Dosage and administration of anti-C5 antibodies for the treatment of atypical hemolytic uremic syndrome (aHUS)

Abstract

To provide dosage and administration of anti-C5 antibodies for treatment of atypical hemolytic uremic syndrome (aHUS).SOLUTION: Provided are methods for clinical treatment of Atypical Hemolytic Uremic Syndrome (aHUS) using an anti-C5 antibody or an antigen binding fragment thereof. Provided herein are compositions and methods for treating aHUS in a human patient (e.g., an adult patient who is 18 years or older), comprising administering to the patient an anti-C5 antibody or antigen binding fragment thereof, wherein the anti-C5 antibody or antigen binding fragment thereof, is administered (or is for administration) according to a particular clinical dosage regimen (i.e., at a particular dose amount and according to a specific dosing schedule).SELECTED DRAWING: None

Description

[Background technology]

[0001] The complement system acts in concert with other immunological systems of the body to defend against invading cellular and viral pathogens. There are at least 25 complement proteins found as a complex collection of plasma proteins and membrane cofactors. Plasma proteins constitute approximately 10% of the globulins in vertebrate serum. Complement components achieve their immune defense function by interacting in a series of complex yet precise enzymatic cleavage and membrane binding events. The resulting complement cascade leads to the production of products with opsonic, immunoregulatory, and lytic functions. A concise summary of the biological activities associated with complement activation can be found, for example, in The Provided in the Merck Manual, 16th Edition.

[0002] A properly functioning complement system provides a robust defense against infectious microorganisms, but inappropriate regulation or activation of the complement pathway is involved in the pathogenesis of various disorders, including atypical hemolytic uremic syndrome (aHUS), an extremely rare disorder driven by chronic uncontrolled complement activation. The resulting inflammation and cellular damage lead to the devastating clinical manifestations of these diseases.

[0003] Hemolytic uremic syndrome (HUS) is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure. HUS is classified as one of two types: diarrhea-associated (D+HUS; also called Shiga toxin-producing E. coli (STEC)-HUS or typical HUS) and non-diarrheal or atypical HUS (aHUS). D+HUS is the most common form, accounting for more than 90% of cases, and is caused by a preceding illness with Shiga-like toxin-producing bacteria, such as E. coli O157:H7.

[0004] aHUS can be hereditary, acquired, or idiopathic. Hereditary forms of aHUS can be associated with mutations in several human complement components, including, for example, complement factor H (CFH), membrane cofactor protein (MCP), complement factor I (CFI), C4b-binding protein (C4BP), complement factor B (CFB), and complement component 3 (C3). See, for example, Caprioli et al. See, e.g., Esparza-Gordillo et al. (2006) Blood 108:1267-1279. Certain mutations in the gene encoding CD55, although not yet associated with aHUS, are associated with the severity of aHUS. See al. (2005) Hum Mol Genet 14:703-712.

[0005] aHUS is rare and has a mortality rate of up to 25%. Many patients with this disease sustain permanent neurological or renal damage; for example, at least 50% of aHUS patients progress to end-stage renal failure (ESRF). See, e.g., Kavanagh et al. (2006) British Medical Bulletin 77 and 78:5-22. Until recently, treatment options for patients with aHUS were limited and often involved plasma infusion or plasma exchange. In some cases, aHUS patients undergo unilateral or bilateral nephrectomy or kidney transplantation (see, Artz et al. (2003) Transplantation 76:821-826). However, disease recurrence in treated patients is common. Patients with aHUS are at risk of substantial morbidity and mortality. Accordingly, it is an object of the present invention to provide improved methods for treating patients with aHUS. [Prior art documents] [Non-patent literature]

[0006] [Non-Patent Document 1] Caprioli et al. (2006)Blood 108:1267-1279 [Non-patent document 2] Esparza-Gordillo et al. (2005) Hum Mol Genet 14:703-712 [Non-patent document 3] Kavanagh et al. (2006) British Medical Bulletin 77 and 78:5-22 [Non-patent document 4] Artz et al. (2003) Transplantation 76:821-826 Summary of the Invention [Means for solving the problem]

[0007] Provided herein are compositions and methods for treating aHUS in a human patient (e.g., an adult patient 18 years of age or older), comprising administering to the patient an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered (or is for administration) according to a specific clinical dosage regimen (i.e., at a specific dose and according to a specific dosing schedule).

[0008] Any suitable anti-C5 antibody or antigen-binding fragment thereof can be used in the methods described herein. An exemplary anti-C5 antibody is ravulizumab (also known as Ultomiris®, ALXN1210, and antibody BNJ441), comprising heavy and light chains having the sequences set forth in SEQ ID NOs: 14 and 11, respectively, or antigen-binding fragments and variants thereof. In other embodiments, the antibody comprises the heavy and light chain complementarity-determining regions (CDRs) or variable regions (VRs) of ravulizumab. Thus, in one embodiment, the antibody comprises the CDR1, CDR2, and CDR3 domains of the heavy chain variable (VH) region of ravulizumab having the sequence set forth in SEQ ID NO: 12 and the CDR1, CDR2, and CDR3 domains of the light chain variable (VL) region of ravulizumab having the sequence set forth in SEQ ID NO: 8. In another embodiment, the antibody comprises the CDR1, CDR2, and CDR3 heavy chain sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively. In another embodiment, the antibody comprises VH and VL regions having the amino acid sequences set forth in SEQ ID NO: 12 and SEQ ID NO: 8, respectively. In another embodiment, the antibody comprises the heavy chain constant region set forth in SEQ ID NO: 13.

[0009] In another embodiment, the antibody comprises a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434, respectively, in EU numbering, of the native human IgG Fc constant region.

[0010] In another embodiment, the antibody comprises the CDR1, CDR2, and CDR3 heavy chain sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively, and a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434, respectively, in EU numbering, of the native human IgG Fc constant region.

[0011] In another embodiment, the antibody has an affinity dissociation constant (K) at pH 7.4 and 25°C in the range of 0.1 nM to 1 nM. D In another embodiment, the antibody binds to human C5 at a K D In yet another embodiment, the K of the antibody or antigen-binding fragment thereof against human C5 at pH 6.0 and 25°C is ≥ 10 nM. D ) / (K of an antibody or antigen-binding fragment thereof against human C5 at pH 7.4 and 25°C D )] is greater than 25.

[0012] Another exemplary anti-C5 antibody is the 7086 antibody described in U.S. Patent Nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 7086 antibody (see U.S. Patent Nos. 8,241,628 and 8,883,158). In another embodiment, the antibody or antigen-binding fragment thereof comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 21, 22, and 23, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 24, 25, and 26, respectively. In another embodiment, the antibody or antigen-binding fragment thereof comprises the VH region of the 7086 antibody having the sequence set forth in SEQ ID NO: 27 and the VL region of the 7086 antibody having the sequence set forth in SEQ ID NO: 28.

[0013] Another exemplary anti-C5 antibody is the 8110 antibody, also described in U.S. Patent Nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 8110 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 29, 30, and 31, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 32, 33, and 34, respectively. In another embodiment, the antibody comprises the VH region of the 8110 antibody having the sequence set forth in SEQ ID NO: 35 and the VL region of the 8110 antibody having the sequence set forth in SEQ ID NO: 36.

[0014] Another exemplary anti-C5 antibody is the 305LO5 antibody described in US 2016 / 0176954A1. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 305LO5 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 37, 38, and 39, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 40, 41, and 42, respectively. In another embodiment, the antibody comprises the VH region of the 305LO5 antibody having the sequence set forth in SEQ ID NO: 43 and the VL region of the 305LO5 antibody having the sequence set forth in SEQ ID NO: 44.

[0015] Another exemplary anti-C5 antibody is the SKY59 antibody described in Fukuzawa T., et al., Rep. 2017 Apr 24;7(1):1080. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the SKY59 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises a heavy chain comprising SEQ ID NO:45 and a light chain comprising SEQ ID NO:46.

[0016] Another exemplary anti-C5 antibody is the REGN3918 antibody (also known as H4H12166PP), described in US20170355757. In one embodiment, the antibody comprises a heavy chain variable region comprising SEQ ID NO: 47 and a light chain variable region comprising SEQ ID NO: 48. In another embodiment, the antibody comprises a heavy chain comprising SEQ ID NO: 49 and a light chain comprising SEQ ID NO: 50.

[0017] In another embodiment, the antibody competes for binding to and / or binds to the same epitope on C5 as an antibody described above (e.g., eculizumab, ravulizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In another embodiment, the antibody has at least about 90% variable region amino acid sequence identity (e.g., at least about 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% variable region identity) with an antibody described above.

[0018] In one embodiment, the dose of the anti-C5 antibody or antigen-binding fragment thereof is based on the patient's weight. For example, in one embodiment, 2400 mg or 3000 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 kg but < 60 kg. In another embodiment, 2700 mg or 3300 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 60 kg but < 100 kg. In another embodiment, 3000 mg or 3600 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 100 kg. In certain embodiments, the dosage regimen is adjusted to provide the optimal desired response (e.g., an effective response).

[0019] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered in one or more administration cycles. In one embodiment, the administration cycle is 26 weeks. In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered once on day 1 of the administration cycle, once on day 15 of the administration cycle, and every 8 weeks thereafter. In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered every 8 weeks (e.g., at a dose of 3000 mg, 3300 mg, or 3600 mg) for an extension period of up to 2 years following the administration cycle.

[0020] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered in one or more administration cycles. In one embodiment, the administration cycle is 26 weeks. In another embodiment, the treatment includes at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or 11 cycles. In another embodiment, the treatment continues for the life of the human patient.

[0021] In another embodiment, a method of treating a human patient with aHUS comprises administering to the patient (e.g., during an administration cycle) an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 heavy chain sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is (a) Once on day 1, at a dose of 2400 mg for patients weighing ≥ 40 to < 60 kg, 2700 mg for patients weighing ≥ 60 to < 100 kg, or 3000 mg for patients weighing ≥ 100 kg; (b) On day 15, and every 8 weeks thereafter, at a dose of 3000 mg for patients weighing ≥ 40 to < 60 kg, 3300 mg for patients weighing ≥ 60 to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg. A method is provided in which the

[0022] In another embodiment, a method of treating a human patient with aHUS comprises administering to the patient (e.g., during an administration cycle) an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 heavy chain sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, the CDR1, CDR2, and CDR3 light chain sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively, and a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434, respectively, in EU numbering, of a native human IgG Fc constant region; and wherein the anti-C5 antibody or antigen-binding fragment thereof is (a) Once on day 1, at a dose of 2400 mg for patients weighing ≥ 40 to < 60 kg, 2700 mg for patients weighing ≥ 60 to < 100 kg, or 3000 mg for patients weighing ≥ 100 kg; (b) On day 15, and every 8 weeks thereafter, at a dose of 3000 mg for patients weighing ≥ 40 to < 60 kg, 3300 mg for patients weighing ≥ 60 to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg. A method is provided in which the

[0023] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 to < 60 kg. (a) at a dose of 2400 mg once on day 1; (b) on day 15 and every 8 weeks thereafter at a dose of 3000 mg It is administered.

[0024] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 60 to < 100 kg. (a) at a dose of 2700 mg once on day 1; (b) on day 15 and every 8 weeks thereafter at a dose of 3300 mg It is administered.

[0025] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧100 kg. (a) at a dose of 3000 mg once on day 1; (b) on day 15 and every 8 weeks thereafter at a dose of 3600 mg It is administered.

[0026] In some embodiments, the patient has not been previously treated with a complement inhibitor (eg, the patient is a complement inhibitor treatment naive patient).

[0027] In other embodiments, the patient has previously been treated with one anti-C5 antibody or antigen-binding fragment thereof and is switched to another anti-C5 antibody during the course of treatment. For example, in certain embodiments, different anti-C5 antibodies are administered during the course of treatment. In one embodiment, different anti-C5 antibodies are administered during separate treatment and extension periods. For example, in one embodiment, the patient is treated with eculizumab for a treatment period (e.g., 26 weeks), and then treated with another anti-C5 antibody (e.g., ravulizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody), for example, during an extension period. In another embodiment, eculizumab is administered to a patient at a dose of 600 mg on days 1, 8, 15, and 22 of a dosing cycle during an induction phase, followed by a maintenance dose of 900 mg eculizumab on day 19 of the dosing cycle and every two weeks thereafter (e.g., for a total of 26 weeks), followed by treatment with ravulizumab for an extension period of up to two years. In another embodiment, a patient is treated with ravulizumab (e.g., for 26 weeks), and then treated with another anti-C5 antibody (e.g., eculizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody), for example, during an extension period.

[0028] Exemplary alternative anti-C5 antibodies include (i) ravulizumab, (ii) an antibody or antigen-binding fragment thereof comprising heavy chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 21, 22, and 23, respectively, and light chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 24, 25, and 26, respectively, (iii) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO: 27 and a light chain variable region comprising SEQ ID NO: 28, (iv) an antibody or antigen-binding fragment thereof comprising heavy chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 29, 30, and 31, respectively, and light chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 32, 33, and 34, respectively, and (v) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO: 35 and a light chain variable region comprising SEQ ID NO: 36, respectively. (vi) an antibody or antigen-binding fragment thereof comprising heavy chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 37, 38, and 39, respectively, and light chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 40, 41, and 42, respectively; (vii) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO: 43 and a light chain variable region comprising SEQ ID NO: 44; (viii) an antibody or antigen-binding fragment thereof comprising a heavy chain comprising SEQ ID NO: 45 and a light chain comprising SEQ ID NO: 46; (ix) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO: 47 and a light chain variable region comprising SEQ ID NO: 48; and (x) an antibody or antigen-binding fragment thereof comprising a heavy chain comprising SEQ ID NO: 49 and a light chain comprising SEQ ID NO: 50.

[0029] In some embodiments, the patient has been previously treated with an anti-C5 antibody or antigen-binding fragment thereof (e.g., eculizumab) for at least 1 month, at least 2 months, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 7 months, at least 8 months, at least 9 months, at least 10 months, at least 11 months, at least 12 months, at least 18 months, or at least 24 months before switching to another anti-C5 antibody or antigen-binding fragment thereof (e.g., ravulizumab). In certain embodiments, the patient has been previously treated with eculizumab for at least 6 months.

[0030] In another embodiment, when a patient (e.g., an aHUS patient) is treated with a first anti-C5 antibody and then switched to treatment with a second, different anti-C5 antibody, particularly when the second, different anti-C5 antibody binds to a different epitope on C5 than the first anti-C5 antibody, the administration schedule takes into account the half-life of the first anti-C5 antibody. For example, the half-life of the first anti-C5 antibody is taken into account to ensure that the first anti-C5 antibody is removed (e.g., "washed out") from the patient before the second (different) anti-C5 antibody is administered (e.g., to avoid problems associated with aggregation, immune complex formation, etc.). In one embodiment, the second (different) anti-C5 antibody is not administered until a period of time equivalent to 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, or 7.5 half-lives of the first anti-C5 antibody has elapsed after the final administration of the first anti-C5 antibody.

[0031] In another embodiment, the patient has previously been treated with eculizumab and is then switched to treatment with a second (different) anti-C5 antibody (e.g., ravulizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In one embodiment in which eculizumab is the first antibody administered, the second (different) anti-C5 antibody is not administered until, for example, at least 36, 45, 54, 63, 72, 81, 90, 99, 108, 117, or 126 days after the last administration of eculizumab.

[0032] In another embodiment, the patient has previously been treated with ravulizumab and is then switched to treatment with a different anti-C5 antibody (e.g., eculizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In one embodiment in which ravulizumab is the first antibody administered, the second (different) anti-C5 antibody is not administered until, for example, at least 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 375, or 400 days have passed since the last administration of ravulizumab.

[0033] Additionally or alternatively, a technique is used to remove or enhance the clearance of the first anti-C5 antibody before switching to treatment with a second (different) anti-C5 antibody. Exemplary techniques include, but are not limited to, plasmapheresis or blood transfusion. In another embodiment, an antibody against the first anti-C5 antibody (e.g., an anti-eculizumab antibody, an anti-ravulizumab antibody, an anti-7086 antibody, an anti-8110 antibody, an anti-305LO5 antibody, an anti-SKY59 antibody, or an anti-REGN3918 antibody) is administered to remove or enhance the clearance of the first anti-C5 antibody before the second (different) anti-C5 antibody is administered.

[0034] In another embodiment, an anti-C5 antibody or antigen-binding fragment thereof (e.g., ravulizumab) is administered to a patient and the administration cycle begins at least about 2 weeks, at least about 3 weeks, at least about 4 weeks, at least about 6 weeks, at least about 7 weeks, or at least about 8 weeks after the patient's last dose of eculizumab. In another embodiment, an anti-C5 antibody or antigen-binding fragment thereof (e.g., ravulizumab) is administered to a patient and the administration cycle begins at least 2 weeks after the patient's last dose of eculizumab.

[0035] In some embodiments, patients treated according to the methods described herein have been vaccinated against meningococcal infection within three years prior to or at the time of initiating treatment. In one embodiment, patients treated less than two weeks after receiving a meningococcal vaccine are also treated with appropriate prophylactic antibiotics up to two weeks after vaccination. In another embodiment, patients treated according to the methods described herein are vaccinated against meningococcal serogroups A, C, Y, W135, and / or B.

[0036] In another aspect, the described treatment regimen is sufficient to maintain a particular serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof. For example, in one embodiment, the treatment is administered at a concentration of 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 200, 205, 210, 215, 220, 225, 230, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 300, 310, 315, 320, 325, 330, 335, 340, 345, 350, 355, 360, 365, 370, 375, 380, 385, 390, 400, 410, 415, 420, 425, 430, 440, 450, 460, 470, 480, 490, 510, 520, 530, 540, 550, 560, 570, 580, 590, 610, 620, 630, 640, 650, 660, 670, 680, 69

[0013] In one embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 5, 250, 255, 260, 265, 270, 280, 290, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345, 350, 355, 360, 365, 370, 375, 380, 385, 390, 395, or 400 μg / ml or greater. In one embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 100 μg / ml or greater. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 150 μg / ml or greater. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 200 μg / ml or greater. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 250 μg / ml or higher. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 300 μg / ml or higher. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof between 100 μg / ml and 200 μg / ml. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at about 175 μg / ml.

[0037] In another embodiment, to achieve an effective response, the anti-C5 antibody needs to be administered at least 50 μg, 55 μg, 60 μg, 65 μg, 70 μg, 75 μg, 80 μg, 85 μg, 90 μg, 95 μg, 100 μg, 105 μg, 110 μg, 115 μg, 120 μg, 125 μg, 130 μg, 135 μg, 140 μg, 145 μg, 150 μg, 160 μg, 170 μg, 175 μg, 180 μg, 185 μg, 190 μg, 200 μg, 210 μg, 220 μg, 230 μg, 240 μg, 250 μg, 260 μg, 270 μg, 280 μg, 290 μg, 300 μg, 310 μg, 320 μg, 330 μg, 340 μg, 350 μg, 360 μg, 370 μg, 380 μg, 390 μg, 400 μg, 410 μg, 420 μg, 430 μg, 440 μg, 450 μg, 460 μg, 470 μg, 480 μg, 490 μg, 500 μg, 510 μg, 520 μg, 530 μg, 540 μg, 550 μg, 560 μg, 570 μg, 580 μg, 590 μg, 600 μg, 610 μg, 620 μg, 630 μg, 6 In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency to maintain a C5 antibody level between 50 μg and 250 μg per milliliter of blood. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency to maintain a C5 antibody level between 100 μg and 200 μg per milliliter of blood. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency to maintain about 175 μg of antibody per milliliter of blood in the patient.

