Methods and compositions for preventing or treating acute exacerbations with polyclonal immunoglobulins

Abstract

To provide further improved therapeutic compositions for those with infection-related exacerbations, such as chronic obstructive pulmonary disease (COPD) and non-cystic fibrosis bronchiectasis (NCFB), to prevent or treat acute exacerbations.SOLUTION: The present invention provides a composition for preventing or treating acute exacerbations in chronic lung diseases, such as COPD and NCFB, by administration of polyclonal immunoglobulin to the respiratory tract, in particular by direct application of an aerosolized composition comprising polyclonal immunoglobulin.SELECTED DRAWING: None

Description

[Technical Field]

[0001] The present invention is in the field of preventing or treating acute exacerbations in chronic lung diseases such as chronic obstructive pulmonary disease and non-cystic fibrosis bronchiectasis by administering polyclonal immunoglobulin to the airways, particularly by direct application of aerosolized compositions comprising polyclonal immunoglobulin. [Background technology]

[0002] Chronic lung diseases, especially those with exacerbations driven primarily by infection, are characterized by a patient's difficulty expelling air adequately from the lungs. Patients with such chronic lung diseases experience shortness of breath due to difficulty expelling all air from the lungs. Due to lung damage or narrowing of the airways within the lungs, exhalation is slower than normal. At the end of a complete exhalation, an abnormally high volume of air may still remain in the lungs. Chronic obstructive pulmonary disease (COPD) and non-cystic fibrosis bronchiectasis (NCFB) are examples of such chronic lung diseases. COPD is characterized by persistent airflow limitation, which is usually progressive and associated with an increased chronic inflammatory response in the airways and lungs to harmful particles or gases. Exacerbations and comorbidities contribute to the overall severity of an individual patient's disease [1]. NCFB is characterized by pathological dilation of the airways, identified clinically by radiographic evidence of airway enlargement (i.e., CT scan) [2]. Exacerbation is considered a key event in the progression of NCFB [3].

[0003] Acute exacerbations of respiratory symptoms frequently occur in patients with chronic lung diseases such as COPD and NCFB. These exacerbations are caused by bacterial or viral infections, which may coexist. During an exacerbation, there is a flare-up of inflammation, increased hyperinflation and gas trapping, decreased expiratory flow, and increased dyspnea. Other medical conditions, such as pneumonia, can exacerbate COPD exacerbations.

[0004] An acute exacerbation of COPD is defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) as an acute worsening of a patient's respiratory symptoms that exceeds normal daily variation and leads to further medication [4]. The rate at which exacerbations occur varies greatly among patients. Chronicity of exacerbations in COPD patients supports airway tissue remodeling, contributing to disease progression. These acute exacerbations correlate with high levels of systemic inflammation and immune activation. The frequency of exacerbations increases as COPD severity worsens. Similarly, acute exacerbations can increase COPD progression, and the inflammatory state created by acute exacerbations can increase susceptibility to further recurrent acute exacerbations. This creates a vicious cycle that drives COPD progression.

[0005] An NCFB exacerbation is defined as an acute worsening of one or more symptoms of NCFB beyond normal daily variation, e.g., the need for antibiotics in the presence of one or more symptoms such as increased cough, increased sputum production, or worsening sputum purulence. A severe exacerbation is defined as the need for unplanned hospitalization or emergency department visit [3].

[0006] Patients with chronic lung diseases such as COPD or NCFB may present with recurrent airway infections that can trigger acute exacerbations. The most common cause of acute exacerbations in COPD is viral infection of the upper respiratory tract and tracheobronchial tree. The most common virus detected during COPD exacerbations is human rhinovirus (HRV) [5], which is associated with the proliferation of bacterial airway microbiome [6]. The microbiota in COPD is generally highly diverse. Many different bacteria are associated with COPD. However, the most pathogenic bacteria include influenza. These include Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus catarrhalis, Haemophilus parainfluenzae, and Staphylococcus aureus. Furthermore, Pseudomonas aeruginosa (PA) has been described as one of the most harmful bacteria found in patients with stable COPD and extremely severe airflow obstruction during exacerbations [7].

[0007] Treatment for COPD is based on inhaled corticosteroids (ICS), inhaled bronchodilators, including long-acting β2-agonists, and anticholinergics, including long-acting muscarinic receptor antagonists, as well as combinations of these. For example, severe COPD patients with a high risk of exacerbations are commonly treated with a combination of all three classes of drugs. While these therapies reduce exacerbations, patients receiving maximal inhaled therapy continue to experience exacerbations, and new therapeutic approaches are therefore needed. Indeed, ICS therapy is associated with adverse effects, including a high risk of pneumonia, oral candidiasis, hoarseness, and skin bruising. Other adverse effects include new-onset diabetes, diabetes progression, and an increased risk of cataracts and tuberculosis. Long-term use is also associated with an increased risk of fractures in COPD patients. [8] Notably, ICS therapy only slightly reduces the frequency of exacerbations, and clinical trials have reported an increased risk of pneumonia with ICS use in COPD. This may be because ICS appear to reduce antiviral immunity, leading to mucus hypersecretion and increased bacterial burden in the lungs. [9]

[0008] In COPD patients with chronic bronchitis, phosphodiesterase 4 enzyme inhibitors (e.g., roflumilast) are added to the treatment of choice. Roflumilast is a nonsteroidal anti-inflammatory active substance designed to target both systemic and pulmonary inflammation associated with COPD. Roflumilast is indicated as an adjunct to bronchodilator therapy for the maintenance treatment of severe COPD associated with chronic bronchitis in adult patients with a history of frequent exacerbations.

[0009] Acute exacerbations of COPD are currently managed with medications including bronchodilators, ICS, and antibiotics. ICS therapy is associated with side effects, as discussed above. Antibiotics are used to treat bacterial respiratory tract infections to reduce the occurrence and severity of exacerbations. Macrolides also have anti-inflammatory effects and are used in patients with severe COPD and a history of frequent exacerbations. However, long-term macrolide therapy is associated with the risk of microbial resistance and adverse cardiovascular effects. Currently, there are no medications available to treat viral infections, such as rhinovirus infections, in COPD.

[0010] There is no treatment available for NCFB. Acute exacerbations of NCFB are generally treated with antibiotics to eliminate the underlying respiratory tract infection. Some patients with NCFB receive prophylactic antibiotic therapy to prevent exacerbations, but the efficacy of such therapy is unproven. [Prior art documents] [Non-patent literature]

[0011] [Non-Patent Document 1] Vestbo et al. (2013) Am J Respir Crit Care Med 187(4):347~65. [Non-patent document 2] Flume et al. (2018) Lancet 392(10150): pages 880-90. [Non-patent document 3] Chalmers et al. (2018) Am J Respir Crit Care Med 197(11):1410~20. [Non-patent document 4] Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, 2018 report; Global initiative for chronic obstructive lung disease (GOLD). [Non-Patent Document 5] Mohan A et al. (2010) Respirology 15(3):536~42. [Non-patent document 6] Molyneaux et al. (2013) Am J Respir Crit Care Med 188(10):1224~31. [Non-Patent Document 7] Hassett et al. (2014) J Microbiol 52(3):211~26. [Non-patent document 8] Miravitlles et al. (2017) Respiratory Research 18:198 pages. [Non-Patent Document 9] Singanayagam et al. (2018) Nature Communications 9(1):2229 pages. Summary of the Invention [Problem to be solved by the invention]

[0012] It is an object of the present invention to provide further and improved treatments for chronic lung diseases, particularly those with infection-related exacerbations such as COPD and NCFB, particularly to prevent or treat acute exacerbations. [Means for solving the problem]

[0013] In contrast to prior art therapies based on antibiotics (optionally in combination with corticosteroids, beta-2 agonists and / or anticholinergic bronchodilators) for preventing or treating acute exacerbations, according to the present invention acute exacerbations are prevented or treated by administering to the airways of a human subject a composition comprising polyclonal immunoglobulin.

[0014] Thus, the present invention provides a composition comprising a polyclonal immunoglobulin for use in the prevention or treatment of an acute exacerbation of a chronic lung disease in a human subject, said composition being administered to the respiratory tract of the subject.

[0015] The present invention also provides a method of preventing or treating an acute exacerbation in a human subject with chronic lung disease by administering a composition comprising a polyclonal immunoglobulin to the airways of the subject.

[0016] The invention also provides the use of a polyclonal immunoglobulin for the manufacture of a medicament for preventing or treating an acute exacerbation of a chronic lung disease in a human subject, wherein the medicament is administered to the respiratory tract of the subject.

[0017] Surprisingly, application of immunoglobulin to the mucosal epithelium of the respiratory tract reduces inflammation and promotes immune elimination of potentially pathogenic microorganisms (e.g., bacteria and / or viruses) present in the mucosal layer, preventing direct damage to the epithelium caused by, for example, bacterial extracellular enzymes and toxins and / or viral replication (excretion). These effects are advantageous for the prevention or treatment of acute exacerbations that may result from, for example, bacterial and / or viral respiratory tract infections.

[0018] Commercially available immunoglobulin compositions are administered intravenously or subcutaneously, i.e., by systemic administration. Direct local administration to the target airways, for example, by aerosol inhalation, can achieve the same exposure to immunoglobulin in the airways, but requires a smaller total dose than required for systemic administration (e.g., intravenous). This localized administration directly to the target airway tissue can thereby avoid systemic side effects. Furthermore, because only a small portion of systemically administered immunoglobulin reaches the airways, administration to the airways can enable the achievement of higher local concentrations than can be achieved by systemic administration.

[0019] Furthermore, intravenous or subcutaneous immunoglobulin therapy is expensive. Direct targeted local administration to the airways provides the same immunoglobulin, e.g., Ig, in the airways as can be achieved by systemic administration. A smaller dose may be required to achieve exposure to G. As a result, administration directly to the respiratory tract may be more cost-effective, as less of the composition is required to achieve the same therapeutic effect in the respiratory tract.

[0020] Furthermore, intravenous or subcutaneous immunoglobulin therapy usually requires the attention of a medical professional. For example, intravenous administration requires a nurse or doctor and is usually performed in a clinic. Inhalation of aerosolized immunoglobulin may not require supervision by a medical professional and may therefore be suitable for self-administration at home. As a result, direct administration to the airways may be more practical for subjects, and therefore subjects may be more likely to adhere to treatment. Improved adherence reduces treatment failure, which may lead to, for example, acute exacerbations and hospitalizations.

[0021] acute exacerbation The present invention includes the prevention or treatment of acute exacerbations in human subjects with chronic lung disease, typically COPD or NCFB.

[0022] An acute exacerbation is an acute event characterized by a worsening of the patient's respiratory symptoms that exceeds normal day-to-day variation and requires further therapy. Such acute exacerbations can vary in severity.

[0023] In subjects with COPD, mild acute exacerbation requires a change in medication for subjects, especially for subjects treated with short-acting bronchodilators (SABDs).Moderate acute exacerbation requires medical intervention, especially treatment with SABDs plus antibiotics and / or oral corticosteroids.Severe acute exacerbation requires hospitalization or emergency department visit.Subjects of the present invention may have mild, moderate or severe acute exacerbation.Typically, subjects have moderate or severe acute exacerbation.

[0024] In subjects with NCFB, acute exacerbations are characterized by worsening local symptoms (cough, increased sputum volume or viscosity, wheezing, shortness of breath, increased sputum purulence with or without increased hemoptysis) and / or general ill health.

[10] Severe acute exacerbations are characterized as requiring unplanned hospitalization or emergency department visit.[3]

[0025] In one embodiment, the compositions of the present invention are used for the prevention of acute exacerbation, i.e., prophylactic therapy.In certain embodiments, the compositions of the present invention are used for the prevention of acute exacerbation, and the compositions prevent and / or treat established infections in the subject's respiratory tract.This prophylactic therapy can prevent viral infections and bacterial infections, and can be particularly effective because it is effective against bacteria that are resistant to one or more antibiotics.

[0026] Thus, in one embodiment, the compositions of the invention are for use in preventing acute exacerbations, particularly by treating and / or preventing underlying respiratory tract infections. Polyclonal immunoglobulins are particularly suitable because they can treat viral and bacterial infections and are effective against bacteria resistant to one or more antibiotics.

[0027] In another embodiment, the composition of the present invention is used in the treatment of acute exacerbation. Typically, acute exacerbation is caused by viral or bacterial infection of the respiratory tract. Polyclonal immunoglobulins recognize a wide range of potentially pathogenic microorganisms (typically bacteria and viruses) in the respiratory tract. Recognizing a wide range of bacteria means that the immunoglobulin is effective in treating bacterial respiratory tract infections, for example, by immune elimination. Recognizing a wide range of viruses means that the immunoglobulin is effective in treating viral respiratory tract infections, for example, by preventing viruses from binding to host cells, thereby preventing viral replication and excretion. The compositions of the present invention can also be effectively used without the need for diagnostic testing to identify the specific bacterial or viral infection that may be causing or is causing an acute exacerbation, meaning that administration of the composition can begin sooner.

[0028] Treating an acute exacerbation can prevent the acute exacerbation from becoming more severe, for example, treating a mild acute exacerbation can prevent it from progressing to a severe acute exacerbation.

[0029] The compositions of the present invention are intended for use in the treatment or prevention of acute exacerbations. For this treatment or prevention of acute exacerbations, the compositions of the present invention are enriched for antibodies that recognize specific pathogens. In one embodiment, a subject with an acute exacerbation is tested to identify the pathogen (e.g., bacteria and / or virus) causing the infection underlying the acute exacerbation, and the compositions of the present invention are enriched for antibodies specific to the identified pathogen. In one embodiment, the compositions of the present invention are enriched by adding a monoclonal antibody specific to the identified pathogen to the composition. In another embodiment, the compositions of the present invention are enriched by adding a monoclonal antibody specific to a pathogen identified in the subject's respiratory tract. Additionally or alternatively, the compositions are enriched for polyclonal immunoglobulins specific to a particular pathogen, obtained, for example, by immunizing transgenic animals engineered to produce human immunoglobulins, or by screening a library of human antibody repertoires for antibodies specific to a desired pathogen and then recombinantly producing the identified antibodies.

