5;H4H12166P6;H4H12166P7;H4H12166P8;H4H12166P9;H4H12166P10;H4H12167P;H4H12168P;H4H12169P;H and H2M11695N. In one embodiment of the present invention, the subject (e.g., suffering from CHAPLE) is administered a therapeutically effective dose (e.g., 30 mg / kg intravenously) of an antagonist antigen binding protein that specifically binds to C5 selected from: H4H12170P; H4H12171P; H4H12175P; H4H12176P2; H4H12177P2; H4H12183P2; H2M11682N; H2M11684N; H2M11694N; and H2M11695N, or a pharmaceutical formulation thereof. In one embodiment of the present invention, the subject (e.g., suffering from CHAPLE) is administered a therapeutically effective dose (e.g., 30 mg / kg intravenously) of an antagonist antigen binding protein that specifically binds to C5 selected from: H4H12170P; H4H12171P; H4H12175P; H4H12176P2; H4H12177P2; H4H12183P2; H2M11682N; H2M11684N; H2M11694N; and H2M11695N. (i) about 30 mg / kg of antigen-binding protein is administered intravenously (IV) (on day 1); and then (ii) One or more doses administered subcutaneously (SC) starting on about day 8 (e.g., day 8, day 8+1, day 8+2, or day 8+3) and continuing weekly thereafter at a dose proportionate to body weight (BW) as follows: For body weight (BW) < 10 kg: approx. 125 mg; · For BW ≥ 10 kg and < 20 kg: approximately 200 mg; · For BW ≥ 20 kg and < 40 kg: approximately 350 mg; For BW ≥ 40 kg and < 60 kg: approximately 500 mg; and For BW≧60kg: approximately 800mg.

[0140] Weekly dosing, or weekly dosing, or QW dosing, refers to one or more administrations, each occurring about 7 (eg, +1, +2, or +3) days after the immediately preceding administration.

[0141] In one embodiment of the present invention, the IV and first SC doses are given on the same day.

[0142] In one embodiment of the invention, an antagonist antigen binding protein that specifically binds C5, when administered subcutaneously (SC), is delivered in a volume of less than 7 ml, about 0.625 ml, about 1 ml, about 1.75 ml, about 2.5 ml, about 4 ml, about 0.5-4.0 ml, or about 0.625-4.0 ml. In one embodiment of the invention, each SC administration is delivered in a single injection. In one embodiment of the invention, the SC injection is delivered in about 60 seconds or less.

[0143] In one embodiment of the invention, a subject (e.g., suffering from a C5-related disease) is administered one or more doses of an antagonist antigen binding protein that specifically binds C5 as follows: 1 mg / kg IV; 3 mg / kg IV; 300 mg SC; 800 mg SC; 10 mg / kg IV; 600 mg SC; or 30 mg / kg IV; or a loading dose of 15 mg / kg IV followed by one or more SC administrations of 400 mg administered once weekly.

[0144] A serum concentration in a human subject of approximately 100 mg / liter of an antagonist antigen binding protein (e.g., REGN3918) that specifically binds to C5 maximally inhibits C5 activity (e.g., alternative, classical, and lectin pathways) (e.g., as measured by AH50 and / or CH50 assays). Thus, the present invention includes methods of suppressing complement activity or C5 activity (e.g., alternative pathway (AP)) in a subject (e.g., suppressing C5 activity to about its maximal level (e.g., at least about 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99% or 100%); e.g., measured as AH50 and / or CH50 activity), comprising one or more administrations of an anti-C5 antigen binding protein at a level sufficient to maintain a serum concentration of the antigen binding protein at about 100 mg / liter or greater (e.g., 150, 400, 600 or 700 mg / liter). In one embodiment of the invention, the dosing regimen comprises: (i) administering one or more (e.g., one) dose of about 30 mg / kg (body weight (BW)) of the antigen binding protein intravenously (IV); (ii) administering about 800 mg of the antigen binding protein one or more times (e.g., two or more times) weekly (e.g., subcutaneously (SC)); or This includes one or more weekly doses administered subcutaneously (SC) according to body weight (BW) as follows: for body weight (BW) < 10 kg: about 125 mg; for BW > 10 kg and < 20 kg: about 200 mg; for BW > 20 kg and < 40 kg: about 350 mg; for BW > 40 kg and < 60 kg: about 500 mg; or for BW > 60 kg: about 800 mg. Weekly administration can be continued indefinitely, for example, as long as maintenance of serum concentrations of anti-C5 antigen binding protein and / or suppression of C5 activity is desired.

[0145] The present invention provides a method of achieving, or achieving and maintaining in a subject, a serum concentration (e.g., a steady-state serum trough concentration over time) of about 100 mg / liter or greater of an antagonist antigen binding protein that specifically binds to C5, comprising: (i) administering one or more (e.g., a single) dose of about 30 mg / kg (body weight (BW)) of the antigen binding protein intravenously (IV); then, optionally, (ii) one or more weekly administrations (e.g., two or more times) of about 800 mg of antigen binding protein (e.g., subcutaneously (SC)); or the method comprising one or more weekly administrations administered subcutaneously (SC) according to body weight (BW) as follows: for body weight (BW) < 10 kg: about 125 mg; for BW > 10 kg and < 20 kg: about 200 mg; for BW > 20 kg and < 40 kg: about 350 mg; for BW > 40 kg and < 60 kg: about 500 mg; or for BW > 60 kg: about 800 mg. Weekly administration can be continued indefinitely, for example, as long as maintenance of anti-C5 antigen binding protein serum concentrations is desired.

[0146] The present invention further provides therapeutic regimens comprising administration of eculizumab or ravulizumab: H2M11683N; H2M11686N; H4H12159P; H4H12161P; H4H12163P; H4H12164P; H4H12166P; H4H12166P2; H4H12166P3; H4H12166P4; H4H12166P5; H4H12166P6; H4H12166P7; H4H12166P8; H4H12166P9; H4H12166P10; H4H12167P; H4H12168P; H4H12169P; H4H12170P; H4H12 and H2M11695N, comprising administering an initial dose of the antigen binding protein to the subject when the next dose is scheduled for an eculizumab or ravulizumab treatment regimen, and discontinuing further administrations of eculizumab or ravulizumab. In one embodiment of the invention, the initial dose of the antigen binding protein is about 30 mg / kg (body weight (BW)) of the antigen binding protein intravenously (IV), optionally followed by one or more further IV administrations. In one embodiment of the invention, after IV administration(s), the subject receives one or more weekly subcutaneous doses of about 800 mg of the antigen binding protein (e.g., two or more doses); or one or more weekly subcutaneous doses depending on body weight (BW) as follows: for body weight (BW) < 10 kg: about 125 mg; for BW > 10 kg and < 20 kg: about 200 mg; for BW > 20 kg and < 40 kg: about 350 mg; for BW > 40 kg and < 60 kg: about 500 mg; or for BW > 60 kg: about 800 mg. In one embodiment of the invention, such a switching method eliminates overlap between the eculizumab or ravulizumab administration regimen and the administration regimen of the antagonist antigen binding protein that specifically binds C5.

[0147] In one embodiment of the present invention, intravenous infusion of an antagonist antigen binding protein that specifically binds C5 is interrupted and resumed at 50% of the original infusion rate if the subject experiences one or more adverse events during the infusion, such as, for example: cough, chills / chills, rash, pruritus (itching), urticaria (hives, weals, wheals), diaphoresis (sweating), hypotension, dyspnea (shortness of breath), vomiting, or flushing.

[0148] The term "C5-associated disease" refers to a disease, disorder, condition, or syndrome caused, maintained, or exacerbated directly or indirectly by complement system activity, or a disease, disorder, condition, or syndrome whose signs and / or symptoms are caused, maintained, or exacerbated, and whose complement system activity can be reduced, stabilized, or eliminated by inhibiting C5 activity. Such C5 activity can be inhibited, for example, by preventing cleavage of C5 precursors into C5a and C5b chains, formation of the membrane attack complex (MAC), and / or binding of the MAC to the surface of target cells (e.g., red blood cells). In one embodiment of the present invention, C5 activity inhibition is measured by a CH50 assay.

[0149] The CH50 (50% Hemolytic Complement) is an assay that determines the level of the classical complement pathway and is sensitive to the reduction, absence, and / or inactivation of any component of the pathway, as is known in the art. CH50 tests the functional ability of serum complement components of the classical pathway to lyse sheep red blood cells (SRBCs) precoated with rabbit anti-sheep red blood cell antibodies (hemolysins). For example, when antibody-coated SRBCs are incubated with test serum, the classical pathway of complement is activated and hemolysis occurs. If complement components are absent, the CH50 level will be zero; if one or more components of the classical pathway are reduced, the CH50 will decrease. A fixed volume of optimally sensitized SRBCs is added to each serum dilution. For example, after incubation, the mixture is centrifuged, and the degree of hemolysis is quantified by measuring the absorbance of hemoglobin released into the supernatant at 540 nm. The amount of complement activity is determined by examining the ability of various dilutions of test serum to lyse antibody-coated SRBCs. See Costabile, Measuring the 50% hemolytic complement (CH50) activity of serum, J Vis Exp. 2010(37):1923; and E.A. Kabat and M.M. Mayer (eds.), Complement and complement fixation, in Experimental immunochemistry. Thomas, Springfield, 1961, pp. 133-240. AH50 is a similar test that measures alternative pathway function. See, e.g., E. Kabat and M.M. Mayer (eds.), Complement and complement fixation, in Experimental immunochemistry. CC Thomas, Springfield, 1961, pp. 133-240; and Rapp and Borsos, Molecular basis of complement action, Appton Century Crofts, New York, NY 1970.The test to assess functional activity of the alternative pathway (AH50) uses guinea pig, rabbit, or chicken red blood cells as target cells. AP has weak hemolytic activity against sheep red blood cells. Here, activation of the classical pathway is mediated by EGTA chelate 2. + It must be blocked by adding Mg2 + An optimal concentration of CH50 and / or AH50 is required. Detection of low or absent hemolytic activity in CH50 and / or AH50 indicates further complement analysis. See, e.g., Joiner et al., 1983. A study of optimal reaction conditions for an assay of the human alternative complement pathway. Am. J. Clin. Pathol. 79:65-72.

[0150] A therapeutically effective amount of an antagonist antigen-binding protein that specifically binds to C5 is an amount that reverses, stabilizes, or eliminates an undesirable disease or disorder (e.g., a C5-related disease) to any clinically measurable extent, e.g., by causing a reduction or maintenance of complement activity, e.g., with respect to a C5-related disease, thereby causing regression, stabilization, or elimination of one or more signs or symptoms of such disease or disorder. The dosing regimens described herein are examples of therapeutically effective amounts of antagonist antigen-binding proteins.

[0151] The term "treat" or "treatment" refers to a therapeutic measure that reverses, stabilizes, or eliminates an undesirable disease or disorder (e.g., a C5-related disease such as PNH, MG, aHUS, or CHAPLE) to any clinically measurable extent, e.g., by causing a reduction or maintenance of complement activity, e.g., with respect to a C5-related disease, thereby causing the regression, stabilization, or elimination of one or more signs or symptoms of such disease or disorder.

[0152] Subjective evidence of a disease, disorder, condition, or syndrome is a symptom. A sign is objective evidence of a disease, disorder, condition, or syndrome. For example, blood flowing from the nostrils is a sign insofar as it is obvious to the patient, the doctor, and others. Anxiety, back pain, and fatigue are symptoms insofar as they can only be perceived by the patient.

[0153] The term "subject" refers to a mammal such as a human, mouse, goat, rabbit, rat, dog, non-human primate, or monkey. In one embodiment of the present invention, the amino acid arginine 885 is mutated to another amino acid, for example, R885H or R885C, in the subject's C5 (e.g., human C5). In one embodiment of the present invention, the subject has previously taken an antagonist antigen-binding protein that specifically binds to C5 other than the one currently being administered. For example, the subject has previously taken ravulizumab or eculizumab.

[0154] C5-related diseases include, for example: ·Adult respiratory distress syndrome Age-related macular degeneration (AMD) ·allergy Alport syndrome Alzheimer's disease Amyotrophic lateral sclerosis (ALS) Antiphospholipid syndrome (APS) ·asthma Atherosclerosis ·Atypical hemolytic uremic syndrome (aHUS) ·Autoimmune diseases ·Autoimmune hemolytic anemia (AIHA) Balloon angioplasty Bronchoconstriction Bullous pemphigoid ·burn C3 glomerulopathy ·Capillary leak syndrome Cardiovascular disorders Fulminant antiphospholipid syndrome (CAPS) Cerebrovascular disorders CHAPLE disease (CD55 deficiency with complement hyperactivation, vasculopathic thrombosis, and protein-losing enteropathy) ·Chemical damage ·Chronic obstructive pulmonary disease (COPD) ·Cold agglutinin disease (CAD) Corneal and / or retinal tissue Crohn's disease Degos disease Dense deposit disease (DDD) ·Dermatomyositis ·Diabetes ·Diabetic vasculopathy ·Diabetic macular edema (DME) ·Diabetic nephropathy ·Diabetic retinopathy Dilated cardiomyopathy Impaired inappropriate or unwanted complement activation ·Difficulty breathing Eclampsia Emphysema ·Epidermolysis bullosa Epilepsy Fibrogenic pneumoconiosis ·frostbite Geographic atrophy (GA) Glomerulonephritis Glomerulopathy Goodpasture's syndrome Graves' disease Guillain-Barré syndrome Hashimoto's thyroiditis ·Hemodialysis complications Hemolysis, elevated liver enzymes, and thrombocytopenia (HELLP) syndrome ·Hemolytic anemia Hemoptysis Henoch-Schönlein purpura nephritis Hereditary angioedema Hyperacute allograft rejection ·Hypersensitivity pneumonitis Idiopathic thrombocytopenic purpura (ITP) IgA nephropathy Immune complex disorders ·Immune complex vasculitis Immune complex-related inflammation ·Infectious disease Inflammation caused by autoimmune diseases Inflammatory disorders Hereditary CD59 deficiency Damage caused by inert dust and / or inorganic materials Interleukin-2-induced toxicity during IL-2 therapy Ischemia-reperfusion injury Kawasaki disease Lung disease or disorder Lupus nephritis Membranoproliferative glomerulonephritis Membranoproliferative nephritis Mesenteric artery reperfusion after aortic reconstruction Mesenteric / intestinal vascular disorders Multifocal motor neuropathy (MMN) Multiple sclerosis ·Myasthenia gravis Myocardial infarction Myocarditis Neuropathy Neuromyelitis optica ·obesity ·Intraocular neovascularization Intraocular neovascularization affecting the choroid Organic pneumoconiosis Parasitic diseases Parkinson's disease Paroxysmal nocturnal hemoglobinuria (PNH), e.g., active PNH ·Microimmune vasculitis ·Pemphigus Percutaneous transluminal coronary angioplasty (PTCA) Peripheral (e.g., musculoskeletal) vascular disorders ·pneumonia Post-ischemic reperfusion state Post-pump syndrome in cardiopulmonary bypass surgery Post-pump syndrome in renal bypass surgery Preeclampsia ·Progressive renal failure Proliferative nephritis Proteinuria and kidney disease ·psoriasis Pulmonary embolism Pulmonary fibrosis ·Pulmonary infarction ·Pulmonary vasculitis Habitual miscarriage Kidney damage ·renal ischemia Renal ischemia-reperfusion injury Renal vascular disorders Restenosis after stent placement Rheumatoid arthritis (RA) Rotational atherectomy Schizophrenia ·Sepsis Septic shock ·SLE nephritis Smoke damage Spinal cord injury Spontaneous abortion ·stroke ·Systemic inflammatory response to sepsis Systemic lupus erythematosus (SLE) Systemic lupus erythematosus-associated vasculitis ·Takayasu disease Burns Thrombotic thrombocytopenic purpura (TTP) Traumatic brain injury ·Type I diabetes ·Typical hemolytic uremic syndrome (tHUS) Uveitis ·Vasculitis Vasculitis associated with rheumatoid arthritis Venous gas embolism (VGE); or xenograft rejection

[0155] Thus, the present invention provides a method of treating or preventing a C5-related disease (e.g., PNH or aHUS) in a subject (e.g., a human) in need thereof, e.g., a subject suffering from a C5-related disease, comprising administering to a subject an antagonist antigen binding protein that specifically binds to C5 (e.g., H2M11683N; H2M11686N; H4H12159P; H4H12161P; H4H12163P; H4H12164P; H4H12166P; H4H12166P2; H4H12166P3; H4H12166P4; H4H12166P5; H4H12166P6; H4H12166P 7;H4H12166P8;H4H12166P9;H4H12166P10;H4H12167P;H4H12168P;H4H12169P;H4H12170P;H4H12171P;H4H12175P;H4H12176P2;H4H12177P2;H4H12183P2;H2M11682N;H2M11684N;H2M11694N;H2M11695N;ravulizumab or eculizumab), optionally in combination with an additional therapeutic agent (e.g., semdisirane), to a subject according to a dosing regimen described herein. Additionally, the present invention provides methods for reducing the need for therapeutic intervention required to address the various signs and symptoms of C5-related diseases such as PNH or CHAPLE.

[0156] Paroxysmal nocturnal hemoglobinuria (PNH) results from pluripotent hematopoietic stem cells (HSCs) that acquire mutations in the phosphatidylinositol glycan anchor biosynthesis class A (PIGA) gene. The PIGA gene product is required for the biosynthesis of glycophosphatidylinositol (GPI) anchors, glycolipid moieties that attach dozens of proteins to the cell membrane. As a result, PNH stem cells and all of their progeny exhibit reduced or absent GPI-anchored proteins. Mature blood cells derived from hematopoietic clones can have a complete (type III) or partial (type II) deficiency of GPI-linked proteins (Hillmen et al., Effect of eculizumab on hemolysis and transfusion requirements in patients with paroxysmal nocturnal hemoglobinuria. N Engl J Med 2004;350(6):552-9). Two proteins affected by the absence of GPI anchors are the complement regulatory proteins CD55 and CD59. CD55 regulates complement activation by inhibiting complement component 3 (C3) convertase, whereas CD59 inhibits the assembly of the membrane attack complex (MAC) C5b-C9 by interacting with C8 and C9 (Brodsky, How I treat paroxysmal nocturnal hemoglobinuria. Blood 2009;113(26):6522-7). Their absence renders PNH red blood cells susceptible to complement-mediated intravascular hemolysis. This intravascular hemolysis in PNH patients leads to anemia (often requiring transfusions) and hemoglobinuria. Complications of PNH include thrombosis, abdominal pain, dysphagia, erectile dysfunction, and pulmonary hypertension (Hillmen et al., The complement inhibitor eculizumab in paroxysmal nocturnal hemoglobinuria. N Engl J Med 2006;355(12):1233-43). Thromboembolism is a common cause of mortality in patients with PNH.Potential mechanisms of thromboembolism include platelet activation, free hemoglobin toxicity, nitric oxide depletion, loss of other GPI-linked proteins, and endothelial dysfunction (Hill et al., Thrombosis in paroxysmal nocturnal hemoglobinuria. Blood 2013;121(25):4985-96). PNH is frequently accompanied by autoimmune aplastic anemia (Luzzatto and Risitano, Advances in understanding the pathogenesis of acquired aplastic anemia. Br J Haematol 2018;182(6):758-76). The present invention includes methods of reducing the need for blood transfusions to address anemia secondary to hemolysis caused by PNH, reducing the need for erythropoietin, iron supplements and / or folic acid, reducing the incidence of anemia, reducing the incidence of hemoglobinuria, or reducing the incidence of hemolysis in a subject suffering from PNH by administering to the subject an antagonist antigen binding protein that specifically binds C5, such as REGN3918, according to the dosing regimens described herein.