[0038] In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency sufficient to maintain a minimum free C5 concentration to achieve an effective response. For example, in one embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency sufficient to maintain a free C5 concentration of 0.2 μg / mL, 0.3 μg / mL, 0.4 μg / mL, 0.5 μg / mL, or less. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency sufficient to maintain a free C5 concentration of 0.309-0.5 μg / mL or less. In another embodiment, the treatment described herein reduces free C5 concentrations by greater than 99% throughout the treatment period. In another embodiment, the treatment reduces free C5 concentrations by greater than 99.5% throughout the treatment period.

[0039] The anti-C5 antibody or antigen-binding fragment thereof can be administered to a patient by any suitable means. In one embodiment, the antibody is formulated for intravenous administration.

[0040] The effectiveness of the treatment methods provided herein can be assessed using any suitable means. In another embodiment, for aHUS patients, treatment results in at least one therapeutic effect selected from the group consisting of a reduction or cessation of severe hypertension, proteinuria, uremia, lethargy / fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and renal dysfunction (e.g., acute renal failure).

[0041] In other embodiments, the treatment results in terminal complement inhibition.

[0042] In other embodiments, treatment results in a shift toward normal levels of hemolysis-related hematological biomarkers selected from the group consisting of free hemoglobin, haptoglobin, reticulocyte count, PNH red blood cell (RBC) clone, and D-dimer.

[0043] In another embodiment, treatment results in an increase in hemoglobin stabilization from the patient's pre-treatment baseline. In another embodiment, treatment results in an increase in hemoglobin of ≧20 g / dL. In another embodiment, treatment results in the prevention of a decrease in hemoglobin levels of ≧2 g / dL from baseline in the absence of transfusions from baseline to day 183.

[0044] In other embodiments, treatment results in platelet normalization (≥ 150 x 10 9 In other embodiments, treatment results in platelet normalization (≧150×10 / L) for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years). 9 / L) as a result.

[0045] In other embodiments, treatment results in LDH normalization (≦246 U / L). In other embodiments, treatment results in LDH normalization (≦246 U / L) for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

[0046] In other embodiments, treatment results in a ≧25% improvement from baseline in serum creatinine. In other embodiments, treatment results in a ≧25% improvement from baseline in serum creatinine for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

[0047] In other embodiments, treatment is defined as achieving a complete TMA response (i.e., platelet normalization (≥ 150 x 10 9 / L), LDH normalization (≦246 U / L), and a ≧25% improvement from baseline in serum creatinine. In other embodiments, the treatment results in a complete TMA response for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

[0048] In other embodiments, treatment is achieved by modifying complete TMA response (i.e., platelet normalization (≥ 150 x 10 9 / L), LDH normalization (≦246 U / L), and, if the patient is on dialysis at baseline, a ≧25% improvement from baseline in serum creatinine for patients discontinued from dialysis or discontinued from dialysis at baseline. In other embodiments, treatment results in a modified complete TMA response for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

[0049] In other embodiments, treatment results in a reduction in the need for transfusions. In another embodiment, treatment results in a greater than 70% increase in transfusion avoidance. In another embodiment, treatment results in transfusion avoidance from baseline to day 183.

[0050] In other embodiments, treatment results in the elimination of breakthrough hemolysis during the treatment period, hi another embodiment, treatment results in a reduction in breakthrough hemolysis compared to the pre-treatment baseline amount of breakthrough hemolysis.

[0051] In other embodiments, treatment results in a reduction in major adverse vascular events (MAVE).

[0052] In other embodiments, treatment results in a change from baseline in quality of life, as assessed via the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue Scale, Version 4 and the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire-Core 30 Scale. In one embodiment, treatment results in a change from baseline in quality of life, as assessed via the FACIT-Fatigue scale, of one or more (e.g., 1, 2, or 3) points. In another embodiment, treatment is initiated 150 days or more (e.g., 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 2010, 2011, 2012, 2013, 2014, 2015, 2016, 2017, 2018, 2020, 2021, 2022, 2023, 2024, 2025, 2026, 2027, 2028, 2029, 210, 2110, 2120, 2130, 2140, 2151, 2152, 2153, 2160, 2161, 2162, 2163, 2164, 2165, 2166, 2167, 2168, 2169, 220, 2211, 222 Change from baseline in quality of life, as assessed via the 3-point FACIT-Fatigue scale, after 80, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 205, 210, 215, 220, or 225 days.

[0053] Chronic kidney disease (CKD) stages are classified based on the National Kidney Foundation's Chronic Kidney Disease Stages. CKD stages and corresponding estimated glomerular filtration rate (eGFR) values ​​are as follows: Stage 1: eGFR >= 90 (normal), Stage 2: eGFR 60-89, Stage 3A: eGFR 45-59, Stage 3B: eGFR 30-44, Stage 4: eGFR 15-29, and Stage 5: eGFR < 15 (including end-of-life dialysis). Stage 1 is considered the highest category. Stage 5 is considered the worst category. An improvement in eGFR (e.g., > 15) corresponds to an improvement in CKD stage (e.g., a lower CKD stage). Thus, in other embodiments, the patient's chronic kidney disease (CKD) improves by one or more stages after initiation of treatment. For example, the patient's CKD improves by 1, 2, 3, 4, or 5 stages. In another embodiment, the patient's CKD has progressed beyond 150 days or more (e.g., 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 2010, 2011, 2012, 2013, 2014, 2015, 2016, 2017, 2018, 2019, 210, 2110, 2120, 2130, 2140, 2151, 2152, 2161, 2162, 2163, 2164, 2165, 2166, 2177, 2178, 2180, 2181, 2182, 2183, 2184, 2185, 2186, 2187, 2188, 2189, 2200, 2201, 2202, 6 days, 177 days, 178 days, 179 days, 180 days, 181 days, 182 days, 183 days, 184 days, 185 days, 186 days, 187 days, 188 days, 189 days, 190 days, 191 days, 192 days, 193 days, 194 days, 195 days, 196 days, 197 days, 198 days, 199 days, 200 days, 205 days, 210 days, 215 days, 220 days, or 225 days) to improve by one or more stages.

[0054] In other embodiments, treatment results in an increase in eGFR compared to baseline. In other embodiments, treatment results in a shift in eGFR toward normal levels (e.g., ≧90). In other embodiments, treatment results in an increase in eGFR compared to baseline and the patient's CKD improves by one or more stages. In other embodiments, treatment results in a shift in eGFR toward normal levels (e.g., ≧90) compared to baseline and the patient's CKD improves by one or more stages.

[0055] In other embodiments, the treatment results in an EQ-5D-3L US Time Trade-Off Value Set (US TTO) of >0.94.

[0056] In another embodiment, to a patient with aHUS: (a) Once on day 1, at a dose of 2400 mg for patients weighing ≥ 40 to < 60 kg, 2700 mg for patients weighing ≥ 60 to < 100 kg, or 3000 mg for patients weighing ≥ 100 kg; (b) On day 15, and every 8 weeks thereafter, at a dose of 3000 mg for patients weighing ≥ 40 to < 60 kg, 3300 mg for patients weighing ≥ 60 to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg. An anti-C5 antibody or antigen-binding fragment thereof for administration is provided, which comprises the CDR1, CDR2, and CDR3 domains of a heavy chain variable region having the sequence set forth in SEQ ID NO: 12 and the CDR1, CDR2, and CDR3 domains of a light chain variable region having the sequence set forth in SEQ ID NO: 8.

[0057] In one embodiment, the antibody is determined to be safe, tolerated, and sufficiently non-immunogenic after multiple IV doses for use in aHUS patients.

[0058] Further provided are kits comprising a pharmaceutical composition containing an anti-C5 antibody or antigen-binding fragment thereof, e.g., antibody ravulizumab, in a therapeutically effective amount adapted for use in the methods described herein, and a pharmaceutically acceptable carrier. In one embodiment, the kit comprises: (a) a dose of an anti-C5 antibody or antigen-binding fragment thereof, comprising the CDR1, CDR2, and CDR3 domains of a heavy chain variable region having the sequence set forth in SEQ ID NO: 12 and the CDR1, CDR2, and CDR3 domains of a light chain variable region having the sequence set forth in SEQ ID NO: 8; and (b) Instructions for using the anti-C5 antibody or antigen-binding fragment thereof in the methods described herein. Includes.

[0059] In one embodiment, 2400 mg or 3000 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥40 kg but <60 kg. In another embodiment, 2700 mg or 3300 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥60 kg but <100 kg. In another embodiment, 3000 mg or 3600 mg of an anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥100 kg. The present invention provides, for example, the following items. (Item 1) 1. A method of treating a human patient with atypical hemolytic uremic syndrome (aHUS), comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 heavy chain sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is (a) once on day 1 at a dose of 2400 mg for patients weighing ≥ 40 kg to < 60 kg, 2700 mg for patients weighing ≥ 60 kg to < 100 kg, or 3000 mg for patients weighing ≥ 100 kg; and (b) On day 15, and every 8 weeks thereafter, at a dose of 3000 mg for patients weighing ≥ 40 kg to < 60 kg, 3300 mg for patients weighing ≥ 60 kg to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg. The method, wherein (Item 2) 1. A method of treating a human patient with atypical hemolytic uremic syndrome (aHUS), comprising administering to the patient an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 heavy chain sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, the CDR1, CDR2, and CDR3 light chain sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively, and a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434, respectively, of a native human IgG Fc constant region, according to EU numbering, and wherein the anti-C5 antibody or antigen-binding fragment thereof is (a) once on day 1 at a dose of 2400 mg for patients weighing ≥ 40 kg to < 60 kg, 2700 mg for patients weighing ≥ 60 kg to < 100 kg, or 3000 mg for patients weighing ≥ 100 kg; and (b) On day 15, and every 8 weeks thereafter, at a dose of 3000 mg for patients weighing ≥ 40 kg to < 60 kg, 3300 mg for patients weighing ≥ 60 kg to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg. The method, wherein (Item 3) 3. The method of item 1 or 2, wherein the patient has been previously treated with eculizumab. (Item 4) The method of any one of the preceding items, wherein the treatment begins at least two weeks after the patient's last dose of eculizumab. (Item 5) The method of any one of the preceding items, wherein the patient has been treated with eculizumab for at least 6 months prior to day 1 of the treatment. (Item 6) The method of any one of the preceding items, wherein the patient has previously been treated with eculizumab at a dose of 900 mg every two weeks. (Item 7) 10. The method of any one of the preceding items, wherein the anti-C5 antibody comprises a heavy chain variable region set forth in SEQ ID NO: 12 and a light chain variable region set forth in SEQ ID NO: 8. (Item 8) The method of any one of the preceding items, wherein the anti-C5 antibody further comprises a heavy chain constant region set forth in SEQ ID NO:13. (Item 9) 10. The method of any one of the preceding items, wherein the antibody comprises a heavy chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 14 and a light chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 11. (Item 10) The anti-C5 antibody has an affinity dissociation constant (K) in the range of 0.1 nM to 1 nM at pH 7.4 and 25°C. D Item 10. The method of any one of the preceding items, wherein the antibody binds to human C5 via a C5 antibody. (Item 11) The anti-C5 antibody is D The method of any one of the preceding items, wherein the antibody binds to human C5 at ≧10 nM. (Item 12) The anti-C5 antibody is administered to a patient weighing ≧40 kg to <60 kg, (a) at a dose of 2400 mg once on day 1; and (b) on day 15 and every 8 weeks thereafter at a dose of 3000 mg 4. The method of any one of the preceding items, wherein the (Item 13) The anti-C5 antibody is administered to a patient weighing ≧60 kg to <100 kg, (a) at a dose of 2700 mg once on day 1; and (b) on day 15 and every 8 weeks thereafter at a dose of 3300 mg 12. The method of any one of items 1 to 11, wherein the patient is administered (Item 14) The anti-C5 antibody is administered to a patient weighing ≥ 100 kg, (a) at a dose of 3000 mg once on day 1; and (b) on day 15 and every 8 weeks thereafter at a dose of 3600 mg 12. The method of any one of items 1 to 11, wherein the patient is administered (Item 15) The method of any one of the preceding items, wherein the treatment maintains a serum trough concentration of the anti-C5 antibody of 100 μg / ml or greater during the treatment. (Item 16) The method of any one of the preceding items, wherein the treatment maintains a serum trough concentration of the anti-C5 antibody of 200 μg / ml or greater during the treatment. (Item 17) The method of any one of the preceding items, wherein the treatment maintains a free C5 concentration of 0.309 μg / mL to 0.5 μg / mL or less. (Item 18) 10. The method of any one of the preceding items, wherein the treatment reduces free C5 levels by greater than 99% throughout the treatment period. (Item 19) 10. The method of any one of the preceding items, wherein the treatment reduces free C5 levels by greater than 99.5% throughout the treatment period. (Item 20) The method of any one of the preceding items, wherein the anti-C5 antibody is administered at a dose of 3000 mg, 3300 mg, or 3600 mg every 8 weeks for up to 2 years following said treatment. (Item 21) The method of any one of the preceding items, wherein the anti-C5 antibody is formulated for intravenous administration. (Item 22) The method of any one of the preceding items, wherein the treatment is for a total of 26 weeks of treatment. (Item 23) The method of any one of the preceding items, wherein said treatment results in terminal complement inhibition. (Item 24) The method of any one of the preceding items, wherein the treatment results in a reduction in hemolysis compared to baseline as assessed by lactate dehydrogenase (LDH) levels. (Item 25) The method of any one of the preceding items, wherein said treatment results in normalization of LDH levels. (Item 26) 10. The method of any one of the preceding items, wherein the treatment results in the disappearance of breakthrough hemolysis during the treatment period. (Item 27) The method of any one of the preceding items, wherein the treatment results in a shift toward normal levels of a hemolysis-related hematological biomarker selected from the group consisting of free hemoglobin, haptoglobin, reticulocyte count, PNH red blood cell (RBC) clone, and D-dimer. (Item 28) 10. The method of any one of the preceding items, wherein said treatment results in at least one therapeutic effect selected from the group consisting of a reduction or cessation in severe hypertension, proteinuria, uremia, lethargy, fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and renal dysfunction compared to baseline. (Item 29) The method of any one of the preceding items, wherein the treatment results in a shift toward normal levels of Ba factor, soluble tumor necrosis factor receptor 1 [sTNFR1], soluble vascular adhesion molecule 1 [sVCAM1], thrombomodulin, D-dimer, and cystatin C. (Item 30) The method of any one of the preceding items, wherein the treatment results in an increase in hemoglobin stabilization compared to baseline. (Item 31) The method of any one of the preceding items, wherein the treatment results in a reduction in the need for blood transfusions compared to baseline. (Item 32) The method of any one of the preceding items, wherein said treatment results in a reduction in major adverse vascular events (MAVE). (Item 33) The method of any one of the preceding items, wherein the treatment results in a change from baseline in quality of life as assessed via the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale, version 4 and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 scale. (Item 34) 10. The method of any one of the preceding items, wherein said treatment results in platelet normalization. (Item 35) The method of any one of the preceding items, wherein said treatment results in a ≧25% improvement from baseline in serum creatinine. (Item 36) The method of any one of the preceding items, wherein said treatment results in a complete TMA response. (Item 37) The method of any one of the preceding items, wherein said treatment results in an altered complete TMA response. (Item 38) The method of any one of the preceding items, wherein the patient's chronic kidney disease (CKD) improves by one or more stages after initiation of treatment. (Item 39) The method of any one of the preceding items, wherein said treatment results in a shift in eGFR towards normal levels. (Item 40) The method of any one of the preceding items, wherein said treatment results in an EQ-5D-3L US Time Trade-off Value Set (US TTO) of >0.94. (Item 41) 1. A kit for treating aHUS in a human patient, comprising: (a) a dose of an anti-C5 antibody comprising the CDR1, CDR2, and CDR3 domains of a heavy chain variable region having the sequence set forth in SEQ ID NO: 12 and the CDR1, CDR2, and CDR3 domains of a light chain variable region having the sequence set forth in SEQ ID NO: 8; and (b) instructions for using the anti-C5 antibody in the method of any one of the preceding paragraphs; The kit comprises: (Item 42) The anti-C5 antibody is administered to a patient weighing ≧40 kg to <60 kg, (a) at a dose of 2400 mg once on day 1; and (b) On the 15th day 42. The kit according to item 41, wherein the kit is administered. (Item 43) The anti-C5 antibody is administered to a patient weighing ≧60 kg to <100 kg, (a) at a dose of 2700 mg once on day 1; and (b) on day 15 and every 8 weeks thereafter at a dose of 3300 mg 42. The kit according to item 41, wherein the kit is administered. (Item 44) The anti-C5 antibody is administered to a patient weighing ≥ 100 kg, (a) at a dose of 3000 mg once on day 1; and (b) on day 15 and every 8 weeks thereafter at a dose of 3600 mg 42. The kit according to item 41, wherein the kit is administered. (Item 45) An anti-C5 antibody or an antigen-binding fragment thereof, comprising CDR1, CDR2, and CDR3 domains of a heavy chain variable region having the sequence shown in SEQ ID NO: 12 and CDR1, CDR2, and CDR3 domains of a light chain variable region having the sequence shown in SEQ ID NO: 8, (a) once on day 1 at a dose of 2400 mg for patients weighing ≥ 40 kg to < 60 kg, 2700 mg for patients weighing ≥ 60 kg to < 100 kg, or 3000 mg for patients weighing ≥ 100 kg; and (b) On day 15, and every 8 weeks thereafter, at a dose of 3000 mg for patients weighing ≥ 40 kg to < 60 kg, 3300 mg for patients weighing ≥ 60 kg to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg. The anti-C5 antibody or antigen-binding fragment thereof is administered. [Brief explanation of the drawings]

[0060] [Figure 1] The study design for ALXN1210-aHUS-311 is shown. [Figure 2] The primary, secondary, and safety endpoints for ALXN1210-aHUS-311 are summarized. [Figure 3] Summary of inclusion and exclusion criteria for ALXN1210-aHUS-311. [Figure 4] The patient breakdown for ALXN1210-aHUS-311 is shown. [Figure 5] Set fourth data point for derivation with confirmed complete TMA response. [Figure 6] FIG. 1 is a Venn diagram showing key efficacy data for primary complete TMA response during the primary evaluation period. [Figure 7] Graph showing time to complete TMA response. [Figure 8] Graph showing mean serum concentrations (μg / mL) versus time (linear scale). Weight-based dosing resulted in maximal steady-state and trough exposure as expected, with no unexpected pharmacokinetic findings. [Figure 9]

[0023] Figure 1 is a series of bar graphs showing key efficacy data for primary complete TMA response during the primary evaluation period and through the data cut. The 95% confidence interval is represented by the line above each bar. [Figure 10] Complete TMA response overall and by subgroup during the initial 26-week evaluation period is shown. [Figure 11] Key efficacy outcomes of complete TMA response status (open circles) over time are shown, including platelet count normalization (open triangles), hematological normalization (+), 25% improvement from baseline in serum creatinine (open squares), and LDH normalization (X). [Figure 12] Mean eGFR change from baseline (mL / min / 1.73m2) and 95% confidence intervals are shown over time. [Figure 13] Chronic kidney disease (CKD) stage shift from baseline to day 183 is shown. [Figure 14]Observed and model-based mean changes from baseline and 95% confidence intervals in platelets (109 / L) over time are shown. [Figure 15] The observed mean platelets (109 / L) and 95% confidence intervals are shown over time. [Figure 16] Observed and model-based mean changes from baseline and 95% confidence intervals in LDH (U / L) over time are shown. [Figure 17] The observed mean LDH (U / L) and 95% confidence intervals are shown over time. [Figure 18] Observed and model-based mean changes from baseline and 95% confidence intervals in hemoglobin (HGB) (g / L) over time are shown. [Figure 19] The observed mean HGB (g / L) and 95% confidence intervals are shown over time. [Figure 20] Mean FACIT fatigue change from baseline and 95% confidence intervals are shown over time. FACIT scores range from 0 to 52, with higher scores indicating lower fatigue. [Figure 21] Mean EQ-5D-3L change from baseline and 95% confidence intervals are shown over time. [Figure 22] Serum free complement C5 concentrations (μg / L) over time from baseline to day 183 are shown. [Figure 23] Compare study populations and outcomes between Study ALXN1210-aHUS-311 and the eculizumab adult study (C10-004). DETAILED DESCRIPTION OF THE INVENTION

[0061] I. Anti-C5 antibody The anti-C5 antibodies described herein bind to complement component C5 (e.g., human C5) and inhibit cleavage of C5 into fragments C5a and C5b. As noted above, such antibodies also have, for example, improved pharmacokinetic properties compared to other anti-C5 antibodies used for therapeutic purposes (e.g., eculizumab).