[0030] In certain embodiments, the composition is used for preventing or treating superinfection of the respiratory tract of a subject.Superinfection is a second infection that occurs in the respiratory tract during the first infection of the respiratory tract.In particular, superinfection of the respiratory tract can occur together with infection caused by a second infectious agent that shows resistance to the treatment used for the first infectious agent.In one embodiment, both infectious diseases are bacterial respiratory tract infections.In another embodiment, the infectious diseases include one bacterial respiratory tract infection and one viral respiratory tract infection.

[0031] In one embodiment, the subject of the present invention has a respiratory tract infection caused by bacteria resistant to at least one antibiotic. In particular, bacteria may be resistant to multiple antibiotics (multidrug resistance). Because polyclonal immunoglobulins recognize many epitopes of bacteria, including epitopes unrelated to antibiotic activity and resistance mechanisms, the compositions of the present invention are effective against these resistant bacteria, including multidrug-resistant bacteria.

[0032] In one embodiment, the subject of the present invention has respiratory tract infection caused by virus.The composition of the present invention recognizes virus and treats the infection.In particular, polyclonal immunoglobulin binds to virus and prevents virus binding to its host cell, such as epithelial cell.Polyclonal immunoglobulin prevents virus entry into host cell, virus replication and virus excretion.Since there is no effective antiviral agent for use in treating respiratory tract infection, this treatment can be particularly useful.

[0033] Patient history The subject of the present invention may be a patient with chronic lung disease who has a history of acute exacerbation.

[0034] The rate of acute exacerbations may vary between subjects.The subject of the present invention may have frequent acute exacerbations, for example, experiencing two or more acute exacerbations per year.One of the best predictors of subjects with frequent acute exacerbations is a history of acute exacerbations that have been treated before.Therefore, the composition of the present invention is particularly useful for treating subjects at risk of frequent acute exacerbations, which corresponds to subjects with a history of exacerbations.Therefore, in one embodiment, the composition of the present invention is for use in preventing or treating acute exacerbations in subjects, and the subject is before prevention or treatment. The subject has experienced one or more acute exacerbations in the 12 months prior to the prophylaxis or treatment. Preferably, the subject has experienced two or more acute exacerbations in the 12 months prior to the prophylaxis or treatment. In particular, the subject has experienced three or more acute exacerbations in the 12 months prior to the prophylaxis or treatment.

[0035] Maintenance therapy (discussed below) is particularly suitable for such subjects with a history of acute exacerbations. Thus, in certain embodiments, the subject of the present invention has experienced at least one acute exacerbation in the 12 months prior to therapy and is treated with the composition for at least 12 months.

[0036] Specifically, one of the strongest predictors of the frequency of a patient's further acute exacerbations in COPD is the number of acute exacerbations experienced in the previous year. [4] In particular, subjects with COPD who have experienced two or more acute exacerbations in the previous year are likely to have frequent exacerbations. Thus, in certain embodiments, the compositions of the present invention are for use in the prevention of acute exacerbations in subjects with COPD, where the prevention is maintenance therapy for a subject with COPD who has experienced two or more acute exacerbations in the 12 months prior to initiating maintenance therapy, and the maintenance therapy continues for at least 12 months.

[0037] Specifically, in NCFB, one of the strongest predictors of the frequency of a patient's further acute exacerbations is the number of acute exacerbations experienced in the previous year [3]. In particular, subjects with NCFB who have experienced three or more acute exacerbations in the previous year are likely to have frequent exacerbations. Thus, in certain embodiments, the compositions of the present invention are for use in preventing acute exacerbations in subjects with NCFB, where the prevention is maintenance therapy for subjects with NCFB, where the subject has experienced three or more acute exacerbations in the 12 months prior to starting maintenance therapy, and the maintenance therapy continues for at least 12 months.

[0038] chronic lung disease The present invention includes the prevention or treatment of acute exacerbations in subjects with chronic lung disease, particularly chronic lung diseases where infection is a major driver of exacerbations, typically COPD and / or NCFB.

[0039] COPD Subjects with COPD typically have a post-bronchodilator FEV1 (forced expiratory volume in 1 second) / FVC (forced vital capacity) ratio of less than 0.7. FEV1 and FVC can be measured by spirometry using standard methods in the art.

[11] As an example, for post-bronchodilator spirometry measurements, spirometry is performed: (i) 10–15 minutes after administration of a short-acting beta-agonist (400 μg); (ii) 30–45 minutes after administration of a short-acting anticholinergic (160 μg); or (iii) 30–45 minutes after administration of a combination of the two classes of medications.

[0040] The present invention is particularly suitable for preventing or treating acute exacerbations of moderate to very severe COPD, i.e., moderate COPD, severe COPD, or very severe COPD. Typically, the subject has severe or very severe COPD.

[0041] Such grading of COPD severity is described in reference [1] and is based on the severity of airflow limitation in a subject. Briefly, for subjects with an FEV1 / FVC ratio <0.7, the grading of airflow limitation severity is based on the measured post-bronchodilator FEV1 and how this measurement compares to the predicted value for healthy subjects. Subjects with mild COPD have an FEV1 at least 80% of the predicted value. Subjects with moderate COPD have an FEV1 between 50% and 80% of the predicted value. Subjects with severe COPD have an FEV1 between 30% and 50% of the predicted value. Subjects with very severe COPD have an FEV1 less than 30% of the predicted value.

[0042] The predicted FEV1 for healthy subjects is calculated using the formula

[12] : Male FEV1 {liters} = 4.30 x height {meters} - 0.029 x age {years} - 2.49 Women's FEV1 (liters) = 3.95 x height (meters) - 0.025 x age (years) - 2.60 It is calculated using

[0043] As an example, a 50-year-old male subject who is 1.8 m tall would have a predicted FEV1 of 3.8 L (4.3 x 1.8 - 0.029 x 50 - 2.49). If this subject then had a post-bronchodilator FEV1 measured by spirometry of 2.09 L, this value would be 55% of the predicted FEV1 (3.8 L), and therefore the subject would be considered to have moderate COPD.

[0044] Moderate to very severe COPD is difficult to treat, and even triple therapy (inhaled corticosteroid / beta2 agonist / anticholinergic bronchodilator) is not always successful. The polyclonal immunoglobulins of the present invention are believed to prevent or treat acute exacerbations in subjects with COPD through mechanisms distinct from those of current treatments, including prevention of respiratory tract infections and reduction of airway inflammation, thereby providing an additional and complementary therapy.

[0045] In another embodiment, the composition of the present invention is used in the treatment of COPD in a subject, and the composition is administered to the subject's airway. Acute exacerbations contribute to the pathology of COPD and may contribute to the vicious cycle between inflammation and further infections. Prevention of acute exacerbations is therefore a treatment for COPD. Maintenance therapy (discussed below) using the composition of the present invention in a subject with COPD is particularly suitable for treating COPD because it prevents acute exacerbations (including reducing the occurrence and / or severity of acute exacerbations). For similar reasons, seasonal administration of the composition of the present invention is particularly suitable for treating COPD.

[0046] Non-cystic fibrosis bronchiectasis The present invention encompasses the treatment of acute exacerbations in subjects with chronic lung disease, particularly those in whom infection is a primary driver of exacerbations, typically NCFB. NCFB has multiple causes and can present with a wide range of symptoms. NCFB is characterized by pathological dilation of the airways. Specifically, NCFB is defined as permanent enlargement of the airways, as evidenced radiographically, e.g., by computed tomography (CT) scan. [2] Signs of NCFB range from subtle dilation of the airways to cystic changes. Patients may be asymptomatic (and unexpectedly discovered airway dilation) or may have a range of symptoms with periodic exacerbations, such as coughing and / or sputum production.

[0047] The present invention is particularly suitable for the prevention or treatment of acute exacerbations in subjects with NCFB. In one embodiment, the compositions of the present invention are for use in the prevention or treatment of acute exacerbations in subjects with NCFB. The compositions are particularly suitable for use in the prevention of severe acute exacerbations in subjects with NCFB. In another embodiment, the compositions of the present invention are for use in the treatment of NCFB in a subject, wherein the compositions are administered to the subject's airway. Acute exacerbations contribute to the pathology of NCFB and may contribute to a vicious cycle between inflammation and further infection. Prevention of acute exacerbations is therefore a treatment for NCFB. Maintenance therapy using the compositions of the present invention (discussed below) in subjects with NCFB is particularly suitable for the treatment of NCFB because it prevents acute exacerbations (including reducing the occurrence and / or severity of acute exacerbations). For similar reasons, seasonal administration of the compositions of the present invention is particularly suitable for the treatment of NCFB.

[0048] A subject may present with COPD and NCFB as comorbidities. In fact, NCFB is associated with more advanced stages of COPD [2]. Therefore, in another embodiment, the composition of the present invention is used to prevent acute exacerbations in subjects with COPD and NCFB. or are particularly suitable for use in therapy.

[0049] Low IgG levels The subject of the present invention may have a level of immunoglobulin G (IgG) lower than the normal range for healthy adults. These subjects are at increased risk of developing COPD, increasing the severity of COPD, and / or increasing the risk of acute exacerbation of COPD. NCFB is also a common symptom of subjects with immune deficiencies, including low levels of IgG.

[0050] IgG in the respiratory tract, particularly the lungs, comes from two sources: it is produced locally by plasma cells in the bronchial mucosa, and it is obtained from plasma by transudation. Thus, subjects of the present invention may have low levels of IgG in the respiratory tract, for example, due to low systemic levels of IgG and / or low local production of IgG.

[0051] In one embodiment, the subject has a low plasma level of IgG. As presented in Reference

[13] , the normal range of plasma total IgG in healthy adults is 639-1,349 mg / dL, with an average of 994 mg / dL. A low plasma IgG level in an adult can be a level below 700 mg / dL. Lower plasma total IgG levels in adults are classified as mild to moderate (300-600 mg / dL), high (100-300 mg / dL), or significantly reduced (less than about 100 mg / dL). In certain embodiments, the subject has a plasma IgG level below about 700 mg / dL, less than about 600 mg / dL, less than about 300 mg / dL, or less than about 100 mg / dL. In some embodiments, the subject has a plasma IgG level in the range of about 100 to about 600 mg / dL (including a range of about 300 to about 600 mg / dL, or about 100 to about 300 mg / dL).

[0052] Various methods for determining total plasma IgG concentrations, such as rate nephelometry and / or radial immunodiffusion, are known in the art.

[14] Serum IgG can also be quantified by ELISA, for example, according to the protocol described in the methods for carrying out the invention below.

[0053] The acute exacerbation that is prevented or treated by the present invention appears in the respiratory tract.Therefore, the local concentration of IgG in the respiratory tract is an important factor in determining the risk of respiratory tract infection, and therefore the risk of acute exacerbation.Subjects whose respiratory tract IgG level is lower than that of healthy adults have a greater risk of respiratory tract infection and acute exacerbation.Therefore, in one embodiment, the subject of the present invention has a lower respiratory tract IgG level than that of healthy adults.

[0054] Respiratory IgG levels can be measured by analyzing sputum from a subject. Sputum is a mixture of saliva and mucus that is typically expelled from the respiratory tract as a result of an infection or other disease, such as COPD or NCFB. Sputum is often examined microscopically to aid in medical diagnosis. Sputum can also be analyzed for the content of biomolecules, including immunoglobulins (e.g., IgG, IgA, and / or IgM) and cytokines (e.g., IL-1b, IL-6, and / or IL-8). Various methods for determining sputum immunoglobulin concentrations, such as kinetic nephelometry and / or radial immunodiffusion, are known in the art

[15] . Sputum immunoglobulins can also be quantified by ELISA, for example, according to the protocol described in the methods for carrying out the present invention below.

[0055] Therapeutic Effects of the Invention Prevention and / or treatment of respiratory tract infections Respiratory tract infections can be one of the causes of acute exacerbations. Therefore, preventing or treating respiratory tract infections is particularly useful for preventing or treating acute exacerbations. In one embodiment, the composition of the present invention is a composition in which polyclonal immunoglobulins are delivered to one or more latent antigens in the respiratory tract. The polyclonal immunoglobulins are intended for use in preventing acute exacerbations, resulting in immune elimination of pathogenic microorganisms (e.g., bacteria and / or viruses) in the respiratory tract. Polyclonal immunoglobulins can achieve immune elimination by binding to potentially pathogenic microorganisms in the respiratory tract. For example, polyclonal immunoglobulins bind to potentially pathogenic microorganisms and prevent them from adhering to the mucosal epithelium of the respiratory tract.

[0056] In another embodiment, the compositions of the invention are for use in the prevention or treatment of acute exacerbations in which the polyclonal immunoglobulins cause one or more potentially pathogenic microorganisms (e.g., bacteria and / or viruses) in the respiratory tract to aggregate, also known as agglutination.

[0057] In another embodiment, the compositions of the invention are for use in the prevention or treatment of acute exacerbations, where the polyclonal immunoglobulin recruits immune cells that kill microorganisms, for example, in a process called antibody-dependent cellular cytotoxicity (ADCC).

[0058] Preventing and / or reducing damage caused by respiratory tract infections Microbial activity in a subject's respiratory tract can have pathogenic effects. Thus, in one embodiment, the composition of the present invention is for use in preventing or treating acute exacerbations, in which the polyclonal immunoglobulin reduces airway damage caused by pathogens (e.g., bacteria and / or viruses). For example, the polyclonal immunoglobulin can inhibit the activity of extracellular enzymes. Such extracellular enzymes are, for example, enzymes secreted by bacteria into the mucosa, including enzymes with tissue-degrading activity, such as proteases. Blocking the activity of such extracellular enzymes protects the subject's respiratory epithelium from damage. In certain embodiments, the composition of the present invention prevents the loss of epithelial barrier integrity and prevents the passage of pathogens across the epithelium. In certain embodiments, the pathogen is a virus, and the polyclonal immunoglobulin binds to the virus and prevents the virus from directly binding to host cells in the subject's respiratory tract. The immunoglobulin therefore prevents the entry, replication, and excretion of the virus in the subject's respiratory tract.