[0157] A diagnosis of PNH can be established using the internationally accepted definition of the presence of a PNH granulocyte clone size >10% measured in peripheral blood by flow cytometry. The accepted definition of "active disease" (active PNH) is the presence within three months of one or more of the following PNH-associated signs or symptoms: fatigue, hemoglobinuria, abdominal pain, shortness of breath (dyspnea), anemia (hemoglobin <10 g / dL), a history of a major adverse vascular event (MAVE; including thrombosis), dysphagia, or erectile dysfunction. Alternatively, activity can be established by a history of RBC transfusion within three months due to PNH. Methods of treating active PNH are also within the scope of the present invention.

[0158] CHAPLE disease (CD55 deficiency with complement hyperactivation, vasculopathic thrombosis, and protein-losing enteropathy) is an autosomal recessive disorder caused by loss-of-function mutations in CD55 (also known as decay-accelerating factor, DAF). Signs and symptoms of CHAPLE include hypoproteinemia (low serum levels of albumin and immunoglobulins, which leads to facial and extremity edema and recurrent infections), malabsorption syndrome (chronic diarrhea, growth failure, anemia, and micronutrient deficiencies), complement hyperactivation, intestinal lymphangiectasia (IL) and intestinal inflammation; and / or increased susceptibility to visceral thrombosis. CHAPLE disease is caused by biallelic loss-of-function mutations in the CD55 gene. Clinically, CHAPLE disease manifests as a familial form of protein-losing enteropathy (PLE) caused by primary intestinal lymphangiectasia (PIL) or Waldmann's disease, often resulting in severe and potentially fatal systemic manifestations. CD55 is a glycophosphatidylinositol (GPI)-anchored membrane protein that inhibits the enzymatic activity of C3b and C4b, thus preventing the formation of C3 and C5 convertases, which ultimately lead to the assembly of the membrane attack complex (C5b-C9). Therefore, lack of CD55 leads to overactivation of the complement system, resulting in the production of various complement products, including anaphylatoxins and the membrane attack complex. Somatic mutations in the PIGA gene (required for GPI anchor biosynthesis) in hematopoietic stem cells result in the loss of CD55 and CD59 (another GPI-linked complement regulatory protein) specific to hematopoietic cells. Typically, the resulting complement-mediated lysis of red blood cells and platelets results in intravascular hemolysis and thrombosis in PNH. In CHAPLE, isolated germline deletion of CD55 expression in any tissue manifests in the GI tract as primary intestinal lymphangiectasia, leading to PLE. Unlike PNH, hemolysis is generally not observed in patients with CHAPLE.The present invention includes methods of reducing the need for administration of corticosteroids, immunoglobulins, albumin, biotherapeutics (e.g., anti-TNF-alpha, or antibodies or antigen-binding fragments thereof such as vedolizumab), immunomodulators (e.g., azathioprine or mesalazine), micronutrients, enteral or parenteral supplementation, anticoagulants (e.g., low molecular weight heparin), antibiotics and / or antiplatelet agents (e.g., aspirin, such as low-dose aspirin) in a subject suffering from CHAPLE by administering to the subject an antagonist antigen binding protein that specifically binds C5, such as REGN3918, according to the dosing regimens described herein. See Kurolap et al., Loss of CD55 in Eculizumab-Responsive Protein-Losing Enteropathy. N Engl J Med 2017;377(1):87-9; and Ozen et al., CD55 Deficiency and Protein-Losing Enteropathy. N Engl J Med 2017b;377(15):1499-500.

[0159] CD55 mutations associated with CHAPLE disease include, for example: 149-150delAA; 149-150insCCTT; 109delC; 800G>C; 287-1G>C; 149-150delAAinsCCTT; (described in WO2018 / 053039) or CD55 mutations resulting in the same mutant amino acid sequence. Thus, the present invention includes methods of treating CHAPLE disease characterized by any one or more of such mutations. In one embodiment of the present invention, human CD55 comprises the amino acid sequence set forth in SEQ ID NO: 364; * Human CD55, including 12, comprises the amino acid sequence set forth in SEQ ID NO: 365 (residues 101-200); *Human CD55 containing SEQ ID NO: 24 comprises the amino acid sequence (residues 1-100) set forth in SEQ ID NO: 366; human CD55 containing the mutation Cys267Ser comprises the amino acid sequence (residues 201-300) set forth in SEQ ID NO: 367 (see International Patent Application Publication No. WO2018 / 053039).

[0160] Diagnosis of CHAPLE can be made by genetic analysis to identify loss-of-function mutations in CD55. Diagnosis can be confirmed by flow cytometry or Western blotting of peripheral blood cells to identify reduced presence of CD55. In one embodiment of the present invention, active CHAPLE disease is characterized by hypoalbuminemia of 3.2 g / dL or less and one or more of the following signs or symptoms attributable to CHAPLE: diarrhea, vomiting, abdominal pain, peripheral or facial edema, or episodes of infection complicated by hypogammaglobulinemia, or new thromboembolic events. The normal range for serum albumin is typically approximately 3.5 to 5.5 g / dL.

[0161] Atypical hemolytic uremic syndrome (aHUS) is a rare disorder characterized by low levels of circulating red blood cells due to destruction (hemolytic anemia), low platelet counts due to platelet consumption (thrombocytopenia), and the inability of the kidneys to process waste products from the blood and excrete them in the urine (acute renal failure), a condition known as uremia. Most aHUS cases are caused by a complement system abnormality that impairs normal regulatory mechanisms. Activation events therefore lead to progressive, unchecked complement activity and widespread endothelial damage. Signs and symptoms of aHUS include, for example, malaise, fatigue, irritability, and somnolence, anemia, thrombocytopenia, acute renal failure, hypertension, and organ damage.

[0162] Antiphospholipid syndrome (APS) is an autoimmune disease characterized by arterial and venous thrombosis due to antiphospholipid antibodies. When this disorder occurs in the absence of another autoimmune disease, it is called primary. Secondary APS occurs in association with autoimmune disorders such as systemic lupus erythematosus. Fulminant APS (CAPS) is a rare, fatal form of APS in which widespread intravascular thrombosis leads to multiple organ ischemia and failure.

[0163] Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease that causes weakness of the skeletal muscles involved in breathing and movement parts of the body, including the limbs.

[0164] Typical hemolytic uremic syndrome (tHUS) can occur secondary to gastrointestinal infection with Shiga toxin-producing Escherichia coli (STEC). Typical HUS (STEC-HUS; Shiga toxin-producing Escherichia coli (STEC)-hemolytic uremic syndrome (HUS)) is initiated when Shiga toxin (or Shiga-like toxin), a known potent cytotoxin, binds to the cell membrane glycolipid Gb3 (via domain B). Domain A is internalized, subsequently halting protein synthesis and inducing apoptosis of affected cells. Shiga toxin has several additional effects on endothelial cells, one of which is increased expression of functional tissue factor, which may contribute to microvascular thrombosis. The toxin causes damage or activation of the endothelium, red blood cells, and platelets.

[0165] The present invention includes methods of administering to a subject an antagonist antigen binding protein (e.g., REGN3918) that specifically binds to C5, comprising: (i) administering about 30 mg / kg (body weight (BW)) of the antigen binding protein (e.g., REGN3918) intravenously (IV) one or more times (e.g., one time); optionally, followed by (ii) administering (e.g., subcutaneously (SC)) about 800 mg of the antigen binding protein one or more times (e.g., two or more times). Such SC administration(s) are given on a weekly basis following an initial IV administration(s). The present invention also provides a method of administering an antigen-binding protein (e.g., REGN3918) to a subject, comprising: (i) administering about 30 mg / kg (body weight (BW)) of the antigen-binding protein intravenously (IV) one or more times (e.g., once); and, optionally, (ii) administering one or more SC doses according to body weight as follows: for body weight (BW) < 10 kg: about 125 mg; for BW > 10 kg and < 20 kg: about 200 mg; for BW > 20 kg and < 40 kg: about 350 mg; for BW > 40 kg and < 60 kg: about 500 mg; and for BW > 60 kg: about 800 mg. Such SC dose(s) are given on a weekly basis after the initial IV dose(s). Optionally, the subject is also administered one or more doses of an oligonucleotide (e.g., semdisirane) in conjunction with the antigen-binding protein. In one embodiment of the present invention, the subject suffers from a C5-associated disease, such as, for example, CHAPLE, PNH, aHUS or MG.

[0166] Diagnostic methods The present invention includes methods for treating or preventing C5-related diseases, such as PNH. PNH can be caused by, for example: (i) Flow cytometry analysis of peripheral blood; (ii) serum lactate dehydrogenase (LDH) level ≥ 2 × upper limit of normal (ULN); and / or (iii) PNH granulocytes (shown as polymorphonuclear [PMN]) >10% is diagnosed in the subject based on

[0167] Flow cytometric analysis of peripheral blood is a means for laboratory detection of PNH. Flow cytometric immunophenotyping is performed using fluorescently labeled monoclonal antibodies or FLAER (fluorescein-labeled proaerolysin) to detect the presence or absence of GPI-linked proteins in granulocytes, monocytes, and red blood cells. FLAER is a fluorescently labeled variant of aerolysin that binds directly to the GPI anchor and can be used to assess GPI-linked expression. Individuals with PNH have reduced or absent expression of CD14 on monocytes, CD16 on neutrophils and NK cells, CD24 on neutrophils, CD59 on red blood cells, and FLAER on neutrophils and monocytes.

[0168] Proaerolysin is a 52-kDa protein secreted by Aeromonas hydrophila. After proteolytic nicking at the C-terminus, active aerolysin is generated, which binds to cell surface structures, multimerizes, and forms channels that result in cell lysis (Howard and Buckley, Activation of the hole-forming toxin aerolysin by extracellular processing. J. Bacteriol. 1985;163:336-340). Aerolysin does not lyse PNH cells, and the toxin has been shown to bind to the GPI moiety of GPI-linked structures (Diep et al., Glycosyl-phosphatidylinositol anchors of membrane glycoproteins are binding determinants for the channel-forming toxin aerolysin. J. Biol. Chem. 1998;273:2355-2360.25; Brodsky et al., Resistance of paroxysmal nocturnal hemoglobinuria cells to the glycosylphosphatidylinositol-binding toxin aerolysin. Blood 1999;93:1749-1756). Initially, this reagent was used to enrich for rare GPI-negative PNH clones. Subsequently, a nonlytic mutant, fluorescent dye-conjugated (Alexa 488) version of proaerolysin (FLAER) was generated that retains specificity for GPI-linked structures without causing cell lysis.

[0169] PNH is characterized by chronic, uncontrolled terminal complement activation and hemolysis. Uncontrolled complement activation leads to red blood cell (RBC) hemolysis, platelet activation, and subsequent thromboembolism (TE), kidney and other organ dysfunction, pain, severe fatigue, reduced quality of life, and premature death. An indicator of cell lysis is the appearance of abnormally high levels of lactate dehydrogenase (LDH) in serum. LDH serum levels of ≥ 1.5 or 2.0 × the upper limit of normal (LDH ≥ 1.5 ×; LDH ≥ 2.0 ×) are markers of uncontrolled complement activation used in multinational PNH clinical trials. Normal serum levels of LDH vary depending on the institution and the method used for measurement; however, normal levels in children are approximately 60–170 U / L and in adults are approximately 100–190 U / L. Other reports suggest a normal adult LDH range of 140–280 U / L. In one embodiment of the present invention, the normal female LDH ULN is 330 U / L and the male LDH ULN is 281 U / L. Receipt of one or more red blood cell transfusions, for example within a three month period, is also indicative of PNH.

[0170] A large population of GPI-AP (glycosylphosphatidylinositol-anchored protein)-deficient PMNs (polymorphonuclear cells) is also indicative of PNH. Flow cytometry is a means of determining the presence of such PMNs.

[0171] Signs and symptoms of PNH also include fatigue, hemoglobinuria, abdominal pain, shortness of breath (dyspnea), anemia (hemoglobin <10 g / dL), a history of major adverse vascular events (MAVEs; including thrombosis), dysphagia, or erectile dysfunction.

[0172] CHAPLE disease can be diagnosed, for example, based on a genotype characterized by biallelic CD55 loss-of-function mutations and persistent protein-losing enteropathy (PLE). In one embodiment of the present invention, active CHAPLE disease is identified in patients who exhibit hypoalbuminemia of 3.2 g / dL or less; and at least one of the following symptoms or signs within the past six months and for at least seven days (not necessarily consecutive) that can be attributed to CD55-deficient PLE: diarrhea, vomiting, abdominal pain, peripheral or facial edema, or an episode of infection complicated by hypogammaglobulinemia, or a new thromboembolic event. Other features that can be used to diagnose CHAPLE disease include, for example, primary intestinal lymphangiectasia or Wartmann's disease, growth retardation, anemia, vitamin or micronutrient deficiency, GI mucosal ulcers, lymphocytic infiltration of the GI mucosa, recurrent pulmonary infections, hypothyroidism, arthritis, arthralgia, or digital clubbing. See, e.g., Ozen et al., CD55 Deficiency, Early-Onset Protein-Losing Enteropathy, and Thrombosis, New England J. of Med. 377(1):52-61 (2017).

[0173] The present invention provides a method for treating or preventing a C5-associated disease (e.g., PNH) in a subject, comprising: (i) evaluating the subject for the presence of signs and / or symptoms of the disease, and diagnosing the subject with the disease if one or more of such signs and / or symptoms are identified (e.g., as discussed herein); and (ii) administering to a subject an antagonist antigen-binding protein that specifically binds to C5 (e.g., an antibody or antigen-binding fragment thereof; e.g., REGN3918) according to a dosing regimen of the present invention—for example, (i) administering about 30 mg / kg (body weight (BW)) of the antigen-binding protein intravenously (IV) one or more times (e.g., one time); and, optionally, (ii) administering about 800 mg of the antigen-binding protein subcutaneously (SC) one or more times (e.g., two or more times). In one embodiment of the present invention, SC administration is given on a weekly basis. In one embodiment of the present invention, the signs and symptoms include an LDH level of ≧1.5 or 2×ULN; type III PNH granulocytes >10%; and / or signs and symptoms of active PNH disease.

[0174] The present invention provides a method for treating or preventing a C5-associated disease (e.g., CHAPLE) in a subject, comprising: (i) evaluating the subject for the presence of signs and / or symptoms of the disease, e.g., CHAPLE, and diagnosing the subject with the disease if one or more of such signs and / or symptoms are identified (e.g., as discussed herein); and (ii) administering intravenously (IV) one or more times (e.g., once) about 30 mg / kg (body weight (BW)) of an antagonist antigen-binding protein that specifically binds to C5; followed by (ii) administering SC one or more times according to body weight, as follows: for body weight (BW) < 10 kg: about 125 mg; for BW > 10 kg and < 20 kg: about 200 mg; for BW > 20 kg and < 40 kg: about 350 mg; for BW > 40 kg and < 60 kg: about 500 mg; and for BW > 60 kg: about 800 mg. In one embodiment of the invention, SC administration is given on a weekly basis. In one embodiment of the present invention, such signs and symptoms include loss-of-function mutations in the CD55 gene, flow cytometry or Western blot of peripheral blood cells to identify reduced presence of CD55, hypoalbuminemia of 3.2 g / dL or less, and / or one or more of: diarrhea, vomiting, abdominal pain, peripheral or facial edema, or episodes of infection complicated by hypogammaglobulinemia, or a new thromboembolic event.

[0175] Pharmaceutical Formulations and Compositions The present invention provides for the administration of antagonist antigen binding proteins that specifically bind to C5 (e.g., H2M11683N; H2M11686N; H4H12159P; H4H12161P; H4H12163P; H4H12164P; H4H12166P; H4H12166P2; H4H12166P3; H4H12166P4; H4H12166P5; H4H12166P6; H4H12166P7; H4H12166P8; H4H12166P9; H4H12166P10; H4H12167P ;H4H12168P;H4H12169P;H4H12170P;H4H12171P;H4H12175P;H4H12176P2;H4H12177P2;H4H12183P2;H2M11682N;H2M11684N;H2M11694N;H2M11695N; ravulizumab, eculizumab, tesidormab, or mubodina) (e.g., (i) administering about 30 mg / kg (body weight (BW)) of the antigen binding protein one or more times 1 dose intravenously (IV); then optionally (ii) about 800 mg of antigen binding protein administered SC weekly, either in one or more doses; or one or more doses SC weekly according to body weight as follows: for body weight (BW) < 10 kg: about 125 mg; for BW > 10 kg and < 20 kg: about 200 mg; for BW > 20 kg and < 40 kg: about 350 mg; for BW > 40 kg and < 60 kg: about 500 mg; and for BW > 60 kg: about 800 mg; optionally one or more further doses In one embodiment of the present invention, the antagonist antigen-binding protein that specifically binds C5 is administered to a subject in a pharmaceutical formulation comprising a pharmaceutically acceptable carrier. A pharmaceutically acceptable carrier comprises one or more excipients. In one embodiment of the present invention, the pharmaceutical formulation is aqueous, i.e., comprises water. In one embodiment of the present invention, the pharmaceutical formulation comprises about 200 mg / ml of the antagonist antigen-binding protein that specifically binds C5.

[0176] Pharmaceutical formulations comprising an antagonist antigen binding protein that specifically binds to C5 (e.g., REGN3918) are prepared by mixing the antigen binding protein with one or more excipients (e.g., Hardman et al. (2001) Goodman and Gilman's The Pharmacological Basis of Therapeutics, McGraw-Hill, New York, NY; Gennaro (2000) Remington: The Science and Practice of Pharmacy, Lippincott, Williams, and Wilkins, New York, NY; Avis et al. (eds.) (1993) Pharmaceutical Dosage Forms: Parenteral Medications, Marcel Dekker, NY; Lieberman et al. (eds.) (1990) Pharmaceutical Dosage Forms: Tablets, Marcel Dekker, NY; Lieberman et al. (eds.) (1990) Pharmaceutical Dosage Forms: Disperse Systems, Marcel Dekker, NY). Dekker, NY; Weiner and Kotkoskie (2000) Excipient Toxicity and Safety, Marcel Dekker, Inc., New York, NY).