[0062] The term "antibody" describes a polypeptide comprising at least one antibody-derived antigen-binding site (e.g., a VH / VL region or Fv, or CDR). Antibodies include known forms of antibodies. For example, an antibody can be a human antibody, a humanized antibody, a bispecific antibody, or a chimeric antibody. An antibody can also be a Fab, Fab'2, ScFv, SMIP, Affibody®, nanobody, or domain antibody. An antibody can also be of any of the following isotypes: IgG1, IgG2, IgG3, IgG4, IgM, IgA1, IgA2, IgAsec, IgD, and IgE. An antibody can be a naturally occurring antibody or an antibody that has been altered by protein engineering techniques (e.g., by mutation, deletion, substitution, conjugation to a non-antibody moiety). For example, an antibody can contain one or more variant amino acids that alter the properties (e.g., functional properties) of the antibody (compared to a naturally occurring antibody). Many such modifications are known in the art that affect, for example, the half-life in a patient, effector functions, and / or immune response to the antibody. The term antibody also includes artificial or engineered polypeptide constructs that contain at least one antibody-derived antigen-binding site.

[0063] Anti-C5 antibodies (or VH / VL domains derived therefrom) suitable for use in the present invention can be generated using methods well known in the art. Alternatively, art-recognized anti-C5 antibodies can be used. Antibodies that compete with any of these art-recognized antibodies for binding to C5 can also be used.

[0064] Eculizumab (also known as Soliris®) is an anti-C5 antibody comprising heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOS: 1, 2, and 3, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOS: 4, 5, and 6, respectively. Eculizumab comprises a heavy chain variable region having the amino acid sequence set forth in SEQ ID NO: 7 and a light chain variable region having the amino acid sequence set forth in SEQ ID NO: 8. The variable regions of eculizumab are described in PCT / US1995 / 005688 and U.S. Patent No. 6,355,245, the teachings of which are incorporated herein by reference. Eculizumab comprises a heavy chain comprising the amino acid sequence set forth in SEQ ID NO: 10 and a light chain having the amino acid sequence set forth in SEQ ID NO: 11. The complete heavy and light chains of eculizumab are described in PCT / US2007 / 006606, the teachings of which are incorporated herein by reference.

[0065] An exemplary anti-C5 antibody is ravulizumab, or an antigen-binding fragment or variant thereof, comprising heavy and light chains having the sequences set forth in SEQ ID NOs: 14 and 11, respectively. Ravulizumab (also known as ULTOMIRIS®, BNJ441, and ALXN1210) is described in PCT / US2015 / 019225 and U.S. Patent No. 9,079,949, the teachings of which are incorporated herein by reference. The terms ravulizumab, BNJ441, and ALXN1210 may be used interchangeably throughout this document but all refer to the same antibody. Ravulizumab selectively binds to the human complement protein C5 and inhibits its cleavage into C5a and C5b during complement activation. This inhibition prevents the release of the proinflammatory mediator C5a and the formation of the cytolytic pore-forming membrane attack complex (MAC) C5b-9, while preserving the proximal or early components of complement activation (e.g., C3 and C3b) that are important for microbial opsonization and immune complex clearance.

[0066] In other embodiments, the antibody comprises the heavy and light chain CDRs or variable regions of ravulizumab. For example, in one embodiment, the antibody comprises the CDR1, CDR2, and CDR3 domains of the VH region of ravulizumab having the sequence set forth in SEQ ID NO: 12 and the CDR1, CDR2, and CDR3 domains of the VL region of ravulizumab having the sequence set forth in SEQ ID NO: 8. In another embodiment, the antibody comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively. In another embodiment, the antibody comprises VH and VL regions having the amino acid sequences set forth in SEQ ID NO: 12 and SEQ ID NO: 8, respectively.

[0067] Another exemplary anti-C5 antibody is antibody BNJ421, or antigen-binding fragments and variants thereof, comprising heavy and light chains having the sequences set forth in SEQ ID NOs: 20 and 11, respectively. BNJ421 (also known as ALXN1211) is described in PCT / US2015 / 019225 and U.S. Patent No. 9,079,949, the teachings of which are incorporated herein by reference.

[0068] In other embodiments, the antibody comprises the heavy and light chain CDRs or variable regions of BNJ421. Thus, in one embodiment, the antibody comprises the CDR1, CDR2, and CDR3 domains of the VH region of BNJ421 having the sequence set forth in SEQ ID NO: 12 and the CDR1, CDR2, and CDR3 domains of the VL region of BNJ421 having the sequence set forth in SEQ ID NO: 8. In another embodiment, the antibody comprises the heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, and the light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively.

[0069] The exact boundaries of CDRs have been defined differently according to different methods. In some embodiments, the locations of CDRs or framework regions within a light or heavy chain variable domain may be as defined by Kabat et al. [(1991) "Sequences of Proteins of Immunological Interest." NIH Publication No. 91-3242, USDapartment of Health and Human Services, Bethesda, MD]. In such cases, the CDRs may be referred to as "Kabat CDRs" (e.g., "Kabat LCDR2" or "Kabat HCDR1"). In some embodiments, the locations of CDRs in a light or heavy chain variable region may be as defined by Chothia et al. (1989) Nature 342:877-883. Accordingly, these regions may be referred to as "Chothia CDRs" (e.g., "Chothia LCDR2" or "Chothia HCDR3"). In some embodiments, the locations of CDRs in light and heavy chain variable regions may be as defined by the combined Kabat-Chothia definition. In such embodiments, these regions may be referred to as "combined Kabat-Chothia CDRs." Thomas et al. [(1996) Mol Immunol 33(17 / 18):1389-1401] exemplify the identification of CDR boundaries according to the Kabat and Chothia definitions.

[0070] In another embodiment, the antibody comprises VH and VL regions having the amino acid sequences set forth in SEQ ID NO: 12 and SEQ ID NO: 8, respectively. In another embodiment, the antibody comprises a heavy chain constant region set forth in SEQ ID NO: 13. In another embodiment, the antibody comprises a heavy chain polypeptide set forth in SEQ ID NO: 14 and a light chain polypeptide set forth in SEQ ID NO: 11. In another embodiment, the antibody comprises a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn), and the variant human Fc CH3 constant region has the amino acid sequences set forth in SEQ ID NO: 15, each with EU numbering, of native human IgG It contains Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434 of the Fc constant region.

[0071] In another embodiment, the antibody comprises the CDR1, CDR2, and CDR3 heavy chain sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively, and a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434, respectively, in EU numbering, of the native human IgG Fc constant region.

[0072] In another embodiment, the anti-C5 antibodies described herein comprise a heavy chain CDR1 comprising or consisting of the following amino acid sequence: GHIFSNYWIQ (SEQ ID NO: 19). In another embodiment, the anti-C5 antibodies described herein comprise a heavy chain CDR2 comprising or consisting of the following amino acid sequence: EILPGSGHTEYTENFKD (SEQ ID NO: 18).

[0073] In another embodiment, the antibody has an affinity dissociation constant (K) at pH 7.4 and 25°C in the range of 0.1 nM to 1 nM. D In another embodiment, the antibody binds to human C5 at a K D In yet another embodiment, the K of the antibody or antigen-binding fragment thereof against human C5 at pH 6.0 and 25°C is ≥ 10 nM. D ) / (K of an antibody or antigen-binding fragment thereof against human C5 at pH 7.4 and 25°C D )] is greater than 25.

[0074] Another exemplary anti-C5 antibody is the 7086 antibody described in U.S. Patent Nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 7086 antibody (see U.S. Patent Nos. 8,241,628 and 8,883,158). In another embodiment, the antibody or antigen-binding fragment thereof comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 21, 22, and 23, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 24, 25, and 26, respectively. In another embodiment, the antibody or antigen-binding fragment thereof comprises the VH region of the 7086 antibody having the sequence set forth in SEQ ID NO: 27 and the VL region of the 7086 antibody having the sequence set forth in SEQ ID NO: 28.

[0075] Another exemplary anti-C5 antibody is the 8110 antibody, also described in U.S. Patent Nos. 8,241,628 and 8,883,158. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 8110 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 29, 30, and 31, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 32, 33, and 34, respectively. In another embodiment, the antibody comprises the VH region of the 8110 antibody having the sequence set forth in SEQ ID NO: 35 and the VL region of the 8110 antibody having the sequence set forth in SEQ ID NO: 36.

[0076] Another exemplary anti-C5 antibody is the 305LO5 antibody described in US 2016 / 0176954A1. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the 305LO5 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises heavy chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 37, 38, and 39, respectively, and light chain CDR1, CDR2, and CDR3 domains having the sequences set forth in SEQ ID NOs: 40, 41, and 42, respectively. In another embodiment, the antibody comprises the VH region of the 305LO5 antibody having the sequence set forth in SEQ ID NO: 43 and the VL region of the 305LO5 antibody having the sequence set forth in SEQ ID NO: 44.

[0077] Another exemplary anti-C5 antibody is the SKY59 antibody described in Fukuzawa T., et al., Rep. 2017 Apr 24;7(1):1080. In one embodiment, the antibody comprises the heavy and light chain CDRs or variable regions of the SKY59 antibody. In another embodiment, the antibody or antigen-binding fragment thereof comprises a heavy chain comprising SEQ ID NO:45 and a light chain comprising SEQ ID NO:46.

[0078] Another exemplary anti-C5 antibody is the REGN3918 antibody (also known as H4H12166PP), described in US20170355757. In one embodiment, the antibody comprises a heavy chain variable region comprising SEQ ID NO: 47 and a light chain variable region comprising SEQ ID NO: 48. In another embodiment, the antibody comprises a heavy chain comprising SEQ ID NO: 49 and a light chain comprising SEQ ID NO: 50.

[0079] In another embodiment, the antibody competes for binding to and / or binds to the same epitope on C5 as an antibody described above (e.g., eculizumab, ravulizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In another embodiment, the antibody has at least about 90% variable region amino acid sequence identity (e.g., at least about 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, or 99% variable region identity) with an antibody described above.

[0080] In some embodiments, the anti-C5 antibodies described herein may comprise a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn) with higher affinity than the affinity of the native human Fc constant region from which the variant human Fc constant region was derived. For example, the Fc constant region may contain one or more (e.g., 2, 3, 4, 5, 6, 7, or 8 or more) amino acid substitutions compared to the native human Fc constant region from which the variant human Fc constant region was derived. The substitutions may increase the binding affinity of an IgG antibody containing the variant Fc constant region for FcRn at pH 6.0 while maintaining the pH dependence of the interaction. Methods for testing whether one or more substitutions in an antibody's Fc constant region increase the affinity of the Fc constant region for FcRn at pH 6.0 (while maintaining the pH dependence of the interaction) are known in the art and are exemplified in the Examples. See, e.g., PCT / US2015 / 019225 and U.S. Patent No. 9,079,949. The disclosures of each of these are incorporated herein by reference in their entirety.

[0081] Substitutions that enhance the binding affinity of antibody Fc constant regions to FcRn are known in the art and include, for example, (1) the M252Y / S254T / T256E triple substitution described by Dall'Acqua et al. (2006) J Biol Chem 281:23514-23524; (2) the M428L or T250Q / M428L substitutions described by Hinton et al. (2004) J Biol Chem 279:6213-6216 and Hinton et al. (2006) J Immunol 176:346-356; and (3) the N434A or T307 / E380A / N434A substitutions described by Petkova et al. (2006) Int Immunol 18(12):1759-69. Additional substitution pairings: P257I / Q311I, P257I / N434H, and D376V / N434H are described, for example, in Datta-Mannan et al. (2007) J Biol Chem 282(3):1709-1717, the disclosure of which is incorporated herein by reference in its entirety.

[0082] In some embodiments, the variant constant region has a substitution at EU amino acid residue 255 to valine. In some embodiments, the variant constant region has a substitution at EU amino acid residue 309 to asparagine. In some embodiments, the variant constant region has a substitution at EU amino acid residue 312 to isoleucine. In some embodiments, the variant constant region has a substitution at EU amino acid residue 386.

[0083] In some embodiments, the variant Fc constant region comprises no more than 30 (e.g., no more than 29, 28, 27, 26, 25, 24, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, 5, 4, 3, or 2) amino acid substitutions, insertions, or deletions relative to the native constant region from which it is derived. In some embodiments, the variant Fc constant region comprises one or more amino acid substitutions selected from the group consisting of M252Y, S254T, T256E, N434S, M428L, V259I, T250I, and V308F. In some embodiments, the variant human Fc constant region comprises a methionine at position 428 and an asparagine at position 434, each according to EU numbering. In some embodiments, the variant Fc constant region comprises a 428L / 434S double substitution, for example, as described in US Pat. No. 8,088,376.

[0084] In some embodiments, the exact location of these mutations may be shifted from their native human Fc constant region locations due to antibody engineering. For example, the 428L / 434S double substitution, when used in an IgG2 / 4 chimeric Fc, may correspond to 429L and 435S, such as the M429L and N435S variant found in BNJ441 (ravulizumab), described in U.S. Patent No. 9,079,949, the disclosure of which is incorporated herein by reference in its entirety.

[0085] In some embodiments, the variant constant region comprises a substitution at amino acid position 237, 238, 239, 248, 250, 252, 254, 255, 256, 257, 258, 265, 270, 286, 289, 297, 298, 303, 305, 307, 308, 309, 311, 312, 314, 315, 317, 325, 332, 334, 360, 376, 380, 382, ​​384, 385, 386, 387, 389, 424, 428, 433, 434 or 436 (EU numbering) relative to a native human Fc constant region. In some embodiments, the substitutions are, all in EU numbering, glycine to methionine at position 237; proline to alanine at position 238; serine to lysine at position 239; lysine to isoleucine at position 248; threonine to alanine, phenylalanine, isoleucine, methionine, glutamine, serine, valine, tryptophan, or tyrosine at position 250; methionine to phenylalanine, tryptophan, or tyrosine at position 252; serine to threonine at position 254; arginine to glutamic acid at position 255; threonine to aspartic acid, glutamic acid, or glutamine at position 256; proline to alanine, glycine, isoleucine, leucine, methionine, asparagine, serine, threonine, or valine at position 257; glutamine to threonine at position 258 aspartic acid to histidine at position 265; aspartic acid to alanine at position 270; asparagine to alanine or glutamic acid at position 286; threonine to histidine at position 289; asparagine to alanine at position 297; serine to glycine at position 298; valine to alanine at position 303; valine to alanine at position 305; threonine to alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, methionine, asparagine, proline, glutamine, arginine, serine, valine, tryptophan or tyrosine at position 307; valine to alanine, phenylalanine, isoleucine, leucine, methionine, proline, glutamine or threonine at position 308;Leucine or valine to alanine, aspartic acid, glutamic acid, proline, or arginine at position 309; glutamine to alanine, histidine, or isoleucine at position 311; aspartic acid to alanine or histidine at position 312; leucine to lysine or arginine at position 314; asparagine to alanine or histidine at position 315; lysine to alanine at position 317; asparagine to glycine at position 325; isoleucine to valine at position 332; lysine to leucine at position 334; lysine to histidine at position 360; aspartic acid to alanine at position 376; glutamic acid to alanine at position 380; glutamic acid to alanine at position 382; asparagine or selenium at position 384 phosphonium to alanine; glycine to aspartic acid or histidine at position 385; glutamine to proline at position 386; proline to glutamic acid at position 387; asparagine to alanine or serine at position 389; serine to alanine at position 424; methionine to alanine, aspartic acid, phenylalanine, glycine, histidine, isoleucine, lysine, leucine, asparagine, proline, glutamine, serine, threonine, valine, tryptophan or tyrosine at position 428; histidine to lysine at position 433; asparagine to alanine, phenylalanine, histidine, serine, tryptophan or tyrosine at position 434; and tyrosine or phenylalanine to histidine at position 436.

[0086] Anti-C5 antibodies suitable for use in the methods described herein, in some embodiments, comprise a heavy chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 14 and / or a light chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 11. Alternatively, anti-C5 antibodies for use in the methods described herein, in some embodiments, comprise a heavy chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 20 and / or a light chain polypeptide comprising the amino acid sequence set forth in SEQ ID NO: 11.

[0087] In one embodiment, the antibody has an affinity dissociation constant (K) of at least 0.1 (e.g., at least 0.15, 0.175, 0.2, 0.25, 0.275, 0.3, 0.325, 0.35, 0.375, 0.4, 0.425, 0.45, 0.475, 0.5, 0.525, 0.55, 0.575, 0.6, 0.625, 0.65, 0.675, 0.7, 0.725, 0.75, 0.775, 0.8, 0.825, 0.85, 0.875, 0.9, 0.925, 0.95, or 0.975) nM at pH 7.4 and 25°C (and otherwise under physiological conditions). D In some embodiments, the K D is 1 or less (e.g., 0.9, 0.8, 0.7, 0.6, 0.5, 0.4, 0.3, or 0.2 or less) nM.

[0088] In another embodiment, the K of an antibody against C5 at pH 6.0 and 25°C D ) / (K of antibody against C5 at pH 7.4 and 25°C D )] is greater than 21 (e.g., 22, 23, 24, 25, 26, 27, 28, 29, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 110, 120, 130, 140, 150, 160, 170, 180, 190, 200, 210, 220, 230, 240, 250, 260, 270, 280, 290, 300, 310, 320, 330, 340, 350, 360, 370, 380, 390, 400, 410, 420, 430, 440, 450, 460, 470, 480, 490, 500, 510, 520, 530, 540, 550, 560, 570, 580, 590, 600, 610, 620, 630, 640, 650, 660, 670, 680, 690, 700, 710, 720, 730, 740, 750, 760, 770, 780, 790, 800, 810, 820, 830, 840, 850, 860, 870, 880, 890, 900, 910 greater than 0, 250, 260, 270, 280, 290, 300, 350, 400, 450, 500, 600, 700, 800, 900, 1000, 1500, 2000, 2500, 3000, 3500, 4000, 4500, 5000, 5500, 6000, 6500, 7000, 7500 or 8000).