[0059] Reduced inflammation Chronic inflammation causes structural changes and narrowing of small airways, contributing to the symptoms of COPD and the irreversible dilation of bronchi in NCFB, resulting in airway injury and remodeling.Increased inflammation and the resulting damage can increase the risk of acute exacerbation.The composition of the present invention can reduce inflammation in subjects.Therefore, the composition of the present invention is particularly suitable for use in preventing or treating acute exacerbation in subjects with COPD or NCFB.

[0060] In one embodiment, the compositions of the present invention reduce inflammation in a subject, typically local inflammation, such as airway inflammation. In particular, the compositions reduce pathogen-induced inflammation, particularly pathogen-induced inflammation in the airway of a subject.

[0061] Inflammation can be characterized by elevated levels of one or more pro-inflammatory cytokines, such as IL-1b and / or IL-6 and / or IL-8. Accordingly, in certain embodiments, the compositions of the invention reduce levels of IL-1b and / or IL-6 and / or IL-8, particularly in the mucus layer of the airways.

[0062] The levels of one or more cytokines in the mucus layer of the respiratory tract (e.g., IL-1b and / or IL-6 and / or IL-8 levels) can be quantified by analyzing the levels in sputum produced by the subject. Cytokine concentrations in sputum can be quantified according to standard methods, such as kinetic nephelometry

[14] or ELISA (e.g., in the methods of the invention described below).

[0063] Polyclonal immunoglobulin The present invention includes the use of polyclonal immunoglobulins for the prevention or treatment of acute exacerbations in subjects with chronic lung disease. Such polyclonal immunoglobulins have been used successfully to treat infectious diseases as replacement therapy in subjects with primary immunodeficiency disorders, as well as to prevent and treat a variety of inflammatory and autoimmune conditions, and certain neurological disorders.

[0064] These polyclonal immunoglobulin preparations were developed for systemic administration and contain mostly IgG. Currently, these preparations are derived from pooled plasma from thousands of healthy donors (1,000–60,000 donors) and contain both specific and natural antibodies, reflecting the cumulative antigen experience of the donor population. This large spectrum of specific and natural antibodies can recognize a wide range of antigens (e.g., pathogens, foreign antigens, and self / autoantigens).

[0065] Polyclonal immunoglobulins are generally administered intravenously or subcutaneously, and several commercial preparations are available for these routes of administration.

[0066] The composition of the present invention comprises polyclonal immunoglobulins, also called Ig. Typically, polyclonal immunoglobulins are obtained from human donor plasma. Preferably, to maximize the diversity of target antigen specificity, plasma from multiple donors is pooled, for example, from more than 100 donors, preferably more than 500 donors, even more preferably more than 1,000 donors.

[0067] Typically, the plasma pool is subjected to an ethanol fractionation step and several subsequent purification steps such as further precipitation and / or column chromatography steps, as well as steps to inactivate and remove viruses and other pathogens such as nanofiltration or solvent / detergent treatment, e.g., as shown in Reference 1.

[0068] Alternatively, polyclonal immunoglobulins are recombinantly produced, eg, from libraries containing the human immune repertoire.

[0069] Typically, the polyclonal immunoglobulin is polyclonal IgG, polyclonal monomeric IgA, polyclonal dimeric IgA, polyclonal IgM, or a combination thereof. In certain embodiments, the composition comprises polyclonal IgG. The polyclonal immunoglobulin may also comprise J-chain-containing IgA and / or IgM combined with secretory component, as described in WO2013 / 132052.

[0070] IgG The present invention relates to a composition comprising polyclonal immunoglobulin for use in preventing or treating acute exacerbations in subjects with chronic lung disease, typically COPD and / or NCFB. Surprisingly, the inventors have found that large immune complexes form between IgG and Pseudomonas aeruginosa. Antigen binding by immunoglobulins is largely dependent on the target antigen-binding (Fab) domain. Such an assembly (immune complex) between Pseudomonas aeruginosa and IgG was unexpected, since IgG is only bivalent with respect to the Fab domain. Thus, in one embodiment, the composition of the present invention comprises polyclonal human plasma-derived IgG. The polyclonal immunoglobulin is at least 95% IgG, preferably at least 98% IgG. The polyclonal IgG is particularly suitable for use in preventing or treating acute exacerbations in subjects with chronic lung disease, typically COPD and / or NCFB, by treating and / or preventing one or more respiratory tract infections. is doing.

[0071] One explanation for the unexpected formation of immune complexes between IgG and P. aeruginosa is that IgG may additionally bind to P. aeruginosa outside of the Fab region, possibly via its carbohydrates. IgG may therefore be surprisingly potent at signaling P. aeruginosa to the immune system. Consequently, in certain embodiments, compositions of the present invention comprising IgG are used to prevent or treat acute exacerbations in subjects with chronic lung disease, typically COPD and / or NCFB, where the subject has a concurrent P. aeruginosa infection. In another embodiment, compositions of the present invention comprising IgG are administered to subjects to prevent P. aeruginosa airway infection. Thus, in a preferred embodiment, compositions of the present invention comprising IgG are used to prevent acute exacerbations, and the compositions are administered as maintenance therapy. Because P. aeruginosa is an opportunistic pathogen that can affect subjects with compromised lung defenses, such as COPD or NCFB patients, this composition is particularly useful for maintenance therapy in subjects with chronic lung disease, typically COPD and / or NCFB. In particular, P. aeruginosa has been described as one of the most harmful bacteria found in subjects with COPD and during acute exacerbations of COPD [7].

[0072] Normal human IgG can be obtained with a purity of at least 95% IgG, meaning that 95% of polyclonal Ig is IgG. Thus, in one embodiment, the IgG contained in the composition of the present invention generally has a purity of at least 95% IgG, preferably at least 96% IgG, more preferably at least 98% IgG, for example, at least 99% IgG.

[0073] Administration of a composition containing IgA to a subject with selective IgA deficiency can cause anaphylaxis in the subject. Anaphylaxis is a severe allergic reaction that often begins suddenly and can lead to the subject's death. Therefore, in some embodiments, the compositions of the present invention contain only trace amounts of IgA, for example, less than 200 μg / mL of IgA, preferably less than 25 μg / mL of IgA. These compositions are particularly suitable for administration to subjects with selective IgA deficiency. Furthermore, selective IgA deficiency does not have severe symptoms, so subjects of the present invention may not be aware that they have selective IgA deficiency. Therefore, these compositions are particularly useful for administration to subjects who are unaware of whether they have selective IgA deficiency.

[0074] Thus, in a preferred embodiment, the compositions of the invention comprise polyclonal immunoglobulins that are at least 98% IgG and contain less than 25 μg / mL IgA.

[0075] In a specific embodiment, the composition used in the invention is Pirivigen™. Commercially available immune globulin preparations that may also be used in accordance with the invention include: Bivigam™, Claryg™, Flebogam™ 5%, Flebogamma™ DIF 5%, Gammagard™ Liquid 10%, Gammaplex™, Gamunex™ 10%, IG Vena™ N, Intratect™, Kiovig™, Nanogam™, Octagam™, Octagam™ 10%, Polyglobin™ N 10%, Sandoglobulin™ NF Liquid, Vigam™, and IQYMUNE™.

[0076] Polyclonal immunoglobulins enriched for specific antibodies The present invention relates to a composition for use in the prevention and / or treatment of acute exacerbations in subjects with chronic lung disease, typically COPD and / or NCFB. As described above, acute exacerbations can be caused by respiratory tract infections in subjects. In one embodiment, the present invention The compositions are enriched with one or more antibodies specific to one or more particular pathogens (e.g., bacteria and / or viruses) or potentially pathogenic microorganisms (e.g., bacteria and / or viruses). Such compositions may be particularly useful because they increase the effective dosage of immunoglobulin active against a microorganism or pathogen, and therefore have a greater therapeutic effect or can achieve an equivalent therapeutic effect when a lower total dose of the composition is administered. In one embodiment, the compositions of the invention are enriched in pathogen-specific antibodies by adding pathogen-specific monoclonal antibodies to the composition.

[0077] In one embodiment, the compositions of the present invention are enriched with antibodies specific to one or more of rhinovirus, influenza A, human metapneumovirus, RSV, coronavirus, influenza B, adenovirus, Pseudomonas aeruginosa, Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus catarrhalis, Haemophilus parainfluenzae, and / or Staphylococcus aureus. Such compositions may be particularly useful because these pathogens are the most common cause of acute exacerbations in subjects with chronic obstructive pulmonary disease, typically COPD and / or NCFB. Preferably, the compositions of the present invention are enriched with antibodies specific to Pseudomonas aeruginosa. Pseudomonas aeruginosa has been described as one of the most harmful bacteria found in subjects with COPD and during COPD exacerbations. [7] Preferably, the compositions of the present invention are enriched with antibodies specific to human rhinovirus, the most common viral infection causing acute exacerbations of COPD.

[0078] In one embodiment, a composition of the present invention enriched in antibodies specific for a particular pathogen can be obtained by adding a monoclonal Ab or a mixture of two or more monoclonal antibodies specific for one or more pathogens selected from rhinovirus, influenza A, human metapneumovirus, RSV, coronavirus, influenza B, adenovirus, Pseudomonas aeruginosa, Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus catarrhalis, Haemophilus parainfluenzae and / or Staphylococcus aureus to a composition comprising polyclonal immunoglobulin.

[0079] In one embodiment, a composition of the invention enriched in antibodies specific for a particular pathogen can be obtained by adding polyclonal immunoglobulins obtained from transgenic animals that have been modified to express human immunoglobulins after immunization with a particular pathogen to a composition comprising polyclonal immunoglobulins.

[0080] In one embodiment, a composition of the invention enriched in antibodies specific for a particular pathogen can be obtained by screening a library of human antigen binding sites with a particular pathogen or antigens derived from a particular pathogen, and recombinantly producing pathogen-specific immunoglobulins having these antigen binding sites, and adding several specific immunoglobulins to a composition comprising polyclonal immunoglobulins.

[0081] IgA and IgM In one embodiment, the composition of the invention comprises IgA and / or IgM. In a specific embodiment, at least 95% by weight of the polyclonal immunoglobulin is IgA and / or IgM. The IgA and / or IgM are combined with a recombinant secretory component to construct a secretory antibody. In a specific embodiment, the composition comprises IgA and IgM in a mass ratio of about 2:1.

[0082] Preferably, the IgA and / or IgM are prepared from plasma, for example as described in detail in WO2013 / 132053.

[0083] The compositions preferably used in the present invention are prepared as described in detail in WO2013 / 132053. Preferably, plasma-derived preparations containing IgA and / or IgM are combined with SC in vitro without the need for prior purification of dimeric / multimeric J chain-containing IgA / IgM. Such substances are called secretory-like IgA or secretory-like IgM, or abbreviated as SCIgA or SCIgM. However, these substances behave more similarly to in vivo-produced secretory IgA (usually abbreviated SIgA) and in vivo-produced secretory IgM (usually abbreviated SIgM).

[0084] In one embodiment, the composition comprises polyclonal human plasma-derived multimeric IgA and IgM. In a preferred embodiment, the IgA and IgM are assembled into secretory antibodies by combination with recombinant secretory component (SC). Preferably, the composition comprises IgA and IgM in a 2:1 mass ratio.

[0085] In another specific embodiment, the composition contains IgA with a purity of at least 90%, preferably at least 92%, more preferably at least 94%, even more preferably at least 96%, and most preferably at least 98%. Preferably, the IgA is purified from human plasma; however, other sources of IgA, such as milk, saliva, or other IgA-containing body fluids, can also be used. In another specific embodiment, the IgA is monomeric IgA. In yet another specific embodiment, the IgA is enriched for dimeric IgA, which also contains a J chain; preferably at least 20%, more preferably at least 30%, even more preferably at least 40%, and most preferably at least 50% of the IgA is in dimeric form. Optionally, the IgA composition may further contain a secretory component (SC), preferably a recombinantly produced secretory component. For example, the composition disclosed in WO 2013 / 132052, the entire contents of which are incorporated by reference, may be used.

[0086] In yet another specific embodiment, the composition comprises IgM. In one embodiment, the composition comprises IgM and IgA. In a preferred embodiment, the composition comprises IgM and dimeric IgA, and also includes a J chain. Optionally, the composition may also include secretory component, preferably recombinantly produced secretory component. In yet another embodiment, the composition comprises IgM, IgA, and IgG. In a specific embodiment, such a composition may contain 76% IgG, 12% IgA, and 12% IgM.

[0087] The IgA and / or IgM are produced from human plasma. Preferably, the IgA and / or IgM are combined in vitro with secretory component (SC). More preferably, the SC is human secretory component. Even more preferably, the SC is recombinant SC expressed in a mammalian cell line.

[0088] Preferably at least 10% of the proteins in the composition are SCIgA (IgA in combination with SC), more preferably at least 15%, 18%, 20%, or 25%, even more preferably at least 30%, 40%, or 50% of the proteins in the composition are SCIgA. Preferably at least 10% of the proteins in the composition are SCIgM (IgM in combination with SC), more preferably at least 15%, 18%, 20%, or 25%, even more preferably at least 30%, 40%, or 50% of the proteins in the composition are SCIgM.

[0089] Preferably, at least 10% of the proteins in the composition are SCIgA and at least 10% of the proteins in the composition are SCIgM, more preferably at least 15% are SCIgA and at least 15% are SCIgM, and even more preferably at least 20% are SCIgA and at least 20% are SCIgM.

[0090] aerosol The present invention relates to compositions comprising polyclonal immunoglobulins for use in the treatment or prevention of acute exacerbations in patients with chronic lung disease, particularly COPD and / or NCFB, wherein the compositions are administered to the subject's airways. Typically, the compositions of the present invention are administered to the subject's airways as an aerosol. The aerosol is generated by nebulizing a liquid aqueous polyclonal immunoglobulin-containing composition. Alternatively, the aerosol may be a dry powder aerosol produced, for example, by a dry powder inhalation system

[17] . Alternatively, a soft mist inhaler, aqueous droplet inhaler, or pressurized metered-dose inhaler, or any other device suitable for delivering immunoglobulins to the patient's airways, may be used.