[0177] In one embodiment of the present invention, the additional therapeutic agent is, for example, an oligonucleotide (e.g., double-stranded DNA or RNA or both) that binds to DNA or mRNA encoding C5 and inhibits C5 expression. In one embodiment of the present invention, the oligonucleotide is up to about 23, about 19-22, about 19-23, or about 19, about 20, about 21, about 22, or about 23 nucleotides in length (e.g., a 19-23 nucleotide RNA molecule). In one embodiment of the present invention, the oligonucleotide is single-stranded (e.g., in antisense orientation) or double-stranded. A double-stranded oligonucleotide comprises a strand in sense orientation and a strand in antisense orientation. In one embodiment of the present invention, the double-stranded oligonucleotide (e.g., RNA) has, for example, a 3' overhang and / or a 5' overhang of at least two nucleotides. In one embodiment of the present invention, the oligonucleotide is naked; in another embodiment, the oligonucleotide is chemically modified.

[0178] In one embodiment of the present invention, the additional therapeutic agent is an oligonucleotide that is an RNAi agent that binds to the RNA or its part that codes for C5.RNAi agent refers to the agent that contains RNA and mediates the targeted cleavage of RNA transcripts through the RNA-induced silencing complex (RISC) pathway.RNAi directs the sequence-specific degradation of mRNA through a process known as RNA interference.RNAi regulates, for example, inhibits, the expression of C5 in cells, for example, cells in subjects such as mammalian subjects.

[0179] In one embodiment of the present invention, the RNAi agent of the present invention comprises a single-stranded RNA that interacts with a target RNA sequence, e.g., a C5 target mRNA sequence, to direct cleavage of the target RNA. Without wishing to be bound by theory, it is believed that long double-stranded RNA introduced into cells is degraded into short interfering RNAs (siRNAs) by a type III endonuclease known as Dicer (Sharp et al. (2001) Genes Dev. 15:485). Dicer, a ribonuclease III-like enzyme, processes dsRNA into 19-23 base pair short interfering RNAs (siRNAs) with characteristic two-base 3' overhangs (Bernstein et al. (2001) Nature 409:363). The siRNAs are then incorporated into the RNA-induced silencing complex (RISC), where one or more helicases unwind the siRNA duplex, allowing the complementary antisense strand to guide target recognition (Nykanen et al. (2001) Cell 107:309). Upon binding to the appropriate target mRNA, one or more endonucleases in RISC cleave the target, inducing silencing (Elbashir et al., (2001) Genes Dev. 15:188). Thus, in one aspect, the present invention relates to a single-stranded RNA (siRNA) that is produced in cells and promotes the formation of a RISC complex, resulting in the silencing of a target gene, i.e., the C5 gene. Therefore, the term "siRNA" is also used herein to refer to the RNAi described herein.

[0180] In another embodiment, the RNAi agent may be a single-stranded siRNA introduced into a cell or organism to inhibit the target mRNA. In one embodiment of the present invention, the single-stranded RNAi agent binds to the RISC endonuclease, Argonaute 2, which then cleaves the target mRNA. In one embodiment of the present invention, the single-stranded siRNA is 15-30 nucleotides and chemically modified. The design and testing of single-stranded siRNAs is described in U.S. Patent No. 8,101,348 and Lima et al. (2012) Cell 150:883-894, the entire contents of each of which are hereby incorporated by reference. Any of the antisense nucleotide sequences described herein may be used as the single-stranded siRNA described herein, or in a chemically modified form by the method described in Lima et al. (2012) Cell 150:883-894.

[0181] In one embodiment of the invention, the oligonucleotide (e.g., RNAi) is linked to another molecule, e.g., a sugar, e.g., an N-acetylgalactosamine (GalNAc) derivative, e.g., [ka] is conjugated to

[0182] In one embodiment of the present invention, an oligonucleotide (e.g., an RNAi) is conjugated to another molecule as shown in the following schematic diagram: [ka] where X is O or S.

[0183] In one embodiment of the invention, the additional therapeutic agent is semdisilane. In one embodiment of the invention, the additional therapeutic agent is the antisense strand nucleotide sequence: 5'-UAUUAUAAAAAUAUCUUGCUUUU-3' (SEQ ID NO: 370); and / or the sense strand has the nucleotide sequence: 5'-AAGCAAGAUAUUUUUAUAAUA-3' (SEQ ID NO: 371).

[0184] In one embodiment of the invention, the additional therapeutic agent is a double-stranded ribonucleic acid (dsRNA) agent that inhibits expression of complement component C5, said dsRNA agent comprising a sense strand and an antisense strand, wherein the sense strand is: Contains 5'-asasGfcAfaGfaUfAfUfuUfuuAfuAfaua-3' (SEQ ID NO: 372) The antisense strand is: 5'-usAfsUfuAfuaAfaAfauaUfcUfuGfcuususudTdT-3' (SEQ ID NO: 373), a, g, c, and u are 2'-O-methyl (2'-OMe) A, G, C, and U, respectively; Af, Gf, Cf, and Uf are 2'-fluoro A, G, C, and U, respectively; dT is a deoxy-thymine nucleotide; and s is a phosphorothioate linkage; and the sense strand contains at its 3' end the ligand: [ka] See U.S. Patent No. 9,249,415.

[0185] In one embodiment of the present invention, RNAi is in pharmaceutical preparations that comprise lipid nanoparticles (LNP).LNP is a vesicle that comprises a lipid layer that encapsulates pharmaceutically active molecules such as RNAi.LNP is described in, for example, United States Patent No. 6,858,225, No. 6,815,432, No. 8,158,601 and No. 8,058,069, and the entire contents thereof are hereby incorporated by reference herein.

[0186] In one embodiment of the invention, the additional therapeutic agent is selected from the group consisting of acetaminophen, albumin (e.g., in injectable form), ancrod, angiotensin converting enzyme inhibitors, antibiotics (e.g., oral antibiotics), additional antibodies, anti-CD20 agents, rituximab, anticoagulants, antifungals, antihypertensives, anti-inflammatory agents, antiplasmin-a1, anticonvulsants, antithrombotic agents, anti-TNF alpha agents, antivirals, argatroban, aspirin, biological therapeutic agents, bivalirudin, C3 inhibitors, corticosteroids, cyclosporine A, dabigatran, defibrotide, E-aminocaproic acid, enteral nutrition, erythromycin, erythropoietin, fibrinolytic agents, These include folic acid, fondaparinux, heparin, hormone replacement therapy, ibuprofen, idraparinux, immunosuppressants, infliximab, hydroxymethylglutaryl-CoA reductase inhibitors, iron supplements, lepirudin, lipid-lowering agents, magnesium sulfate, meningococcal vaccine (e.g., serogroups A, C, Y, W, and serogroup B), methotrexate, nonsteroidal anti-inflammatory drugs (NSAIDs), oligonucleotides, paracetamol, parenteral nutrition, penicillin, phenindione, contraceptives, prostacyclin, rituximab, thrombin inhibitors, vaccines, vincristine, vitamins, and / or warfarin.

[0187] The term "in association with" indicates, for example, that the components of a composition comprising (1) an antagonist antigen-binding protein that specifically binds C5 and a pharmaceutically acceptable carrier component, together with (2) one or more additional therapeutic agents, e.g., semdisirane, are formulated into a single composition, e.g., for simultaneous delivery, or are formulated separately into two or more compositions (e.g., a kit comprising each component, e.g., where the additional therapeutic agent is in a separate formulation). Components administered in association with another may be administered to a subject at the same time or at a different time than when the other component is administered; e.g., each administration may be given simultaneously (e.g., together in a single composition or during the same administration session, essentially simultaneously) or non-concurrently at one or more intervals over a period of time. Furthermore, separate components administered in association with another may be administered to a subject by the same or different routes.

[0188] C5 Oligonucleotide Dosage The present invention provides a method of treating or preventing a C5-associated disorder in a subject, comprising administering an antagonist antigen binding protein (e.g., REGN3918) that specifically binds to C5, for example, (i) administering about 30 mg / kg (body weight (BW)) of the antigen binding protein intravenously (IV) in one or more doses; optionally followed by (ii) administering about 800 mg of the antigen binding protein SC weekly in either one or more doses; or one or more doses according to body weight as follows: and about 800 mg for BW≧60 kg; optionally, the subject is further administered a therapeutically effective amount of an oligonucleotide that binds to a polynucleotide encoding C5 and inhibits expression of C5 (C5 oligonucleotide).

[0189] In one embodiment of the present invention, a therapeutically effective dose of dsRNA, RNAi, or other oligonucleotide that binds to a polynucleotide encoding C5 and inhibits C5 expression will be in the range of about 0.001 to about 200.0 milligrams per kilogram of recipient's body weight per day, generally in the range of about 1 to 50 mg per kilogram of recipient's body weight per day. For example, the dsRNA may be administered at about 0.01 mg / kg, about 0.05 mg / kg, about 0.5 mg / kg, about 1 mg / kg, about 1.5 mg / kg, about 2 mg / kg, about 3 mg / kg, about 10 mg / kg, about 20 mg / kg, about 30 mg / kg, about 40 mg / kg, or about 50 mg / kg per single dose.

[0190] In one embodiment of the present invention, the C5 dsRNA is administered at a concentration of about 0.1 to about 20 mg / kg, about 0.1 to about 30 mg / kg, about 0.1 to about 40 mg / kg, about 0.1 to about 45 mg / kg, about 0.1 to about 50 mg / kg, about 0.25 to about 20 mg / kg, about 0.25 to about 30 mg / kg, about 0.25 to about 40 mg / kg, about 0.25 to about 45 mg / kg, about 0.25 to about 50 mg / kg, about 0.5 to about 20 mg / kg, about 0.5 to about 30 mg / kg, about 0.5 to about 40 mg / kg, about 0.5 to about 45 mg / kg, about 0.5 to about 50 mg / kg, or about 0.75 ~about 20mg / kg, about 0.75 to about 30mg / kg, about 0.75 to about 40mg / kg, about 0.75 to about 45mg / kg, about 0.75 to about 50mg / kg, about 1 to about 20mg / mg, about 1 to about 30mg / mg, about 1 to about 40mg / mg, about 1 to about 45mg / mg, about 1 to about 50 mg / mg, about 1.5 to about 20 mg / kb, about 1.5 to about 30 mg / kb, about 1.5 to about 40 mg / kb, about 1.5 to about 45 mg / kb, about 1.5 to about 50 mg / kb, about 10 to about 20 mg / kg, about 10 to about 30 mg / kg, about 1 0~40mg / kg, 10~45mg / kg, 10~50mg / kg, 15~20mg / kg, 15~30mg / kg, 15~45mg / kg, 15~50mg / kg, 2~20mg / kg , about 2 to about 30 mg / kg, about 2 to about 40 mg / kg, about 2 to about 45 mg / kg, about 2 to about 50 mg / kg, about 2.5 to about 20 mg / kg, about 2.5 to about 30 mg / kg, about 2.5 to about 40 mg / kg, about 2.5 to about 45 mg / kg, about 2.5 to about 50 m g / kg, about 20 to about 30 mg / kg, about 20 to about 40 mg / kg, about 20 to about 45 mg / kg, about 20 to about 50 mg / kg, about 25 to about 30 mg / kg, about 25 to about 40 mg / kg, about 25 to about 45 mg / kg, about 25 to about 50 mg / kg, about 3 to about 2 0mg / kg, about 3 to about 30mg / kg, about 3 to about 40mg / kg, about 3 to about 45mg / kg, about 3 to about 50mg / kg, about 3.5 to about 20mg / kg, about 3.5 to about 30mg / kg, about 3.5 to about 40mg / kg, about 3.5 to about 45mg / kg, about 3.5 to about 50 mg / kg, about 30 to about 40 mg / kg, about 30 to about 45 mg / kg, about 30 to about 50 mg / kg, about 35 to about 40 mg / kg, about 35 to about 45 mg / kg, about 35 to about 50 mg / kg, about 4 to about 20 mg / k g, about 4 to about 30 mg / kg, about 4 to about 40 mg / kg, about 4 to about 45 mg / kg, about 4 to about 50 mg / kg, about 4.5 to about 20 mg / kg, about 4.5 to about 30 mg / kg, about 4.5 to about 40 mg / kg, about 4.5 to about 4 The dsRNA may be administered at a dose of about 5 mg / kg, about 4.5 to about 50 mg / kg, about 40 to about 45 mg / kg, about 40 to about 50 mg / kg, about 45 to about 50 mg / kg, about 5 to about 20 mg / kg, about 5 to about 30 mg / kg, about 5 to about 40 mg / kg, about 5 to about 45 mg / kg, about 5 to about 50 mg / kg, about 7.5 to about 20 mg / kg, about 7.5 to about 30 mg / kg, about 7.5 to about 40 mg / kg, about 7.5 to about 45 mg / kg, or about 7.5 to about 50 mg / kg. Values ​​and ranges intermediate to the recited values ​​are also contemplated as part of the present invention. In one embodiment, the dsRNA is administered at a dose of about 10 mg / kg to about 30 mg / kg.

[0191] For example, C5 dsRNA or RNAi or other oligonucleotides may be administered, for example, subcutaneously or intravenously, at doses of about 0.01, 0.02, 0.03, 0.04, 0.05, 0.06, 0.07, 0.08, 0.09, 0.1, 0.125, 0.15, 0.175, 0.2, 0.225, 0.25, 0.275, 0.3, 0.325, 0.35, 0.375, 0.4, 0.425, 0.45, 0.475, 0.5, 0.525, 0.55, 0.575, 0.6, 0.625, 0.65, 0.675, 0. 7, 0.725, 0.75, 0.775, 0.8, 0.825, 0.85, 0.875, 0.9, 0.925, 0.95, 0.975, 1, 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3, 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7, 3.8, 3.9, 4, 4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 5, 5. 1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, 6, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, 7, 7.1, 7.2, 7.3, 7.4, 7.5, 7.6, 7.7, 7.8, 7.9, 8, 8.1, 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, 8.9, 9, 9.1, 9.2, 9.3, 9.4, 9.5, 9.6, 9.7, 9.8, 9.9, 10, 10.5, 11, 11.5, 12, 12.5, 13, 13.5 , 14, 14.5, 15, 15.5, 16, 16.5, 17, 17.5, 18, 18.5, 19, 19.5, 20, 20.5, 21, 21.5, 22, 22.5, 23, 23.5, 24, 24.5, 25, 25.5, 26, 26.5, 27, 27.5, 28, 28.5, 29, 29.5, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 or 50 mg / kg (or repeated doses). A multiple dose regimen may involve administering a therapeutic amount of C5 dsRNA or RNAi or other oligonucleotide daily, for example, for 2, 3, 4, 5, 6, 7, or more days.Repeated administration regimens may include administering therapeutic amounts of C5 dsRNA or RNAi or other oligonucleotides on a regular basis, for example, every other day, every third day, twice a week, once a week, every other week, or every month.

[0192] C5 dsRNA or RNAi or other oligonucleotide is administered, for example, subcutaneously or intravenously, in a dose (or repeated doses) of about 600 mg.

[0193] The pharmaceutical composition comprising the oligonucleotide is administered by intravenous infusion for a certain period of time, for example, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 21, 22, 23, 24, or about 25 minutes. Administration is repeated, for example, periodically, for example, once a week or once every two weeks (i.e., every two weeks) for one month, two months, three months, four months, or more. After the initial treatment regimen, treatment is performed less frequently. For example, after administration once a week or once every two weeks for three months, administration is repeated once a month for six months, one year, or more. [Example]

[0194] These examples are intended to illustrate, but not limit, the invention. The compositions and methods illustrated in the examples form a part of the invention. [Example]

[0195] An open-label, single-arm trial evaluating the efficacy and safety of REGN3918 in patients with paroxysmal nocturnal hemoglobinuria (PNH) who are complement inhibitor-naive or have not recently received complement inhibitor therapy The trial was an open-label, single-arm, 26-week treatment trial in patients with a confirmed diagnosis of PNH and active signs and symptoms who were complement inhibitor-naive or had previously been treated with a complement inhibitor but not within 6 months prior to the screening visit.

[0196] This trial had two cohorts: a dose confirmation cohort (Cohort A) and a dose expansion cohort (Cohort B). Dose confirmation, consisting of REGN3918 30 mg / kg IV followed by 800 mg weekly SC, was performed at an interim analysis. Inclusion and exclusion criteria and event schedules were identical for Cohort A and Cohort B. Recruitment into the trial continued during the evaluation period for data from Cohort A. Patients received a single loading dose of REGN3918 30 mg / kg intravenously (IV) on Day 1, followed by subcutaneous SC once weekly (QW; ±1 day) at doses up to 800 mg for up to 26 weeks.

[0197] The primary objective of this study was to demonstrate that REGN3918 reduces intravascular hemolysis over 26 weeks in patients with active PNH who were complement inhibitor therapy-naive or had not recently received complement inhibitor therapy. Secondary objectives of the study were to evaluate the safety and tolerability of REGN3918; assess the effect of REGN3918 on parameters of intravascular hemolysis; evaluate serum total REGN3918 concentrations; evaluate the incidence of treatment-emergent anti-drug antibodies to REGN3918; and evaluate the effect of REGN3918 on patient-reported outcomes (PROs) measuring fatigue and health-related quality of life.

[0198] Clinical trial period Patients' study duration was approximately 27 weeks, excluding the screening period. The study consisted of a screening period (up to 4 weeks), a 26-week treatment period, and an end-of-study visit 1 week after the last dose of study drug. After the 26-week treatment period, patients could enroll in a separate open-label extension study offering non-intermittent treatment with REGN3918. Patients who discontinued treatment had a minimum follow-up period of 21 weeks.

[0199] Clinical trial population Approximately 30-42 adult male and female patients participated. The study population consisted of adult male and female patients with a diagnosis of PNH and active signs and symptoms who were complement inhibitor naive or had been previously treated with a complement inhibitor, but not within the 6 months prior to the screening visit.