[0089] Methods for determining whether an antibody binds to a protein antigen and / or the affinity of an antibody for a protein antigen are known in the art. For example, the binding of an antibody to a protein antigen can be detected and / or quantified using various techniques, including, but not limited to, Western blot, dot blot, surface plasmon resonance (SPR) (e.g., BIAcore system; Pharmacia Biosensor AB, Uppsala, Sweden and Piscataway, NJ), or enzyme-linked immunosorbent assay (ELISA). See, for example, Benny KC Lo (2004) "Antibody Engineering: Methods and Protocols," Humana Press (ISBN: 1588290921); Johne et al. (1993) J Immunol Meth 160:191-198; Jonsson et al. (1993) Ann Biol Clin 51:19-26; and Jonsson et al. (1991) Biotechniques 11:620-627. Additionally, methods for measuring affinity (e.g., dissociation and association constants) are provided in the Examples.

[0090] As used herein, the term "k a " refers to the rate constant for the association of an antibody to an antigen. d " refers to the rate constant for dissociation of an antibody from the antibody / antigen complex. D " refers to the equilibrium dissociation constant of the antibody-antigen interaction. The equilibrium dissociation constant is the ratio of the kinetic rate constants, K D =k a / k d Such determinations are preferably measured at 25°C or 37°C (see Examples). For example, the kinetics of antibody binding to human C5 can be determined at pH 8.0, 7.4, 7.0, 6.5, and 6.0 via surface plasmon resonance (SPR) on a BIAcore 3000 instrument using an anti-Fc capture method to immobilize the antibody.

[0091] In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof blocks the production or activity of C5a and / or C5b active fragments of a C5 protein (e.g., a human C5 protein). Through this blocking effect, the antibody inhibits, for example, the pro-inflammatory effects of C5a and the generation of the C5b-9 membrane attack complex (MAC) on the surface of cells.

[0092] Methods for determining whether the specific antibodies described herein inhibit C5 cleavage are known in the art. Inhibition of human complement component C5 can reduce the cytolytic ability of complement in a subject's body fluid. Such reduction in the cytolytic ability of complement present in body fluid(s) can be measured by methods well known in the art, for example, by conventional hemolytic assays, such as the hemolytic assay described by Kabat and Mayer (eds.), "Experimental Immunochemistry, 2nd Edition," 135-240, Springfield, IL, CC Thomas (1961), pages 135-139, or conventional variants of the assay, such as the chicken erythrocyte hemolysis method described in Hillmen et al. (2004) N Engl J Med 350(6):552. Methods for determining whether a candidate compound inhibits cleavage of human C5 into the forms C5a and C5b are known in the art and are described in Evans et al. (1995) Mol Immunol 32(16):1183-95. For example, the concentration and / or biological activity of C5a and C5b in body fluids can be measured by methods well known in the art. For C5b, the hemolytic assay discussed herein or an assay for soluble C5b-9 can be used. Other assays known in the art can also be used. These or other suitable types of assays can be used to screen candidate agents capable of inhibiting human complement component C5.

[0093] Immunological techniques, such as, but not limited to, ELISA, can be used to measure the protein concentration of C5 and / or its cleavage products to determine the ability of an anti-C5 antibody or antigen-binding fragment thereof to inhibit the conversion of C5 to biologically active products. In some embodiments, C5a production is measured. In some embodiments, a C5b-9 neoepitope-specific antibody is used to detect terminal complement formation.

[0094] Hemolytic assays can be used to determine the inhibitory activity of anti-C5 antibodies or their antigen-binding fragments on complement activation. To determine the effect of anti-C5 antibodies or their antigen-binding fragments on in vitro classical complement pathway-mediated hemolysis in serum test solutions, for example, sheep red blood cells coated with hemolysin or chicken red blood cells sensitized with anti-chicken red blood cell antibodies are used as target cells. The percentage of lysis is normalized by considering lysis equivalent to that occurring in the absence of an inhibitor as 100%. In some embodiments, the classical complement pathway is activated by a human IgM antibody, such as that used in the Wieslab® Classical Pathway Complement Kit (Wieslab® COMPL CP310, Euro-Diagnostica, Sweden). Briefly, test serum is incubated with anti-C5 antibodies or their antigen-binding fragments in the presence of human IgM antibodies. The amount of C5b-9 produced is measured by contacting the mixture with an enzyme-conjugated anti-C5b-9 antibody and a fluorogenic substrate and measuring absorbance at an appropriate wavelength. As a control, test serum is incubated in the absence of anti-C5 antibody or its antigen-binding fragment. In some embodiments, the test serum is C5-deficient serum reconstituted with C5 polypeptide.

[0095] To determine the effect of an anti-C5 antibody or its antigen-binding fragment on alternative pathway-mediated hemolysis, naive rabbit or guinea pig red blood cells can be used as target cells. In some embodiments, the serum test solution is C5-deficient serum reconstituted with C5 polypeptide. The percentage of lysis is normalized by considering lysis equivalent to that occurring in the absence of an inhibitor as 100%. In some embodiments, the alternative complement pathway is activated by a lipopolysaccharide molecule, such as that utilized in the Wieslab® Alternative Pathway Complement Kit (Wieslab® COMPL AP330, Euro-Diagnostica, Sweden). Briefly, test serum is incubated with an anti-C5 antibody or its antigen-binding fragment in the presence of lipopolysaccharide. The amount of C5b-9 produced is measured by contacting the mixture with an enzyme-conjugated anti-C5b-9 antibody and a fluorogenic substrate and measuring fluorescence at an appropriate wavelength. As a control, test serum is incubated in the absence of anti-C5 antibody or antigen-binding fragment thereof.

[0096] In some embodiments, C5 activity or its inhibition is quantified using a CH50eq assay. The CH50eq assay is a method for measuring total classical complement activity in serum. This test is a lytic assay that uses antibody-sensitized red blood cells as an activator of the classical complement pathway and various dilutions of test serum to determine the amount required to obtain 50% lysis (CH50). Percent hemolysis can be determined, for example, using a spectrophotometer. The CH50eq assay provides an indirect measure of terminal complement complex (TCC) formation, because TCC itself is directly responsible for the hemolysis measured.

[0097] The assay is well known and commonly performed by those skilled in the art. Briefly, to activate the classical complement pathway, an undiluted serum sample (e.g., a reconstituted human serum sample) is added to a microassay well containing antibody-sensitized red blood cells, thereby generating TCC. The activated serum is then diluted in a microassay well coated with a capture reagent (e.g., an antibody that binds to one or more components of TCC). TCC present in the activated sample binds to the monoclonal antibody coating the surface of the microassay well. The wells are washed, and a detectably labeled detection reagent that recognizes the bound TCC is added to each well. The detectable label can be, for example, a fluorescent label or an enzyme label. The assay results are expressed in CH50 unit equivalents per milliliter (CH50 U Eq / mL).

[0098] Inhibition, e.g., with respect to terminal complement activity, includes at least a 5 (e.g., at least 6, 7, 8, 9, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, or 60)% decrease in terminal complement activity, e.g., in a hemolytic assay or CH50eq assay, compared to the effect of a control antibody (or antigen-binding fragment thereof) under similar conditions and at an equimolar concentration. Substantial inhibition, as used herein, refers to at least 40 (e.g., at least 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, or 95 or more)% inhibition of a given activity (e.g., terminal complement activity). In some embodiments, the anti-C5 antibodies described herein contain one or more amino acid substitutions compared to the CDRs of eculizumab (i.e., SEQ ID NOs: 1-6), but still retain at least 30 (e.g., at least 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 55, 60, 65, 70, 75, 80, 85, 90 or 95)% of the complement inhibitory activity of eculizumab in a hemolytic assay or a CH50eq assay.

[0099] The anti-C5 antibodies described herein have a serum half-life in humans that is at least 20 (e.g., at least 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, or 55) days. In another embodiment, the anti-C5 antibodies described herein have a serum half-life in humans that is at least 40 days. In another embodiment, the anti-C5 antibodies described herein have a serum half-life in humans that is approximately 43 days. In another embodiment, the anti-C5 antibodies described herein have a serum half-life in humans that is between 39 and 48 days. Methods for measuring the serum half-life of an antibody are known in the art. In some embodiments, the anti-C5 antibodies or antigen-binding fragments thereof described herein have a serum half-life that is at least 20% (e.g., at least 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 125, 150, 175, 200, 250, 300, 400, 500)% longer than the serum half-life of eculizumab, e.g., as measured in one of the mouse model systems described in the Examples (e.g., a C5-deficient / NOD / scid mouse or an hFcRn transgenic mouse model system).

[0100] In one embodiment, the antibody competes for binding to and / or binds to the same epitope on C5 as an antibody described herein. In reference to two or more antibodies, the term "binds to the same epitope" means that the antibodies bind to the same segment of amino acid residues as determined by a given method. Techniques for determining whether an antibody binds to the "same epitope on C5" as an antibody described herein include, for example, epitope mapping methods, such as x-ray analysis of crystals of antigen:antibody complexes, which provide atomic resolution of the epitope, and hydrogen / deuterium exchange mass spectrometry (HDX-MS). Other methods monitor antibody binding to peptide antigen fragments or mutated variants of the antigen, where loss of binding due to alteration of amino acid residues within the antigen sequence is often considered an indication of epitope components. Additionally, combinatorial computational methods for epitope mapping can also be used. These methods rely on the ability of an antibody of interest to affinity isolate specific short peptides from combinatorial phage display peptide libraries. Antibodies with the same VH and VL or the same CDR1, 2, and 3 sequences are predicted to bind to the same epitope.

[0101] An antibody that "competes with another antibody for binding to a target" refers to an antibody that inhibits (partially or completely) the binding of the other antibody to a target. Whether two antibodies compete with each other for binding to a target, i.e., whether and to what extent one antibody inhibits the binding of the other antibody to a target, can be determined using known competition experiments. In certain embodiments, an antibody competes with another antibody for binding to a target and inhibits the binding of the other antibody to the target by at least 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100%. The level of inhibition or competition can vary depending on which antibody is the "blocking antibody" (i.e., the cold antibody that is first incubated with the target). Competing antibodies bind to the same epitope, overlapping epitopes, or adjacent epitopes (e.g., as evidenced by steric hindrance).

[0102] The anti-C5 antibodies or antigen-binding fragments thereof described herein used in the methods described herein can be produced using a variety of art-recognized techniques. Monoclonal antibodies can be obtained by a variety of techniques known to those skilled in the art. Briefly, spleen cells from an animal immunized with a desired antigen are immortalized, typically by fusion with myeloma cells (see Kohler & Milstein, Eur. J. Immunol. 6:511-519 (1976)). Alternative methods of immortalization include transformation with Epstein-Barr virus, oncogenes, or retroviruses, or other methods known in the art. Colonies arising from a single immortalized cell are screened for the production of antibodies with the desired specificity and affinity for the antigen, and the yield of monoclonal antibodies produced by such cells can be enhanced by a variety of techniques, including injection into the peritoneal cavity of a vertebrate host. Alternatively, DNA sequences encoding monoclonal antibodies or binding fragments thereof can be isolated by screening DNA libraries derived from human B cells according to the general protocol outlined by Huse, et al., Science 246:1275-1281 (1989).

[0103] II. Composition Also provided herein are compositions comprising an anti-C5 antibody or antigen-binding fragment thereof. In one embodiment, the composition comprises an anti-C5 antibody comprising CDR1, CDR2, and CDR3 domains in a heavy chain variable region having the sequence set forth in SEQ ID NO: 12 and CDR1, CDR2, and CDR3 domains in a light chain variable region having the sequence set forth in SEQ ID NO: 8. In another embodiment, the anti-C5 antibody comprises heavy and light chains having the sequences set forth in SEQ ID NOs: 14 and 11, respectively. In another embodiment, the anti-C5 antibody comprises heavy and light chains having the sequences set forth in SEQ ID NOs: 20 and 11, respectively.

[0104] The composition can be formulated as a pharmaceutical solution for administration to a subject, for example, for the treatment or prevention of a complement-associated disorder, such as aHUS. Pharmaceutical compositions generally contain a pharmaceutically acceptable carrier. As used herein, "pharmaceutically acceptable carrier" refers to and includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like that are physiologically compatible. The composition can include pharmaceutically acceptable salts, such as acid or base addition salts, sugars, carbohydrates, polyols, and / or tonicity modifying agents.

[0105] The compositions can be formulated according to standard methods. Pharmaceutical formulation is a well-established technical field, see, for example, Gennaro (2000) "Remington: The Science and Practice of Pharmacy," 20th Edition, Lippincott, Williams & Wilkins (ISBN: 0683306472); Ansel et al. (1999) "Pharmaceutical Dosage Forms and Drug Delivery Systems," 7th Edition, Lippincott Williams & Wilkins Publishers (ISBN: 0683305727); and Kibbe (2000) "Handbook of Pharmaceutical Excipients, American Pharmaceutical Association," 3rd Edition (ISBN: 091733096X). In some embodiments, the compositions may be formulated, for example, as a buffer solution of appropriate concentration suitable for storage at 2-8°C (e.g., 4°C). In some embodiments, the compositions may be formulated for storage at temperatures below 0°C (e.g., -20°C or -80°C). In some embodiments, the compositions may be formulated for storage at 2-8°C (e.g., 4°C) for up to 2 years (e.g., 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, 1.5 years, or 2 years). Thus, in some embodiments, the compositions described herein are stable upon storage at 2-8°C (e.g., 4°C) for at least 1 year.

[0106] Pharmaceutical compositions can be in a variety of forms. These forms include, for example, liquid, semi-solid, and solid dosage forms, such as liquid solutions (e.g., injectable and infusible solutions), dispersions or suspensions, tablets, pills, powders, liposomes, and suppositories. The preferred form depends in part on the intended mode of administration and the therapeutic application. For example, compositions containing compositions intended for systemic or local delivery can be in the form of an injectable or infusible solution. Thus, the composition can be formulated for parenteral administration (e.g., intravenous, subcutaneous, intraperitoneal, or intramuscular injection). The terms "parenteral administration," "administered parenterally," and other grammatically equivalent phrases, as used herein, refer to modes of administration other than enteral and topical administration, usually by injection, including, without limitation, intravenous, intranasal, intraocular, pulmonary, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intrapulmonary, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal, epidural, intracerebral, intracranial, intracarotid, and intrasternal injection and infusion.

[0107] In one embodiment, the composition comprises ravulizumab for injection (ULTOMIRIS®, also known as antibody BNJ441 or ALXN1210). In one embodiment, the injection is a sterile, clear to translucent, slightly whitish, preservative-free solution for intravenous use. In another embodiment, each single-dose vial contains 300 mg of ravulizumab for injection at a concentration of 10 mg / mL at a pH of 7.0. In another embodiment, ravulizumab for injection requires dilution to a final concentration of 5 mg / mL. In another embodiment, each mL further comprises polysorbate 80 (0.2 mg) (vegetable origin), sodium chloride (8.77 mg), sodium monohydrogen phosphate (1.78 mg), sodium dihydrogen phosphate (0.46 mg), and distilled water for injection.

[0108] III. Treatment Methods Provided herein is a method for treating aHUS in a human patient, comprising administering to the patient an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered (or is for administration) according to a specific clinical dosage regimen (i.e., at a specific dose and according to a specific dosing schedule).

[0109] As used herein, the terms "induction" and "induction phase" are used interchangeably and refer to the first phase of treatment in a clinical trial.

[0110] As used herein, the terms "maintenance" and "maintenance phase" are used interchangeably and refer to the second phase of treatment in a clinical trial. In certain embodiments, treatment is continued as long as clinical benefit is observed or until unmanageable toxicity or disease progression occurs.

[0111] As used herein, the term "subject" or "patient" refers to a human patient (e.g., a patient with a complement-associated condition). In one embodiment, the complement-associated condition is atypical hemolytic uremic syndrome (aHUS). The pathology and clinical manifestations of patients with aHUS are also driven by terminal complement activation. More specifically, dysregulation of C5 activation and complement activation leads to endothelial damage, platelet consumption, and thrombotic microangiopathy (TMA) events characterized by thrombocytopenia, mechanical intravascular hemolysis, and kidney injury. Importantly, approximately 20% of patients also experience extrarenal manifestations of the disease, including central nervous system, cardiac, gastrointestinal, distal limb, and severe systemic organ damage (Loirat, et al., Orphanet. J. Rare Dis. 2011;6:60). Symptoms of aHUS are well known to those skilled in the art of rare disease or kidney disease medicine and include, for example, severe hypertension, proteinuria, uremia, lethargy / fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and renal dysfunction (e.g., acute renal failure).

[0112] aHUS can be hereditary, acquired, or idiopathic. aHUS can be considered hereditary if two or more (e.g., 3, 4, 5, 6, or more) members of the same family suffer from the disease at least 6 months apart, and exposure to a common precipitating agent is excluded, or if one or more aHUS-associated gene mutations (e.g., one or more mutations in CFH, MCP / CD46, CFB, or CFI) are identified in the subject. For example, the subject may have CFH-associated aHUS, CFB-associated aHUS, CFI-associated aHUS, or MCP-associated aHUS. Up to 30% of hereditary aHUS cases are associated with mutations in CFH, 12% with mutations in MCP, 5-10% with mutations in CFI, and less than 2% with mutations in CFB. Hereditary aHUS can be multiplex (i.e., familial; two or more affected family members) or simplex (i.e., a single occurrence in a family). aHUS can be considered acquired if an underlying environmental factor (e.g., a drug, systemic illness, or a viral or bacterial agent that does not result in Shiga-like exotoxin) or trigger can be identified. aHUS can be considered idiopathic if no trigger (genetic or environmental) is apparent.

[0113] Laboratory tests can be carried out to determine whether human subject has thrombocytopenia, microangiopathic hemolytic anemia or acute renal insufficiency.Thrombocytopenia can be diagnosed by medical personnel as one or more of the following: (i) platelet count is less than 150,000 / mm 3 (for example, less than 60,000 / mm 3); (ii) the platelet survival time is reduced, which reflects the enhanced destruction of platelets in circulation; and (iii) the giant platelets observed in peripheral smear, which is consistent with the secondary activation of thrombopoiesis. Microangiopathic hemolytic anemia can be diagnosed by a healthcare professional as one or more of the following: (i) a hemoglobin concentration of less than 10 mg / dL (e.g., less than 6.5 mg / dL); (ii) an elevated serum lactate dehydrogenase (LDH) concentration (>460 U / L); (iii) hyperbilirubinemia, reticulocytosis, circulating free hemoglobin, and a low or undetectable haptoglobin concentration; and (iv) detection of fragmented red blood cells (schistocytes) with the typical appearance of cuttlefish or helmet cells in a peripheral smear, along with a negative Coombs test. See, for example, Kaplan et al. (1992) "Hemolytic Uremic Syndrome and Thrombotic Thrombocytopenic Purpura," Informa Health Care (ISBN 0824786637) and Zipfel (2005) "Complement and Kidney Disease," Springer (ISBN 3764371668). Blood levels of C3 and C4 can also be used as a measure of complement activation or dysregulation. Furthermore, a subject's condition can be further characterized by identifying the subject as having one or more mutations in a gene associated with aHUS, such as CFI, CFB, CFH, or MCP (supra). Suitable methods for detecting mutations in genes include, for example, DNA sequencing and nucleic acid array technology. See, e.g., Breslin et al. (2006) Clin Am Soc Nephrol 1:88-99 and Goicoechea de Jorge et al. (2007) Proc Natl Acad Sci USA 104:240-245.