[0091] liquid aqueous composition Liquid aqueous composition is particularly suitable for nebulization to form aerosol that is administered to the respiratory tract of a subject.Therefore, the composition of the present invention is generally in liquid aqueous form.Liquid aqueous composition is a liquid system in which liquid carrier or solvent is mainly or completely composed of water.In some cases, liquid carrier can contain a small fraction of one or more liquids that are at least partially miscible with water.

[0092] The present invention relates to the administration of compositions of the present invention to the respiratory tract of a subject. For such administration to the respiratory tract, it is preferable to use high-concentration polyclonal immunoglobulin. While high doses of polyclonal immunoglobulin are generally useful for enhancing efficacy, it is also useful to minimize the administered volume, e.g., when administered by nebulizer, to keep nebulization time as short as possible. Keeping nebulization time as short as possible is particularly useful for maintaining subject compliance. Thus, in one embodiment, the compositions of the present invention have a high concentration of polyclonal immunoglobulin, e.g., about 20 to about 200 mg / mL. The concentration of polyclonal immunoglobulin can range from 20 to 190 mg / mL, 20 to 180 mg / mL, 20 to 170 mg / mL, 20 to 160 mg / mL, 20 to 150 mg / mL, 30 to 200 mg / mL, 30 to 190 mg / mL, 30 to 180 mg / mL, 30 to 170 mg / mL, 30 to 160 mg / mL, 30 to 150 mg / mL, 40 to 200 mg / mL, 40 to 190 mg / mL, 40 to 180 mg / mL, 40 to 170 mg / mL, 40 to 160 mg / mL, and 40 to 150 mg / mL. Suitable polyclonal immunoglobulin concentrations for the compositions of the present invention range from 20 to 140 mg / mL, 20 to 130 mg / mL, 20 to 120 mg / mL, 30 to 140 mg / mL, 30 to 130 mg / mL, 30 to 120 mg / mL, 40 to 140 mg / mL, 40 to 130 mg / mL, 40 to 120 mg / mL, 50 to 140 mg / mL, 50 to 130 mg / mL, or 50 to 120 mg / mL; in particular, the polyclonal immunoglobulin concentration is about 50 mg / mL, about 60 mg / mL, about 70 mg / mL, about 80 mg / mL, about 90 mg / mL, about 100 mg / mL, about 110 mg / mL, or about 120 mg / mL.

[0093] A relatively high concentration allows for a low loading volume and short spray time, which is therefore important for ensuring the therapeutic efficacy of the treatment. In certain preferred embodiments, the composition contains polyclonal IgG at a concentration of about 50 mg / mL to about 100 mg / mL. Most preferably, the composition contains polyclonal IgG at a concentration of about 100 mg / mL.

[0094] Typically, the liquid aqueous compositions of the present invention contain one or more stabilizers. A problem commonly encountered when formulating liquid immunoglobulin preparations is the tendency of immunoglobulins to form aggregates and precipitates if not adequately stabilized with appropriate additives. Thus, in one embodiment, the compositions of the present invention contain stabilizers, such as amino acids such as proline, glycine, and histidine, or saccharides, or sugar alcohols, or proteins such as albumin, or combinations thereof. These stabilizers are useful in treating immunoglobulin-containing aqueous solutions. Each of the additives is known to stabilize immunoglobulins in liquid aqueous formulations and is used in the liquid aqueous compositions of the invention. In certain embodiments, the compositions of the invention include a stabilizer, wherein the stabilizer is proline, glycine, or histidine, preferably proline.

[0095] Increasing the immunoglobulin concentration in a liquid aqueous composition results in a nonlinear increase in viscosity. As disclosed in WO2011 / 095543, the present compositions achieve a relatively low viscosity even at high polyclonal immunoglobulin concentrations, and therefore proline has been found to be particularly suitable as a stabilizer to avoid spraying problems caused by high viscosity. On the one hand, proline provides the desired stability of polyclonal immunoglobulin in the liquid aqueous composition, and on the other hand, it reduces the viscosity of the composition, thus enabling spraying of a small liquid volume at high polyclonal immunoglobulin concentrations and resulting in rapid and effective treatment by spraying. Therefore, in certain embodiments, the present compositions contain proline, especially when the present compositions are in liquid aqueous form.

[0096] L-proline is normally present in the human body and has a very favorable toxicity profile, so it is particularly suitable for use in the composition of the present invention.The safety of L-proline has been investigated in repeated dose toxicity test, reproductive toxicity test, mutagenicity test and safety pharmacology test, and no adverse effects have been found.Therefore, in a preferred embodiment, the composition of the present invention comprises L-proline.

[0097] Generally, the composition of the present invention contains proline, preferably L-proline, in the range of about 10 to about 1000 mmol / L, for example, about 100 to about 500 mmol / L, particularly about 250 mmol / L.

[0098] In a preferred embodiment, the composition of the present invention contains about 210 to 290 mmol / L of L-proline, particularly 250 mmol / L of L-proline. In a specific embodiment, the composition comprises polyclonal IgG and about 250 mmol / L of L-proline.

[0099] In one embodiment, the viscosity of a liquid aqueous composition of the invention comprising polyclonal immunoglobulin and proline ranges from 1 mPa-s to 17 mPa-s (at a temperature of 20.0° C. + / - 0.1° C.). In a specific embodiment, the viscosity of a composition comprising 100 mg / mL polyclonal IgG and 250 mmol / L L-proline is about 3 mPa-s at a temperature of 20.0° C. + / - 0.1° C.

[0100] Typically, compositions of the invention comprising polyclonal IgG and containing proline have a pH of 4.2 to 5.4, preferably 4.6 to 5.0, and most preferably about 4.8, which further contributes to high stability of the preparation.

[0101] The use of proline allows for the preparation of compositions that use one single agent to improve formulation stability and reduce composition viscosity, making the composition particularly useful in methods of generating aerosols with mesh nebulizers.

[0102] The compositions of the invention usually include components in addition to polyclonal immunoglobulins. For example, the compositions typically include one or more additional pharmaceutical carriers and / or excipients. A discussion of such components is available in reference 2.

[0103] In one embodiment, the compositions of the present invention also include pharmaceutically acceptable excipients that help optimize the composition's and / or aerosol's properties. Examples of such excipients include excipients for adjusting or buffering pH, excipients for adjusting osmolality, antioxidants, and the like. These excipients are surfactants, excipients for sustained release or sustained local retention, taste masking agents, sweeteners, and flavorings. These excipients are used to achieve optimal pH, osmolality, viscosity, surface tension, and taste that support formulation stability, aerosolization of the formulation upon inhalation, tolerability, and / or efficacy.

[0104] Liquid aqueous compositions of the present invention typically have a surface tension of about 60-75 mLM / m, preferably about 64-71 mLM / m. Surfactants are added to the compositions of the present invention. These may help control the rate of aggregation of polyclonal immunoglobulins in the composition (i.e., during storage and in the reservoir) and during aerosolization (i.e., during and after passage through the nebulizer mesh), thereby affecting the activity of polyclonal immunoglobulins in the aerosol. Thus, in one embodiment, the compositions of the present invention are liquid aqueous compositions containing a surfactant, e.g., a polysorbate such as polysorbate 80.

[0105] spray The present invention involves administering a composition to the respiratory tract of a subject. The composition of the present invention is administered to the respiratory tract of a subject as an aerosol produced by nebulizing a liquid aqueous composition of the present invention using a nebulizer.

[0106] A nebulizer is a device that can aerosolize a liquid substance into a dispersed liquid phase. An aerosol is a system that contains a continuous gas phase and, dispersed therein, a discontinuous or dispersed phase of solid or liquid particles (typically liquid particles when produced by atomization of a liquid aqueous composition).

[0107] The liquid aqueous composition of the present invention is nebulized by mesh nebulizer or ultrasonic nebulizer or jet nebulizer, or any other device that can nebulize the composition of the present invention.In one embodiment, mesh nebulizer is used to generate the aerosol for administering to subject.For example, the mesh nebulizer and generated aerosol disclosed in WO2015 / 150510 are used, the whole of which is incorporated herein by reference.

[0108] The dispersed liquid phase (aerosol) essentially consists of droplets. The dispersed phase droplets contain polyclonal Ig, such as IgG, IgA, IgM, or a combination thereof, in a liquid environment. The liquid environment is primarily an aqueous phase, with or without additional excipients, as further described below. Those skilled in the art will understand that the characteristics and preferences disclosed herein regarding the liquid composition also apply to the dispersed phase of the aerosol produced therefrom, and vice versa.

[0109] Two values ​​can be experimentally determined and useful for describing the particle or droplet size of the generated aerosol: the mass median diameter (MMD) and the mass median aerodynamic diameter (MMAD). The difference between the two values ​​is that the MMAD is normalized to the density of water (equivalent aerodynamic).

[0110] MMAD is measured by an impactor, such as an Andersen Cascade Impactor (ACI) or a Next Generation Impactor (NGI). Alternatively, laser diffraction methods, such as the Malvern MasterSizer X™, are used to measure MMD.

[0111] The dispersed phase of the aerosol produced by the method of the present invention typically exhibits a particle size, e.g., MMD, preferably less than 10 μm, preferably from about 1 to about 6 μm, more preferably from about 1.5 to about 5 μm, and even more preferably from about 2 to about 4.5 μm. Alternatively, the particle size is preferably The MMD may be less than 10 μm, preferably between about 1 and about 6 μm, more preferably between about 1.5 and about 5 μm, and even more preferably between about 2 and about 4.5 μm. Another parameter describing the dispersed phase of an aerosol is the particle size distribution of the aerosolized liquid particles or droplets. The geometric standard deviation (GSD) is a frequently used measure of the spread of the particle size or droplet size distribution of the generated aerosol particles or droplets. The selection of the exact MMD within the above range should take into account the target region or tissue of aerosol deposition. For example, the optimal droplet size will vary depending on whether oral, nasal, or tracheal inhalation is intended, and whether the focus is on upper and / or lower respiratory tract delivery (e.g., to the oropharynx, pharynx, trachea, bronchi, alveoli, lungs, nose, and / or sinuses). Furthermore, age-dependent anatomical geometry (e.g., geometry of the nose, mouth, or respiratory tract) as well as the subject's respiratory disease and condition and the subject's breathing pattern are important factors in determining the optimal particle size (e.g., MMD and GSD) for drug delivery to the lower or upper respiratory tract.

[0112] Generally, small airways, defined by an internal diameter of less than 2 mm, account for approximately 99% of lung volume and therefore play an important role in lung function. Alveoli are the areas in the deep lung where oxygen and carbon dioxide are exchanged with the blood. Inflammation of alveoli induced by some viruses or bacteria leads to fluid secretion in situ, which directly affects the oxygen intake by the lungs. Therapeutic targeting of deep lung airways using aerosols requires aerosols with MMDs of less than 5.0 μm, preferably less than 4.0 μm, more preferably less than 3.5 μm, and even more preferably less than 3.0 μm. Such MMD values ​​are therefore contemplated for use in the present invention.

[0113] For aerosol delivery to the respiratory tract, the aerosol has an MMD of less than 10.0 μm, preferably less than 5.0 μm, more preferably less than 3.3 μm, and even more preferably less than 2.0 μm. Preferably, the MMD (droplet diameter) ranges from about 1.0 to about 5.0 μm, with a size distribution having a GSD of less than 2.2, preferably less than 2.0, more preferably less than 1.8, or even more preferably less than 1.6. Such particle size and particle size distribution parameters are particularly useful for achieving high local drug concentrations in the human respiratory tract (e.g., lungs), including the bronchi and bronchioles, relative to the amount of drug aerosolized. In this regard, it should be considered that deep lung deposition requires a smaller MMD than deposition in the central airways of adults and children, with even smaller droplet diameters (MMDs) in the range of about 1.0 to about 3.3 μm being more preferred for infants and toddlers, with a range of less than 2.0 μm being even more preferred. Therefore, in aerosol therapy, it is common to evaluate the fraction of droplets smaller than 5 μm (corresponding to the fraction respirable by adults) and smaller than 3.3 μm (corresponding to the fraction respirable by children or the fraction deposited in the deeper lungs of adults). The fraction of droplets smaller than 2 μm is also often evaluated, because this fraction represents the fraction of aerosol that can optimally reach the terminal bronchioles and alveoli of adults and children and penetrate the lungs of infants and young children.

[0114] In the present invention, the fraction of droplets having a particle size smaller than 5 μm is preferably greater than 65%, more preferably greater than 70%, and even more preferably greater than 80%. The fraction of droplets having a particle size smaller than 3.3 μm is preferably greater than 25%, more preferably greater than 30%, even more preferably greater than 35%, and even more preferably greater than 40%. The fraction of droplets having a particle size smaller than 2 μm is preferably greater than 4%, more preferably greater than 6%, and even more preferably greater than 8%.

[0115] The aerosol may also be characterized by its delivered dose (DD), which is determined in a simulated breath experiment. The delivered dose may be measured by laser diffraction (e.g., Malvern MasterSizer X™) or using an impactor (e.g., Andersen Cascade Impactor - ACI, or Next Generation Impactor - NGI) The respirable dose (RD) is calculated based on the reactive fraction (RF). When the method of the present invention is applied in a breathing simulation experiment (using, for example, a breathing simulator such as Copley's BRS3000 or PARI's Compass II™) using an adult breathing pattern (sinusoidal flow, 500 mL tidal volume, 15 breaths / min) and 2 mL of a composition (e.g., 200 mg Ig, 200 mg IgG, 200 mg IgA, 200 mg IgM, or a combination thereof) is loaded into a mesh nebulizer, the delivered dose (DD) is preferably greater than 40% (80 mg Ig, e.g., IgG, IgA, IgM, or a combination thereof), more preferably greater than 45% (90 mg Ig, e.g., IgG, IgA, IgM, or a combination thereof), and even more preferably greater than 50% (100 mg Ig, such as IgG, IgA, IgM or a combination thereof).

[0116] For treatment of the upper respiratory tract, particularly the nose, nasal and / or sinus mucosa, osteomeatal complex, and paranasal sinuses, an MMD of less than about 5.0 μm, or less than about 4.5 μm, or less than about 4.0 μm, or less than about 3.3 μm, or less than about 3.0 μm is particularly suitable.