[0200] Inclusion criteria To be eligible for inclusion in this study, patients must meet the following criteria: 1. Male or female, aged 18 years or older or of legal adult age (whichever is older) at the time of screening; 2. Diagnosis of PNH confirmed by high-sensitivity flow cytometry; 3. PNH granulocytes (expressed as polymorphonuclear [PMN]) >10% at the screening visit; 4. Active disease as defined by the presence of one or more PNH-related signs or symptoms (e.g., fatigue, hemoglobinuria, abdominal pain, shortness of breath [dyspnea], anemia [hemoglobin less than 10 g / dL], history of MAVE (major adverse vascular event) [including thrombosis], dysphagia, or erectile dysfunction) or a history of RBC transfusion attributable to PNH within 3 months of screening; 5. LDH level ≥ 2 × ULN (upper limit of normal) at the screening visit; 6. Willing and able to comply with clinic visits and study-related procedures; 7. Provide informed consent signed by the study patient; and 8. Able to understand and fill out clinical trial-related questionnaires without omissions.

[0201] Exclusion criteria Patients who met any of the following criteria were excluded from the trial: 1. Previous treatment with a complement inhibitor within 6 months prior to the screening visit or, in the opinion of the investigator, the patient was refractory to complement inhibitor therapy at any time (excluding eculizumab-refractory patients due to the C5 variant R885H / C); 2. History of bone marrow transplant; 3. Weight less than 40 kilograms at the screening visit; 4. Planned modifications (starting, discontinuing, or changing the dose / interval) of the following background concomitant medications administered as needed during the screening and treatment periods: erythropoietin, immunosuppressants, corticosteroids, antithrombotic drugs, anticoagulants, iron supplements, and folic acid; 5. Peripheral blood absolute neutrophil count (ANC) less than 500 / μL [1.0 × 10 9 / L or less], or peripheral blood platelet count less than 50,000 / μL; 6. No documented meningococcal vaccination within 3 years prior to screening and patient unwilling to be vaccinated during the study period; 7. Documented history of systemic fungal disease or unresolved TB, or evidence of active or latent TB infection (LTBI) during the screening period. Evaluation for active TB and LTBI was to follow local practice or guidelines, including those related to risk assessment, and the use of tuberculin skin testing or T-cell interferon-gamma release assays; 8. Any contraindication to receiving Neisseria meningitidis vaccination and antibiotic prophylaxis as recommended in this study; 9. Any active ongoing infection within 2 weeks of screening or during the screening period; 10. Recent infection requiring ongoing systemic treatment with antibiotics, antivirals, or antifungals within 2 weeks of screening or during the screening period; 11. Immunization with a live attenuated vaccine within 1 month prior to REGN3918 administration; 12. Known inherited complement deficiency; 13. Documented history of active ongoing systemic autoimmune disease; 14. Patients with a documented history of cirrhosis or liver disease unrelated to PNH with ALT or AST >3 × ULN at the screening visit; 15. Estimated glomerular filtration rate (eGFR) 30 mL / min / 1.73 m at the screening visit 2 patients with < (according to Chronic Kidney Disease Epidemiology Collaboration Equation 2009); 16. Recent unstable medical conditions, excluding PNH and PNH-related complications, within the past 3 months prior to the screening visit (e.g., myocardial infarction, New York Heart Association class III or higher congestive heart failure, severe uncontrolled cardiac arrhythmia, cerebrovascular accident, active gastrointestinal bleeding); 17. Anticipated need for major surgery during the study period; 18. Concurrent chronic anemia unrelated to PNH; 19. History of cancer within the past 5 years, except for adequately treated basal cell skin cancer, squamous cell skin cancer, or in situ cervical cancer; 20. Participation in another interventional clinical trial or, with the exception of complement inhibitors, use of any experimental therapy within 30 days prior to the screening visit or within 5 half-lives of the investigational drug, whichever is longer; 21. Known sensitivity to doxycycline or any of the components of the REGN3918 formulation and drug product; 22. History of significant multiple and / or severe allergies (including latex gloves) or having had an anaphylactic reaction or significant intolerance to prescription or non-prescription drugs; 23. Any clinically significant abnormality identified at screening, such as significant systemic disease, that, in the judgment of the investigator or any sub-investigator, would preclude safe completion of the trial or limit endpoint assessment, or patients with a short life expectancy; 24. The investigator or any investigator determines that the study is not effective for any reason, including: Deemed unable to meet certain protocol requirements, such as scheduled visits - Deemed unable to tolerate prolonged injections based on the patient, investigator, study coordinator, pharmacist, study coordinator, other study staff, or their associates directly involved in the implementation of the protocol The existence of any other actual or anticipated conditions (e.g., geographic, social, etc.) that the investigator feels may limit or restrict the duration of the trial or patient participation; considered inappropriate for this study; 25. Pregnant, lactating women, or women with a positive pregnancy test at the screening visit or on Day 1; 26. Patients who are institutionalized pursuant to an order issued by a judicial or administrative authority; 27. Pregnant or lactating women; 28.Females of childbearing potential who are unwilling to practice highly effective contraception before the first dose / initiation of treatment, during the study period, and for at least 21 weeks after the last dose. * As a highly effective form of contraception: a. Stable use of combined (estrogen and progesterone-containing) hormonal contraception (oral, intravaginal, transdermal) or progesterone-only hormonal contraception (oral, injectable, implantable) associated with ovulation inhibition initiated in 2 or more menstrual cycles prior to screening b. Intrauterine device (IUD); Intrauterine hormone-releasing system (IUS) c. Bilateral tubal ligation d. Partner's vasectomy e. and / or abstinence †‡ ; * Postmenopausal women must be amenorrheic for at least 12 months to be considered fertile. Pregnancy testing and contraception are not required for women with a documented hysterectomy or tubal ligation. † Abstinence is considered a highly effective strategy only if it is defined as abstinence from heterosexual intercourse throughout the entire duration of the study treatment and its associated risks. The reliability of abstinence needs to be assessed in relation to the duration of the clinical trial and the subject's usual preferred lifestyle. ‡Periodic abstinence (calendar, symptom-temperature, and postovulatory methods), interruption (abortive intercourse), spermicide alone, and lactational amenorrhea (LAM) are not acceptable methods of contraception. Both female and male condoms should not be used; or 29. Known chronic infection with hepatitis B or C defined as a history of testing currently positive for hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), hepatitis B virus DNA, or hepatitis C virus RNA (HCV RNA).

[0202] endpoint Co-primary endpoints were: The proportion of patients who achieved adequate control of their intravascular hemolysis, defined as LDH ≤ 1.5 x ULN, at each scheduled time point, including 4 weeks and 26 weeks; and Percentage of patients achieving fluid avoidance, defined as no protocol-based post-baseline RBC transfusions through 26 weeks It was.

[0203] Secondary endpoints are: · The incidence of breakthrough hemolysis through 26 weeks, defined as an LDH measurement of ≥2×ULN (at any time) with associated signs or symptoms following an early disease control outcome (i.e., LDH ≥1.5×ULN); The proportion of patients achieving normalization of their intravascular hemolysis, defined as an LDH of 1.0 × ULN or less at each scheduled time point therebetween, including 4 weeks and 26 weeks; · Time to first LDH <1.5 × ULN; Percentage of days during the 4th and 26th weeks inclusive when LDH was ≤1.5 × ULN; · Change and percent change in LDH levels from baseline to week 26; ·Rate of RBC infusion and number of units up to 26 weeks; · Change in RBC hemoglobin levels from baseline to week 26; · Change in free hemoglobin levels from baseline to week 26; · Change and percent change in CH50 from baseline to week 26; · Change in patient-reported outcomes (FACIT-Fatigue, European Organisation for Research and Treatment of Cancer [EORTC]-QLQ-30, and EQ-5D-3L) from baseline to week 26; ·The incidence and severity of treatment-emergent adverse events (TEAEs) and other safety variables over 26 weeks; Serum total REGN3918 concentrations assessed throughout the trial; and The incidence of treatment-emergent anti-drug antibodies to REGN3918 in patients over time It was.

[0204] Efficacy indicators / procedures Serum lactate dehydrogenase (LDH). Samples for LDH testing were collected at the time of the clinic visit. Serum LDH levels were measured at a central laboratory. On days when blood chemistry was tested, LDH was included in the panel (also tested at a central laboratory). For self-administering patients, samples could be drawn at home by a nurse visit when scheduled on a non-clinic visit day.

[0205] Updating infusion records. Patients were asked to provide an update on their infusion history for the past year since screening. The rate and number of units of RBC infusions were recorded on the case report form (CRF) during the study. RBC infusions during the study were to follow the algorithm described herein. The rate and number of units of RBC infusions were recorded on the CRF. Hemoglobin levels were obtained before and after infusion (including values ​​obtained locally).

[0206] Total hemolytic complement activity. Samples for CH50 testing were collected at the time of the clinic visit. Serum CH50 levels were measured in a central laboratory. For self-administering patients, samples could be collected at home by a nurse visit when scheduled on a non-clinic visit day.

[0207] Red blood cell hemoglobin. Red blood cell hemoglobin testing was to be measured in the safety hematology panel collected at the clinic visit and performed at a central laboratory.

[0208] Free Hemoglobin. Free hemoglobin testing was to be measured in the safety hematology panel collected at the clinic visit and performed at a central laboratory.

[0209] Clinical outcome assessments. COAs were patient self-reported. Clinical outcome assessments (COAs) included the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue), two health-related quality of life (HRQoL) questionnaires (EORTC Quality of Life Questionnaire-Core 30 [QLQ-C30] and EQ-5D-3L), and the Patient Global Impression of Severity (PGIS) / Patient Global Impression of Change (PGIC).

[0210] The FACIT-Fatigue is a 13-item, self-reported PRO measure assessing the level of fatigue experienced by individuals during the previous week in their usual daily activities. This questionnaire is part of the FACIT measurement system, a collection of questions measuring health-related quality of life (QoL) in patients with cancer and other chronic diseases. The FACIT-Fatigue assesses fatigue level using a 4-point Likert scale ranging from 0 (not at all) to 4 (very much). Scores range from 0 to 52, with higher scores representing more severe fatigue. The FACIT-Fatigue was originally developed to assess fatigue in cancer patients but has been used in trials evaluating the efficacy of eculizumab. The FACIT-Fatigue has demonstrated content validity in patients with PNH. (Brodsky et al., Multicenter phase 3 study of the complement inhibitor eculizumab for the treatment of patients with paroxysmal nocturnal hemoglobinuria. Blood 2008;111(4):1840-7; Hillmen et al., The complement inhibitor eculizumab in paroxysmal nocturnal hemoglobinuria. N Engl J Med 2006;355(12):1233-43.) The Fatigue Fact-Fit instrument has demonstrated content validity in patients with PNH (Weitz et al., Cross-sectional validation study of patient-reported outcomes in patients with paroxysmal nocturnal hemoglobinuria. Intern Med J 2013;43(3):298-307).

[0211] The EORTC QLQ-C30 is a 30-item general questionnaire commonly used to assess HRQoL in cancer patients (Stead et al., Development of an EORTC questionnaire module to be used in health-related quality-of-life assessment for patients with multiple myeloma. European Organization for Research and Treatment of Cancer Study Group on Quality of Life. Br J Haematol 1999;104(3):605-11; Cocks et al., An international field study of the reliability and validity of a disease-specific questionnaire module (the QLQ-MY20) in assessing the quality of life of patients with multiple myeloma. Eur J Cancer 2007;43(11):1670-8). The EORTC QLQ C30 assesses HRQoL across multiple domains, including overall health status, global quality of life, function (physical, occupational, emotional, cognitive, and social functioning), symptom scales (fatigue, nausea and vomiting, pain, loss of appetite), and single items (dyspnea, insomnia, constipation, diarrhea, sleep, financial impact). The EORTC QLQ 30 was originally developed to assess HRQoL in cancer patients but has been used in trials evaluating the efficacy of eculizumab.The EORTC QLQ has also been validated in patients with PNH (Brodsky et al., Multicenter phase 3 study of the complement inhibitor eculizumab for the treatment of patients with paroxysmal nocturnal hemoglobinuria. Blood 2008;111(4):1840-7; Hillmen et al., The complement inhibitor eculizumab in paroxysmal nocturnal hemoglobinuria. N Engl J Med 2006;355(12):1233-43). The EORTC QLQ has also been validated in patients with PNH (Weitz et al., Cross-sectional validation study of patient-reported outcomes in patients with paroxysmal nocturnal hemoglobinuria. Intern Med J 2013;43(3):298-307).

[0212] The EQ-5D-3L is a self-administered, general, standardized health status measure consisting of six questions. The EQ-5D-3L narrative system assesses five dimensions of health: mobility, self-care, daily activities, pain / discomfort, and anxiety / depression. Each dimension is graded on a three-level scale: no problem, some problem, and extreme problem. The EQ visual analog scale component is a vertical visual analog scale used by patients to rate their health.

[0213] Patient Global Impression of Severity / Patient Global Impression of Change. Patient Global Impression of Severity consists of three self-administered PRO questions assessing the patient's perception of the symptoms of their disease and / or the overall severity of specific symptoms of their disease. At the study visit, patients were asked to rate the severity of their PNH symptoms on a 6-point Likert scale ranging from "not experiencing PNH symptoms" to "very severe"; the impact their PNH symptoms have on their ability to perform normal daily activities on a 5-point Likert scale ranging from "not at all affected" to "extremely affected"; and their overall fatigue on a 5-point Likert scale ranging from "not fatigued" to "extremely fatigued."

[0214] The Patient Impression of Global Change consists of three self-administered PRO questions that assess the patient's perception of the change in the symptoms of their disease and / or the overall severity of specific symptoms of their disease compared to the start of the trial. At key time points during the trial, patients were asked to rate the change in their PNH symptoms, their ability to perform normal daily activities, and overall fatigue compared to before the start of the trial on a 7-point Likert scale ranging from "much better" to "no change" to "much worse."

[0215] PGIS and PGIC questions were developed for this trial to allow for interpretation of PRO findings and exploration of responder definitions. Responses to the PGIS and PGIC items served as "anchors" to help interpret mean changes over time in disease-specific PRO measures and estimate responder definitions. This experimental anchor-based approach is the primary FDA-recommended approach for defining responders and analyzing responder-based PRO outcomes.

[0216] Clinical trial design This was an open-label, single-arm, 26-week treatment trial in patients with a diagnosis of PNH and active signs and symptoms who were complement inhibitor-naive or had previously been treated with a complement inhibitor but not within 6 months prior to the screening visit.

[0217] This trial had two cohorts: a dose confirmation cohort (Cohort A) and a dose expansion cohort (Cohort B). Dose confirmation was performed at an interim analysis. The inclusion / exclusion criteria and event schedule were identical for Cohort A and Cohort B. While data from Cohort A were being evaluated, recruitment into the trial continued, and enrolled patients were allocated as follows: if a decision was made to extend Cohort A, patients were allocated to Cohort A. If a decision was made to advance to Cohort B, patients were allocated to Cohort B.

[0218] Patients received a single loading dose of REGN3918, 30 mg / kg intravenously (IV), on day 1, followed by doses of 800 mg or less administered subcutaneously (SC) once weekly (QW; ±1 day) for up to 26 weeks.

[0219] Dosage A single loading dose of REGN3918 at 30 mg / kg IV on day 1, followed by 800 mg (SC) once weekly (QW) was initially selected. A minimum concentration of 100 mg / L of REGN3918 was required to maximally suppress C5 activity. A loading dose of 30 mg / kg IV helped rapidly achieve the steady-state trough concentration required for sustained maximal inhibition of CH50.

[0220] Pharmacokinetics (PK) PK variables were total REGN3918 concentrations at each time point. Sampling time points are defined in Table 1-1.

[0221] Anti-drug antibodies (ADA) Anti-drug antibody (ADA) variables were ADA status, titer, and time point / visit. Samples in this study were collected at clinic visits as defined in Table 1-1. Blood samples for serum ADA assessment were collected before drug administration.

[0222] Clinical trial cohort This trial had two cohorts: a dose confirmation cohort (Cohort A) and a dose expansion cohort (Cohort B). Dose confirmation was performed at an interim analysis. The inclusion / exclusion criteria and event schedule were identical for Cohort A and Cohort B. During the evaluation period for data from Cohort A, recruitment into the trial continued, and enrolled patients were allocated as follows: if a decision was made to extend Cohort A, the patient was allocated to Cohort A. If a decision was made to advance to Cohort B, the patient was allocated to Cohort B. A trial flow diagram illustrating the treatment of each cohort is provided in Figure 1.

[0223] When making a decision, other relevant available data, including clinical data, REGN3918 PK (when available), CH50, total C5, LDH levels achieved in patients who did not achieve ≤1.5 × ULN, and safety, were available for consideration as part of the decision-making process.

[0224] The decision to progress from Cohort A to Cohort B was made by the sponsor in collaboration with the principal investigator based on achieving LDH reduction to ≤1.5 × ULN at week 8 and safety, as follows: If all 6 of 6 patients in Cohort A achieved LDH ≤1.5 × ULN at week 8 and the dosing regimen was deemed well tolerated, the dosing regimen was confirmed and the trial progressed to Cohort B, or the dosing regimen was modified and a lower dose and / or longer dosing interval was tested in Expansion Cohort A (up to 6 additional subjects). This revision was not considered substantive and therefore did not require a formal protocol amendment. If one or more patients failed to achieve LDH ≤1.5 × ULN at week 8, the following decisions were made after review of all data (including clinical and safety data, REGN3918 PK, CH50, total C5, baseline LDH, and achieved LDH levels): Confirm dosing regimen and proceed to Cohort B, or Continue with the selected dosing regimen and expand Cohort A to a maximum of 12 patients, or Increase the dose and / or shorten the dosing interval and reassess Cohort A. This option requires substantial protocol amendments.

[0225] After the first dose of REGN3918 was administered at the investigational site, subsequent doses could continue at the clinical site, by site staff, or at the patient's home by another healthcare professional (if possible), or could be self-administered / administered by the patient or designated personnel, respectively.

[0226] Drug administration Patients received a single loading dose of REGN3918, 30 mg / kg IV, on Day 1, followed by doses of 800 mg or less SC QW (±1 day) throughout the treatment period. Weekly subcutaneous dosing was 800 mg SC QW (±1 day) for initial Cohort A patients.

[0227] For Cohort A, after a loading dose of REGN3918 administered IV at the investigational site, subsequent SC administration could continue at the clinical site by site staff or at the patient's home by another healthcare professional. From week 8 onwards, self-administration / administration by the patient or designated personnel was permitted.

[0228] For Cohort B, subsequent administrations could continue at the clinic facility, in the patient's home by another healthcare professional, or by the patient / designated personnel. The location and administration options for the SC administration route depended on investigator and patient preference (e.g., abdomen, thigh, or upper arm), clinical supply availability, and home healthcare visiting professionals. A clinic visit for SC administration may or may not have been required.