[0114] As used herein, "effective treatment" refers to treatment that produces a beneficial effect, e.g., amelioration of at least one symptom of a disease or disorder. A beneficial effect can take the form of an improvement over baseline, i.e., an improvement over measurements or observations made before initiation of treatment according to the method. For example, in the context of PNH, effective treatment can refer to a reduction in one or more symptoms selected from the group consisting of fatigue, abdominal pain, dyspnea, dysphagia, chest pain, and / or erectile dysfunction. For example, in the context of aHUS, effective treatment can refer to a reduction in one or more symptoms selected from the group consisting of severe hypertension, proteinuria, uremia, lethargy / fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and / or renal dysfunction (e.g., acute renal failure).

[0115] The term "effective amount" refers to the amount of an agent that provides a desired biological, therapeutic, and / or prophylactic result. The result can be a reduction, amelioration, alleviation, reduction, delay, and / or amelioration of one or more of the signs, symptoms, or causes of a disease, or any other desired alteration of a biological system. In one example, an "effective amount" is an amount of an anti-C5 antibody or antigen-binding fragment thereof that has been clinically proven to reduce at least one symptom of aHUS (e.g., severe hypertension, proteinuria, uremia, lethargy / fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and renal dysfunction (e.g., acute renal failure)). An effective amount can be administered in one or more administrations.

[0116] In one embodiment, the dose of the anti-C5 antibody or antigen-binding fragment thereof is based on the patient's weight. For example, in one embodiment, 2400 mg or 3000 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 kg but < 60 kg. In another embodiment, 2700 mg or 3300 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 60 kg but < 100 kg. In another embodiment, 3000 mg or 3600 mg of the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 100 kg. In certain embodiments, the dosage regimen is adjusted to provide the optimal desired response (e.g., an effective response).

[0117] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered in one or more administration cycles. In one embodiment, the administration cycle is 26 weeks. In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered once on day 1 of the administration cycle, once on day 15 of the administration cycle, and every 8 weeks thereafter. In one embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered every 8 weeks (e.g., at a dose of 3000 mg, 3300 mg, or 3600 mg) for an extension period of up to 2 years following the administration cycle.

[0118] In another embodiment, a method of treating a human patient with aHUS comprises administering to the patient, during an administration cycle, an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 heavy chain sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, and the CDR1, CDR2, and CDR3 light chain sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively, wherein the anti-C5 antibody or antigen-binding fragment thereof is (a) Once on day 1, at a dose of 2400 mg for patients weighing ≥ 40 to < 60 kg, 2700 mg for patients weighing ≥ 60 to < 100 kg, or 3000 mg for patients weighing ≥ 100 kg; (b) On day 15, and every 8 weeks thereafter, at a dose of 3000 mg for patients weighing ≥ 40 to < 60 kg, 3300 mg for patients weighing ≥ 60 to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg. A method is provided in which the

[0119] In another embodiment, a method of treating a human patient with aHUS comprises administering to the patient, during an administration cycle, an effective amount of an anti-C5 antibody or antigen-binding fragment thereof comprising the CDR1, CDR2, and CDR3 heavy chain sequences set forth in SEQ ID NOs: 19, 18, and 3, respectively, the CDR1, CDR2, and CDR3 light chain sequences set forth in SEQ ID NOs: 4, 5, and 6, respectively, and a variant human Fc constant region that binds to the human neonatal Fc receptor (FcRn), wherein the variant human Fc CH3 constant region comprises Met-429-Leu and Asn-435-Ser substitutions at residues corresponding to methionine 428 and asparagine 434, respectively, in EU numbering, of a native human IgG Fc constant region; and wherein the anti-C5 antibody or antigen-binding fragment thereof is (a) Once on day 1, at a dose of 2400 mg for patients weighing ≥ 40 to < 60 kg, 2700 mg for patients weighing ≥ 60 to < 100 kg, or 3000 mg for patients weighing ≥ 100 kg; (b) On day 15, and every 8 weeks thereafter, at a dose of 3000 mg for patients weighing ≥ 40 to < 60 kg, 3300 mg for patients weighing ≥ 60 to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg. A method is provided in which the

[0120] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 to < 60 kg. (a) at a dose of 2400 mg once on day 1 of the dosing cycle; (b) on day 15 of the treatment cycle and every 8 weeks thereafter at a dose of 3000 mg It is administered.

[0121] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 60 to < 100 kg. (a) at a dose of 2700 mg once on day 1 of the dosing cycle; (b) on day 15 of the treatment cycle and every 8 weeks thereafter at a dose of 3300 mg It is administered.

[0122] In another embodiment, the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≧100 kg. (a) at a dose of 3000 mg once on day 1 of the dosing cycle; (b) on day 15 of the treatment cycle and every 8 weeks thereafter at a dose of 3600 mg It is administered.

[0123] In some embodiments, the patient has not been previously treated with a complement inhibitor (eg, the patient is a complement inhibitor treatment naive patient).

[0124] In other embodiments, the patient has previously been treated with one anti-C5 antibody or antigen-binding fragment thereof and is switched to another anti-C5 antibody during the course of treatment. For example, in certain embodiments, different anti-C5 antibodies are administered during the course of treatment. In one embodiment, different anti-C5 antibodies are administered during separate treatment and extension periods. For example, in one embodiment, the patient is treated with eculizumab for a treatment period (e.g., 26 weeks), and then treated with another anti-C5 antibody (e.g., ravulizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody), for example, during an extension period. In another embodiment, eculizumab is administered to a patient at a dose of 600 mg on days 1, 8, 15, and 22 of a dosing cycle during an induction phase, followed by a maintenance dose of 900 mg eculizumab on day 19 of the dosing cycle and every two weeks thereafter (e.g., for a total of 26 weeks), followed by treatment with ravulizumab for an extension period of up to two years. In another embodiment, a patient is treated with ravulizumab (e.g., for 26 weeks), and then treated with another anti-C5 antibody (e.g., eculizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody), for example, during an extension period.

[0125] Exemplary alternative anti-C5 antibodies include (i) ravulizumab, (ii) an antibody or antigen-binding fragment thereof comprising heavy chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 21, 22, and 23, respectively, and light chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 24, 25, and 26, respectively, (iii) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO: 27 and a light chain variable region comprising SEQ ID NO: 28, (iv) an antibody or antigen-binding fragment thereof comprising heavy chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 29, 30, and 31, respectively, and light chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 32, 33, and 34, respectively, and (v) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO: 35 and a light chain variable region comprising SEQ ID NO: 36, respectively. (vi) an antibody or antigen-binding fragment thereof comprising heavy chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 37, 38, and 39, respectively, and light chain CDR1, CDR2, and CDR3 domains comprising SEQ ID NOs: 40, 41, and 42, respectively; (vii) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO: 43 and a light chain variable region comprising SEQ ID NO: 44; (viii) an antibody or antigen-binding fragment thereof comprising a heavy chain comprising SEQ ID NO: 45 and a light chain comprising SEQ ID NO: 46; (ix) an antibody or antigen-binding fragment thereof comprising a heavy chain variable region comprising SEQ ID NO: 47 and a light chain variable region comprising SEQ ID NO: 48; and (x) an antibody or antigen-binding fragment thereof comprising a heavy chain comprising SEQ ID NO: 49 and a light chain comprising SEQ ID NO: 50.

[0126] In some embodiments, the patient has been previously treated with an anti-C5 antibody or antigen-binding fragment thereof (e.g., eculizumab) for at least 1 month, at least 2 months, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 7 months, at least 8 months, at least 9 months, at least 10 months, at least 11 months, at least 12 months, at least 18 months, or at least 24 months before switching to another anti-C5 antibody or antigen-binding fragment thereof (e.g., ravulizumab). In certain embodiments, the patient has been previously treated with eculizumab for at least 6 months.

[0127] In another embodiment, when a patient (e.g., an aHUS patient) is treated with a first anti-C5 antibody and then switched to treatment with a second, different anti-C5 antibody, particularly when the second, different anti-C5 antibody binds to a different epitope on C5 than the first anti-C5 antibody, the administration schedule takes into account the half-life of the first anti-C5 antibody. For example, the half-life of the first anti-C5 antibody is taken into account to ensure that the first anti-C5 antibody is removed (e.g., "washed out") from the patient before the second (different) anti-C5 antibody is administered (e.g., to avoid problems associated with aggregation, immune complex formation, etc.). In one embodiment, the second (different) anti-C5 antibody is not administered until a period of time equivalent to 2, 2.5, 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, 7, or 7.5 half-lives of the first anti-C5 antibody has elapsed after the final administration of the first anti-C5 antibody.

[0128] In another embodiment, the patient has previously been treated with eculizumab and is then switched to treatment with a second (different) anti-C5 antibody (e.g., ravulizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In one embodiment in which eculizumab is the first antibody administered, the second (different) anti-C5 antibody is not administered until, for example, at least 36, 45, 54, 63, 72, 81, 90, 99, 108, 117, or 126 days after the last administration of eculizumab.

[0129] In another embodiment, the patient has previously been treated with ravulizumab and is then switched to treatment with a different anti-C5 antibody (e.g., eculizumab, 7086 antibody, 8110 antibody, 305LO5 antibody, SKY59 antibody, or REGN3918 antibody). In one embodiment in which ravulizumab is the first antibody administered, the second (different) anti-C5 antibody is not administered until, for example, at least 100, 125, 150, 175, 200, 225, 250, 275, 300, 325, 375, or 400 days after the last administration of ravulizumab.

[0130] Additionally or alternatively, techniques are used to remove or enhance the clearance of the first anti-C5 antibody before switching to treatment with a second (different) anti-C5 antibody. Exemplary techniques include, but are not limited to, plasmapheresis or transfusion. In another embodiment, an antibody against the first anti-C5 antibody is administered to remove or enhance the clearance of the first anti-C5 antibody (e.g., anti-eculizumab antibody, anti-ravulizumab antibody, anti-7086 antibody, anti-8110 antibody, anti-305LO5 antibody, anti-SKY59 antibody, or anti-REGN3918 antibody) before the second (different) anti-C5 antibody is administered.

[0131] In another embodiment, an anti-C5 antibody or antigen-binding fragment thereof (e.g., ravulizumab) is administered to a patient and the administration cycle begins at least about 2 weeks, at least about 3 weeks, at least about 4 weeks, at least about 6 weeks, at least about 7 weeks, or at least about 8 weeks after the patient's last dose of eculizumab. In another embodiment, an anti-C5 antibody or antigen-binding fragment thereof (e.g., ravulizumab) is administered to a patient and the administration cycle begins at least 2 weeks after the patient's last dose of eculizumab.

[0132] In some embodiments, patients treated according to the methods described herein have been vaccinated against meningococcal infection within three years prior to or at the time of initiating treatment. In one embodiment, patients treated less than two weeks after receiving a meningococcal vaccine are also treated with appropriate prophylactic antibiotics up to two weeks after vaccination. In another embodiment, patients treated according to the methods described herein are vaccinated against meningococcal serogroups A, C, Y, W135, and / or B.

[0133] As used herein, the term "serum trough level" refers to the lowest level at which a drug (e.g., an anti-C5 antibody or its antigen-binding fragment) or medicine is present in serum. In contrast, "peak serum level" refers to the highest level of a drug in serum. "Mean serum level" refers to the average level of a drug in serum over time.

[0134] In one embodiment, the described treatment regimen is sufficient to maintain a particular serum trough concentration of an anti-C5 antibody or antigen-binding fragment thereof. For example, in one embodiment, the treatment is for a period of 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 200, 205, 210, 215, 220, 225, 230, 240, 245, 250, 255, 260, 265, 270, 275, 280, 285, 290, 300, 310, 315, 320, 325, 330, 340, 345, 350, 360, 370, 380, 390, 400, 410, 420, 430, 440, 450, 460, 470, 480, 490, 510, 520, 530, 540, 550, 560, 570, 580, 590, 610, 620, 630, 640, 650, 660, 670, 680, 690, 710, 720, 730, 740, 750, 760, 770 The treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 50, 255, 260, 265, 270, 280, 290, 300, 305, 310, 315, 320, 325, 330, 335, 340, 345, 350, 355, 360, 365, 370, 375, 380, 385, 390, 395, or 400 μg / ml or higher. In one embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 100 μg / ml or higher. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 150 μg / ml or higher. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 200 μg / ml or higher. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 250 μg / ml or higher. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at 300 μg / ml or higher. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof between 100 μg / ml and 200 μg / ml. In another embodiment, the treatment maintains a serum trough concentration of the anti-C5 antibody or antigen-binding fragment thereof at about 175 μg / ml.

[0135] In another embodiment, to achieve an effective response, the anti-C5 antibody needs to be administered at least 50 μg, 55 μg, 60 μg, 65 μg, 70 μg, 75 μg, 80 μg, 85 μg, 90 μg, 95 μg, 100 μg, 105 μg, 110 μg, 115 μg, 120 μg, 125 μg, 130 μg, 135 μg, 140 μg, 145 μg, 150 μg, 160 μg, 170 μg, 175 μg, 180 μg, 185 μg, 190 μg, 200 μg, 210 μg, 220 μg, 230 μg, 240 μg, 250 μg, 260 μg, 270 μg, 280 μg, 290 μg, 300 μg, 310 μg, 320 μg, 330 μg, 340 μg, 350 μg, 360 μg, 370 μg, 380 μg, 390 μg, 400 μg, 410 μg, 420 μg, 430 μg, 440 μg, 450 μg, 460 μg, 470 μg, 480 μg, 490 μg, 500 μg, 510 μg, 520 μg, 530 μg, 540 μg, 550 μg, 560 μg, 570 μg, 580 μg, 590 μg, 600 μg, 610 μg, 620 μg, 630 μg, 6 In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency to maintain a C5 antibody level between 50 μg and 250 μg per milliliter of blood. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency to maintain a C5 antibody level between 100 μg and 200 μg per milliliter of blood. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency to maintain about 175 μg of antibody per milliliter of blood in the patient.

[0136] In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency sufficient to maintain a minimum free C5 concentration to achieve an effective response. For example, in one embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency sufficient to maintain a free C5 concentration of 0.2 μg / mL, 0.3 μg / mL, 0.4 μg / mL, 0.5 μg / mL, or less. In another embodiment, the anti-C5 antibody is administered to the patient in an amount and frequency sufficient to maintain a free C5 concentration of 0.309-0.5 μg / mL or less. In another embodiment, the treatment described herein reduces free C5 concentrations by greater than 99% throughout the treatment period. In another embodiment, the treatment reduces free C5 concentrations by greater than 99.5% throughout the treatment period.

[0137] IV. Outcome Provided herein are methods for treating aHUS in a patient, the methods comprising administering to the patient an anti-C5 antibody or antigen-binding fragment thereof.

[0138] Symptoms of aHUS include, but are not limited to, severe hypertension, proteinuria, uremia, lethargy / fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, and renal dysfunction (e.g., acute renal failure). Patients treated according to the methods disclosed herein preferably experience improvement in at least one symptom of aHUS.

[0139] In other embodiments, the treatment results in terminal complement inhibition.

[0140] In other embodiments, treatment results in a shift toward normal levels of hemolysis-related hematological biomarkers selected from the group consisting of free hemoglobin, haptoglobin, reticulocyte count, PNH red blood cell (RBC) clone, and D-dimer.

[0141] In another embodiment, treatment results in an increase in hemoglobin stabilization from the patient's pre-treatment baseline. In another embodiment, treatment results in an increase in hemoglobin of ≧20 g / dL. In another embodiment, treatment results in the prevention of a decrease in hemoglobin levels of ≧2 g / dL from baseline in the absence of transfusions from baseline to day 183.

[0142] In other embodiments, treatment results in platelet normalization (≥ 150 x 10 9 In other embodiments, treatment results in platelet normalization (≧150×10 / L) for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years). 9 / L) as a result.

[0143] In other embodiments, treatment results in LDH normalization (≦246 U / L). In other embodiments, treatment results in LDH normalization (≦246 U / L) for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

[0144] In other embodiments, treatment results in a ≧25% improvement from baseline in serum creatinine. In other embodiments, treatment results in a ≧25% improvement from baseline in serum creatinine for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

[0145] In other embodiments, treatment is defined as achieving a complete TMA response (i.e., platelet normalization (≥ 150 x 10 9 / L), LDH normalization (≦246 U / L), and a ≧25% improvement from baseline in serum creatinine. In other embodiments, the treatment results in a complete TMA response for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

[0146] In other embodiments, treatment is achieved by modifying complete TMA response (i.e., platelet normalization (≥ 150 x 10 9 / L), LDH normalization (≦246 U / L), and, if the patient is on dialysis at baseline, a ≧25% improvement from baseline in serum creatinine for patients discontinued from dialysis or discontinued from dialysis at baseline. In other embodiments, treatment results in a modified complete TMA response for at least 28 days (e.g., at least 28 days, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year, or 2 years).

[0147] In other embodiments, treatment results in a reduction in the need for transfusions. In another embodiment, treatment results in a greater than 70% increase in transfusion avoidance. In another embodiment, treatment results in transfusion avoidance from baseline to day 183.

[0148] In other embodiments, treatment results in the elimination of breakthrough hemolysis during the treatment period, hi another embodiment, treatment results in a reduction in breakthrough hemolysis compared to the pre-treatment baseline amount of breakthrough hemolysis.

[0149] In other embodiments, treatment results in a reduction in major adverse vascular events (MAVE).

[0150] In other embodiments, treatment results in a change from baseline in quality of life as assessed via the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale, version 4 and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 scale. In one embodiment, treatment results in a change from baseline in quality of life as assessed via the FACIT-Fatigue scale of one or more (e.g., 1, 2, or 3) points. In another embodiment, treatment is initiated 150 days or more (e.g., 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 2010, 2011, 2012, 2013, 2014, 2015, 2016, 2017, 2018, 2020, 2021, 2022, 2023, 2024, 2025, 2026, 2027, 2028, 2029, 210, 2110, 2120, 2130, 2140, 2151, 2152, 2153, 2160, 2161, 2162, 2163, 2164, 2165, 2166, 2167, 2168, 2169, 220, 2211, 222 Change from baseline in quality of life, as assessed via the 3-point FACIT-Fatigue scale, after 80, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 205, 210, 215, 220, or 225 days.