[0117] The suitability of the generated aerosol for application to the upper respiratory tract can be assessed in a nasal inhalation model, such as the human nose model described in WO 2009 / 027095. For nasal aerosol delivery, there are, for example, the Sinus™ device (jet nebulizer) manufactured by PARI and also mesh nebulizers (prototypes of Vibrent™ technology).

[0118] The nebulizer used in the present invention may be a mesh nebulizer. Preferably, the mesh nebulizer is a vibrating membrane nebulizer. The latter type of nebulizer includes a reservoir filled with the liquid to be nebulized. When the nebulizer is operated, the liquid is sent to a mesh that is made to oscillate, i.e., vibrate (for example, by a piezoelectric element). The liquid present on one side of the vibrating mesh is thereby transported through the openings (also called "pores" or "holes") of the vibrating mesh and takes the form of an aerosol on the other side of the vibrating mesh (for example, eFlow High Speed ​​and eRapid manufactured by PARI, HL100 manufactured by Health and Life, and AeronebGo and AeronebSolo manufactured by Aerogen). Such nebulizers are called "active membrane nebulizers."

[0119] In other useful mesh nebulizers, the composition is nebulized by vibrating the liquid rather than the membrane. Such oscillating fluid mesh nebulizers include a reservoir filled with the liquid to be nebulized. When the nebulizer is operated, the liquid is delivered to the membrane by a delivery system that is configured to oscillate (i.e., vibrate, for example, via a piezoelectric element). This delivery system can be a vibrating back wall of the reservoir (e.g., AerovectRx™ Technology, Pfeifer Technology) or a vibrating liquid delivery slider (e.g., Respironics I-Neb™ device or Omron U22™ device). These nebulizers are referred to as "passive mesh nebulizers."

[0120] Different membrane types are available for nebulizing liquids with mesh nebulizers. These membranes are characterized by different pore sizes that generate aerosols with different droplet sizes (MMD and GSD). Depending on the properties of the composition and the desired aerosol properties, different membrane types (i.e., different modified mesh nebulizers or aerosol generators) are used. In the present invention, the MMD ranges from 2.0 μm to 5.0 μm, preferably from 3.0 μm to 5.0 μm. It is preferred to use a membrane type that generates aerosols with an MMD in the range of 4.9 μm, more preferably in the range of 3.4 μm to 4.5 μm. In another embodiment of the present invention, it is preferred to use a membrane type that is incorporated into an aerosol generator device that generates aerosols with an MMD in the range of 2.8 μm to 5.5 μm, preferably in the range of 3.3 μm to 5.0 μm, more preferably in the range of 3.3 μm to 4.4 μm, such as isotonic saline (NaCI 0.9%). In another embodiment of the present invention, it is preferred to use a membrane type that is incorporated into an aerosol generator device that generates aerosols with an MMD in the range of 2.8 μm to 5.5 μm, preferably in the range of 2.9 μm to 5.0 μm, more preferably in the range of 3.8 μm to 5.0 μm, such as isotonic saline.

[0121] When the treatment is intended to target the lower airways, such as the bronchi or deep lungs, it is particularly preferred to select a piezoelectric perforated mesh nebulizer for generating aerosol.Examples of suitable nebulizers include passive mesh nebulizers such as I-Neb™, U22™, U1™, Micro Air™, ultrasonic nebulizers such as Multisonic™, and / or passive mesh nebulizers such as HL100™, Respimate™, eFlow™ Technology nebulizers, AeroNeb™, AeroNeb Pro™, AeronebGo™ and AeroDose™ device family, and prototype Pfeifer, Chrysalis (Philip Morris) or AerovectRx™ device. Particularly preferred nebulizers for targeting drugs to the lower respiratory tract are vibrating perforated membrane nebulizers or so-called active mesh nebulizers, such as the eFlow™ nebulizer (an electronic vibrating membrane nebulizer available from PARI, Germany).Alternatively, passive mesh nebulizers are used, such as the U22™ or U1™ manufactured by Omron, or nebulizers based on Telemaq.fr technology or Ing. Erich Pfeiffer GmbH technology.

[0122] Preferred mesh nebulizers for targeting the upper airways are those that generate aerosols by a perforated vibrating membrane principle, such as modified investigational membrane nebulizers using eFlow™ technology, which can also emit a pulsating airflow so that the generated aerosol cloud pulsates (i.e., undergoes pressure fluctuations) at or during transport of the aerosol cloud to the desired location (e.g., sinonasal sinus or paranasal sinus). This type of nebulizer has a nosepiece for directing the flow that transports the aerosol cloud to the nose. Aerosols delivered by such modified electronic nebulizers are much better at dissolving in the sinuses than when the aerosol is delivered in a continuous (non-pulsating) mode. The pulsatile pressure waves achieve a more intensive ventilation of the paranasal cavities, so that the simultaneously applied aerosol is better dispersed and deposited in these cavities.

[0123] More specifically, preferred nebulizers for targeting the upper respiratory tract of a subject are those suitable for generating an aerosol at an effective flow rate of less than about 5 liters per minute while simultaneously operating a means for producing pressure pulsations of the aerosol at a frequency in the range of about 10 to about 90 Hz, the effective flow rate being the flow rate of the aerosol as it enters the subject's respiratory system. Examples of such electronic nebulizer devices are disclosed in WO2009 / 027095.

[0124] In a preferred embodiment of the present invention, the nebulizer for targeting the upper airways is a nebulizer that uses a transport flow that is interrupted when the aerosol cloud reaches the desired location and then starts pulsating the aerosol cloud, for example in an alternating mode. 097119 and WO2011 / 134940.

[0125] Whether suitable for pulmonary or sinus delivery, the nebulizer should preferably be selected or adapted to aerosolize a unit dose at a desirable output rate. A unit dose is defined herein as the volume of liquid aqueous composition containing an effective amount of the active compound, i.e., Ig, IgG, IgA, IgM, or a combination thereof, designated to be administered during a single administration. Preferably, the nebulizer can deliver such a unit dose at a rate of at least 0.1 mL / min, or at a rate of at least 100 mg / min, assuming the relative density of the composition is typically approximately 1. More preferably, the nebulizer can generate an output rate of at least 0.4 mL / min or 400 mg / min, respectively. In further embodiments, the liquid output rate of the nebulizer or aerosol generator is at least 0.50 mL / min, preferably at least 0.55 mL / min, more preferably at least 0.60 mL / min, even more preferably at least 0.65 mL / min, and most preferably at least 0.7 mL / min, and such devices, referred to as aerosol generators, have a high output or high output rate. Preferably, the liquid output rate ranges from about 0.35 to about 1.0 mL / min or from about 350 to about 1000 mg / min; preferably, the liquid output rate ranges from about 0.5 to about 0.90 mL / min or from about 500 to about 800 mg / min. The liquid output rate refers to the amount of liquid composition nebulized per time unit. The liquid may contain an active compound, a drug, Ig, IgG, IgA, IgM, or a combination thereof, and / or a substitute such as sodium chloride 0.9%.

[0126] The discharge rate of the nebulizer should typically be selected to achieve a short nebulization time of the liquid composition. Obviously, the nebulization time will depend on the volume of the composition to be aerosolized and the discharge rate. Preferably, the nebulizer should be selected or adapted to aerosolize a volume of liquid composition containing an effective dose of polyclonal Ig, e.g., IgG, IgA, IgM, or a combination thereof, within 20 minutes. More preferably, the nebulization time per unit dose is 15 minutes or less. In further embodiments, the nebulizer is selected or adapted to allow a nebulization time per unit dose of 10 minutes or less, more preferably 6 minutes or less, and even more preferably 3 minutes or less. Currently, a nebulization time in the range of 0.5 to 5 minutes is most preferred.

[0127] The volume of the composition nebulized according to the present invention is preferably low to allow for short nebulization times. The volume, also referred to as the dose volume, unit dose volume, or unit dose volume, should be understood as the volume intended for use in a single administration or nebulizer therapy session. Specifically, the volume may range from 0.3 mL to 6.0 mL, preferably 0.5 mL to 4.0 mL, or more preferably 1.0 mL to about 3.0 mL, or even more preferably about 2.0 mL. If a residual volume is desired or useful, this residual volume should be less than 1.0 mL, more preferably less than 0.5 mL, and most preferably less than 0.3 mL. The effective nebulization volume, then, is preferably in the range of 0.2 to 3.0 mL or 0.5 to 2.5 mL, or more preferably in the range of 0.75 to 2.5 mL or 1.0 to 2.5 mL.

[0128] Preferably, the nebulizer is adapted to generate an aerosol in which a major fraction of the charged dose of the liquid composition is delivered as an aerosol, i.e., to have a high output. More specifically, the nebulizer is adapted to generate an aerosol containing at least 50% of the dose of Ig, such as IgG, IgA, IgM, or a combination thereof, in the composition, or in other words, to discharge at least 50% of the liquid composition charged in the reservoir. In particular, it is important to select a nebulizer that can generate such a high output of polyclonal Ig, such as IgG, IgA, IgM, or a combination thereof, compared to monoclonal antibodies, which do not require a high dose due to their specificity. It has been found that the mesh nebulizers used in the methods of the present invention are capable of producing aerosols of polyclonal Ig, e.g., IgG, IgA, IgM, or combinations thereof, in compositions with particularly high output.

[0129] dry powder inhalation The composition of the present invention can also be dry powder.Various types of dry powder inhalers are available, such as capsule dry powder inhalers and multi-dose dry powder inhalers, single-dose forms such as rotary inhalers, and multi-dose forms such as Accuhaler inhalers and disk inhalers.Dry powder inhalers can be advantageous because they provide an easy-to-use, rapid inhalation system suitable for more frequent use.

[0130] dosage The compositions of the invention are for use in the prevention or treatment of acute exacerbations.

[0131] In one embodiment, the composition of the present invention is used for preventing acute exacerbation of the subject with chronic lung disease (typically COPD or NCFB), and the composition is administered as maintenance therapy.Maintenance therapy means that once therapy begins, subject continues therapy for a long period of time.For example, therapy lasts for at least 6 months.Typically, therapy lasts for at least 1 year.

[0132] The compositions of the present invention are typically administered to the respiratory tract of a subject as an aerosol, particularly an aerosol generated from a liquid aqueous composition using a nebulizer. Suitable liquid aqueous compositions are described above. In a preferred embodiment, the liquid aqueous composition has a polyclonal immunoglobulin (e.g., IgG, IgA, IgM, or a combination thereof) concentration of about 50 mg / mL to about 150 mg / mL, e.g., about 100 mg / mL.

[0133] For administration to the respiratory tract of a subject of the present invention, the liquid aqueous composition used to generate the aerosol is administered in a volume of 2 to 10 mL.

[0134] For use in the treatment or prevention (typically prevention) of acute exacerbations, such as acute exacerbations of COPD or NCFB, the composition is administered once every 48 hours, once every 24 hours, or once every 12 hours during therapy. In certain embodiments, the composition of the present invention is administered once every 12 hours. In certain embodiments, the composition of the present invention is administered every 24 hours. In certain embodiments, the composition of the present invention is administered every 48 hours.

[0135] For use in the prevention or treatment (typically prevention) of acute exacerbations, such as COPD or NCFB, doses of about 0.01 g to about 1.5 g of polyclonal immunoglobulin are used. Particularly suitable doses of the compositions of the invention are about 0.1 g to about 1.5 g of polyclonal immunoglobulin, e.g., about 0.2 g to about 1 g, particularly about 0.2 g. In certain embodiments, a dose of about 0.2 g is administered once daily.

[0136] Such doses can be adjusted depending on factors that may increase the risk of acute exacerbations, such as the risk of respiratory tract infections. By way of example, the dose and / or frequency of administration according to the present invention is increased in autumn and winter, particularly in winter.

[0137] In another embodiment, the aerosol is generated from the dry composition using a dry powder inhaler. Typically, the dose delivered in a single administration may be relatively low, such as approximately 0.5 mg, but the subject may use multiple inhalations per day, for example, from 1 to about 20 inhalations per day, preferably from 2 to about 15 inhalations per day.

[0138] Seasonal administration The therapy (prevention or treatment) of the present invention is particularly useful during colder weather, which is associated with increased rates of respiratory tract infections and acute exacerbations in subjects with chronic lung disease, typically COPD and / or NCFB. In one embodiment, the composition is administered in autumn and / or winter. In particular, the composition is administered in winter. The occurrence of acute exacerbations of COPD shows seasonal variation, with higher rates in autumn and winter

[19] . This increase in acute exacerbations can be attributed to an increased rate of respiratory tract infections, such as rhinovirus infections. Therefore, administering the composition in autumn and winter provides protection against such infections during periods of increased risk.

[0139] Such seasonal variations are likely to affect all subjects with COPD, and therefore, this seasonal dosing, for example, in the fall and winter, particularly in the winter, may be useful for any subject with COPD as characterized herein. The similarities between COPD and NCFB, particularly acute exacerbations that may result from respiratory tract infections, suggest that such seasonal dosing may be useful for subjects with NCFB.

[0140] As used herein, the term "autumn" refers to the months commonly recognized as occurring during fall or autumn. In the Northern Hemisphere, these months include September, October, and November. In the Southern Hemisphere, these months include March, April, and May.

[0141] As used herein, the term "winter" refers to months commonly recognized as occurring during the winter. In the Northern Hemisphere, these months include October, November, December, January, and February. In the Southern Hemisphere, these months include April, May, June, July, and August.

[0142] Combination therapy with antibiotics The polyclonal immunoglobulins of the invention are particularly suitable for administration in combination with antibiotics, for example to prevent or treat bacterial airway infections in subjects with chronic lung disease, typically COPD and / or NCFB.

[0143] In one embodiment, the compositions of the invention are administered in conjunction with antibiotics during the acute phase of a bacterial infection while the subject is undergoing antibiotic therapy, i.e., the compositions are administered during the first 2 days, particularly the first 3 days, first 4 days, or first 5 days of the infection, in addition to standard antibiotic therapy.