[0229] If patient / designated person self-administration / administration was permitted locally, adequate injection training was provided for scheduled REGN3918 injections. After training, observation of patient / designated person self-administration / administration was conducted by clinical site staff or visiting healthcare professionals. If this observation was deemed satisfactory, the study drug could then be administered independently by the patient / designated person for the remainder of the study. In addition, patient diaries were provided prior to the start of self-administration (i.e., Week 8 for Cohort A and Week 4 for Cohort B). Diaries were to be completed after each study drug administration. Study drug kits were distributed at clinical site visits using a direct-to-patient (DTP) service provider or transported by healthcare professionals as needed.

[0230] Red blood cell (RBC) infusion RBC infusions during the study were to proceed according to the following predefined infusion trigger criteria; however, the actual number of units infused was at the investigator's discretion: RBC transfusion if post-baseline hemoglobin level is <9 g / dL and symptoms are due to anemia; or · If post-baseline hemoglobin level is <7 g / dL, administer RBC transfusion.

[0231] Pretreatment Enrolled patients were required to have evidence of meningococcal immunization or administration of vaccination during the screening period, and oral antibiotics were recommended during the treatment period, according to local practice.

[0232] Dose Modification and Study Treatment Discontinuation Rules Dose modifications for individual patients were not permitted. Patients who permanently discontinued study drug but did not withdraw from the study were asked to return to the clinic for all remaining study visits. Patients who permanently discontinued study drug and chose to withdraw from the study were asked to complete study assessments.

[0233] Study drug administration was permanently discontinued if: · Pregnancy evidence; ·Severe or severe allergic reaction thought to be related to the investigational product; Liver impairment as evidenced by one or more of the following criteria: alanine aminotransferase (ALT) or aspartate aminotransferase (AST) >8 × ULN; or ALT or AST >5 × ULN for more than 2 weeks; or ALT or AST >3 x ULN and total bilirubin >2 x ULN (or international normalized ratio (INR) >1.5), and no other reason can be found to explain the combined increase in AST / ALT and total bilirubin, such as viral hepatitis A, B, or C; pre-existing or acute liver disease; or another drug capable of causing the observed injury; · The patient withdraws consent; Patient non-adherence (e.g., failure to adhere to protocol-required visits, evaluations, and / or administration instructions); or The investigator's clinical judgment that doing so is in the patient's best interest

[0234] Temporary discontinuation was open to the investigator because of a suspected AE. If the investigator, based on his or her best medical judgment, believed that the study drug was unlikely to be responsible for the occurrence of the event of concern, the investigator could resume treatment with the study drug under close and appropriate clinical and / or laboratory monitoring.

[0235] Acute reactions Patients were to be observed for 30 minutes after IV infusion. Emergency equipment and medications to treat infusion reactions had to be available for immediate use. All infusion reactions were to be reported and graded as AEs. If any of the following AEs were observed, the infusion was to be interrupted: cough, chills / chills, rash, pruritus (itching), urticaria (hives, weals, wheals), diaphoresis (sweating), hypotension, dyspnea (shortness of breath), vomiting, or flushing. Reactions were to be treated symptomatically, and the infusion could be resumed at 50% of the original rate. If the investigator felt there was a medical need for treatment or infusion discontinuation other than those listed above, the investigator was to use clinical judgment to provide an appropriate response based on typical clinical practice.

[0236] If the following AEs occurred, the infusion was to be discontinued and not resumed: anaphylaxis * , laryngeal / pharyngeal edema, severe bronchospasm, chest pain, seizures, severe hypotension, other neurological symptoms (e.g., altered consciousness, loss of consciousness, paresthesia, paralysis); or any other symptom or sign that, in the opinion of the investigator, would cause cessation of IV fluid administration. *Anaphylaxis was considered to be present if the following were observed (Sampson et al., Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease / Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006;117(2):391-7): acute onset (minutes to hours) of illness involving the skin, mucosal tissues, or both (e.g., generalized rash, itching or flushing, swelling of the lips, tongue, or uvula) and at least one of the following: respiratory failure (e.g., dyspnea, wheezing, bronchospasm, constriction sounds, decreased peak expiratory flow, hypoxemia); or associated symptoms of decreased blood pressure or end-organ dysfunction (e.g., hypotonia [collapse], syncope, incontinence).

[0237] Patients were to be observed for 30 minutes after the first SC injection. Emergency equipment and medications to treat systemic reactions had to be available at the facility for immediate use. All infusion reactions were to be reported and graded as AEs. Acute systemic reactions after SC injection were to be treated using clinical judgment to determine the appropriate response based on typical clinical practice. Local injection site reactions were to be reported and graded as AEs.

[0238] Concomitant medication Any treatment administered from the time of informed consent through the end of the final study visit was considered a concomitant medication, including medications started before and continued during the study.

[0239] The following medications are prohibited, except as listed below: When blood was drawn, patients were not permitted to consume any alcohol within 24 hours prior to each clinic visit; Beginning on Day 1 and throughout the study, patients were not to receive any other complement inhibitor therapy while continuing on REGN3918.

[0240] The following medications and procedures were permitted, subject to the following conditions: Any medications required to treat an AE, including systemic corticosteroids, at the investigator's discretion; ·Meningococcal vaccination; · Oral antibiotic prophylaxis; · Oral contraceptives and hormone replacement therapy can be continued; Acetaminophen / paracetamol, aspirin, or ibuprofen in recommended doses according to local labeling; Erythropoietin, immunosuppressants, corticosteroids, antithrombotic agents, anticoagulants, iron supplements, and folic acid were permitted but were to be kept constant throughout the trial, if possible; any changes to these concomitant medications were at the investigator's discretion and consistent with pre-enrollment practice; and Any medications required for the treatment of the patient's background medical condition.

[0241] [Table 3-1] [Table 3-2] [Table 3-3] [Table 3-4]

[0242] result Dose (REGN3918 30 mg / kg intravenously (IV) on day 1, then 800 mg subcutaneously (SC) once weekly (QW; ±1 day)) was confirmed based on only the first 6 subjects through week 8. The trial was open-label, and therefore LDH was continuously monitored in all subjects, as it is a marker for understanding whether patients experienced breakthrough hemolysis.

[0243] All six patients achieved LDH ≦1.5×ULN by day 15 and remained there through day 57 (Figures 5, 6, and 7). Median LDH levels and individual subject LDH levels (normal and semi-log scales) through day 57 are shown in Figures 17, 18, 19, 20, 21, 22, 23, and 24. Figures 21, 22, 23, and 24 reflect LDH values ​​for nine patients. All six patients normalized after day 29, except for one patient who had an LDH of 0.89 on day 29, 1.01 on day 43, and then returned to 0.88 on day 57; and one patient who had an LDH of 0.90 on day 29, 1.19 on day 43, and then returned to 0.91 on day 57 (Figures 8 and 9). See also Table 1-2.

[0244] [Table 4]

[0245] A 51-year-old Asian female patient with a history of PNH, aplastic anemia, and a prior transfusion of 2 units of RBCs in the past year was screened for this trial. The patient had a 2-unit RBC transfusion on day 50 of the trial due to symptomatic anemia that began on day 50 and resolved on day 56. Pre-infusion HB (hemoglobin) was 7.8 g / dL. The most recent HB available after the infusion was 11.8 g / dL on day 57. This infusion is considered a protocol-compliant infusion.

[0246] No SAEs (serious adverse events), AESIs (adverse events of special interest), or infusion reactions were observed. See Tables 1-3.

[0247] [Table 5]

[0248] Serum concentrations of REGN3918 were also assessed in the subjects. See Figures 9 and 10. Individual subject REGN3918 serum concentrations and median REGN3918 serum concentrations over time are shown on a logarithmic scale and a semi-logarithmic scale (Figures 9A, 9B, 10A, and 10B). These data are also broken down by gender (Figures 9C, 9D, 10C, and 10D).

[0249] In subjects administered REGN3918, levels of total C5 were observed to increase over time. See Figures 11, 12, 13, 14, and 15. Figure 11 (A-B) shows individual subject total C5 concentrations and median total C5 concentrations over time. These data are also broken down by gender (Figure 12 (A-B)). The median fold increase from baseline in total C5 over time and the increase in individual subjects are shown in Figure 13 (A-B). These data are also broken down by gender (Figure 14 (A-B)).

[0250] Similar PK / total C5 ratios were observed at steady state across all six patients. The median ratio was 4.02. Figure 16 (A-F).

[0251] The dataset described in this example provides evidence that REGN3918 has advantageous properties over ALXN1210 and eculizumab. Although the data included herein are from only six patients, 100% (6 of 6) of the patients normalized their LDH serum levels. In the clinical trial set forth in Figure 25, only approximately half of the patients receiving ALXN1210 or eculizumab achieved normalization of LDH. [Example]

[0252] A randomized, double-blind, placebo-controlled phase I study of the pharmacokinetics and pharmacodynamics of REGN3918, a human antibody against complement factor C5, in healthy volunteers REGN3918 (pozelimab) is a fully human monoclonal immunoglobulin antibody that targets the terminal complement protein C5 and inhibits terminal complement activation by blocking C5 cleavage and, thereby, the formation of the membrane attack complex (MAC; C5b-9). REGN3918 binds with high affinity to wild-type and variant (R885H / C) human C5. REGN3918 was well tolerated in monkey toxicology studies at doses up to 100 mg / kg / week for up to 26 weeks. These findings supported the conduct of this first-in-human (FIH) clinical trial of REGN3918 in healthy volunteers.

[0253] The primary objective of this study was to evaluate the safety and tolerability of REGN3918 administered to healthy volunteers using both single ascending IV and SC administration, and a multiple-dose regimen consisting of an IV loading dose plus multiple SC weekly administrations. The secondary objective of this study was to evaluate the pharmacokinetic and pharmacodynamic profiles of REGN3918.

[0254] A total of 57 subjects were randomized (56 subjects received study treatment) into four sequentially ascending IV cohorts plus two sequentially ascending SC cohorts, followed by one multiple-dose cohort (consisting of an IV loading dose and SC weekly administration). Each cohort consisted of eight subjects randomized to receive REGN3918 or placebo (6 active: 2 placebo). REGN3918 was administered as follows: Cohort 1: 1 mg / kg IV, single dose Cohort 2a: 3 mg / kg IV, single dose Cohort 2b: 300 mg SC, single dose Cohort 3a: 10 mg / kg IV, single dose Cohort 3b: 600 mg SC, single dose Cohort 4: 30 mg / kg IV, single dose Cohort 5: A loading dose of 15 mg / kg IV followed by four repeat SC doses of 400 mg administered once weekly for 4 weeks. Please refer to Table 2-1 below.

[0255] An adaptive design was implemented to allow for adjustment of dose levels and dosing intervals while utilizing pharmacokinetic and pharmacodynamic parameters obtained during the clinical trial. The pharmacodynamic profile of REGN3918 was evaluated using a sheep erythrocyte complement activation assay (CH50 assay) and serum total C5 concentrations.

[0256] [Table 6]

[0257] Pharmacokinetics and Pharmacodynamics REGN3918 showed a dose-dependent increase in serum exposure, with a trend toward prolonged serum concentrations at IV doses of 10 mg / kg and above (Figure 2). After SC administration, serum REGN3918 concentrations peaked 4 to 8 days after administration, and bioavailability was estimated to be approximately 70%. REGN3918 exposure induced dose-dependent CH50 inhibition. In all four IV cohorts, hemolysis inhibition was observed 15 minutes after injection. Maximum hemolysis inhibition was achieved at doses of 3 mg / kg and above. At 30 mg / kg, maximum hemolysis inhibition was maintained for more than 4 weeks, consistent with the prolonged REGN3918 concentrations observed after administration. In both SC cohorts, peak hemolysis inhibition was observed 3 to 7 days after administration, again consistent with the observed peak serum REGN3918 concentrations. In multiple-dose cohort 5, complete suppression of CH50 was observed over the 4-week dosing period and for 2 weeks after the final dose (Figure 3).

[0258] safety REGN3918 was found to be well tolerated at single doses up to 30 mg / kg IV and 600 mg SC (Table 2-2). In multiple-dose cohort 5, all subjects completed dosing and all safety follow-up. A single serious adverse event, salpingitis, occurred in one cohort 5 subject; the serious adverse event occurred after completion of dosing but resolved completely after treatment with a short course of antibiotics.

[0259] [Table 7]

[0260] REGN3918 was generally well tolerated when administered via both a single ascending IV and SC dose, and a single IV loading dose followed by four consecutive weekly doses. Rapid and maximal suppression of complement activity, as measured by the sheep red blood cell CH50 assay, was demonstrated for IV doses of 3 mg / kg and above. At 30 mg / kg, maximal suppression of hemolysis was maintained for more than four weeks. A regimen consisting of a 15 mg / kg IV loading dose followed by four consecutive weekly 400 mg SC doses maintained CH50 suppression throughout the entire treatment period and for two weeks after the final dose.

[0261] Hemolysis assay To further characterize the impact of REGN3918 on alternative complement pathway (AP) activity, the effect of REGN3918 on alternative pathway-mediated hemolysis was investigated using the AH50 assay in a completed first-in-human (FIH) trial. Additionally, the effects of REGN3918 in both alternative and classical pathway hemolysis assays were compared ex vivo with those of eculizumab and ravulizumab in pooled normal human serum (NHS) samples.

[0262] Serum collected at multiple time points was used to evaluate the effect of REGN3918 on alternative pathway activity. In ex vivo spiking experiments, pooled NHS was used to compare the hemolytic functions of REGN3918, eculizumab, and ravulizumab. Alternative pathway (AP) and classical pathway (CP) hemolysis assays were performed based on the lysis of rabbit red blood cells (RBCs) and sheep RBCs after sensitization, respectively. Both assays measure the amount of hemoglobin released from red blood cells at 412 nm.

[0263] In the FIH trial, baseline AH50 was comparable across treatment groups, averaging 110 U / mL (SD = 19, n = 56). REGN3918 exposure resulted in a dose-dependent inhibition of AH50. Peak suppression of hemolysis was observed at the end of infusion (EOI) in all four IV dosing cohorts. Maximum suppression of hemolysis was approximately -85% change from baseline. This was achieved in the 30 mg / kg IV group and the 15 mg / kg IV + 400 mg SC QW repeat dosing group. In the two SC cohorts, peak suppression of hemolysis was observed 3 to 7 days post-dose, consistent with the observed peak concentrations of REGN3918 in serum. In ex vivo spiking studies, REGN3918, eculizumab, and ravulizumab were spiked into pooled NHS at 10, 25, or 48% for AP and 5, 10, or 25% for CP. Results from the AP hemolysis assay revealed that, at a given spiked antibody concentration, the maximum inhibition of hemolysis decreased for all antibodies as the percentage of serum increased (Figure 4(A-C); Tables 2-3). The maximum inhibition of hemolysis was consistently higher for REGN3918 than for eculizumab (32-169%) and lower for ravulizumab than for REGN3918 and eculizumab at all serum percentages tested. Results from the CP hemolysis assay revealed that maximal inhibition of hemolysis was similar for all antibodies tested, but that ravulizumab required at least 10-fold higher concentrations to achieve a similar effect as the other two anti-C5 antibodies (Figure 4(D-F); Table 2-4).

[0264] Magnesium is an important cofactor for the activity of AP C3 and C5 convertases. Varying the serum percentage (10, 25, or 48%) also alters magnesium concentration, which affects convertase function. To test whether this accounts for the observed differences among the three antibodies tested at different serum percentages, AP assays were performed using 25% NHS and three different concentrations of magnesium. Magnesium concentrations (MgCl2) of 1, 1.5, or 2 mM did not affect individual antibody performance. At the three different magnesium concentrations, relative differences still existed among the three antibodies tested. While magnesium concentration may still be a contributing factor under the conditions tested, there are likely other mechanisms that may be responsible for the observed relative differences.

[0265] Ex vivo studies using pooled NHS demonstrated that REGN3918 robustly blocked both CP and AP hemolysis. Ravulizumab appeared less potent than eculizumab in both CP and AP hemolysis assays. A phase I clinical trial of REGN3918 in healthy volunteers demonstrated dose-dependent, significant inhibition of alternative pathway hemolysis, resulting in a maximal suppression of hemolysis of approximately -85% from baseline.

[0266] [Table 8]

[0267] [Table 9]

[0268] [Table 10]

[0269] The sequences of the eculizumab and ravulizumab antibodies used in these assays were as follows: Eculizumab QVQLVQSGAEVKKPGASVKVSCKASGYIFSNYWIQWVRQAPGQGLEWMGEILPGSGSTEYTENFKDRVTMTRDTSTSTVYMELSSLRSEDTAVYYCARYFFGSPNWYFDVW GQGTLVTVSSASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSNFGTQTYTCNVDHKPSNTKVDKTVERKC CVECPPCPAPPVAGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKGLPSSIEKT ISKAKGQPREPQVYTLPSQEEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGNVFSCSVMHEALHNHYTQKSLSLSLGK (SEQ ID NO: 358) DIQMTQSPSSLSASVGDRVTITCGASENIYGALNWYQQKPGKAPKLLIYGATNLADGVPSRFSGSGSGTDFTLTISSLQPEDFATYYCQNVLNTPLTFGQGTKVEIK RTVAAPSVFIFPPSDEQLKSGTASVVCLLNNFYPREAKVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTLTLSKADYEKHKVYACEVTHQGLSSPVTKSFNRGEC (SEQ ID NO: 359) ravulizumab QVQLVQSGAEVKKPGASVKVSCKASGHIFSNYWIQWVRQAPGQGLEWMGEILPGSGHTEYTENFKDRVTMTRDTSTSTVYMELSSLRSEDTAVYYCARYFFGSPNWYFDVW GQGTLVTVSSASTKGPSVFPLAPCSRSTSESTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSNFGTQTYTCNVDHKPSNTKVDKTVERKC CVECPPCPAPPVAGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSQEDPEVQFNWYVDGVEVHNAKTKPREEQFNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKGLPSSIEKT ISKAKGQPREPQVYTLPSQEEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSRLTVDKSRWQEGNVFSCSVLHEALHSHYTQKSLSLSLGK (SEQ ID NO: 360) DIQMTQSPSSLSASVGDRVTITCGASENIYGALNWYQQKPGKAPKLLIYGATNLADGVPSRFSGSGSGTDFTLTISSLQPEDFATYYCQNVLNTPLTFGQGTKVEIK RTVAAPSVFIFPPSDEQLKSGTASVVCLLNNFYPREAKVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTLTLSKADYEKHKVYACEVTHQGLSSPVTKSFNRGEC (SEQ ID NO: 361) [Example]

[0270] Switching from eculizumab to REGN3918 resulted in C5 hu / hu It caused normalization of C5 concentrations and sustained suppression of hemolytic activity ex vivo in mice. To evaluate the effect of switching treatment from eculizumab to REGN3918, 15 mg / kg of REGN3918 or eculizumab (SEQ ID NOs: 358 and 359) was administered to three groups of C5 hu / huMice were dosed three times on days 0, 15, and 29. One group received only REGN3918 for all three doses, while the second group received only eculizumab. The third group (the "switch group") received eculizumab on day 0 and then switched to REGN3918 on days 15 and 29. Cageside observations and routine wellness checks revealed that the mice were healthy, and all animals survived to their scheduled termination date. Blood was collected serially at multiple time points before and after dosing throughout the trial. C of REGN3918 and eculizumab max Values ​​were comparable after the first dose (151 μg / mL and 144 μg / mL, respectively); however, REGN3918 alone exhibited slower clearance (CL) compared with eculizumab alone, resulting in generally higher serum concentrations for REGN3918 (Figure 4A, Table 4). After switching from eculizumab to REGN3918, the concentration versus time profile of total hIgG initially resembled the PK profile of REGN3918 during the second post-switch dosing interval (Figure 26(A), Table 3-1). These results suggested that switching from eculizumab to REGN3918 had only a modest effect on serum total IgG concentrations compared to those observed when either mAb was administered as a single agent.