[0151] Chronic kidney disease (CKD) stages are classified based on the National Kidney Foundation's Chronic Kidney Disease Stages. CKD stages and corresponding estimated glomerular filtration rate (eGFR) values ​​are as follows: Stage 1: eGFR >= 90 (normal), Stage 2: eGFR 60-89, Stage 3A: eGFR 45-59, Stage 3B: eGFR 30-44, Stage 4: eGFR 15-29, and Stage 5: eGFR < 15 (including end-of-life dialysis). Stage 1 is considered the highest category. Stage 5 is considered the worst category. An improvement in eGFR (e.g., > 15) corresponds to an improvement in CKD stage (e.g., a lower CKD stage). Thus, in other embodiments, the patient's chronic kidney disease (CKD) improves by one or more stages after initiation of treatment. For example, the patient's CKD improves by 1, 2, 3, 4, or 5 stages. In another embodiment, the patient's CKD has progressed beyond 150 days or more (e.g., 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 2010, 2011, 2012, 2013, 2014, 2015, 2016, 2017, 2018, 2019, 210, 2110, 2120, 2130, 2140, 2151, 2152, 2161, 2162, 2163, 2164, 2165, 2166, 2177, 2178, 2180, 2181, 2182, 2183, 2184, 2185, 2186, 2187, 2188, 2189, 2200, 2201, 2202, 6 days, 177 days, 178 days, 179 days, 180 days, 181 days, 182 days, 183 days, 184 days, 185 days, 186 days, 187 days, 188 days, 189 days, 190 days, 191 days, 192 days, 193 days, 194 days, 195 days, 196 days, 197 days, 198 days, 199 days, 200 days, 205 days, 210 days, 215 days, 220 days, or 225 days) to improve by one or more stages.

[0152] In other embodiments, treatment results in an increase in eGFR compared to baseline. In other embodiments, treatment results in a shift in eGFR toward normal levels (e.g., ≧90). In other embodiments, treatment results in an increase in eGFR compared to baseline and the patient's CKD improves by one or more stages. In other embodiments, treatment results in a shift in eGFR toward normal levels (e.g., ≧90) compared to baseline and the patient's CKD improves by one or more stages.

[0153] In other embodiments, the treatment results in an EQ-5D-3L US Time Trade-Off Value Set (US TTO) of >0.94.

[0154] V. Kits and Unit Dosage Forms Also provided herein is a kit containing a pharmaceutical composition containing an anti-C5 antibody or antigen-binding fragment thereof, e.g., ravulizumab, in a therapeutically effective amount adapted for use in the methods described herein, and a pharmaceutically acceptable carrier. The kit may also optionally include instructions, including, for example, an administration schedule, to enable a practitioner (e.g., a doctor, a nurse, or a patient) to administer the composition contained therein to a patient with aHUS. The kit may also include a syringe.

[0155] If desired, the kit includes multiple packages of single-dose pharmaceutical compositions, each containing an effective amount of an anti-C5 antibody or antigen-binding fragment thereof, for single administration according to the method provided above. The equipment or device necessary for administering the pharmaceutical composition(s) may also be included in the kit. For example, the kit may provide one or more pre-filled syringes containing a certain amount of an anti-C5 antibody or antigen-binding fragment thereof.

[0156] In one embodiment, the present invention provides a kit for treating aHUS in a human patient, comprising: (a) a dose of an anti-C5 antibody or antigen-binding fragment thereof, comprising the CDR1, CDR2, and CDR3 domains of a heavy chain variable region having the sequence set forth in SEQ ID NO: 12 and the CDR1, CDR2, and CDR3 domains of a light chain variable region having the sequence set forth in SEQ ID NO: 8; and (b) instructions for using the anti-C5 antibody or antigen-binding fragment thereof according to any of the methods described herein; A kit comprising:

[0157] In one embodiment, the kit comprises a dose of an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 40 to < 60 kg: (a) at a dose of 2400 mg once on day 1; (b) on day 15 and every 8 weeks thereafter at a dose of 3000 mg It is administered.

[0158] In another embodiment, the kit comprises a dose of an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 60 to < 100 kg: (a) at a dose of 2700 mg once on day 1; (b) on day 15 and every 8 weeks thereafter at a dose of 3300 mg It is administered.

[0159] In another embodiment, the kit comprises a dose of an anti-C5 antibody or antigen-binding fragment thereof, wherein the anti-C5 antibody or antigen-binding fragment thereof is administered to a patient weighing ≥ 100 kg: (a) at a dose of 3000 mg once on day 1; (b) on day 15 and every 8 weeks thereafter at a dose of 3600 mg It is administered.

[0160] Since numerous variations and equivalents will become apparent to those of skill in the art upon reading this disclosure, the following examples are illustrative only and should not be construed as limiting the scope of the disclosure in any way.

[0161] The contents of all references, Genbank entries, patents and published patent applications cited throughout this application are hereby expressly incorporated by reference. [Example]

[0162] Example 1: Phase III, Single-Arm, Multicenter Study of Ravulizumab (ALXN1210) in Complement Inhibitor-Naive Adult Patients with Atypical Hemolytic Uremic Syndrome (aHUS) A single-arm study (ALXN1210 aHUS 311) of ravulizumab will be conducted in complement inhibitor treatment-naive adult and adolescent patients with atypical hemolytic uremic syndrome (aHUS). The study design is illustrated in Figure 1.

[0163] aHUS is often caused by mutations in genes encoding proteins involved in the alternative complement pathway (APC), thrombotic microangiopathy (TMA), or autoantibodies against APC regulatory proteins (Noris, et al., Clin. J. Am. Soc. Nephrol. 2010;5:1844-59). Patients with aHUS are at risk for life-threatening manifestations of the disease due to endothelial injury, including thrombocytopenia, intravascular hemolysis, acute renal failure, and extrarenal tissue damage. Importantly, approximately 20% of patients develop extrarenal manifestations of the disease, including central nervous system, cardiac, GI, distal limb, and severe systemic organ damage (Loirat, et al., Orphanet J. Rare Dis. 2011;6:60 and Brodsky, Blood. 2015;126:2459-65). Before eculizumab became available, the mortality rate for patients with aHUS was as high as 15% during the acute, progressive phase of the disease (Noris, et al., Clin. J. Am. Soc. Nephrol. 2010;5:1844-59) and Sellier-Leclerc, J. Am. Soc. Nephrol. 2007;18:2392-2400). Up to 50% of patients progress to end-stage renal disease (ESKD), often within one year of disease onset, requiring dialysis or kidney transplantation to sustain life. Chronic, uncontrolled terminal complement activation, specifically activation of complement component 5 (C5) and dysregulation of complement activity, is central to the pathogenesis of aHUS and its devastating manifestations. Consequently, targeted blockade of C5 using selective inhibition of C5a and C5b-9 production represents an important therapeutic mechanism for treatment.

[0164] 1. Purpose The primary objective of this study was to evaluate the efficacy of ravulizumab to inhibit complement-mediated TMA, characterized by thrombocytopenia, hemolysis, and nephropathy, in adolescent and adult patients with aHUS who were treatment-naive with complement inhibitors.

[0165] Secondary objectives of the study are: (1) to characterize the safety and tolerability of ULTOMIRIS in this patient population; (2) to evaluate the efficacy of ULTOMIRIS on additional measures (e.g., dialysis requirement, time to complete TMA response, status of complete TMA response over time, observed and change from baseline in estimated glomerular filtration rate (eGFR); stage of chronic kidney disease (CKD) (assessed at the selected target date and categorized as improved, stable (no change), or worsening compared to baseline); observed and change from baseline in blood parameters (platelets, LDH, hemoglobin); an increase of 20 g / L or more from baseline in hemoglobin (sustained over at least two consecutive measurements taken at least 4 weeks apart); and change from baseline in quality of life (QoL) (EuroQol 5 dimensions 3). (3) to characterize the PK / pharmacodynamics (PD) of ULTOMIRIS by changes in serum ULTOMIRIS concentrations over time and changes in free C5 concentrations over time; and (4) to evaluate the long-term safety and efficacy of ULTOMIRIS.

[0166] 2. Evaluation items The primary, secondary, and safety endpoints of this study are summarized in Figure 2. The primary efficacy endpoint was complete TMA response during the 26-week initial evaluation period, evidenced by normalization of hematological parameters (platelet count and LDH) and a 25% or greater improvement from baseline in serum creatinine, confirmed by two consecutive measurements taken at least 4 weeks apart.

[0167] Secondary efficacy endpoints of the study include: A. Whether or not your condition requires dialysis; B. Time to complete TMA response; C. Complete TMA response status over time; D. Observed eGFR and change from baseline; E. CKD stage assessed by the investigator on the selection target date and classified as improved, stable (no change), or worsening compared to baseline; F. Observed values ​​and changes from baseline of blood parameters (platelets, LDH, hemoglobin); G. An increase of 20 g / L or more from baseline in hemoglobin sustained over at least two consecutive measurements taken at least 4 weeks apart; H. Change from baseline in QoL as measured by the EQ-5D-3L questionnaire (all patients), the FACIT Fatigue Version 4 questionnaire (patients aged 18 years and older), and the Pediatric FACIT Fatigue questionnaire (patients under 18 years).

[0168] The pharmacokinetic (PK) and pharmacodynamic (PD) endpoints of this study are the change in serum ravulizumab concentration over time and the change in free C5 concentration over time.

[0169] The safety and tolerability of ULTOMIRIS will be assessed by physical examination, vital signs, electrocardiogram (ECG), laboratory evaluations, and the incidence of AEs and SAEs. The proportion of patients who develop anti-drug antibodies (ADAs) will also be assessed.

[0170] Exploratory biomarkers of PD efficacy include, but are not limited to, changes from baseline in levels of markers of complement dysregulation (e.g., Ba factor), markers of vascular inflammation (e.g., soluble tumor necrosis factor receptor 1 [sTNFR1]), markers of endothelial activation / damage (e.g., soluble vascular adhesion molecule 1 [sVCAM1], thrombomodulin), markers of coagulation (e.g., D-dimer), and markers of renal injury (e.g., cystatin C). Additional assessments may include measurement of urinary ravulizumab excretion, chicken red blood cell (cRBC) hemolysis, total C5, autoantibodies to complement proteins (e.g., anti-factor H), and APC activity (e.g., modified Ham's test, complement deposition assay).

[0171] Exploratory genetics may be performed to investigate genetic variants in genes known to be associated with aHUS, as well as to identify novel genetic variants associated with aHUS, complement dysregulation, or the metabolism or efficacy of ULTOMIRIS. Patients may opt out of providing samples for exploratory genetics and still participate in the study.

[0172] 3. Summary of study design The ALXN1210-aHUS-311 study is a Phase 3, open-label, single-arm, multicenter study to evaluate the safety and efficacy of ULTOMIRIS administered by intravenous (IV) infusion to adolescent (ages 12 to <18 years) and adult (ages 18 years or older) patients with aHUS. The study will enroll approximately 55 patients who will receive ULTOMIRIS. The study design is illustrated in Figure 1. All patients will be complement inhibitor treatment-naïve and will include at least six and up to ten adolescent (ages 12 to <18 years at screening) patients and at least ten and up to 25 patients who have received a previous kidney transplant.

[0173] The study consists of a screening period of up to 7 days, an initial evaluation period of 26 weeks, and an extension period of up to 2 years. Dosing is based on the patient's weight at their last recorded study visit (Table 5). Patients will receive a loading dose of ULTOMIRIS IV on Day 1 (2400 mg for patients weighing 40 kg to < 60 kg, 2700 mg for patients weighing 60 kg to < 100 kg, and 3000 mg for patients weighing 100 kg or greater), followed by maintenance doses of ULTOMIRIS IV on Day 15 and every 8 weeks thereafter (3000 mg for patients weighing 40 kg to < 60 kg, 3300 mg for patients weighing 60 kg to < 100 kg, and 3600 mg for patients weighing 100 kg or greater) for a total of 26 weeks of treatment. After the initial evaluation period, patients will enter an extension period in which they will receive ULTOMIRIS until the product is registered or approved (according to country-specific regulations) or for up to two years, whichever comes first. The end of the study will be defined as the last patient's final visit.

[0174] This Phase 3, open-label, single-arm study will evaluate the safety and efficacy of treatment with ULTOMIRIS. While no formal comparative analyses are planned for this study, results from patients treated with ULTOMIRIS will be evaluated against those observed in patients treated with eculizumab, a historical control group. The historical control group consists of patients with aHUS who were treated with eculizumab in the C08-002A / B, C10-003, and C10-004 prospective registration studies, which had similar study design and objective operational characteristics that may affect effect sizes. Furthermore, to further align with the eligibility criteria for this study, the control group is limited to patients aged 12 years or older who had PE / PI for 4 weeks or less prior to treatment with eculizumab.

[0175] The schedule of assessments for the screening and initial evaluation period is shown in Table 1. The schedule of assessments for the extension period is shown in Table 2. Additional (unscheduled) visits beyond the scheduled visits were permitted at the discretion of the investigator. Procedures, tests, and assessments were performed at the discretion of the investigator. Any tests, procedures, or assessments performed at unscheduled visits were recorded on the electronic case report form (eCRF). Testing at unscheduled visits would use local laboratory or central laboratory analysis. However, local laboratory testing should be used, and duplicate samples would be collected for central laboratory testing at unscheduled visits.

[0176] Table 1: Study Visit and Assessment Schedule: Screening through the End of the Initial Assessment Period [Table 1-1] [Table 1-2] [Table 1-3] [Table 1-4] Abbreviations: ADA = anti-drug antibodies; ADAMTS13 = a disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13; aHUS = atypical hemolytic uremic syndrome; APC = alternative complement pathway; ECG = electrocardiogram; EQ-5D-3L = EuroQol 5 dimensions 3 level; ET = early discontinuation; FACIT = functional assessment of chronic illness treatment; HUS = hemolytic uremic syndrome; LDH = lactate dehydrogenase; N / A = not applicable; PD = pharmacodynamics; PK = pharmacokinetics; QoL = quality of life; ST-HUS = Shiga toxin-associated hemolytic uremic syndrome. a All patients will have been vaccinated against meningococcal infection within 3 years prior to or at the time of study drug initiation. Patients who begin study drug treatment less than 2 weeks after receiving meningococcal vaccine will receive appropriate prophylactic antibiotic treatment until 2 weeks after vaccination. Patients who have not been vaccinated before starting ULTOMIRIS treatment will receive prophylactic antibiotic treatment before and for at least 2 weeks after receiving meningococcal vaccination. b Human immunodeficiency virus type 1 and human immunodeficiency virus type 2 screening. c Stool samples for Shiga toxin enzyme immunoassay. d Female patients of childbearing potential only. Serum pregnancy test at screening and day 183; urine pregnancy test at all other required time points. A negative urine test result is required before administering study drug to female patients of childbearing potential at any potential study visit. e For patients 18 years of age and older, use the FACIT-Fatigue version 4 at screening. For patients under 18 years of age, use the Pediatric FACIT-Fatigue at screening. f On dosing days, a patient-reported assessment will be performed prior to dosing. g The abbreviated physical examination consists of a body system-related examination based on the investigator's (or designee's) judgment and the patient's symptoms. The abbreviated physical examination will examine at least one body system. hVital sign measurements are obtained after the patient has rested for at least 5 minutes and include systolic and diastolic BP (millimeters of mercury [mmHg]), pulse oximetry, heart rate (beats / min), respiratory rate (breaths / min), and oral or tympanic temperature (in degrees Celsius [°C] or degrees Fahrenheit [°F]). On dosing days, vital signs are obtained before dosing. i A single 12-lead ECG will be obtained at screening, day 57, and before dosing on day 183. Patients will be in a supine position for approximately 5-10 minutes before ECG collection and will remain supine but awake during ECG collection. j Clinical safety laboratory measurements will be taken pre-dose on the day of dosing. LDH for eligibility will be determined from chemical assessment. Follicle-stimulating hormone levels will be measured during screening only to confirm postmenopausal status. k Serum samples for LDH isoenzyme testing will be collected at any / all time points prior to ULTOMIRIS dosing only at selected centers, depending on sample testing availability. l Evaluation of safety, as well as primary and secondary endpoints. m Serum samples for PK / PD analysis will be collected pre-dose (within 0.5 hours before the start of the infusion) and at the end of infusion (EOI) (within 0.5 hours after the EOI) on Days 1, 15, 71, and 127; and at any time on Days 29, 43, 57, 85, 99, 113, 141, 155, and 169; and pre-dose on Day 183 (note that an additional sample for PK / PD will be collected on Day 183 as part of the extension period). The end-of-infusion sample will be collected from the patient's contralateral, non-infused arm. All collection times will be recorded on the eCRF. n Urine samples for drug determination will be collected at the end of infusion (EOI) on days 1, 15, and 71 (within 0.5 hours after EOI); and at any time point on day 29. oSerum samples will be collected pre-dose on dosing days and at random times on non-dose days. All collection times will be recorded on the eCRF. p Serum, plasma, and urine collections for exploratory biomarker analysis will be performed at baseline and at post-treatment time points immediately prior to ravulizumab dosing. q A single whole blood draw from patients who consent to genetic testing can be performed at any time during the study. r ADA serum samples will be collected pre-dose on Days 1, 71, and 127. The Day 183 collection will occur prior to the first dose of the extension period. All collection times will be recorded on the eCRF. If the test result is positive, the test will be repeated every 3 months until the result becomes negative or stabilizes based on measured potency and safety assessments. s Concomitant medications must be collected at all study visits and checked against a list of prohibited medications. t The dose of ULTOMIRIS will be based on the patient's weight at their last recorded study visit. u Local or central laboratory analysis may be used to determine eligibility at screening; however, if local laboratory testing is used, duplicate samples for LDH, platelet count, hemoglobin, and serum creatinine will be collected at that visit for central laboratory testing. v The primary efficacy endpoint will be assessed prior to dosing on Day 183, which marks the start of the extension period.

[0177] Table 2: Study Visit and Assessment Schedule: Extension Period [Table 2-1] [Table 2-2] Abbreviations: ADA = anti-drug antibodies; aHUS = atypical hemolytic uremic syndrome; ECG = electrocardiogram; EOS = end of study; EQ-5D = EuroQol 5 dimensions; ET = early discontinuation; FACIT = Functional Assessment of Chronic Illness Therapy; PD = pharmacodynamics; PK = pharmacokinetics; QoL = quality of life. a Female patients of childbearing potential only. Serum pregnancy test at ET only; urine pregnancy test at all other required time points. A negative urine test result is required prior to administration of ULTOMIRIS to female patients of childbearing potential at the indicated study visit. b For patients 18 years of age and older, use the FACIT-Fatigue version 4 at screening. For patients under 18 years of age, use the Pediatric FACIT-Fatigue at screening. c On dosing days, a patient-reported assessment will be performed prior to dosing. d The brief physical examination will consist of a body system-related examination based on the investigator's judgment and the patient's symptoms. e Vital sign measurements are obtained after the patient has rested for at least 5 minutes and include systolic and diastolic BP (millimeters of mercury [mmHg]), pulse oximetry, heart rate (beats / min), respiratory rate (breaths / min), and oral or tympanic temperature (in degrees Celsius [°C] or degrees Fahrenheit [°F]). On dosing days, vital signs are obtained before dosing. f A single 12-lead ECG is obtained on day 911 or at ET. Patients must be supine for approximately 5-10 minutes before ECG collection and must remain supine but awake during ECG collection. g Evaluation of safety, as well as primary and secondary endpoints. hSerum samples for PK / PD analysis will be collected pre-dose (within 0.5 hours before the start of the infusion) and EOI (within 0.5 hours after the EOI) on Days 351, 575, and 743; EOI (within 0.5 hours after the EOI) on Day 183; and any time point or ET on Day 911. End-of-infusion samples will be collected from the patient's contralateral, non-infused arm. All collection times will be recorded on the eCRF. i Serum, plasma, and urine for exploratory biomarker analysis will be collected immediately prior to ravulizumab dosing at the indicated time points; and at any time point or ET on Day 911. All collection times will be recorded on the eCRF. j Pre-dose serum samples will be collected on days 351, 575, and 743. Serum samples will also be collected at any time on day 911 or at ET. All collection times will be recorded on the eCRF. If the test result is positive, the test will be repeated every 3 months until the result becomes negative or stabilizes based on measured potency and safety assessments. k Concomitant medications will be collected at all study visits and checked against a list of prohibited medications. l The extension period begins at the start of dosing on Day 183. ULTOMIRIS dose is based on the patient's weight at their last recorded study visit.