[0144] General The term "comprising" encompasses "including" and "consisting." For example, a composition "comprising" X may consist of only X, or it may include something additional, e.g., X+Y. The word "substantially" does not exclude "completely." For example, a composition "substantially free" of Y may be completely free of Y. Where necessary, the word "substantially" may be omitted from the definition of the invention.

[0145] The term "about" in connection with a numerical value x is arbitrary and means, for example, x±10%. The compositions of the invention are compositions that include polyclonal immunoglobulins, and unless otherwise specifically stated, the effects attributable to the compositions are mediated by the polyclonal immunoglobulins and not by any unspecified additional components.

[0146] Unless specifically stated, processes that involve mixing two or more components do not require any particular order of mixing. Thus, the components can be mixed in any order. Where there are three components, two components may be combined with each other and then the combination may be mixed in a second order. It is combined with ingredients 3, etc.

[0147] The invention will now be illustrated in the following non-limiting examples with reference to the following figures: [Brief explanation of the drawings]

[0148] [Figure 1] 1 shows that plasma-derived Ab preparations interact with Pseudomonas aeruginosa (PA). Binding of increasing concentrations of plasma-derived Ab or secretory IgA / M to coated PA as determined by ELISA. [Figure 2] Figure 1: Conjugation of plasma-derived IgG preparations with PA promotes aggregation. Laser scanning confocal microscopy images of immune complexes of PA bound to plasma-derived IgG. Bacteria were labeled with CFSE, and IgG was labeled with Cy3 dye. Images are representative of one observation field from 5-10 observations from two independent slides. [Figure 3] Figure 1 shows plasma-derived immunoglobulin preparation PA-induced LDH tissue release. Tissue damage was assessed by measuring LDH release in MucilAir™ basal medium. Uninfected transwells receiving vehicle alone or plasma-derived immunoglobulin preparation served as controls. PA-infected transwells served as positive controls. Data are representative of three independent experiments. [Figure 4] Figure 1 shows that plasma-derived IgG formulations dose-dependently prevent the loss of transepithelial electrical resistance. Tissue integrity was assessed by measuring transepithelial electrical resistance. Uninfected and proline-treated transwells served as negative controls, while PA-infected transwells served as a positive control for tissue damage. Data are representative of three independent experiments. [Figure 5]Figure 1 shows that plasma-derived IgG formulations prevent PA-induced tissue damage in a dose-dependent manner. Laser scanning confocal microscopy images of paraffin-fixed MucilAir™ sections were acquired and analyzed for cytokeratin and beta-tubulin expression. Uninfected transwells receiving vehicle alone or the IgG formulation served as controls. PA-infected transwells treated with vehicle served as positive controls. Data are representative of three independent experiments. [Figure 6] FIG. 1 shows that plasma-derived immunoglobulin preparations reduce PA-induced IL-8 release by epithelial cells. IL-8 was measured in MucilAir™ basal medium. Uninfected transwells receiving vehicle alone or immunoglobulin preparation served as controls. PA-infected transwells treated with proline served as positive controls. Data are representative of three independent experiments. [Figure 7] Figure 1 shows that plasma-derived IgG preparations dose-dependently reduce PA-induced IL-8 release by epithelial cells. Relative concentrations of IL-8 secretion were calculated with respect to IL-8 secreted by MucilAir™ when exposed to 10 CFU of PA for 24 hours. Uninfected transwells receiving vehicle alone or immunoglobulin preparation served as controls. PA-infected transwells treated with proline served as positive controls. Data are representative of one experiment using MucilAir™ from three different donors per condition. [Figure 8] FIG. 1 shows that plasma-derived Ab preparations reduce PA-induced IL-6 release by epithelial cells. IL-6 was measured in MucilAir™ basal medium. Uninfected transwells receiving vehicle alone or immunoglobulin preparation served as controls. PA-infected transwells treated with vehicle served as positive controls. Data are representative of three independent experiments. [Figure 9] 1 shows that plasma-derived Ab preparations interact with human rhinovirus C15. Binding of increasing concentrations of plasma-derived Ab or secretory IgAM to coated HRV C15 as determined by ELISA. [Figure 10] Figure 1 shows that plasma-derived Abs reduce HRV shedding. HRV-C15 genome copy number was measured in apical lavage using q-PCR. Proline-treated HRV-infected transwells served as a positive control for infection. For efficacy measurements, rupintrivir-treated transwells served as a positive control. [Figure 11] Figure 1 shows that plasma-derived Abs reduce HRV-induced tissue damage. Tissue integrity was assessed by measuring transepithelial electrical resistance. Non-infected transwells treated with proline served as a negative control. HRV-infected transwells treated with proline served as a positive control for infection. For efficacy measurements, rupintrivir-treated transwells served as a positive control. [Figure 12] Figure 1 shows that plasma-derived Abs prevent HRV-induced reduction in mucociliary clearance. Mucociliary clearance was assessed by measuring the velocity of 30 μm diameter polystyrene microbeads added to the apical surface of the MucilAir™. Non-infected transwells treated with proline served as a negative control. HRV-infected transwells treated with proline served as a positive control for infection. For efficacy measurements, rupintrivir-treated transwells served as a positive control. [Figure 13-1] Figure 1 shows that plasma-derived immunoglobulin preparations inhibit HRV proliferation in a dose-dependent manner. HRV-C15 genome copy number was measured using q-PCR in apical lavage after treatment with different immunoglobulin preparations at 4 μg / well, 20 μg / well, 100 μg / well, and 500 μg / well. HRV-infected transwells treated with proline served as a positive control for infection. For efficacy measurements, rupintrivir-treated transwells served as a positive control. [Figure 13-2] Continuation of Figure 13-1. [Figure 14-1]Figure 1 shows that plasma-derived immunoglobulin preparations inhibit influenza virus growth in a dose-dependent manner. Influenza virus genome copy number was measured in the apical lavage using q-PCR after treatment with different immunoglobulin preparations at 4 μg / well, 20 μg / well, 100 μg / well, and 500 μg / well. Influenza virus-infected transwells treated with proline served as a positive control for infection. For efficacy measurements, oseltamivir-treated transwells served as a positive control. [Figure 14-2] Continued from Figure 14-1. DETAILED DESCRIPTION OF THE INVENTION

[0149] The following non-limiting examples serve to illustrate the present invention. The studies included in the following examples demonstrate that immunoglobulin delivered to airway tissues can combine antibacterial (immune clearance) and anti-inflammatory effects, and is therefore an attractive option for the effective treatment or prevention of exacerbations, especially infection-related exacerbations, in subjects suffering from chronic lung diseases such as COPD and NCFB. In particular, preventing chronic infections and acute exacerbations makes it suitable for maintenance therapy in subjects with these diseases.

[0150] Mucosal surfaces are protected from microbial colonization and potential invasion and invasion by a combination of constitutive nonspecific substances (mucus, lysozyme, and defensins) and specific immune mechanisms, including secretory immunoglobulin (SIg) at the humoral level [20;21]. In vivo, experimental and clinical resistance to infection can be correlated with specific secretory IgA (SIgA) antibodies (Abs), which function as an immunological barrier at mucosal surfaces [22;23]. The aggregation, immobilization, and neutralization of pathogens at mucosal surfaces are thought to be facilitated by the multivalency of SIgA [24;25]. SIgM, which functions as a substitute for SIgA in IgA-deficient individuals, appears to act through a similar defense mechanism

[26] .

[0151] For some pathogens, such as poliovirus, Salmonella, or influenza, protection against mucosal infection can be induced by active mucosal immunization with approved vaccines. However, for the vast majority of mucosal pathogens, active mucosal vaccines are not available. Alternatively, protective levels of Abs can be delivered directly to mucosal surfaces by passive immunization. Naturally, this is physiologically achieved in many mammalian species by the transfer of maternal antibodies to the offspring via milk. This occurs

[27] . Human and animal studies using passive mucosal immunization have shown that pIgA and SIgA antibody molecules administered orally, intranasally, intrauterinely, or by pulmonary instillation can prevent, reduce, or cure bacterial and viral infections

[28] . However, the secretory form of IgA naturally found on mucosal surfaces has rarely been used. Large-scale production of SIgA has not been possible to date. Although constructing SIgA using biotechnological methods is challenging, such molecules may have important clinical applications

[29] . The same is true for secretory component-containing IgM.

[0152] Plasma-derived immunoglobulins have been used for decades to protect immunocompromised patients from potentially fatal infections

[30] . Plasma-derived immunoglobulins generally have high IgG purity. However, few IgG products (e.g., Pentaglobin™) contain concentrated IgM in the formulation. Plasma-derived immunoglobulins are delivered intravenously or subcutaneously, ensuring systemic distribution of immunoglobulin throughout the body. Immune replacement therapy has been shown to reduce the incidence of pneumonia in immunocompromised patients, but its impact on upper respiratory tract and bronchial infections appears to be limited. Topical application of plasma-derived immunoglobulins may support higher Ig content at mucosal surfaces without increasing systemic Ig delivery.

[0153] Given their key roles in COPD and NCFB exacerbations, HRV and PA were selected to test the efficacy of plasma-derived immunoglobulins in preventing epithelial tissue infection. To better mimic the human situation, we used a human primary cell-based airway model, MucilAir™ (Epithelix Sarl, Geneva). MucilAir™ is an in vitro reconstituted cellular model of human airway epithelium. The MucilAir™ pool is made from a mixture of nasal or bronchial cells isolated from 14 different donors or a single donor. Cultivated at an air-liquid interface, the model exhibits high transepithelial electrical resistance, ciliary beating, and mucus production, demonstrating the full functionality of epithelial tissue as present in vivo. Cytokine release (e.g., IL-8 and IL-6) and lactate dehydrogenase (LDH) release were detected during infection, reflecting how infection correlates with inflammation and tissue damage in this model.

[0154] material and method Respiratory tract infections are initiated by the deposition of pathogenic bacteria and viruses on the apical side of the airway epithelium. To reach tissues, viruses infect epithelial cells, while bacteria tend to damage cells through the secretion of exotoxins. To test the efficacy of plasma-derived immunoglobulins in preventing tissue damage, a Pseudomonas aeruginosa infection model was used.

[0155] Bacterial strains The Pseudomonas aeruginosa (PA) used in this model was a clinical isolate obtained from the Institute of Infectious Diseases (University of Bern, Switzerland). PA is a pathogen that causes disease in humans and is involved in pulmonary infections. PA was cultured on blood agar Petri dishes. Colonies were selected and cultured in brain heart infusion (BHI) medium at 37°C and 400 revolutions per minute (RPM) for 24 hours. The following day, the culture was diluted 1:10 in fresh BHI medium and incubated at 37°C and 400 rpm for an additional hour. OD was then measured, and bacterial counts were estimated from OD / bacterial load curves generated using multiple cultures prior to the experiment. An aliquot was withdrawn for further dilution prior to dosing, and a second aliquot was withdrawn for further plating on blood agar plates to accurately verify the bacterial load.

[0156] virus strain Rhinovirus C15 is a clinical isolate (designation S07-09-08-U) obtained from the Geneva Hospital. Virus stocks were made in MucilAir™ cultures and diluted in culture medium. They were not purified or concentrated.

[0157] For dose-response studies, rhinovirus C15 (2009) and influenza A / Switzerland / 7717739 / 2013 (H1N1) were isolated directly from clinical specimens using MucilAir™ as described in

[31] . Experimental virus stocks were generated using MucilAir™ and apical washes were collected with culture medium. Production from several days was pooled, quantified by qPCR, aliquoted, and stored at -80°C.

[0158] organization MucilAir™ (Epithelix Sarl, Geneva) was used to mimic human bronchial tissue. Three MucilAir™ transwells were used per test group, each derived from either one different donor or a mix of the 14 donors used in the dose-response study. MucilAir™ cultures were performed at the air-liquid interface. The medium used on the basolateral side was MucilAir™ culture medium (Epithelix Sarl, Geneva) containing growth factors and phenol red. The medium was serum-free.

[0159] Pseudomonas aeruginosa infection model and treatment The infection model using PA is based on the deposition of as few as 10 colony-forming units (CFU) of PA onto the apical side of a single MucilAir™ Transwell in a volume of 10 μL. Over 24 hours, PA grows to >10 9 CFU / transwell are reached. Infection leads to the release of lactate dehydrogenase (LDH) (associated with tissue damage) and pro-inflammatory molecules such as IL-8 and IL-6. Tissue damage is also evidenced by the appearance of tissue holes and loss of transepithelial electrical resistance.

[0160] In some experiments, immunoglobulins were deposited 10 min before or simultaneously with the bacteria. Immunoglobulins were applied in a final volume of 10 μL. The effect of immunoglobulins was compared with that of the vehicle (25 mM proline).

[0161] Human rhinovirus C15 and influenza H1N1 infection models and treatment At time t = 0, the proof-of-concept experiment (Fig. 10) showed 3.8 × 10 7 Genome copies / mL HRV C15 (clinical strain: S07-09-08-U) 15 μL stock solution, and 1.0 × 10 for both HRV and influenza H1N1 in dose-response studies (Figures 13 and 14). 8Ten μL of genome copies / mL was applied to the apical side of the MucilAir™ for 3 hours at 34°C and 5% CO2. Immunoglobulin was applied simultaneously with the virus to the apical surface of the MucilAir™ at 5 μL and refreshed at 3.5 and 24 hours. The effect of immunoglobulin was compared to vehicle (25 mM proline). Three hours after inoculation, the epithelium was washed three times with PBS (Ca2+ / Mg2+) to remove the inoculum.

[0162] Cell-free apical washes (20 min) with 200 μL MucilAir™ culture medium were collected at 3.5 h, then 24 and 48 h post-inoculation and stored at -80°C.

[0163] Immunoglobulin A human plasma-derived IgG preparation (IgPro10, Pilivigen) was produced as previously described

[32] . The preparation containing IgA and IgM was obtained from an ion-exchange chromatography subfraction used in the large-scale production of human plasma-derived IgG. The eluted fractions containing IgA and IgM were purified by tangential flow filtration (TFF; Pellicon). The resulting IgA / M solution, containing IgA and IgM in a 2:1 mass ratio, was further processed to obtain SC IgA / M by combining recombinant human SC and IgA / M in vitro

[33] .