[0271] Serum C5 concentrations were also monitored. In mice treated with REGN3918, serum C5 concentrations increased by up to 1.4-fold throughout the trial. In contrast, eculizumab induced higher serum C5 concentrations after the first, second, and third doses (1.9-, 2.0-, and 2.8-fold increases, respectively) (Figure 26(B)). The first dose of eculizumab administered to the "switch group" induced a similar increase in serum C5 concentrations as animals receiving eculizumab alone. After switching treatment to REGN3918 on day 15, serum C5 concentrations in the "switch group" temporarily decreased below baseline (70%) but returned to levels similar to those of the group receiving REGN3918 alone after the final dose of REGN3918. The accelerated clearance of C5 after the treatment switch may be consistent with the transient formation of immune complexes containing REGN3918, eculizumab, and C5, as demonstrated by the A4F-MALLS study. The effect of switching treatment from eculizumab to REGN3918 on the efficacy of blocking complement-mediated hemolysis was also evaluated. C5 at final sacrifice hu / hu Sera from mice (n=5) were collected before each new dose and 14 days after the third dose and used in a CP-mediated hemolysis assay. Hemolysis was effectively blocked to a similar extent in sera collected from all three groups after the first, second, and third antibody doses (Figure 26(C)). Blockade of hemolysis was associated with a C5:mAb ratio that remained below 1 throughout the duration of the trial (Figure 26(D)). Overall, these results suggest that switching treatment from eculizumab to REGN3918 was generally well tolerated and associated with sustained suppression of ex vivo complement activation.

[0272] [Table 11]

[0273] The complex of REGN3918, eculizumab, and C5 contains primarily one to two molecules of C5. REGN3918 may be a promising treatment option for patients with rare genetic variants of C5 and may also offer an alternative for patients currently treated with eculizumab. However, combining several antibodies that bind to unique epitopes on soluble antigens can generate higher-order protein complexes that may induce type III hypersensitivity reactions similar to serum sickness. Such conditions are self-limiting, and the size of the complexes should be influenced by the molar ratio of antibody to antigen, with the largest complexes generally formed when the components are at or near equimolar amounts. Here, we investigated the size of the complex formed at a 5:1:1 molar ratio of REGN3918:eculizumab:C5 by asymmetric flow field-flow fractionation with multi-angle laser light scattering detection (A4F-MALLS). This molar ratio was selected based on the expected in vivo serum concentrations at the first dose switch in the clinic.

[0274] Representative fractograms generated after A4F-MALLS analysis of the eculizumab / C5 / REGN3918 mixture and each of its individual components are overlaid in Figure 27. Because the concentration of REGN3918 may be in significant molar excess relative to both C5 and the endogenous eculizumab, a major peak representing free REGN3918 (peak 1; approximately 66% of the total peak area, Table 3-2) was detected in the mixture simulation. Several additional minor peaks (peaks 2–4) corresponding to heteromeric complexes of eculizumab, C5, and REGN3918 were also detected in this sample, confirming that both endogenous eculizumab and REGN3918 can associate with the same C5 molecule to form an extended antibody-antigen lattice. However, the majority of these complexes resolved into two independent peaks (peaks 2 and 3; approximately 22% of the total peak area) with calculated average molar masses of approximately 499 kDa and 841 kDa. Based on the calculated molar masses of the individual components, peaks 2 and 3 likely represented 2:1 and 3:2 mAb:C5 heteromeric complexes, respectively. A broad, poorly resolved peak (peak 4), which may correspond to a heterogeneous distribution of higher-order complexes (approximately 1200–2100 kDa), was also detected, but only accounted for approximately 12% of the total peak area. Taken together, these data suggest that eculizumab and REGN3918 may form heteromeric complexes with C5, but that the formation of very large, heterogeneous, and potentially immunogenic complexes may be minimal when each component is present at the expected in vivo concentrations at the time of the initial dosing switch. Furthermore, the formation of such very large complexes may be transient and should steadily decline as eculizumab clears from the circulation and / or with additional dosing with REGN3918.

[0275] [Table 12]

[0276] In addition to offering a promising treatment option for patients with rare C5 variants, REGN3918 also offers an alternative for patients currently treated with eculizumab. For example, REGN3918 may require less frequent dosing regimens and achieve more stable serum C5 levels. A dose-switching study in humanized C5 mice demonstrated that switching from eculizumab to REGN3918 was well tolerated and maintained inhibition of complement activity. However, combining some antibody therapeutics targeting soluble antigens can lead to the generation of higher-order immunogenic protein complexes. Using the expected molar ratio of eculizumab:REGN3918:hC5 at the time of dose switching, A4F-MALS studies demonstrated that eculizumab and REGN3918 can form heteromeric complexes with C5. However, the formation of very large, heterogeneous, potentially immunogenic complexes is minimal and may be transient in vivo. These data may support the use of excess REGN3918 when switching from eculizumab to minimize the potential for inducing a serum sickness-like reaction. [Example]

[0277] An open-label, efficacy and safety study of pozelimab in patients with CD55-deficient protein-losing enteropathy (CHAPLE disease). This was an open-label, single-arm, 104-week treatment trial in patients aged 1 year or older with active clinical signs and symptoms of CD55-deficient PLE / CHAPLE disease and genotypic analysis of CD55 loss-of-function mutations (frameshift, nonsense mutations). Patients received a single loading dose of pozelimbab 30 mg / kg intravenously (IV) on day 1, followed by a fixed-dose subcutaneous (SC) (weight-based) QW (±1 day) treatment period throughout the treatment period. The trial included a screening period (up to 4 weeks) followed by a 104-week treatment period from week 0 to week 103, and a follow-up period from week 104 to week 116. Only patients with active PLE were included in the primary analysis. In this trial, active PLE was defined as hypoalbuminemia of 3.2 g / dL or less during the screening period and one or more of the following symptoms or signs for at least 7 days (not necessarily consecutive) within the last 6 months: diarrhea, vomiting, abdominal pain, peripheral or facial edema, an episode of infection complicated by hypogammaglobulinemia, or a new thrombotic event.

[0278] Clinical trial period The duration of the clinical trial for patients was approximately 117 weeks (weeks 0 to 116), excluding the screening period.

[0279] Clinical trial population Sample size. A minimum of six patients with active PLE were to be enrolled. The registry was then closed 1 year after FPFD or upon enrollment of the 20th patient, whichever occurred first. Eligible patients with inactive PLE were also eligible to enroll, but their data were not included in the primary analysis.

[0280] Eligible population: Patients aged 1 year or older with a clinical diagnosis of CD55-deficient PLE disease and a CD55 loss-of-function mutation determined by genetic analysis (frameshift, nonsense mutation) and confirmed by CD55 flow cytometry or Western blotting in peripheral blood cells (required only if missense or splice-site mutations were suspected). The first two patients had to be aged 6 years or older (exceptions were made for patients under 6 years of age with life-threatening disease).

[0281] [Table 13]

[0282] Inclusion criteria Patients had to meet the following criteria to be eligible for inclusion in the study: 1. Male or female, aged 1 year or older. The first two patients recruited must be aged 6 years or older; 2. Clinical diagnosis of CD55-deficient PLE / CHAPLE disease (based on a history of PLE) confirmed by biallelic CD55 loss-of-function mutations (frameshift, nonsense mutations) detected by genotyping. In the case of missense or suspected splice site mutations, CD55-deficient PLE must be confirmed by flow cytometry or Western blot of peripheral blood cells. These diagnostic tests could be performed as part of the clinical trial screening procedure or as part of the standard clinical evaluation before screening. 3. The patient has any of the following diseases: a. Active disease defined as: (i) hypoalbuminemia of 3.2 g / dL or less during the screening period, and (ii) Within the last 6 months, and for at least 7 days (not necessarily consecutive) attributable to CD55-deficient PLE, at least one of the following symptoms or signs: diarrhea, vomiting, abdominal pain, peripheral or facial edema, or an episode of infection complicated by hypogammaglobulinemia, or a new thromboembolic event Note: The first two patients enrolled in this study had to meet inclusion criterion 3a. b. Inactive disease on eculizumab therapy (and the patient's treating physician has the expectation of future access to updated eculizumab therapy, if this is needed), and willingness to discontinue eculizumab during the screening period and initiate pozelimuab at baseline without an eculizumab washout; 4. Willing and able to comply with clinic visits and study-related procedures; 5. Written informed consent from parent / guardian for minor patients; 6. Written consent of minor patients, as appropriate (e.g., those older than 6 years of age or the applicable age based on local regulatory requirements); and 7. Patients must be able to understand and complete study-related questionnaires independently, or with the assistance of their parent / legal guardian if necessary.

[0283] Exclusion criteria Patients who meet any of the following criteria will be excluded from this study: 1. History of meningococcal infection. 2. No documented meningococcal vaccination within 3 years prior to screening and patient is not willing to be vaccinated during the study (if fully available according to local practice). 3. If applicable, vaccination against Haemophilus influenzae and Streptococcus pneumoniae has not been documented prior to screening per local practice or guidelines, and the patient is not willing to be vaccinated during the study if required per local practice or guidelines. 4. Presence of comorbid conditions that would cause hypoproteinemia at the time of initiation of pozelimab, including urinary protein loss or liver disease affecting protein production by the liver. 5. Comorbid conditions that cause secondary intestinal lymphangiectasia, such as Fontan surgery for congenital heart disease. 6. Recent infection (within 2 weeks of screening or during the screening period) requiring systemic treatment with antibiotics, antivirals, or antifungals. If the patient is adequately treated, the patient may be rescreened. 7. PLE previously refractory to eculizumab, with the exception of patients with the Arg885His variant in the C5 gene. 8. Known hereditary complement deficiencies other than CD55 deficiency. 9. Documented history of active ongoing systemic autoimmune disease. 10. Known or suspected infectious colitis at the time of screening. Once this resolves, patients can be rescreened. 11.30mL / min / 1.73m 2 Patients with an estimated glomerular filtration rate (eGFR) below 18.0 (according to the Chronic Kidney Disease-Epidemiology Collaboration Equation 2009 [adults] or the creatinine-based Schwartz equation [pediatric patients]). 12. Recent unstable medical conditions within the past 3 months prior to the screening visit, excluding PLE and related complications. Re-screening after 3 months is not an option. 13. Known hypersensitivity to the pozeliman formulation or any of the components of the drug. 14. Any clinically significant abnormality identified at screening that, in the investigator's judgment, would preclude safe completion of the study or limit endpoint assessment, such as significant systemic disease, including a history of hepatitis B or C. Patients with known prior hepatitis B or C could be enrolled only if these diseases were no longer active, as demonstrated by negative hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), hepatitis B viral DNA, and hepatitis C viral RNA (HCV RNA), respectively. Note: Testing for Hepatitis B and C was not required for enrollment in this trial, but was available at the investigator's discretion. 15. Participation in another interventional clinical trial or use of any experimental therapy within 30 days prior to the screening visit or within 5 half-lives of the investigational drug, whichever is longer, with the exception of complement inhibitors. 16. The investigator or any investigator determines that the study is not effective for any reason, including: Being deemed unable to meet certain protocol requirements, such as scheduled visits, and / or - is deemed unable to tolerate prolonged injections, based on the patient, investigator, study coordinator, pharmacist, study coordinator, other study staff, or any of their associates directly involved in the conduct of the study; and / or The existence of any other actual or anticipated conditions (e.g., geographic, social, etc.) that the investigator feels may restrict or limit the patient's participation throughout the duration of the trial. Therefore, the patient is deemed unsuitable for this clinical trial. 17. Patients who are institutionalized pursuant to an order issued by a judicial or administrative authority. 18. Women who are pregnant, lactating, or have a positive pregnancy test at the screening visit or Day 1. 19. Pregnant or breastfeeding women. 20. Females of childbearing potential who are not willing to practice highly effective contraception prior to the start of the first dose / initial treatment, throughout the study, and for at least 21 weeks after the final dose * and postmenarcheal (and non-celibate) girls. As a highly effective form of contraception: Stable use of combined (estrogen and progestogen-containing) hormonal contraception (oral, vaginal, transdermal) or progestogen-only hormonal contraception (oral, injectable, implantable) associated with ovulation inhibition initiated for at least two menstrual cycles prior to screening b. Intrauterine device (IUD); Intrauterine hormone-releasing system (IUS) c. Bilateral tubal ligation d. Partner's vasectomy e. and / or abstinence†,‡ Examples include: * Postmenopausal women must be amenorrheic for at least 12 months to be considered fertile. Pregnancy testing and contraception are not required for women with a documented hysterectomy or tubal ligation. † Abstinence is considered a highly effective strategy only if it is defined as abstinence from heterosexual intercourse throughout the entire duration of the study treatment and its associated risks. The reliability of abstinence needs to be assessed in relation to the duration of the clinical trial and the patient's usual preferred lifestyle. ‡ Periodic abstinence (calendar method, symptom-temperature method, postovulatory method), interruption (abortive intercourse), spermicide only, and lactational amenorrhea method (LAM) are not acceptable methods of contraception. Female and male condoms should not be used together; 21. Intentionally leaving things blank 22. Documented history of unresolved tuberculosis (TB) or evidence of active or latent tuberculosis infection (LTBI) during the screening period. Evaluation for active TB and LTBI was to follow local practice or guidelines, including those related to risk assessment, and the use of tuberculin skin testing or T-cell interferon-gamma release assays.

[0284] Outcomes / Endpoints The primary endpoint was the proportion of patients who achieved both of the following: Normalization of serum albumin, as defined by: - Serum albumin within the normal range in at least 70% of measurements taken between 12 and 24 weeks, and - Albumin measurement was not less than 2.5g / dL on any occasion between 12 and 24 weeks, and - No albumin infusion required between 12 and 24 weeks At week 24, improvement in the following clinical outcomes that were evaluable for improvement at baseline, but no worsening of other outcomes (i.e., outcomes not evaluable for improvement): - Number of bowel movements per day based on a weekly average as captured by e-diary. Improvement is defined as a 50% or greater decrease in daily bowel movements based on a weekly average. Patients evaluable for improvement are defined as those with an average of 3 or more bowel movements per day at baseline. Worsening is defined as a 30% or greater increase. -Physician assessment of facial edema (based on a 5-point Likert scale). Improvement is defined as a decrease of 2 or more points. Patients evaluable for improvement are defined as those with a severity of at least 2 out of 5 points at baseline. Worsening is defined as an increase of 2 or more points. - Physician assessment of peripheral edema (based on a 5-point Likert scale). Improvement is defined as a decrease of 2 or more points. Patients evaluable for improvement are defined as those with a severity of at least 2 out of 5 points at baseline. Worsening is defined as an increase of 2 or more points. - Patient / caregiver assessment of abdominal pain frequency as assessed by the Gastric Pain and Damage subscale of the PedsQL™ GI Symptom Scale. Improvement is defined as an increase of 6 points or more (based on a total subscale score converted to 0-100, with lower scores representing worsening GI gastric pain and damage). Patients evaluable for improvement are defined as those with a baseline score of 70 points or less. Worsening is defined as a decrease of 6 points or more.