[0178] 4. Study population A total of approximately 55 patients with documented aHUS will be enrolled and assigned to treatment with ULTOMIRIS at approximately 200 study sites worldwide. The study will enroll at least six and up to 10 adolescent (ages 12 to under 18 at screening) patients with a previous kidney transplant and at least 10 and up to 25 patients.

[0179] Individuals who do not meet the criteria for inclusion in the study (screening failures) may be rescreened. Patients may be rescreened a maximum of two times. Future approval of protocol deviations to recruitment and enrollment criteria, also known as protocol waivers or exemptions, will not be permitted.

[0180] A summary of the inclusion and exclusion criteria is shown in Figure 3. Patients were eligible for enrollment in the study if they met all of the following criteria and none of the exclusion criteria:

[0181] Male or female patients aged 12 years or older and weighing 40 kg or more at the time of consent. Thrombocytopenia, evidence of hemolysis, and evidence of TMA, including renal insufficiency, based on the following screening visit laboratory findings: platelet count less than 150,000 / microliter (μL), LDH ≥ 1.5 × upper limit of normal (ULN), and hemoglobin ≤ age- and sex-specific lower limit of normal (LLN), and serum creatinine level ≥ ULN for adults (18 years and older) or ≥ 97.5th percentile for age at screening for adolescents (12 to < 18 years). (Patients requiring dialysis for acute kidney injury are also eligible.) Among patients undergoing kidney transplantation: known history of aHUS before current kidney transplant or no known history of aHUS and persistent evidence of TMA for a minimum of 4 days and a maximum of 7 days after temporary discontinuation of calcineurin inhibitors (CNIs; e.g., cyclosporine, tacrolimus) or mammalian target of rapamycin inhibitors (mTORi; e.g., sirolimus, everolimus). Among patients who developed postpartum TMA, evidence of persistent TMA for >3 days from the day of delivery. To reduce the risk of meningococcal infection (Neisseria meningitidis), all patients will be vaccinated against meningococcal infection within 3 years prior to or at the time of starting study drug. Patients who begin treatment with ULTOMIRIS less than 2 weeks after receiving a meningococcal vaccine will receive appropriate prophylactic antibiotic treatment up to 2 weeks after vaccination. Patients who have not been vaccinated before starting treatment with ULTOMIRIS will receive prophylactic antibiotic treatment before and for at least 2 weeks after receiving a meningococcal vaccine. Patients under the age of 18 must be vaccinated against Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae according to national and local vaccination schedule guidelines. Female patients of childbearing potential and male patients with female partners of childbearing potential must follow protocol-specified guidance to avoid pregnancy while undergoing treatment and for 8 months after the last dose of study drug. Be willing and able to provide written informed consent and comply with the study visit schedule. For patients under 18 years of age, the patient's legal guardian must be willing and able to provide written informed consent, and the patient must be willing to provide written informed consent.

[0182] Samples collected at screening can be tested either at each site or at a central laboratory. If local testing is used for LDH, platelet count, hemoglobin, and serum creatinine, duplicate samples will be collected for central laboratory testing to ensure that the baseline and post-baseline measurements for analysis are from the central laboratory. While local laboratory test results can be used to expedite the assessment of eligibility, the final determination of these inclusion criteria will be based on the central laboratory results.

[0183] Patients will be excluded from study enrollment if they meet any of the following criteria: A. Known "A disintegrin and metalloproteinase with thrombospondin type 1 motif, member 13" (ADAMTS13) deficiency (activity <5%). B. Shiga toxin-associated hemolytic uremic syndrome (ST-HUS). C. Streptococcus pneumoniae-associated hemolytic uremic syndrome (HUS) evidenced by a positive direct Coombs test and infection with Streptococcus pneumoniae (e.g., culture, antigen test). D. Known human immunodeficiency virus (HIV) infection. E. Unresolved systemic meningococcal disease. F. Patients with an ongoing confirmed diagnosis of sepsis, defined as a positive blood culture within 7 days prior to the start of screening and not treated with antibiotics. G. Presence or suspicion of an active, untreated systemic bacterial infection that, in the opinion of the investigator, may confound the accurate diagnosis of aHUS or interfere with the ability to manage aHUS disease. H. Pregnancy or breastfeeding. I. Heart, lung, small intestine, or liver transplant. J. In patients undergoing kidney transplantation, any of the following: Acute renal insufficiency within 4 weeks of transplantation consistent with a diagnosis of acute antibody-mediated rejection (AMR) according to the Banff 2013 criteria, or b. Acute renal insufficiency and rising donor-specific antibodies (DSA) within 4 weeks of transplantation consistent with a clinical diagnosis of acute AMR. c. History of polycystic kidney disease. K. In patients aged 18 years or older with a systolic blood pressure (SBP) of ≥ 170 mmHg or in patients aged 12 to < 18 years with a clinical diagnosis of hypertension, any of the following: a. Evidence of sustained TMA (inclusion criterion #2) for less than 4 days after blood pressure (BP) reduction to ≤140 mmHg. b. Known left ventricular hypertrophy. c. Known small hyperechoic kidneys on ultrasound. L. Identified drug exposure-associated HUS. M. For the current TMA, have received PE / PI for 28 days or longer prior to the start of screening. N. History of malignant disease within 5 years of screening, with the exception of non-melanoma skin cancer or intraepithelial carcinoma of the cervix that has been treated and has no evidence of recurrence. O. Bone marrow transplant (BMT) / hematopoietic stem cell transplant (HSCT) within 90 days prior to the start of screening. P. HUS associated with vitamin B12 deficiency. Q. Known systemic sclerosis (scleroderma), systemic lupus erythematosus (SLE), or antiphospholipid antibody positivity or syndrome. R. Chronic dialysis (defined as regular dialysis as renal replacement therapy for ESKD). S. Patients receiving chronic intravenous immunoglobulin (IVIg), except for an unrelated medical condition (e.g., hypogammaglobulinemia), within 8 weeks prior to the start of screening; or patients receiving chronic rituximab treatment within 12 weeks prior to the start of screening. T. Patients receiving other immunosuppressive therapy, such as steroids, mTORi (e.g., sirolimus, everolimus), or CNIs (e.g., cyclosporine or tacrolimus), will be excluded unless: a) part of an established post-transplant anti-rejection regimen, or b) the patient has confirmed anti-complement factor antibodies that would require immunosuppressive therapy, or c) steroids are being used for a condition other than aHUS (e.g., asthma). U. Participation in another interventional treatment trial or use of any experimental treatment within 30 days or 5 half-lives of the investigational product (whichever is longer) prior to starting study drug on Day 1 of this study. V. Previous use of eculizumab or other complement inhibitors. W. Hypersensitivity to mouse protein or to one of the excipients. X. Any medical or psychological condition that, in the opinion of the investigator, may increase the patient's risk from participation in the study or may confound the outcome of the study. Y. Known or suspected history of drug or alcohol abuse or dependence within one year prior to the start of screening.

[0184] Test results for exclusion criterion number 1 may not be available before first dose. Later results for exclusion criterion number A may lead to discontinuation and patient recruitment.

[0185] Patients have the right to withdraw from the study at any time. If a patient withdraws consent, a defined evaluation will be conducted for the Early Discontinuation (ET) visit. Patients who withdraw from the study will not be replaced. Patients may discontinue study medication if the investigator or sponsor has reason to believe that stopping treatment is in the patient's best interest.

[0186] Patients who develop AMR (C4d-positive kidney biopsy), have had a previous kidney transplant, and for whom rituximab is deemed appropriate treatment, must be withdrawn from the study and treated with standard of care. The primary reason for discontinuation and any other reason(s) will be recorded on the eCRF.

[0187] If a patient discontinues the study with an ongoing AE or an unresolved laboratory result that is significantly out of reference range and clinically significant, the investigator will attempt to provide follow-up until satisfactory clinical resolution of the laboratory result or adverse event is achieved.

[0188] A sponsor or regulatory authority may terminate a trial for reasonable cause, including, but not limited to, (1) the discovery of an unexpected, serious, or unacceptable risk to patients enrolled in the trial, (2) a decision by the sponsor to temporarily halt or discontinue the testing, evaluation, or development of the investigational drug, (3) the investigator's failure to comply with the approved protocol, relevant guidelines, and / or regulations, and (4) the investigator's willful submission of false information to the sponsor and / or regulatory authority.

[0189] If at any time after receiving at least one dose of investigational product, a patient's screening data are determined to no longer meet one or more of the following inclusion / exclusion criteria (Inclusion Criterion #2 or Exclusion Criterion #1) (e.g., if the patient's local laboratory data used to confirm the eligibility criteria are subsequently determined by a central laboratory to no longer meet the eligibility criteria), the patient may be discontinued from the study and refilled. Early discontinuation procedures will be implemented for patients who terminate early, and all AEs will be collected up to 60 days after the patient's last dose of study drug.

[0190] The end of the study will be defined as the date of the last patient's final visit during the extension period.

[0191] 5. Test Procedures Ravulizumab, a humanized anti-C5 monoclonal antibody composed of two 448-amino acid heavy chains and two 214-amino acid light chains, is an IgG2 / 4 kappa immunoglobulin consisting of mouse complementarity-determining regions grafted onto human constant regions and human framework light and heavy chain variable regions. Ravulizumab and eculizumab share greater than 99% primary amino acid sequence identity and have very similar pharmacology.

[0192] For clinical trials, the ULTOMIRIS formulation was supplied as a sterile, preservative-free 10 mg / mL solution in single-use vials and was designed for infusion by dilution in commercially available saline (0.9% sodium chloride injection; country-specific pharmacopoeia) for administration by IV infusion. Table 3 and the current IB provide additional information.

[0193] Table 3: Test Drugs [Table 3]

[0194] ULTOMIRIS will be packaged in United States Pharmacopeia (USP) / European Pharmacopoeia (EP) Type 1 borosilicate glass vials and stoppered with butyl rubber stoppers with aluminum overseals and flip-off caps. The study drug will be supplied as a kit. ULTOMIRIS will be released to each study site upon receipt of all required documentation required by applicable regulations.

[0195] Upon arrival at the study site, a pharmacist (or trained designee) will immediately remove the study drug kits from the shipping cooler and store them in their original boxes under refrigerated conditions at 2°C–8°C (35°F–47°F), protected from light. ULTOMIRIS should not be frozen. Store the study drug in a secure, restricted-access storage area, with the temperature monitored daily.

[0196] The formulation is allowed to come to room temperature before administration. Materials are not heated other than by ambient air temperature (e.g., by using a microwave or other heat source).

[0197] ULTOMIRIS was not administered as an IV push or bolus injection. Study drug infusions are prepared using aseptic technique. The patient's required dose of ULTOMIRIS is further diluted in commercially available normal saline (0.9% sodium chloride; country-specific pharmacopoeia) at the volumes specified in Table 26. The ULTOMIRIS solution in diluent is administered to patients via an infusion pump using an IV tubing administration set. Use of an in-line filter for infusion is required.

[0198] Table 4: Dosing Reference Chart for Ravulizumab Dose Preparation [Table 4-1] [Table 4-2] Please refer to the Pharmacy Manual for additional dosage preparation instructions. a Body weight recorded at the last study visit.

[0199] Study drug doses will be prepared and administered only by pharmacists or medically qualified staff members. Study drug will be administered only to enrolled patients who are confirmed to be eligible to participate in the study. Once study drug is prepared for a patient, it will be administered only to that patient. Study drug vials are for single use only, and any remaining formulation in the vial will not be used by another patient. Any drug remaining in the infusion tubing or infusion bag will not be used by another patient.

[0200] Store all clinical trial materials in a secure location and allocate and dispense them by appropriately trained personnel. Maintain detailed records of the amounts of investigational product received, dispensed, and discarded. Unless otherwise notified, retain empty vials and vials with residual material for inspection and accountability by study monitoring, after which they will be destroyed or handled in accordance with each site's clinical trial drug standard operating procedures (SOPs). To meet regulatory requirements for drug accountability, reconcile all remaining ULTOMIRIS inventory at the end of the study and destroy or return to Alexion in accordance with applicable regulations.

[0201] Patients will receive ULTOMIRIS for 26 weeks. ULTOMIRIS is administered as a slow IV infusion over approximately 2 hours. ULTOMIRIS is not administered as an IV push or bolus injection.

[0202] During the initial evaluation period, the ULTOMIRIS dosing regimen was based on the patient's weight at their last recorded study visit (Table 5). Patients received a loading dose of ULTOMIRIS IV on Day 1, followed by maintenance doses of ULTOMIRIS IV q8w (every 8 weeks) on Day 15 and thereafter.

[0203] Table 5: Loading and maintenance treatment regimens [Table 5] a Body weight recorded at the last study visit.

[0204] After the initial evaluation period, all patients will roll over into a maximum 2-year extension period, during which they will receive ULTOMIRIS q8w (every 8 weeks). The actual times of all dose administration will be recorded on the patient's eCRF.

[0205] This is an open-label study. Patients who meet all enrollment criteria will be assigned to study treatment with ULTOMIRIS at the baseline visit (Day 1). An interactive voice or web-based response system (IxRS) will be used to assign each patient a vial containing ULTOMIRIS.

[0206] Infusions of other monoclonal antibodies have been associated with infusion reactions that generally occur during or shortly after completion of the infusion.

[0207] Previous medications (including vitamins and herbal preparations) that patients had taken or received within 28 days prior to the start of screening (or within 3 years for documented meningococcal vaccination) up to the first dose of ULTOMIRIS, including those discussed in the exclusion criteria and procedures (any interventions such as surgery / biopsy or physical therapy), were recorded on the patient's eCRF.

[0208] For analytical purposes, any dialysis within the 14-day period immediately following the first ULTOMIRIS dose will not be considered a "new dialysis."

[0209] All medication use and procedures performed during the study will be recorded on the patient's source documents / chart and eCRF. This record will include all prescription medications, herbal products, vitamins, minerals, over-the-counter medications, and current medications. Concomitant medications will be recorded from the first infusion of study medication until 56 days after the patient's last dose of study medication. Any changes in concomitant medications will also be recorded on the patient's source documents / chart and eCRF. Any concomitant medications deemed necessary for the patient's standard of care during the study or to treat any AEs will be provided, at the investigator's discretion, along with the allowed medications listed below. However, the investigator is responsible for ensuring that all medication details are completely recorded on the patient's source documents / chart and eCRF.

[0210] Patients are prohibited from receiving any of the following medications and procedures at any time after the first dose of study drug: eculizumab or other complement inhibitors, use of any other investigational drug or device as part of the clinical trial, IVIg (except for unrelated medical need, e.g., hypogammaglobulinemia), rituximab, PE / PI after the first dose, and new dialysis in the first 48 hours after the first dose of ULTOMIRIS unless there is compelling medical need as assessed by (1) hypervolemia refractory to diuretics, (2) refractory electrolyte imbalance, or (3) new onset of uremic encephalopathy. Exceptions must be approved by the sponsor on a case-by-case basis before dialysis is administered.

[0211] The following concomitant medications and procedures are permitted under certain circumstances and with the following restrictions: Use of other immunosuppressive therapies (e.g., steroids, mTORi [e.g., sirolimus, everolimus], CNIs [e.g., cyclosporine or tacrolimus], etc.) prior to screening or during the study is not permitted unless a) they are part of an established post-transplant anti-rejection regimen, or b) the patient has confirmed anti-complement factor antibodies requiring immunosuppressive therapy, or c) steroids are being used for a condition other than aHUS (e.g., asthma).

[0212] Any patient receiving other complement inhibitors (including eculizumab) or progressing to PE / PI after the first dose of study drug will be withdrawn from the study.

[0213] Due to its mechanism of action, the use of ULTOMIRIS increases the patient's susceptibility to infection. To reduce the risk of infection, all patients are vaccinated against N. meningitidis, Hib, and Streptococcus pneumoniae.

[0214] Patients will be vaccinated against N. meningitidis within 3 years prior to or at the time of the first dose of ULTOMIRIS. Patients treated with the drug less than 2 weeks after receiving a meningococcal vaccine will receive treatment with appropriate prophylactic antibiotics until 2 weeks after vaccination. To protect against common pathogenic meningococcal serotypes, vaccines against serotypes A, C, Y, W135, and B are recommended, if available. Patients will be vaccinated or revaccinated according to current national vaccination guidelines or local practice regarding the use of vaccinations with complement inhibitors (e.g., eculizumab).

[0215] It is understood that some patients who have not been vaccinated against N. meningiditis within 3 years prior to receiving their first dose of ULTOMIRIS may not be able to receive the vaccination at the time of their first dose. Patients who have not been vaccinated prior to initiating treatment with ULTOMIRIS will receive prophylactic antibiotics before and for at least 2 weeks after receiving meningococcal vaccination.

[0216] Vaccination may not be sufficient to prevent meningococcal infection. Appropriate use of antibacterial agents should be considered in accordance with official guidance and local practice. All patients should be monitored for early signs of meningococcal infection and any suspected infection should be evaluated promptly and treated with appropriate antibiotics if necessary.

[0217] To increase risk awareness and facilitate prompt disclosure of any potential signs or symptoms of infection experienced by patients during the course of the study, patients will be provided with a safety card to carry with them at all times. Additional discussion and explanation of potential risks, signs, and symptoms will occur at specific times as part of the patient's safety card review and throughout the study as outlined in the schedule of assessments (Tables 1 and 2).

[0218] Patients must be diagnosed with Haemophilus influenzae type b (Hib) and Streptococcus mutans before or at the time of their first dose of ULTOMIRIS. Receive vaccinations against N. meningitidis, Hib, and S. pneumoniae according to national and local vaccination schedule guidelines. Record vaccination status against N. meningitidis, Hib, and S. pneumoniae on the patient's eCRF.

[0219] Patients will receive the study drug in a controlled environment under the supervision of the Investigator or designee, thereby ensuring compliance with study drug administration. The Investigator or designee will ensure that all patients are adequately informed of the specific dosing regimen required to comply with the study protocol, ensure that patients receive the correct dose at the specified time points during the study, and ensure that appropriate safety monitoring occurs during the infusion.

[0220] Female patients who considered themselves postmenopausal before receiving study drug must provide evidence of menopause based on amenorrhea for at least 1 year in combination with elevated serum follicle-stimulating hormone (FSH) levels (>30 IU / L) (e.g., in the absence of hormone replacement therapy, dietary phytoestrogens).