[0164] ELISA Proinflammatory cytokine release by human bronchial tissue during infection was measured in aliquots of basal medium collected 24 hours post-infection. Specifically, IL-8 (RnD Systems; DY208) and IL-6 (RnD Systems; DY206) were assessed. Measurements were performed according to the user manual.

[0165] For PA ELISA, PAs were cultured overnight at 37°C in BBL Todd Hewitt Broth medium. PAs were pelleted by centrifugation (3220 g) for 10 min. The supernatant was removed, and the pellet was washed twice with 0.1 M carbonate buffer (pH 9.6). The pellet was resuspended in carbonate buffer and 50 μl / well (4 × 10 6 Bacteria were added to polysorbate plates. Coating was performed overnight at 2–8°C. The next day, wells were washed for 3 h with PBS / Tween (0.05%) and blocked with PBS / FCS (2.5%) for 1.5 h at room temperature. The wells were then washed for 3 h with PBS / Tween (0.05%). Ig preparations (0.7 μg / ml–500 μg / ml) were added to the wells at room temperature for 2 h. After two washes with PBS / Tween (0.05%), the secondary antibody, goat anti-human IgG / A / M-HRP (1 mg / ml, 1:2,000 in blocking buffer), was incubated with the samples for 2 h at room temperature. After three final washes with PBS / Tween (0.05%), the TMB substrate for peroxidase was used. Blue precipitate formation is linearly proportional to the amount of enzyme in each well. The enzymatic reaction was stopped with 50 μl / well of 1M HCl. Absorbance was read at 450 nm (reference wavelength 620 nm). The average blank absorbance of each triplicate was subtracted from the bacterial coat absorbance.

[0166] For rhinovirus ELISA, Maxisorp plates (Nunc) were filled with purified rhinovirus C stock (3 × 10 6The plates were coated overnight with 5% BSA in 0.1 M carbonate buffer (clinical name: S07-09-09-U) at 2-4°C. A second Maxisorp plate was coated with 5% BSA in 0.1 M carbonate buffer and served as a "blank" plate. The following day, the wells were washed 3 times with PBS / Tween (0.05%) and blocked with PBS / FCS (2.5%) for 1.5 hours at room temperature. The wells were then washed 3 times with PBS / Tween (0.05%). Ig preparations (0.7 μg / ml to 500 μg / ml) were added to the wells for 2 hours at room temperature. After two washes with PBS / Tween (0.05%), the secondary antibody, goat anti-human IgG / A / M-HRP (1 mg / ml, 1:2,000 in blocking buffer), was incubated with the samples for 2 hours at room temperature. After three final washes with PBS / Tween (0.05%), the TMB substrate for peroxidase was used. Blue precipitate formation is linearly proportional to the amount of enzyme in each well. The enzymatic reaction was stopped with 50 μl / well of 1 M HCl. Absorbance was read at 450 nm (reference wavelength 620 nm). The average blank absorbance of each triplicate was subtracted from the virus coat absorbance.

[0167] immunohistochemistry Tissue damage was assessed using laser scanning confocal microscopy. Tissues were prepared as follows: MucilAir™ transwells were washed once with PBS and fixed with 4% paraformaldehyde overnight at 4°C. The following day, the transwells were washed three times with PBS, and the tissues were permeabilized with ice-cold methanol at -20°C for 30 minutes. The tissues were then washed three times with PBS, and a blocking step was performed overnight at 4°C using 3% goat serum in PBS. After another washing step with PBS (three times), the tissues were stained for 48–72 hours at 4°C with anti-cytokeratin antibody (Abcam; ab192643) (1 / 200), anti-beta-tubulin antibody (Abcam; ab11309) (1 / 200), and DAPI (Sigma D9542) (1 / 2000), all diluted in PBS. The tissues were then washed three times in PBS, and the transwells were separated from the tissues. The tissue was then mounted on a slide, covered with mounting medium and a coverslip. The slide was kept at room temperature for 24 hours to dry, after which it was transferred to Zeiss Images were taken with an LSM800 confocal microscope.

[0168] Transepithelial Electrical Resistance (TEER) TEER is a dynamic parameter that reflects the state of the epithelium. However, it is affected by several factors. For example, if holes are present or if cell tight junctions are lost, the TEER value will be less than 100 Ω.cm. 2 In contrast, when the epithelium is healthy, TEER values ​​typically reach 200 Ω.cm 2 Become higher.

[0169] Untreated samples and samples treated with solvent without virus or bacteria served as negative controls, and 10% Triton X-100 was used as a positive control.

[0170] To measure TEER values, 200 μL of MucilAir™ medium was added to the apical compartment of MucilAir™ cultures and resistance was measured for each condition using an EVOMX volt-ohm meter (World Precision Instruments UK, Stevenage). Resistance (Ω) was calculated using the following formula: TEER(Ω.cm 2 )=(resistance value(Ω)-100(Ω))×0.33(cm 2 ) (where 100 Ω is the resistance of the membrane and 0.33 cm 2 is the entire surface of the epithelium) Use TEER (Ω.cm) 2 ) was converted to

[0171] Lactate dehydrogenase (LDH) assay Lactate dehydrogenase is a stable cytosolic enzyme that is rapidly released into the culture medium upon plasma membrane rupture. 100 μL basal medium was collected at each time point and incubated with the Cytotoxicity Detection Kit PLUS reaction mixture (Sigma, Roche, 11644793001) according to the manufacturer's instructions. The amount of released LDH was then quantified by measuring the absorbance of each sample at 490 nm using a microplate reader. Untreated and solvent (without virus or bacteria) served as negative controls and correspond to physiological release of LDH (≤5%). 10% Triton X-100 was used as a negative control and corresponds to massive LDH release (equivalent to 100% cytotoxicity). To determine the percentage of cytotoxicity, the following equation was used (A = absorbance value): Cytotoxicity (%) = (A (experimental value) - A (low control) / A (high control) - A (low control)) x 100

[0172] Viral shedding At each time point tested, an apical wash was performed with 200 μL MucilAir™ culture medium. 20 μL was then used for viral RNA extraction (QIAamp® Viral RNA Extraction). The viral RNA was further used in a Qiagen kit (Qiagen) to obtain an RNA elution volume of 60 μL. Five μL of viral RNA was used to quantify viral RNA by quantitative RT-PCR (Quantitative RT-PCR, Qiagen). Two picornavirus family-specific primers, a pan-picornavirus primer and a picornavirus primer, as well as an influenza A-specific primer and a probe with a FAM-TAMRA reporter-quencher dye, were also used.

[0173] Four dilutions of known concentrations of HRV-A16 or H3N2 RNA and controls for RT-PCR were included and plates were run on either an Applied Biosystems TaqMan ABI 7000 or a Bio-Rad Chromo4 PCR Detection System. Ct data were reported against a standard curve, corrected for the dilution factor, and graphed as genome copies per ml.

[0174] Mucociliary clearance Mucociliary clearance was measured using an Olympus BX51 microscope equipped with a 5× objective. Monitoring was performed using an attached Sony XCD-U100CR camera. 30 μm diameter polystyrene microbeads (Sigma, 84135) were added to the apical surface of the MucilAir™. Microbead movement was video tracked at 2 frames per second for 30 images at room temperature. Three videos were taken per insert. The average bead movement speed (μm / s) was calculated using ImageProPlus 6.0 software. Data were expressed as mean + SEM (n=3 inserts). [Example]

[0175] Plasma-derived immunoglobulins interact with Pseudomonas aeruginosa PA is associated with many respiratory tract infections, such as those in subjects with cystic fibrosis or severe COPD. Many different strains exist. Clinical isolates were used for clinical context. Commercially available plasma-derived immunoglobulins consist primarily of highly purified IgG obtained from pooled plasma collected from thousands of healthy adult donors. Due to their multiple donor origin, isolated immunoglobulins offer not only polyvalency and polyclonality, but also higher titers against specific pathogens, as a result of vaccination. Monomeric IgA, as well as mixtures of pentameric IgM and monomeric / dimeric IgA, can be isolated from waste fractions. We previously established that polyreactive serum-derived polymeric IgA, IgM, and a mixture of two isotypes (IgA / M) can be assembled into secretory Abs when combined with recombinant secretory component (SC)

[34] . Supporting their use for local passive immunization, the molecules exhibit high in vitro stability upon exposure to protease-rich intestinal lavage fluid

[35] .

[0176] Figure 1 shows the binding of plasma-derived immunoglobulins to PA in an ELISA assay. Importantly, all plasma-derived immunoglobulins were able to bind to PA clinical isolates in this assay (see Materials and Methods). Binding to PA was dose-dependent, with immunoglobulin amounts ranging from 0.7 μg / mL to 500 μg / mL. Comparison between immunoglobulin preparations demonstrated differences in PA binding capacity. For example, a mixture of IgA and IgM, with or without SC conjugation, showed the highest affinity for PA, followed by IgG and IgA. [Example]

[0177] Plasma-derived immunoglobulin IgG forms large aggregates with PA Immunoglobulins can play several roles at mucosal surfaces. They can function as opsonins, leading to enhanced phagocyte recognition, or promote complement precipitation and subsequent lysis. They can bind to infected cells, thus tagging them for destruction through a mechanism called antibody-dependent cell-mediated cytotoxicity (ADCC). They can bind to pathogen surface antigens, inhibiting their growth and neutralizing the pathogen. They can also coat pathogens and prevent their adherence to mucosal epithelia (a mechanism called immune exclusion). Finally, due to their bivalent or multivalent binding properties, immunoglobulins can aggregate microorganisms into larger clusters, allowing for more effective recognition by the immune system and mechanical clearance by the host

[36] . Secretory IgA and IgM present at mucosal sites exhibit tetravalent and 10–12 valencies, respectively. In contrast, IgG exhibits only 2 valencies. IgA and IgM are more prone to microbial agglutination than IgG [37;38].

[0178] Figure 2 shows the confocal microscopy analysis of immune complexes formed between IgG and PA. Using CFSE-labeled PA and Cy3-labeled plasma-derived IgG, it was surprising to detect large IgG-PA immune complexes. Antigen binding by immunoglobulins is largely dependent on their antigen-binding (Fab) fragments. Since IgG is only bivalent, it is not expected to observe such aggregates. This result suggests that IgG may be the This may indicate that IgG may be able to further bind to PA outside of the Fab region through carbohydrates. IgG may therefore be more potent than expected in signaling the immune system about PA. [Example]

[0179] Plasma-derived immunoglobulins prevent PA-induced tissue damage PA is a pathogenic bacterium known for its involvement in biofilm formation and its resistance to many antibiotics

[39] . PA exhibits many virulence factors, some of which are extracellular enzymes such as elastase A and B, protease IV, exotoxin A, exoenzyme S, or hemolysin. Extracellular enzymes function in the defense of PA against components of the immune system and in the involvement of PA in its virulence and associated tissue damage.

[0180] To assess the extent to which PA induces tissue damage in our infection model, we measured the release of lactate dehydrogenase (LDH), which is associated with plasma membrane rupture. Experiments were performed in our primary 3D cell culture system, and LDH was measured in samples harvested 24 hours postinfection. All immunoglobulin preparations (e.g., IgG, IgA, IgAM, and sIgAM) and proline (solvent) were tested. Figure 3 shows that PA infection induces LDH release at levels above the normal LDH levels found in steady-state culture media. Importantly, when given with PA, all immunoglobulin preparations were shown to prevent LDH release and therefore tissue damage.

[0181] Another method for assessing tissue damage is to measure the transepithelial electrical resistance (TEER) of tissue in vitro. Indeed, this parameter reflects the integrity of tight junction dynamics in epithelial monolayer or multilayer cell culture models

[40] . Consequently, TEER decreases when tissue integrity is affected. To understand how PA infection affects barrier tissue equivalent to primary epithelial tissue, we measured TEER before and 24 h after infection. Figure 4 shows how tissue integrity is affected by infection and the role IgG plays in preventing this. Maximum doses of IgG and proline did not affect TEER when bacteria were absent from the apical side of the transwell. PA infection not only releases LDH, as seen in Figure 3, but also decreases TEER (proline sample). This result points to a loss of tissue integrity in MucilAir™ when PA is added. To assess the activity of IgG in this context, we used increasing doses of IgG (ranging from 5 to 500 μg) in combination with PA. The lowest IgG dose did not provide good protection against tissue damage, but increasing doses (50-500 μg) provided good tissue protection, with the two highest doses being the most effective.

[0182] In addition to LDH release and TEER measurements, MucilAir™ tissues were examined microscopically to assess damage occurring during PA infection. Because MucilAir™ is a multilayered epithelial tissue, confocal microscopy was used. The same setup described for Figure 4 was used. 24 hours after infection, tissues were fixed and cut onto slides for staining and analysis. Figure 5 shows the efficacy of IgG in preventing PA-induced tissue damage. Healthy tissue (control) is represented by the section shown in the bottom row, far right. Upon PA infection, large holes appear in the tissue (proline-treated transwell; top row, left). Increasing doses of IgG were applied with PA (doses ranging from 5 to 500 μg). A dose-dependent effect of IgG in preventing tissue damage was observed. The lowest IgG dose did not prevent tissue damage, but appeared to have some effect, as the holes exhibited smaller surface areas. Increasing IgG doses were associated with an absence of holes. However, tissue damage remained observable for doses between 50 and 250 μg. 500 μg IgG gave the best results, with tissues appearing as good as in control wells.

[0183] In summary, all plasma-derived immunoglobulin preparations were able to prevent LDH release. Using IgG, we delineated the mechanism of action behind this finding, demonstrating that immunoglobulins can prevent loss of tissue integrity and tissue damage. [Example]

[0184] Plasma-derived immunoglobulins prevent Pseudomonas aeruginosa-induced tissue release of proinflammatory cytokines Epithelial tissues in the mucosal environment function as a barrier to the outside world, physically preventing microorganisms from invading the tissue. However, once damaged, microorganisms can freely enter. Therefore, to signal potential infection and damage to these barriers, epithelial tissues interact with the immune system through the secretion of "danger" signals or cytokines, alerting cellular components of the immune system to migrate into the tissue and provide a second layer of defense.