[0285] Secondary endpoints are: Incidence and severity of treatment-emergent adverse events (TEAEs) from baseline to week 104 and other safety variables Improvement at 24 weeks in each patient's most bothersome sign / symptom, as determined prior to baseline using a semi-structured, concept-eliciting interview, from among the "core" clinical endpoints consisting of: bowel frequency, peripheral edema, facial edema, abdominal pain frequency, nausea, vomiting, and stool consistency: Improvement in nausea and vomiting was defined as a 6-point increase on the nausea and vomiting subscale of the PedsQL GI Symptom Scale score converted to a 0-100 scale, with lower scores representing worsening nausea and vomiting. Patients were evaluable for improvement in nausea and vomiting if they had a score of 85 or less on the nausea and vomiting subscale at baseline. - Improvement in stool consistency is defined as a 50% or greater reduction in the number of days per week the patient has loose / watery stools. A stool is considered loose / watery if it corresponds to 3 images corresponding to loose or watery stools on the Brussels Infant and Toddler Stool Scale (BITSS), images and descriptors corresponding to classifications 4 or 5 on the modified Bristol Stool Form Scale for Children (mBSFS-C), and images and descriptors corresponding to classifications 6 or 7 on the Bristol Stool Form Scale (BSFS). To be evaluable for improvement in stool consistency, patients must have 2 or more days per week with loose / watery stools at baseline. Proportion of patients with active disease at baseline who maintain disease control at 48 and 104 weeks, as defined below: - Normalization of serum albumin, defined as serum albumin within the normal range for at least 70% of measurements between 12 and 48 weeks (and between 12 and 104 weeks); and no albumin measurements less than 2.5 g / dL between 12 and 48 weeks (and between 12 and 104 weeks); and no need for albumin infusion between 12 and 48 weeks (and between 104 weeks), and - No worsening of facial or peripheral edema, increased bowel movements, or increased frequency of abdominal pain between weeks 12 and 48 (and 104), using the same definition of worsening as the primary endpoint - Not increase the dose of any permitted concomitant medications to treat PLE at any time, and not reintroduce any permitted concomitant medications once discontinued, except for the following: corticosteroids, IV or SC immunoglobulin, IV albumin, biologic immunomodulators (anti-TNF, vedolizumab), small molecule immunomodulators (e.g., azathioprine, mesalazine), micronutrients, enteral or parenteral supplementation The proportion of patients with inactive disease who received eculizumab at baseline who maintained disease control at 24, 48, and 104 weeks, as defined below: - Normalization of serum albumin defined as serum albumin within the normal range for at least 70% of measurements between weeks 12 and 24 (and weeks 12 and 48, and weeks 12 and 104); and no albumin measurements less than 2.5 g / dL between weeks 12 and 24 (and weeks 48 and 104); and no need for albumin infusion between weeks 12 and 24 (and weeks 48 and 104); and - No worsening of facial or peripheral edema, increased bowel movements, or increased frequency of abdominal pain between weeks 12 and 24 (and 48 and 104), using the same definition of worsening as the primary endpoint - Not increase the dose of any permitted concomitant medications to treat PLE at any time, and not reintroduce any permitted concomitant medication once discontinued, except for the following: corticosteroids, IV or SC immunoglobulin, IV albumin, biologic immunomodulators (anti-TNF, vedolizumab), small molecule immunomodulators (e.g., azathioprine, mesalazine), micronutrients, enteral or parenteral supplementation Number of bowel movements per day, based on a weekly average, as captured by e-diary from baseline to week 24. Number of days / weeks with ≥1 bowel movement of loose / watery consistency as measured by BSFS for patients ≥18 years of age, mBSFS-C for toilet-trained patients <18 years of age, or BITSS for non-toilet-trained patients, as captured by e-diary from baseline to week 24 Physician-assessed facial edema (based on a 5-point Likert scale) from baseline to week 104 Physician-assessed peripheral edema (based on a 5-point Likert scale) from baseline to week 104 Change in abdominal symptoms, as assessed by the Gastric Pain and Damage subscale and Food and Drink Restriction subscale of the PedsQL™ GI Symptom Scale, from baseline to week 104 Health-related quality of life assessed by the PedsQL™ generic core scale from baseline to week 104; in addition, the following subscales were reported separately: - Self-occupational / academic and school functioning subscale - Physical Functioning Subscale Assessment of ascites (assessed by abdominal circumference measurement) from baseline to week 24 Frequency of albumin infusions through Week 104, expressed as number per six months. Albumin infusions were permitted during the treatment phase if albumin levels were <3.0 g / dL on two consecutive visits and were accompanied by symptoms of facial or peripheral edema or ascites. If albumin infusions were administered between Weeks 12 and 24, patients were considered non-responders for the primary endpoint. Total albumin, protein, total Ig, IgG, IgM, IgA expressed as: - Absolute values ​​for each scheduled time point, including 24 weeks - Absolute and percent change from baseline over time - Time to first normalization Vitamin B12, folate, iron, iron binding capacity, ferritin, magnesium, fasting cholesterol / triglycerides as follows: - Absolute values ​​for each scheduled time point, including 24 weeks - Change from baseline over time - Time to first normalization Alpha-1 antitrypsin levels in blood and stool, and changes from baseline to weeks 12 and 24 Use and administration / frequency of corticosteroids, IV or SC immunoglobulin, IV albumin, biologic immunomodulators (anti-TNF, vedolizumab), small molecule immunomodulators (e.g., azathioprine, mesalazine), micronutrients, enteral or parenteral supplementation, anticoagulants (e.g., low molecular weight heparin), antibiotics (with the exception of antibiotics used for Neisseria prophylaxis), and antiplatelet agents (e.g., low-dose aspirin) from baseline to week 104 Number of hospitalization days throughout the period (percentage of hospitalized days) Weight and height over time (expressed as z-scores) Serum total pozelimab concentrations assessed throughout the trial Incidence of treatment-emergent anti-drug antibodies (ADA) to pozelimb in patients over time Change and percent change from baseline in total complement activity CH50 over the period

[0286] Exploratory outcomes were as follows: Plasma total C5 concentration throughout the period Markers of thrombosis: D-dimer and N-terminal prothrombin fragment (F1+2) Complement assay: sC5b-9 Change in GI symptoms over time from baseline as measured by the Pediatric Quality of Life Inventory (PedsQL™) GI symptom scale (diarrhea subscale, and nausea and vomiting subscale) Changes from baseline in caregiver health and workload over time as measured by the PedsQL™ Family Impact Module Clinician's Global Impression of Change (CGIC) from baseline to week 104 Clinician Global Impression of Severity (CGIS) from baseline to week 104 Patient / caregiver global impression of change (PGIC / CareGIC) from baseline to week 104 Patient / caregiver global impression of severity (PGIS / CareGIS) from baseline to week 104 Tanner's pubertal stages, if applicable, for ages and stages of sexual maturity Whole exome sequencing (if not already performed)

[0287] Efficacy indicators / procedures Serum albumin, total protein, and immunoglobulins. Samples were collected and tested in the laboratory for blood chemistry or immunoglobulin panels.

[0288] Physician assessment of edema and ascites. Physicians assessed peripheral edema as follows: after performing a general examination and palpation of all four limbs, the investigator rated the overall severity of peripheral edema, taking into account both the extent and distribution, on a 5-point rating scale (1 meaning no edema and 5 meaning very severe edema).

[0289] Physicians assessed facial edema as follows: After performing a general examination of the face, the investigator rated the overall severity of facial edema, taking into account both the extent and distribution, on a 5-point rating scale (1 meaning no edema and 5 meaning very severe edema).

[0290] The severity of ascites was assessed by measuring abdominal circumference as follows: 1. Palpate the lower rib margin (costal margin) and mark it with a short horizontal line; 2. Palpate the iliac crest and mark it with a short horizontal line; 3. Using a tape measure, measure the mid-distance between the two horizontal lines, and mark this with another short horizontal line in the middle; 4. Ask the patient to cross their arms over their chest to allow access to the waist. Instruct them to stand relaxed and look straight ahead. Ensure the patient does not intentionally extend or retract their arms; 5. Pass the measuring tape around your waist, making sure it is level and positioned at the mid-distance mark on each side; 6. Make sure you don't pull the tape too tightly. It should stay on the skin and not indent it. 7. Measurements are taken at the end of expiration; 8. Measure to the nearest 0.1 cm (1 mm); 9. Abdominal circumference measured three times; and 10. Record all three measurements and the mean / average obtained by adding the numbers together and dividing by three.

[0291] In the case of abnormal findings, these evaluations were to be accompanied by clinical photographs, if available. All physician evaluations of patients were to be performed by the same investigator up to 24 weeks.

[0292] Clinical trial design This was an open-label, single-arm, 104-week treatment trial in patients aged 1 year or older with active clinical signs and symptoms of CD55-deficient PLE / CHAPLE disease and CD55 loss-of-function mutations (frameshift, nonsense mutations) detected by genotyping. In cases of suspected missense or splice-site mutations, CD55-deficient PLE was confirmed by flow cytometry of peripheral blood cells. The first two patients enrolled were aged 6 years or older (with the exception of patients younger than 6 years with life-threatening disease).

[0293] A minimum of six patients with active PLE were enrolled. Enrollment was then closed 1 year after the first patient's first dose (FPFD) or at the time of enrollment of the 20th patient, whichever came first. The primary analysis occurred when approximately 6 patients with active PLE had received 6 months of treatment. Subsequent analyses occurred 1 and 2 years after first dose in the last patient enrolled.

[0294] Patients received a single loading dose of pozelimbab, 30 mg / kg IV, on day 1, followed by fixed-dose SC (weight-based) QW (± 1 day) throughout the treatment period.

[0295] The trial consisted of a screening period (up to 4 weeks) followed by a 104-week treatment period from week 0 to week 103, and a follow-up period from week 104 to week 116. After the treatment period, patients had the option to enroll in an open-label extension study that continued until commercialization of pozelimuab was approved in their country (if commercialization had not yet occurred) or until the end of commercialization / development of pozelimuab.

[0296] Active PLE was defined as hypoalbuminemia of 3.2 g / dL or less during the screening period and one or more of the following symptoms or signs for at least 7 days (not necessarily consecutive) within the last 6 months: diarrhea, vomiting, abdominal pain, peripheral or facial edema, or an episode of infection complicated by hypogammaglobulinemia, or a new thrombotic event. Active patients were not receiving current therapy with eculizumab.

[0297] Test drug Pozelimab drug product was provided in sterile single-use glass vials for IV or SC administration and was supplied by the sponsor. Drug product was initially provided in a lyophilized form in sterile single-use glass vials for IV or SC administration (requiring reconstitution with sterile water for injection and then transfer to the sterile single-use glass vial) or in pre-filled syringes containing the liquid, 200 mg / mL pozelimbab formulation (no reconstitution required) for IV or SC administration.

[0298] The study drugs were provided by the sponsor. The lyophilized or mixed solutions required for delivery of the liquid drugs for IV administration were sourced locally or, if necessary, were provided by the sponsor.

[0299] Usage / Dosage Patients received a single loading dose of pozelimab 30 mg / kg IV on Day 1, followed by SC dosing QW (± 2 days) based on weight throughout the treatment period. The final dose of study drug was administered at Week 103. Subcutaneous administration regimen: · For BW less than 10 kg: 125 mg; ·BW ≥ 10 kg but < 20 kg: 200 mg; · BW ≥ 20 kg and < 40 kg: 350 mg; · BW ≥ 40 kg and < 60 kg: 500 mg; For BW 60kg and over: 800mg.

[0300] The location and administration option for the SC route of administration depended on investigator and patient preference (e.g., abdomen, thigh, or upper arm), availability of clinical supplies, and home health care visiting staff. A clinic visit for SC administration may or may not have been required.

[0301] If self-administration / administration by patients / designated personnel was acceptable locally, adequate injection training was provided for scheduled injections with pozeliman. After training, observation of self-administration / administration by patients / designated personnel was conducted by clinical site staff or visiting healthcare professionals. If this observation was deemed satisfactory, the study drug could then be administered independently by patients / designated personnel for the remainder of the study.

[0302] In addition, a patient diary was provided before the start of self-administration (i.e., Day 29). The diary was to be completed at the time of each study drug administration. Study drug kits were dispensed at the clinical site visit using a direct-to-patient (DTP) service provider or transported by healthcare professionals as needed. Detailed information regarding study drug administration was provided in the pharmacy manual.

[0303] Pharmacokinetics (PK) Analysis of Drug Concentration Data. The PK endpoint was serum total pozelimab concentration over time.

[0304] Summaries of total drug concentrations and total C5 were presented by nominal time points (i.e., protocol-defined time points). Individual data were presented by actual time. Plots of pozelimb and total C5 concentrations were shown over time (linear and logarithmic scales). When the scale was linear, concentrations below the lower limit of quantitation (LLOQ) were set to zero. In logarithmic scale plots, concentrations below the LLOQ were placed as LLOQ / 2. Summary statistics for total pozelimb and total C5 concentrations may include, but are not limited to, the arithmetic mean, standard deviation, standard error of the mean, coefficient of variation (expressed as a %), minimum, Q1, median, Q3, and maximum. Formal statistical analysis was not performed.

[0305] Analysis of anti-drug antibody data. Anti-drug antibodies were characterized by the type and level of response observed. Samples positive in the ADA assay were further characterized for neutralizing antibodies (NAb) and ADA titers.

[0306] The anti-drug antibody response categories and titer categories evaluated were as follows: · Negative / pre-existing immune reactivity; Treatment-emergent response; Enhanced response under treatment; ·NAb responses in ADA-positive patients; · Potency numerical classification (potency range); - low (titer less than 1,000), - moderate (titer 1,000 to 10,000); - High (titer > 10,000).

[0307] ADA assay results, treatment-emergent ADAs, NAbs, and patient titers, time points, and treatment cohorts / groups were listed. The incidence of treatment-emergent ADAs and NAbs was assessed as absolute incidence (N) and percentage of patients (%) grouped by ADA titer level.

[0308] Drug concentration plots were examined and the impact of ADA on individual PK profiles was assessed. In some cases, an assessment of the impact of ADA on safety and efficacy was presented.

[0309] Before treatment Enrolled patients were required to have evidence of meningococcal immunization or vaccination administered during the screening period and were recommended oral antibiotics during the treatment period according to local or national practice and investigator assessment.

[0310] Vaccination. Enrolled patients were required to be immunized with meningococcal vaccination. Vaccination administration preferably occurred at least 2 weeks before the initiation of pozelimab or at another time according to local practice or national guidelines. Patients were offered vaccination against serogroups A, C, Y, W, and, if available, serogroup B. Patients with previous and documented vaccination against meningococcus were re-immunized according to local practice. Patients were to be closely monitored for early signs and symptoms of meningococcal infection and promptly evaluated if infection was suspected. Patients were provided with a patient safety card describing the signs and symptoms of meningococcal infection, along with instructions for possible meningococcal infection and information for non-investigator healthcare providers.

[0311] Pediatric patients were encouraged to have evidence of Haemophilus influenzae immunization and Streptococcus pneumoniae immunization or vaccination administration during the screening or treatment period based on local practice, guidelines, and availability. Vaccinations were procured locally by the investigator or their designee and reimbursed by the sponsor.

[0312] Oral Antibiotics. Daily oral antibiotic prophylaxis could be initiated on the day of the first dose and continued for the duration of the study, unless the risks outweighed the benefits or were inconsistent with local practice. Patients discontinuing pozeliman prematurely were recommended to receive oral antibiotic prophylaxis for at least 21 weeks after discontinuing pozeliman, or for a period consistent with local guidelines, whichever was longer. For adults, antibiotic prophylaxis was suggested to be penicillin V 500 mg twice daily (BID); in the case of penicillin allergy, erythromycin 500 mg BID could be used at the investigator's discretion. For pediatric patients, antibiotic prophylaxis was suggested to be penicillin VK 125 mg buccal BID for patients under 5 years of age and 250 mg BID for those 5 years of age or older. If the pediatric patient was allergic to penicillin, erythromycin was administered at 125 mg orally twice daily for patients under 3 years of age and 250 mg orally twice daily for patients 3 years of age or older. Ultimately, the decision on oral antibiotic prophylaxis, duration of prophylaxis, choice of oral antibiotic, and dosing regimen was at the discretion of the investigator. Oral antibiotics were procured locally by the investigator or their designee and reimbursed by the sponsor.

[0313] Dose Modification and Study Treatment Discontinuation Rules Dose Modification. Dosing regimen modifications / reductions were not permitted for individual patients. If a patient moved to a higher BW group, the dose was to be increased as specified in the dosing regimen. For the purpose of this dose escalation, body weight was measured at study visits (not at each weekly dose) as specified in the assessment schedule. Pozelimab was originally provided in vials as a lyophilized powder for reconstitution, so a single format supported all weight-based dosing regimens. The correct number of vials and collected volume for SC injection were administered by a healthcare practitioner (not necessarily a physician) at the study site, during visits, or between visits at a local primary healthcare clinic or at home; self-administration / administration by the patient / designated person was also permitted. Each SC dose could be administered by more than two injections if necessary; each injection was not to exceed a volume of 2 mL.

[0314] Discontinuation of Study Drug. Patients who permanently discontinued study drug but did not withdraw from the study were asked to return to the clinic for all remaining study visits according to the visit schedule. Patients who chose to permanently discontinue study drug and withdraw from the study could be asked to complete study assessments.

[0315] Reasons for permanent discontinuation of study drug. Study drug administration was permanently discontinued in the following cases: ·Severe or severe allergic reaction thought to be related to the investigational product; Liver damage evidenced by one or more of the following criteria occurring without evidence of an alternative etiology: - Alanine aminotransferase (ALT) or aspartate aminotransferase (AST) >8 × ULN, or - ALT or AST >5xULN for >2 weeks, or - ALT or AST >3 x ULN and bilirubin >2 x ULN (or international normalized ratio [INR] >1.5), and no other reason can be found to explain the combined increase in AST / ALT and total bilirubin, such as hepatitis A, B, or C virus; pre-existing or acute liver disease; or another drug capable of causing the observed injury; · The patient withdraws consent; Patient non-adherence (e.g., failure to adhere to protocol-required visits, evaluations, and / or administration instructions); or The investigator's clinical judgment that doing so is in the patient's best interest. Note: Evidence of pregnancy was not considered an automatic reason for permanent discontinuation and was to be discussed with the medical monitor. Pregnancy could be a reason for permanent discontinuation if deemed unfavorable following a benefit-risk assessment of continued treatment with pozelimb.

[0316] Reasons for temporary discontinuation of study drug. Temporary discontinuation was open to the investigator because of a suspected AE. If the investigator, based on his or her best medical judgment, believed that the study drug was unlikely to be responsible for the occurrence of the event of concern, the investigator could resume treatment with the study drug under close and appropriate clinical and / or laboratory monitoring.

[0317] Management of acute reactions Acute intravenous fluid reactions. Patients were to be observed for 30 minutes after infusion. Emergency equipment and medications to treat infusion reactions had to be available for immediate use. All infusion reactions had to be reported as AEs and graded using a grading scale.

[0318] Interruption of intravenous infusion. Infusion was to be interrupted if any of the following AEs were observed: ·cough; · Chills / chilliness; · Rash, pruritus (itching); Urticaria (hives, welts, wheals); Diaphoresis (sweating); Low blood pressure; · dyspnea (shortness of breath); vomiting; or ·Flushing.

[0319] Reactions were treated symptomatically and infusion could be resumed at 50% of the original rate.

[0320] If the investigator felt that there was a medical need to discontinue treatment or infusion other than as described above, the investigator would use clinical judgment and provide an appropriate response based on typical clinical practice.

[0321] Termination of intravenous infusion. If any of the following AEs occurred, the infusion was to be discontinued and not restarted: Anaphylaxis * ; Laryngeal / pharyngeal edema; · Severe bronchospasm; ·Chest pain; Seizures; · Severe hypotension; Other neurological symptoms (such as impaired consciousness, loss of consciousness, paresthesia, or paralysis); or Any other symptoms or signs that, in the opinion of the investigator, would cause IV fluids to be discontinued *Anaphylaxis is considered to be present if the following is observed (Sampson et al., Second symposium on the definition and management of anaphylaxis: summary report - second National Institute of Allergy and Infectious Disease / Food Allergy and Anaphylaxis Network Symposium. Ann Emerg Med 2006;47(4):373-80): acute onset (minutes to hours) of illness involving the skin, mucosal tissues, or both (e.g., generalized rash, itching or flushing, swelling of the lips, tongue, or uvula) AND at least one of the following: respiratory distress (e.g., dyspnea, wheezing, bronchospasm, stenotic sounds, decreased peak expiratory flow, hypoxemia); or · Decreased blood pressure or associated symptoms of end-organ dysfunction (e.g., hypotonia [collapse], syncope, incontinence).

[0322] Systemic Infusion Reactions. Patients were to be observed for 30 minutes after the first SC injection. Emergency equipment and medications to treat systemic reactions had to be available for immediate use. All infusion reactions were to be reported as AEs and graded using a grading scale. Acute systemic reactions after SC injection of the investigational drug were to be treated using clinical judgment to determine the appropriate response based on typical clinical practice.