[0185] IL-6 and IL-8 are proinflammatory cytokines secreted by epithelial tissues when these tissues are insulted. In the next set of experiments, plasma-derived immunoglobulins were evaluated in preventing proinflammatory cytokine release during PA infection. Figure 6 shows IL-8 release by MucilAir™ 24 hours after PA infection. All immunoglobulin preparations (e.g., IgG, IgA, IgAM, and sIgAM) were tested with proline (solvent). Figure 6 shows that IL-8 secretion was highly increased during PA infection, reaching a nearly three-fold increase. None of the immunoglobulin preparations significantly affected IL-8 release by tissues at steady state. However, when applied with PA, all immunoglobulin preparations were able to prevent PA-induced IL-8 secretion.

[0186] To determine the effect of IgG in preventing PA-induced IL-8 release, increasing doses of IgG (ranging from 5 to 500 μg) were tested in combination with PA. Figure 7 details the dose-response of IL-8 secretion to IgG. Experiments were performed with MucilAir™ cells generated from three different donors. To account for donor-to-donor variability, postinfection IL-8 secretion was set to the 100% release condition in combination with proline. Additional conditions were calculated relative to 100% release. As shown in Figure 7, the maximum doses of IgG and proline did not affect IL-8 release. Interestingly, IgG substantially reduced PA-induced IL-8 secretion in a dose-dependent manner, with the best effect observed at the maximum dose (500 μg).

[0187] Similarly, IL-6 secretion after PA infection was examined. Figure 8 shows IL-6 release by MucilAir™ 24 hours after PA infection. All immunoglobulin preparations (e.g., IgG, IgA, IgAM, and sIgAM) were tested together with proline (solvent). Figure 8 shows that PA highly increased IL-6 secretion, reaching a nearly six-fold increase. None of the immunoglobulin preparations significantly affected tissue IL-6 release at steady state. However, when applied together with PA, all immunoglobulin preparations were able to prevent PA-induced IL-6 secretion.

[0188] Collectively, this data set indicates that all immunoglobulin preparations prevent the release of proinflammatory cytokines, such as IL-6 and IL-8, and may reduce local inflammation in PA-infected subjects receiving topically applied immunoglobulin as prophylaxis. The prevention of IL-8 and IL-6 secretion during PA infection may actually translate to the prevention of tissue damage by topically applied immunoglobulin against PA. Plasma-derived immunoglobulin may act through immune clearance against PA and by inhibiting extracellular enzyme activity. [Example]

[0189] Plasma-derived immunoglobulins interact with human rhinoviruses HRV is primarily known to be involved in over half of cold-like illnesses

[41] , but it has also been implicated in chronic obstructive pulmonary disease (COPD) and asthma exacerbations. There are over 100 serotypes of HRV. To evaluate whether nebulized plasma-derived immunoglobulins can protect humans from HRV infection, we tested the binding of various plasma-derived immunoglobulins to clinical isolates of HRV. Figure 9 shows that all immunoglobulin preparations were able to bind to HRV in a dose-dependent manner at doses ranging from 0.7 μg / mL to 500 μg / mL in an ELISA assay (see Materials and Methods). However, binding varied among the immunoglobulin preparations. IgG was a less potent binder, while IgAM and IgA showed good binding. Adding SC to IgAM appears to reduce the potency of IgAM in binding to HRV. It can be noted that some of the binding is not Fab-dependent. [Example]

[0190] Plasma-derived immunoglobulin prevents shedding and tissue damage induced by human rhinovirus Like other viruses, HRV infects cells so that it can replicate. In the next step, virions are then assembled and packaged prior to cellular transport / excretion by cell lysis. Figure 10 shows the effect of plasma-derived immunoglobulins in preventing HRV excretion after MucilAir™ infection. When a solvent control (proline) was used, high excretion of PA (approximately 10 9 HRV C15 genome copies / mL) was detected at the apical side of MucilAir™. Rupintrivir, a rhinovirus 3C protease inhibitor against human rhinovirus, was used as a positive control. As observed, application of rupintrivir effectively reduced HRV shedding by 3 logs. Surprisingly, application of plasma-derived immunoglobulin at the time of infection completely reduced HRV shedding to levels undetectable by our assay. All immunoglobulin preparations except IgAM were able to show such reduction. However, and importantly, IgAM was still able to reduce HRV shedding by at least 4 logs.

[0191] Plasma-derived immunoglobulins could therefore prevent HRV entry into the epithelium and hence subsequent HRV replication and spread.

[0192] During replication, HRV can cause cell lysis. In the context of epithelia, we evaluated whether plasma-derived immunoglobulins can protect epithelial cells against HRV-induced tissue damage. To assess this, we used the TEER parameter as a means of assessing tissue integrity after HRV infection (Figure 11). At steady state (no infection), TEER measurements after treatment with vehicle (negative control) were approximately 260 Ohm.cm. 2After HRV infection, when vehicle was applied to the tissue (positive control), TEER decreased by nearly five-fold, indicating a loss of tissue integrity after infection. As shown in Figure 11, rupintrivir had a positive effect in preventing HRV-induced tissue damage. When HRV was administered, all plasma-derived preparations were able to prevent the loss of tissue integrity. This demonstrated that immune clearance of HRV by plasma-derived immunoglobulins was sufficient to protect lung tissue against PA infiltration and PA-induced cellular damage. [Example]

[0193] Plasma-derived immunoglobulin reduces the reduction in mucociliary clearance induced by human rhinovirus Mucociliary clearance is an important function of bronchial tissue. Pathogens trapped in mucus are expelled into the lungs and expectorated, preventing pathogens from lodgement and replication in lung tissue. Mucociliary clearance can be affected by different mechanisms, one of which is tissue damage.

[0194] Because HRV infection is associated with tissue damage, we assessed the effect of plasma-derived immunoglobulins on mucociliary clearance 48 hours after HRV infection (Fig. 12). At steady state (no infection), mucociliary clearance after vehicle treatment (negative control) was approximately 40 mm / s. After HRV infection, application of vehicle to the tissue (positive control) resulted in a two-fold decrease in mucociliary clearance. As shown in Figure 12, rupintrivir had a positive effect in preventing the HRV-induced decrease in mucociliary clearance. All plasma-derived preparations were able to prevent the decrease in mucociliary clearance. The best effect was obtained for IgA and IgM, for which no loss of mucociliary clearance was observed. [Example]

[0195] Dose-dependent efficacy of human plasma-derived immunoglobulin preparations against human rhinovirus infection Next, we investigated whether the observed effects were dose-dependent. We added immunoglobulin preparations at 4, 20, 100, and 500 μg / well, and assessed their effects on HRV expansion by measuring HRV genome copy number. Figure 13 shows that the plasma-derived human immunoglobulin preparation was able to inhibit HRV expansion in a dose-dependent manner.

[0196] The effect on TEER was also investigated as described above. The immunoglobulin preparations delayed the HRV-induced TEER decrease at 4 μg / well, 20 μg / well, and 100 μg / well. At 500 μg / well, the decrease was completely prevented.

[0197] Furthermore, the effects of different doses of immune globulin preparations on cilia beating frequency and mucociliary clearance were evaluated using the same doses as above. Again, dose-dependent effects on cilia beating frequency and mucociliary clearance were observed for all immune globulin preparations tested.

[0198] HRV-induced IL-8 secretion on day 2 postinfection was also inhibited by plasma-derived immunoglobulin preparations; even 4 μg / well IgAM and SIgAM achieved complete inhibition; IgG and IgA achieved highly significant reductions at 4 μg / well, and all immunoglobulin preparations achieved complete inhibition at higher doses. HRV-induced production of RANTES was also significantly inhibited by the lowest dose of immunoglobulin used (4 μg / ml) and was completely inhibited by higher doses of all immunoglobulin preparations at day 2.

[0199] In summary, plasma-derived immunoglobulins were able to protect lung tissue in vitro against HRV infection and its associated tissue damage. Local prophylactic application of plasma-derived immunoglobulins to the lungs of subjects at risk for pulmonary infection may provide protection against microorganisms of viral or bacterial origin. [Example]

[0200] Effect of human plasma-derived immunoglobulin preparations on influenza virus infection Using influenza strain H1N1, experiments were set up using the same protocol for rhinovirus infection of MucilAir™ cultures. Oseltamivir was used as a positive control at 10 μg / well. As shown in Figure 14, all immune globulin preparations were shown to reduce influenza spread in a dose-dependent manner.

[0201] The perturbation of TEER caused by influenza virus was also reduced by 4 μg / well and 20 μg / well of each immunoglobulin preparation, and was completely prevented by 100 μg / ml and 500 μg / well.

[0202] Influenza virus-induced reduction in cilia beating frequency was observed on day 4 post-infection. IgG showed the best rescue effect on cilia beating frequency, showing complete recovery already at 4 μg / well. IgA, IgAM, and sIgAM preparations were also able to rescue cilia beating frequency, although only at 20 μg / well and higher concentrations. The Ig preparations also restored mucociliary clearance and reduced influenza-induced IL-8 secretion and influenza activity. It also reduced the induced RANTES secretion. [Example]

[0203] Nebulized plasma-derived immunoglobulin prevents airway infection-induced exacerbations in subjects with chronic obstructive pulmonary disease (COPD) and / or non-cystic fibrosis bronchiectasis (NCFB) Subjects with COPD and / or NCFB are prone to chronic airway infections that may contribute to exacerbation of their disease. The chronicity of these infections drives tissue remodeling in the subject, increasing the severity of the disease.

[0204] As shown in the examples above, topically applied plasma-derived immunoglobulins prevented bacterial and viral adhesion and invasion in primary human airway tissue in vitro. Immunoelimination of these microorganisms prevented tissue damage and, indirectly, the release of proinflammatory cytokines and loss of mucociliary clearance.

[0205] To prevent the chronicity of these infections, subjects with NCFB or mild to severe COPD potentially associated with NCFB are treated with nebulized plasma-derived immunoglobulin once or twice daily. Plasma-derived immunoglobulin, formulated in a 50 mg / mL to 150 mg / mL solution, is nebulized using an active vibrating mesh nebulizer. Two to 10 mL of plasma-derived immunoglobulin preparation is applied daily in the morning and / or evening.

[0206] Reducing infection-induced exacerbations will reduce local inflammation in COPD and NCFB subjects and slow disease progression.

[0207] It will be understood that the invention has been described by way of example only and modifications may be made within the scope and spirit of the invention.

[0208] References [1] Vestbo et al. (2013) Am J Respir Crit Care Med 187(4):347-65. [2] Flume et al. (2018) Lancet 392(10150):880-90. [3] Chalmers et al. (2018) Am J Respir Crit Care Med 197(11):1410-20. [4] Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, 2018 report; Global initiative for chronic obstructive lung disease (GOLD). [5] Mohan A et al. (2010) Respirology 15(3):536-42. [6] Molyneaux et al. (2013) Am J Respir Crit Care Med 188(10):1224-31. [7] Hassett et al. (2014) J Microbiol 52(3):211-26. [8] Miravitlles et al. (2017) Respiratory Research 18:198. [9] Singanayagam et al. (2018) Nature Communications 9(1):2229.

[10] British Thoracic Society: Guideline for non-CF Bronchiectasis (2010) Thorax vol. 65, Supp. 1.

[11] Spirometry for health care providers (June 2010). Published by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

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Claims

1. 1. A composition comprising a polyclonal immunoglobulin for use in preventing or treating an acute exacerbation of a human subject having a chronic lung disease, wherein the chronic lung disease is chronic obstructive pulmonary disease (COPD) and / or non-cystic fibrosis bronchiectasis (NCFB), the composition comprising at least 95% human plasma-derived IgG, the composition being administered to the airways of the subject, wherein the subject has a respiratory tract infection caused by a virus, and the polyclonal immunoglobulin reduces direct damage to the subject's epithelial tissue caused by the virus.

2. 2. The composition for use according to claim 1, wherein the COPD is moderate to severe COPD.

3. 3. The composition for use according to claim 1 or 2, wherein the subject has low IgG levels in sputum.

4. The composition for use according to any one of claims 1 to 3, wherein the subject has experienced one or more acute exacerbations in the 12 months prior to initiating prophylaxis or treatment.

5. 5. The composition for use according to any one of claims 1 to 4, wherein the subject has one or more detectable pro-inflammatory cytokines, such as IL-1b and / or IL-6 and / or IL-8, in his or her sputum.

6. The composition for use according to any one of claims 1 to 5, wherein the subject is suffering from pneumonia.

7. The composition for use according to any one of claims 1 to 6, wherein the subject has a rhinovirus infection.

8. The composition for use according to any one of claims 1 to 7, wherein the polyclonal immunoglobulin reduces inflammation in the airways of a subject.

9. The polyclonal immunoglobulin reduces the levels of one or more pro-inflammatory cytokines, such as IL-1b and / or IL6 and / or IL8, in the airways of a subject. The composition for use according to any one of claims 1 to 8,

10. A composition for use as described in claim 6 or 7, wherein the polyclonal immunoglobulin reduces the activity of extracellular enzymes, reduces the loss of epithelial barrier integrity, and / or reduces viral shedding.

11. A composition for use according to any one of claims 1 to 10, comprising human plasma-derived IgG with at least 98% IgG.

12. 12. The composition for use according to claim 11, comprising proline, for example about 210 to about 290 mmol / L of L-proline, preferably about 250 mmol / L of L-proline.

13. The composition for use according to any one of claims 1 to 12, which is administered as an aerosol.

14. The composition for use according to any one of claims 1 to 13, which is an aqueous solution having a polyclonal immunoglobulin concentration of 50 mg / mL to 150 mg / mL, for example about 100 mg / mL.

15. The composition for use according to any one of claims 1 to 14, which is administered in a volume of 2 to 10 mL.

16. The composition for use according to any one of claims 1 to 15, which is administered once every 48 hours or once every 24 hours or once every 12 hours during treatment.

17. The composition for use according to any one of claims 1 to 16, which is administered in autumn and winter.

18. 18. The composition for use according to any one of claims 1 to 17, administered in combination therapy with one or more of an antibiotic, a corticosteroid, a beta2 agonist and an anticholinergic bronchodilator.

19. 14. The composition of claim 13, which is a dry powder.

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