[0323] Local injection site reactions. Local injection site reactions were to be reported as AEs and graded according to the Food and Drug Administration (FDA) September 2007 Guidance for Industry, Toxicity Grading Scale for Healthy Adult and Minor Volunteers Enrolled in Prophylactic Vaccine Clinical Trials.

[0324] Concomitant medication Any treatment administered from the time of informed consent through the end of the final study visit was considered a concomitant medication, including medications started before and continued during the study.

[0325] Prohibited Medications. The following medications are prohibited, except as permitted per the discussion below: When blood was drawn, patients were not permitted to consume any alcohol within 24 hours prior to each clinic visit; Beginning on Day 1 and throughout the study, patients were not to take eculizumab while continuing on REGN3918. · The addition of any experimental therapy, including complement inhibitors, even if approved during the investigational period; Vitamin B12 supplementation should not be given during the first 4 weeks of pozelimab treatment (i.e., it cannot be started before the week 4 visit).

[0326] Authorized Medications. An authorized medication is any medication that is not prohibited. The following medications and procedures are authorized, subject to the following conditions: Albumin infusion was permitted during the screening period only for disease of life-threatening severity, and even after initiation of study drug if the albumin level was <3.0 g / dL and accompanied by symptoms of facial or peripheral edema or ascites. This restriction applied only to albumin infusions administered specifically for PLE. · Any medications needed to treat an AE, including nonsteroidal anti-inflammatory drugs, antihistamines, or topical or systemic corticosteroids, at the investigator's discretion; ·Meningococcal vaccination; · Oral antibiotic prophylaxis; Medicines for treating type III hypersensitivity reactions Oral contraceptives and hormone replacement therapy could be continued or initiated during the study period; Acetaminophen / paracetamol, aspirin, or ibuprofen in recommended doses according to local labeling; Immunosuppressants, biological therapies, immunoglobulins, corticosteroids, antithrombotic agents, anticoagulants, antibiotics, iron supplements, vitamins, and enteral and parenteral nutritional supplements were permitted. Any changes to these concomitant medications were at the investigator's discretion. Weaning and / or withdrawal from any of these medications was permitted at the investigator's discretion in the context of a response to treatment with pozelimb in the underlying disease; or Any medications required for the treatment of the patient's background medical condition.

[0327] [Table 14-1] [Table 14-2]

[0328] [Table 15-1] [Table 15-2] [Table 15-3] [Table 15-4]

[0329] Hematology, chemistry (except total C5, CH50 sC5b-9, and C5a), urinalysis, and pregnancy test samples could be analyzed by local / central laboratories. Other tests were performed by central or specialized laboratories as outlined in the sample management plan. Detailed instructions for blood sample collection are in the sample management plan provided to the investigational site.

[0330] [Table 16]

[0331] Lipid panel (fasting) Total cholesterol (LDL and HDL) triglycerides

[0332] Blood immunoglobulin panel Total Ig, IgG, IgM, IgA

[0333] Micronutrient Panel Vitamin B12, folic acid, iron, iron-binding capacity, ferritin

[0334] [Table 17]

[0335] Coagulation Panel PT / aPTT (PT / aPTT prothrombin time / activated partial thromboplastin time)

[0336] urine analysis glucose Protein - Note: If protein is ++ or greater, promptly check urine protein creatinine ratio. Blood - Note: If blood is ++ or greater, promptly confirm microscopy.

[0337] Other laboratory tests Other laboratory tests included: Complement Hemolysis Assay (CH50) Alpha-1 antitrypsin Pregnancy tests: serum human chorionic gonadotropin pregnancy test, urine pregnancy test Sample collection was described separately for drug concentrations, ADAs, and exploratory biomarkers.

[0338] 21. See blood immunoglobulin panel. 22. In accordance with local practice in the country where the trial was conducted, pregnancy testing (urinary human chorionic gonadotropin) was mandatory for all women from the age of sexual maturity onwards, or for married women, and, at the investigator's discretion, for non-married women from the age of sexual maturity onwards. 23. Blood sampling frequency for this analyte was reduced where necessary to comply with weight-specific local restrictions on blood collection volume. The blood sampling schedule in the SOE table was designed for patients weighing 20 kg or more. It is anticipated that patients weighing less than 20 kg will require reduced blood sampling frequency. A separate blood sampling schedule was provided in the sample handling manual for patients weighing 10 kg to 20 kg. For patients weighing less than 10 kg, the sampling priority was presented in the sample handling manual or kit instructions, and samples were to be collected in this order until volume limits were reached. The chemistry panel was given first priority, followed by complete blood count and drug concentrations. 24.D-dimer, F(1+2) was also present. 25. Samples were to be collected at the baseline visit, but could be collected at any time. 26. Kits were available locally so that chemical panels could be obtained locally without the need for a clinic visit. 27. Drug concentrations and ADA samples were to be collected before administration of the study drug. In the event of any SAE or any AESI of an anaphylactic or systemic allergic reaction related to the study drug and requiring treatment, or a severe injection site reaction lasting longer than 24 hours, drug concentrations and ADA samples were to be collected at or near the time of the event for any further analysis. 28. If a patient sample was positive in the pozelimab ADA assay at Week 12 or the first analysis time point, a Week 4 PK sample could be analyzed in the ADA assay if sufficient volume was present. 29. The screening period could be extended to approximately 10 weeks for patients with conditions requiring consideration.

[0339] COVID-19 Given the public health emergency related to COVID-19, continuing clinical trial conduct and monitoring may have required the implementation of temporary or alternative mechanisms. Examples of such mechanisms may include, but are not limited to, any of the following: telephone contact, virtual clinic visits, telehealth visits, online meetings, noninvasive remote monitoring devices, use of on-site clinics or testing sites, and home visits by trained staff. Furthermore, deviations from protocol enrollment criteria due to COVID-19 will not be exempt from deviations. All temporary mechanisms and deviations from planned trial procedures utilized in response to COVID-19 will be documented as COVID-19-related and will remain in effect only for the duration of the public health emergency.

[0340] result Patients receiving the pozelimab dosing regimen achieved improvements in albumin, total protein, vitamin B12, platelets, fecal a1AT, facial edema, extremity edema, some indications of improvement in abdominal pain scores and bowel frequency; and early signs of reduced hospital stays and reduced steroid use.

[0341] Albumin and Total Protein. CHAPLE is characterized by the loss of serum proteins, such as albumin, throughout the gastrointestinal tract, resulting in hypoproteinemia (which may be complicated by edema, ascites, pleural and pericardial effusions, and malnutrition). In healthy individuals, protein loss across the intestinal epithelium plays only a minor role in total protein metabolism. Gastrointestinal (GI) protein loss in CHAPLE can account for up to 60% of the total albumin pool. Patients receiving the poseliman regimen demonstrated more normal levels of serum albumin and total protein, suggesting reduced GI protein loss. Shortly after initiating treatment, albumin levels improved (increased to above the lower limit of normal (LLN)) and remained above the LLN at all measured time points (Figure 28(a)). Monitoring albumin levels for each patient before treatment demonstrated that albumin levels had historically been subnormal (Figures 28(b)–(e)). Additionally, total protein levels improved (increased to between the lower limit of normal (LLN) and upper limit of normal (ULN)) shortly after initiation of treatment and remained within this normal range at all time points measured (Figure 29).

[0342] Vitamin B12. Malabsorption and deficiency of vitamins, such as B12, have been observed in protein-losing enteropathy. Vitamin B12 levels improved over time in patients receiving the poselima regimen. This is likely due to the reduction in GI malabsorption in patients with CHAPLE. This patient did not receive vitamin B12 supplementation. Shortly after initiating treatment, vitamin B12 levels improved and remained elevated at all time points measured (Figure 30).

[0343] Platelets. Excessive activation of complement activity can lead to the induction of the coagulation cascade. Loss of GPI-anchored complement inhibitory proteins, such as CD55, can lead to terminal-complement-mediated hemolysis, which carries a secondary thrombotic risk. Indeed, patients with CHAPLE are at increased risk for thrombosis. Patients receiving pozelimab regimen benefit from a reduction in platelet count. Shortly after initiating treatment, platelet counts decreased and remained at low levels at all time points measured (Figure 31).

[0344] Fecal Alpha-1-Antitrypsin. Alpha-1-antitrypsin (A1A) is resistant to degradation by digestive enzymes and is therefore used as an endogenous marker for the presence of intestinal blood proteins. Patients receiving the pozelimab regimen showed a decrease in A1A. Shortly after initiation of treatment, fecal alpha-1-antitrypsin concentrations decreased in each patient and remained at low levels at all time points measured (Figure 32).

[0345] Facial and peripheral edema. CHAPLE is characterized by excessive loss of serum protein into the gastrointestinal tract, which causes reduced serum protein levels and, in severe cases, fluid loss from the intravascular space and edema. Evidence of reduced edema was observed in patients receiving the pozelimab regimen. Shortly after initiating treatment, the severity (grade) of facial and peripheral edema generally decreased in patients and remained low at all measured time points (Figures 33 and 34).

[0346] Bowel Frequency. Patients with CHAPLE disease commonly experience diarrhea and excessive bowel movement frequency. These factors can have a significant impact on a patient's quality of life and may lead to secondary medical conditions, such as vitamin or electrolyte imbalances. There was evidence that patients receiving the pozelimab regimen achieved improvement in bowel frequency. Patients showed early signs of decreased bowel movement frequency shortly after initiating treatment (Figure 35). Therefore, the present invention provides a method for treating C5-related diseases, such as CHAPLE disease, in patients with the following conditions: (i) one or more intravenous (IV) administrations of about 30 mg / kg of an antagonist antigen-binding protein that specifically binds to C5 (e.g., pozelimab); and (ii) one or more subcutaneous (SC) administrations (e.g., weekly administrations) of about 800 mg of an antagonist antigen-binding protein that specifically binds to C5; or (i) one or more intravenous (IV) administrations of about 30 mg / kg of an antagonist antigen-binding protein that specifically binds to C5 (e.g., pozelimab); and (ii) In the following cases: - Body weight (BW) less than 10 kg: 125 mg; - BW ≥ 10 kg and < 20 kg: 200 mg; - BW ≥ 20 kg and < 40 kg: 350 mg; - BW ≥ 40 kg but < 60 kg: 500 mg; and - BW 60kg or more: 800mg one or more subcutaneous (SC) administrations (e.g., weekly administrations) of an antagonist antigen binding protein that specifically binds to C5 according to By administering to the patient: ·Increasing serum albumin levels or decreasing its loss through the GI tract; ·Increasing total serum protein levels or decreasing their loss through the GI tract; · Increase serum vitamins (e.g., vitamin B12), e.g., even in the absence of supplementation of such vitamins or their GI absorption; Decreasing platelet count or reducing activation of the coagulation cascade or reducing the incidence of thrombotic events (e.g., heart attack, stroke); · Reduces loss of alpha-1-antitrypsin through the GI tract; · Treating or preventing edema (e.g., facial or peripheral); · Reduce the frequency of bowel movements or treat or prevent diarrhea; · Treat or prevent abdominal pain; · Reduce the use of steroids (e.g., corticosteroids such as cortisone, hydrocortisone, or prednisone); ·Reducing the incidence of hospitalization; This provides a method for:

[0347] All references cited herein are incorporated by reference to the same extent as if each individual publication, database entry (e.g., GenBank sequence or GeneID entry), patent application, or patent were specifically and individually indicated to be incorporated by reference. This incorporation-by-reference statement is intended by the applicant to relate to each publication, database entry (e.g., GenBank sequence or GeneID entry), patent application, or patent, each of which is clearly identified even if such citation is not immediately adjacent to the dedicated incorporation-by-reference statement. The inclusion of a dedicated incorporation-by-reference statement, if any, within this specification does not in any way weaken this general incorporation-by-reference statement. The citation of a reference herein is not intended as an admission that the reference is relevant prior art, nor does it constitute any admission as to the content or date of these publications or documents.

Claims

1. A pharmaceutical preparation for use in a method for treating CD55 deficiency associated with complement hyperactivation, vasculopathic thrombosis, and protein-losing enteropathy (CHAPLE disease) in a subject, the pharmaceutical preparation comprising an antibody or antigen-binding fragment thereof that specifically binds to C5 and comprises three heavy chain complementarity-determining regions (HCDR1, HCDR2, and HCDR3) of a heavy chain variable region (HCVR) comprising the amino acid sequence set forth in SEQ ID NO: 98 and three light chain complementarity-determining regions (LCDR1, LCDR2, and LCDR3) of a light chain variable region (LCVR) comprising the amino acid sequence set forth in SEQ ID NO: 106; The method comprises: (a) selecting a subject suffering from CHAPLE disease; (b) administering the pharmaceutical formulation intravenously (IV) to the subject one or more times, wherein the one or more IV administrations comprise about 30 mg / kg of the antibody or antigen-binding fragment thereof; and (c) administering the pharmaceutical formulation subcutaneously (SC) to a subject one or more times.

2. 10. The pharmaceutical formulation of claim 1, wherein the one or more SC administrations comprise 10 mg / kg of the antibody or antigen-binding fragment thereof.

3. 10. The pharmaceutical formulation of claim 1, wherein the one or more SC administrations are sufficient to maintain a serum concentration of the antibody or antigen-binding fragment thereof in the subject of at least 100 mg / L, at least 150 mg / L, at least 400 mg / L, at least 600 mg / L, or at least 700 mg / L.

4. 4. The pharmaceutical formulation of claim 3, wherein the one or more SC administrations are sufficient to maintain a serum concentration of the antibody or antigen-binding fragment thereof in the subject of at least 100 mg / L.

5. The pharmaceutical preparation according to any one of claims 1 to 4, wherein the subject is a human.

6. The pharmaceutical preparation according to any one of claims 1 to 5, wherein the subcutaneous administration is once a week.

7. The pharmaceutical preparation according to any one of claims 1 to 6, which is administered intravenously only once.

8. 8. The pharmaceutical formulation according to any one of claims 6 to 7, wherein the once-weekly administration is about 7 days, 7 days (+1 day), 7 days (+2 days), or 7 days (+3 days) after the immediately preceding administration.

9. The pharmaceutical preparation according to any one of claims 1 to 8, wherein the subcutaneous administration is administration to a subject using a pre-filled syringe.

10. the antibody or antigen-binding fragment thereof HCDR1 comprising the amino acid sequence set forth in SEQ ID NO: 100; HCDR2 comprising the amino acid sequence set forth in SEQ ID NO: 102; HCDR3 comprising the amino acid sequence set forth in SEQ ID NO: 104; LCDR1 comprising the amino acid sequence set forth in SEQ ID NO: 108; LCDR2 comprising the amino acid sequence set forth in SEQ ID NO: 110, and LCDR3 comprising the amino acid sequence set forth in SEQ ID NO: 112; The pharmaceutical formulation according to any one of claims 1 to 9, comprising:

11. The pharmaceutical formulation of any one of claims 1 to 10, wherein the antibody or antigen-binding fragment thereof comprises an HCVR comprising the amino acid sequence set forth in SEQ ID NO: 98 and an LCVR comprising the amino acid sequence set forth in SEQ ID NO:

106.

12. (i) the subject has a serum lactate dehydrogenase (LDH) level ≥ 2 x upper limit of normal (ULN); (ii) subjects have >10% PNH granulocytes (polymorphonuclear [PMN]); (iii) the subject has hypoalbuminemia of 3.2 g / dL or less; (iv) the subject suffers from diarrhea; (v) the subject is suffering from vomiting; (vi) the subject is suffering from abdominal pain; (vii) the subject has peripheral or facial edema; (viii) the subject has suffered an episode of infection or a thromboembolic event complicated by hypogammaglobulinemia; (ix) the subject suffers from fatigue; (x) the subject has hemoglobinuria; (xi) the subject suffers from shortness of breath (dyspnea); (xii) the subject has anemia; (xiii) the subject has a history of a major adverse vascular event; (xiv) the subject suffers from dysphagia; or (xv) the subject suffers from erectile dysfunction; The pharmaceutical formulation according to any one of claims 1 to 11.

13. (i) the subject has biallelic loss-of-function mutations in CD55; (ii) the subject has a biallelic loss-of-function mutation in CD55 that is a frameshift mutation, a missense mutation, a splice site mutation, or a nonsense mutation; (iii) the subject has hypoalbuminemia with a serum albumin of 3.2 g / dL or less; (iv) the subject suffers from diarrhea; (v) the subject is suffering from vomiting; (vi) the subject is suffering from abdominal pain; (vii) the subject has peripheral or facial edema; (viii) the subject has suffered an episode of infection complicated by hypogammaglobulinemia; or (ix) the subject has suffered a thrombotic event; The pharmaceutical formulation according to any one of claims 1 to 12.

14. The pharmaceutical formulation of any one of claims 1 to 13, wherein the antibody or antigen-binding fragment thereof is pozelimb.

15. The pharmaceutical formulation of any one of claims 1 to 14, wherein the antibody or antigen-binding fragment thereof is administered in combination with an additional therapeutic agent.

16. Additional therapeutic agents include acetaminophen, albumin infusion, ancrod, angiotensin converting enzyme inhibitors, antibiotics, additional antibodies, anti-CD20 agents, anticoagulants, antifungals, antihypertensives, anti-inflammatory agents, antiplasmin-a1, anticonvulsants, antithrombotic agents, anti-TNF alpha agents, antivirals, argatroban, aspirin, biological therapeutic agents, bivalirudin, C3 inhibitors, corticosteroids, cyclosporine A, dabigatran, defibrotide, E-aminocaproic acid, enteral nutrition, erythromycin, erythropoietin, fibrinolytic agents, folic acid, fondaparinux, hepatocellular carcinoma (HCC), urea, erythromycin, erythropoietin, urea, urea-associated steroids ...

16. The pharmaceutical formulation of claim 15, which is selected from the group consisting of phosphorus, hormone replacement therapy, ibuprofen, idraparinux, immunosuppressants, infliximab, hydroxymethylglutaryl CoA reductase inhibitors, iron supplements, lepirudin, lipid-lowering agents, magnesium sulfate, meningococcal vaccines, methotrexate, nonsteroidal anti-inflammatory drugs (NSAIDs), oligonucleotides, paracetamol, parenteral nutrition, penicillin, phenindione, contraceptives, prostacyclin, rituximab, thrombin inhibitors, vaccines, vincristine, vitamins and / or warfarin.

17. The additional therapeutic agent is: DNA oligonucleotides, RNA oligonucleotides, single-stranded DNA oligonucleotides, single-stranded RNA oligonucleotides, a double-stranded DNA oligonucleotide, or Double-stranded RNA oligonucleotides an oligonucleotide which is 16. The pharmaceutical formulation of claim 15, wherein the oligonucleotide is optionally conjugated to a sugar.

Images