[0221] Female patients of childbearing potential will begin using highly effective contraceptive methods (as defined below) at screening and continue for at least 8 months after the last dose of study medication. Highly effective contraceptive methods* include hormonal contraception with ovulation inhibition, intrauterine devices, intrauterine hormone-releasing systems, bilateral tubal occlusion, partner vasectomy (provided the partner is the patient's only sexual partner), abstinence (defined as abstinence from heterosexual intercourse for the entire period of risk associated with study medication treatment; the reliability of abstinence must be assessed in the context of the duration of the clinical trial and the patient's preferred usual lifestyle), and a combination of male condoms and either spermicide-impregnated caps, contraceptive diaphragms, or sponges (dual-barrier methods). Male patients with a female spouse / partner of childbearing potential or a pregnant or lactating spouse or partner will agree to use double-barrier contraception (male condoms plus an appropriate barrier method for the female partner) while receiving treatment and for at least 8 months after the last dose of study medication. Even with a documented medical evaluation of the surgical success of a vasectomy, double barrier contraception is necessary.

[0222] Male patients will not donate sperm while undergoing treatment and for at least 8 months after the last dose of study drug.

[0223] 6.Efficacy evaluation The primary efficacy outcome was complete TMA response during the 26-week initial evaluation period. Criteria for complete TMA response were (1) normalization of platelet count, (2) normalization of LDH, and (3) a 25% or greater improvement from baseline in serum creatinine.

[0224] Patients who meet all of the criteria for a complete TMA response, confirmed by two consecutive measurements taken at least four weeks apart, will be classified as meeting the primary efficacy endpoint.

[0225] The following secondary efficacy endpoints will be measured during the study: A. Whether dialysis is necessary B. Time to complete TMA response C. Complete TMA response status over time D. Observed eGFR values ​​and changes from baseline E. CKD stage as assessed by the investigator on the selected target date and classified as improved, stable (no change), or worsening compared to baseline F. Observed values ​​and changes from baseline of blood parameters (platelets, LDH, hemoglobin) G. A sustained increase in hemoglobin from baseline of 20 g / L or more over at least two consecutive measurements taken at least 4 weeks apart H. Change from baseline in QoL as measured by the EQ-5D-3L questionnaire (all patients), the FACIT Fatigue Version 4 questionnaire (patients aged 18 years and older), and the Pediatric FACIT Fatigue questionnaire (patients under 18 years).

[0226] 7. Safety Assessment The investigator or the patient's designee will meet with the patient to discuss potential safety risks of ULTOMIRIS and to provide the investigator an opportunity to address any safety concerns the patient may have regarding the study.

[0227] Collection of AEs will be monitored from the time informed consent is obtained until study completion. The investigator will follow any AEs until their outcome (resolution or stabilization). If a patient withdraws from the study, AE monitoring will continue until the last patient's final study visit, if possible. The timing of clinical and laboratory evaluations will be performed according to the schedule of evaluations (Tables 1 and 2). Any clinically significant abnormal results will be followed until resolution or stabilization.

[0228] A survey of demographic parameters including age, sex, race, and ethnicity will be conducted. A complete medical history will be obtained and recorded. Weight and height will be recorded. Height will be measured only at screening.

[0229] The patient's aHUS history, including the onset of the first aHUS symptom and the date of diagnosis, will be recorded at the screening visit.

[0230] Patient medical history, including previous and concurrent conditions / disorders, will be recorded at the screening visit. In addition to meningococcal vaccination, medication use (prescription or over-the-counter, including vitamin and / or herbal supplements) over the 28 days (or 3 years for documented meningococcal vaccination) prior to the start of screening will also be recorded.

[0231] The physical examination will include an evaluation of the following: general appearance; skin; head, ears, eyes, nose, and throat; neck; lymph nodes; chest; heart; abdominal cavity; limbs; central nervous system; and musculoskeletal system. The abbreviated physical examination will consist of relevant body system tests based on the investigator's judgment and the patient's symptoms. Vital sign measurements will be obtained after the patient has rested for at least 5 minutes and will include systolic and diastolic BP (millimeters of mercury [mmHg]), pulse oximetry, heart rate (beats / min), respiratory rate (breaths / min), and oral or tympanic temperature (in degrees Celsius [°C] or degrees Fahrenheit [°F]).

[0232] Samples for serum pregnancy, hematology, chemistry, coagulation, and urinalysis will be taken at the specified time points in the schedule of evaluations (Tables 1 and 2). Samples for laboratory evaluations will be taken before each study drug administration.

[0233] Samples collected at screening can be tested either at each site or at a central laboratory. If local testing is used for LDH, platelet count, hemoglobin, and serum creatinine, duplicate samples will be collected for central laboratory testing to ensure that the baseline and post-baseline measurements for analysis are from the central laboratory. If duplicate samples are from each site and the central laboratory, the central laboratory results will be used for analysis.

[0234] It is expected that some laboratory values ​​will be outside the normal range due to underlying disease. Investigators should use medical judgment in assessing the clinical significance of these values. Clinical significance is defined as any variation in a laboratory measurement that has medical relevance and results in a change in practice. If a clinically significant laboratory change from baseline is observed, the change will be recorded as an AE on the AE eCRF. Investigators will assess the relationship of all clinically significant out-of-range values ​​to study treatment. Investigators will continue to monitor patients with additional laboratory evaluations until (1) values ​​return to normal range or baseline levels, or (2) in the investigator's judgment, the out-of-normal values ​​are no longer related to study drug administration or other protocol-specific procedures.

[0235] For women of childbearing potential, a serum or urine pregnancy test (i.e., beta-human chorionic gonadotropin [β-hCG]) will be performed according to the schedule of evaluations (Tables 1 and 2). Blood samples will be analyzed for hematological parameters.

[0236] Blood samples are analyzed for serum chemistry parameters. Indirect bilirubin is calculated from total and direct bilirubin values; therefore, if direct bilirubin is below the limit of quantitation, an indirect bilirubin result is unavailable. For postmenopausal female patients, serum FSH levels are measured during screening to confirm postmenopausal status.

[0237] Chemistry assessments will be performed at the time points specified in the Schedule of Assessments (Tables 1 and 2). At all visits where serum chemistry is collected, eGFR will be calculated using the Modification of Diet in Renal Disease formula in patients 18 years of age and older and the Schwartz formula in patients under 18 years of age.

[0238] Blood samples are analyzed for coagulation parameters.

[0239] Analyze a urine sample. If the macroscopic analysis is abnormal, perform a microscopic examination of the urine sample. Analyze the urine sample for protein and creatinine to calculate the urinary total protein:creatinine ratio.

[0240] For each patient, a single 12-lead digital ECG will be collected according to the schedule of assessments (Tables 1 and 2). Patients must be supine for approximately 5-10 minutes before ECG collection and must remain supine but awake during ECG collection. The investigator or designee is responsible for reviewing the ECG to assess whether it is within normal limits and to determine the clinical significance of the results. These assessments will be presented on the CRF.

[0241] As indicated in the evaluation schedule, blood samples were collected to test for the presence and titer of ADAs to ULTOMIRIS in serum prior to study drug administration (see Tables 1 and 2). If the test results were positive, the test could be repeated every 3 months until the results became negative or stabilized, based on the measured titer and safety assessments. Further characterization of antibody response, including binding and neutralizing antibodies, PK / PD, safety, and ULTOMIRIS activity, could be performed as needed.

[0242] An AE is any untoward medical occurrence in a patient administered a medicinal product, which does not necessarily have a causal relationship to that treatment. Thus, an AE can be any untoward or unintended sign (e.g., abnormal laboratory finding), symptom, or disease temporally associated with the use of a medicinal product, whether or not it is considered medicinal product-related.

[0243] The absence of an untoward medical event (e.g., hospitalization for elective surgery if planned before the start of the study, hospitalization for social or convenience reasons), and expected day-to-day fluctuations in pre-existing disease(s) or condition(s) present or detected at the start of the study that do not worsen are not AEs.

[0244] The lack of efficacy of a drug is not an AE in a clinical trial because the purpose of the clinical trial is to establish the efficacy of the drug.

[0245] Medication errors (including intentional misuse, abuse, and overdose of the product) or use other than that defined in the protocol will not be considered an AE unless there is an adverse medical event as a result of the medication error.

[0246] If pregnancy occurs during maternal or paternal exposure to an investigational product, it should be reported within 24 hours of the investigator / institution's knowledge. Data on fetal outcome and lactation will be collected for regulatory reporting and safety evaluation.

[0247] Adverse events will be recorded from the time of consent signing. AEs reported after informed consent but before study drug administration will be considered pre-treatment AEs.

[0248] The following events are important identified risks in this study: meningococcal infection.

[0249] AEs are graded for severity using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.03 or later. A grading (severity) scale is provided for each AE term. Each CTCAE term is a Lowest Level Term (LLT) according to the Medication Description and Regulation of Drugs (MedDRA®). Each LLT is coded to a MedDRA Preferred Term. Grade refers to the severity of the AE. In the CTCAE, grades 1 to 5 are assigned for each AE, along with a unique clinical description of severity (Table 6).

[0250] Table 6: Adverse Event Severity Grading Scale [Table 6] Abbreviations: ADL = activities of daily living; AE = adverse events a Instrumental ADLs include preparing meals, shopping for groceries and clothing, using the telephone, and managing finances. b Daily ADL refers to bathing, dressing and undressing, eating, using the toilet, taking medicine, and not being bedridden.

[0251] Any changes in the severity of an AE will be recorded based on specific guidelines within the eCRF completion guidelines. A distinction is made between severity and seriousness: severity describes the intensity of an AE, whereas the term seriousness refers to an AE that meets specific criteria for a serious adverse event (SAE).

[0252] For all AEs (both serious and non-serious), the investigator must provide a causality assessment (absent, probably not, possible, probably, definitely) based on the investigator's medical judgment and the symptoms associated with the observed event (Table 7). This assessment will be recorded on the eCRF and any additional forms as needed.

[0253] Table 7: Causality assessment explanations [Table 7-1] [Table 7-2]

[0254] A serious adverse event (SAE) is any untoward medical occurrence that: Life-threatening (i.e., the patient was at risk of death when the event occurred) ·Needing admission as an inpatient or an extension of an existing hospital stay Leading to persistent or significant disability / incapacity · Birth abnormality / birth defect

[0255] A significant medical event that may not result in death, may not be immediately life-threatening, or may not require hospitalization may be considered a serious adverse event if, based on sound medical judgment, intervention may be required to put the patient at risk or prevent one of the outcomes listed above.

[0256] Suspected Unexpected Serious Adverse Reactions (SUSARs) are serious events not listed in the IB that are identified by the investigator as related to an investigational product or procedure. Reporting of SUSARs is required by United States Title 21 Code of Federal Regulations (CFR) 312.32 and the European Union Clinical Trial Directive 2001 / 20 / EC and accompanying detailed guidance or national regulatory requirements of participating countries.

[0257] All AEs (serious and non-serious) were collected from the ICF symptoms until 60 days after the last dose of study drug for patients with ET or until 56 days after the last dose of study drug for patients who completed the study. All AEs were recorded in the eCRF when the investigator or patient's personnel became aware of their occurrence.

[0258] All SAEs will be recorded regardless of the investigator's assessment of causality. There is no deadline for reporting SAEs that are believed to be causally related to the study drug. Investigators are free to report SAEs at any time, regardless of causality.

[0259] For all SAEs, the investigator must provide the following: appropriate and necessary follow-up information, causality of the SAE(s), treatment / intervention for the SAE(s), outcome of the SAE(s), and supporting medical records and testing / diagnostic information.

[0260] Pregnancy data will be collected during the study for all patients and for female spouses / partners of male patients. Exposure during pregnancy (also referred to as intrauterine exposure) can be the result of either maternal exposure or transmission of the product through semen after paternal exposure. Pregnancy itself is not considered an AE unless there is suspicion that the investigational product may have interfered with the effectiveness of the contraceptive. However, pregnancy complications and abnormal pregnancy outcomes are AEs and may meet the criteria for an SAE (e.g., ectopic pregnancy, spontaneous abortion, intrauterine fetal death, neonatal death, or congenital anomaly). Uncomplicated induced abortion should not be reported as an AE.

[0261] 8. Pharmacokinetic and pharmacodynamic evaluation Blood samples for serum drug concentration determination and PD assessment will be collected before and after administration of study drug at the time points indicated in the Schedule of Evaluations (see Tables 1 and 2). The actual date and time (time in a 24-hour period) of each sample collection will be recorded. The number of PK sample collection time points for any given patient will not exceed the number of time points currently planned.

[0262] Blood samples for PK and PD assessments will be collected from the arm opposite the arm used for drug infusion. PK / PD assessments will include: (1) changes in serum ravulizumab concentrations over time and (2) changes in free C5 concentrations.

[0263] 9. Exploratory Evaluation For exploratory biomarker analyses, summary statistics are presented for actual change and percentage change from baseline.

[0264] The relationship between ULTOMIRIS concentrations and exploratory biomarkers or the correlation between clinical benefit and key exploratory biomarkers can be assessed by graphical display. Exploratory analysis of clinical outcomes, PK / PD, gene profile, and biomarker levels and the potential relationships between them can be performed. APC activity and autoantibody results, if assessed, will be summarized.

[0265] Exploratory genetics can be performed to investigate genetic variants in genes known to be associated with aHUS, as well as to identify novel genetic variants associated with aHUS, complement dysregulation, or ULTOMIRIS metabolism or efficacy.

[0266] Genetic variants of known clinical relevance for aHUS will be communicated by the investigator to the patient or patient's guardian with appropriate genetic counseling. Genetic variants of unknown clinical significance will not be communicated to the patient or investigator.

[0267] A patient questionnaire regarding resource utilization and a patient-reported aHUS symptom questionnaire will be used to assess additional signs or symptoms of aHUS.

[0268] The extrarenal sign or symptom components of aHUS, including vital signs and laboratory tests, can be summarized narratively at baseline and post-baseline time points and for changes from baseline. Patient-specific tabulations can be provided.

[0269] Analyses of symptoms, symptomatology, and resource utilization may include standard methods for categorizing outcomes with or without repeated measures.

[0270] If the Day 1 assessment is missing, the screening assessment will be used as the baseline assessment.

[0271] To assess complete TMA response (primary endpoint) during the 26-week initial evaluation period, patients who are missing efficacy assessments that are part of the definition of complete TMA response but are still on study will have last observation carried forward (LOCF). For patients who discontinue the study before week 26, data up to the time of discontinuation will be used to assess complete TMA response.

[0272] Missing data for QoL instruments will be handled as specified in the instructions for each instrument.

[0273] An interim analysis of the study is planned at the end of the 26-week primary evaluation period, after all patients have completed or withdrawn from the period. Additionally, a second analysis to summarize long-term efficacy, safety, and PK parameters will be conducted at the end of the 2-year extension period.

[0274] Example 2: Data from a Phase III, single-arm, multicenter study of ravulizumab (ALXN1210) in complement inhibitor-naive adult patients with atypical hemolytic uremic syndrome (aHUS) The following is a summary of data from a single-arm study of ravulizumab (ALXN1210 aHUS 311) in complement inhibitor treatment-naive patients with atypical hemolytic uremic syndrome (aHUS), conducted substantially according to the protocol described above in Example 1. The initial evaluation period was 26 weeks, followed by an extension period of up to 2 years. The study design is shown in Figure 1.

[0275] The objective of this study was to evaluate the efficacy of ULTOMIRIS to inhibit complement-mediated thrombotic microangiopathy (TMA), characterized by thrombocytopenia, hemolysis, and renal impairment, in adult patients with aHUS who were treatment-naive with complement inhibitors. The primary endpoint was complete TMA response during the 26-week initial evaluation period. The primary, secondary, and safety endpoints of this study are summarized in Figure 2. A summary of the inclusion and exclusion criteria is provided in Figure 3.

[0276] Enrollment requirements were (1) at least 6 adolescents (deferred on ALXN1210-aHUS-312), (2) at least 10 patients before kidney transplant (8 enrolled), and (3) at least 30 patients who met TMA testing criteria on day 1 based on central testing results (32 enrolled).

[0277] The data cut includes data from the initial evaluation period for all patients, plus any available extension period data up to October 2019.

[0278] Fifty-eight (58) subjects enrolled and received at least one dose (included in the safety analysis population), two subjects enrolled and replaced (deemed ineligible after the first dose and discontinued as pre-specified in the protocol), 56 (56) subjects were in the full analysis population, 11 (11) subjects discontinued treatment, and nine (9) subjects discontinued the study. A schematic of patient disposition is shown in Figure 4. Treatment compliance was 100%. Baseline demographics are shown in Table 8, baseline disease characteristics are shown in Table 9, and baseline laboratory values ​​are shown in Table 10.

[0279] Table 8: Baseline Demographics [Table 8-1] [Table 8-2]

[0280] Table 9: Baseline disease characteristics [Table 9]

[0281] Table 10: Baseline laboratory values [Table 10] TMA criteria: Platelet count <150×10 9 / L, LDH ≥ 1.5 × upper limit of normal (ULN), hemoglobin ≤ lower limit of normal (LLN), and serum creatinine level ≥ ULN.

[0282] TMA response definitions are shown in Table 11. A response was achieved if all criteria were met simultaneously and each criterion was met for at least 28 days. Platelet values ​​obtained from the day of platelet transfusion through 3 days post-transfusion were excluded from all analyses. All serum creatinine values ​​obtained while the patient was on dialysis were excluded from all analyses. If the patient was on dialysis at baseline, the first available creatinine value used as the baseline value was the first assessment on or after 6 days post-dialysis. If the patient was on dialysis during the entire 26-week initial assessment period, a baseline creatinine was not calculated.

[0283] Table 11: Complete TMA response definitions [Table 11]

[0284] Key efficacy results are shown in Tables 12-14. Figure 5 is a derived example showing the results of confirmed complete TMA response at day 57, including platelet normalization for 112 days, LDH normalization for 35 days, and creatinine improvement ≥ 25% for 70 days.

[0285] The criteria for a complete TMA response were met if all criteria were met simultaneously and each criterion was met for at least 28 days. The components of a complete TMA response, as well as other secondary efficacy endpoints, indicate a consistent response to treatment. As shown in Figure 9, 53.6% (30 / 56) of patients achieved a complete TMA response during the initial evaluation period. 33.9% (19 / 56) of patients had a partial response.

[0286] Hematological normalization included simultaneous normalization of platelet count and LDH. Each criterion was met for at least 28 days. 73.2% (41 / 56) of subjects achieved hematological normalization during the initial evaluation period (see Table 12). 83.9% (47 / 56) of subjects achieved platelet count normalization during the initial evaluation period (see Table 12, Figure 10, Figure 14, and Figure 15).

[0287] 76.8% (43 / 56) of subjects achieved LDH normalization during the initial evaluation period (see Table 12, Figure 10, Figure 16 and Figure 17).

[0288] Table 12: Key Efficacy Outcomes: Primary Complete TMA Responses During the Primary Evaluation Period [Table 12]

[0289] As shown in Figure 6, there were 30 complete TMA responders. Forty of 56 subjects (71.4%) achieved a hemoglobin (HGB) response (increase of ≥ 20 g / L). Of the 30 complete TMA responders, four did not have a hemoglobin (HGB) response. Figure 10 shows the overall complete TMA responses broken down by subgroups during the 26-week initial evaluation period.

[0290] Figure 7 shows the time to complete TMA response. The median time to complete TMA response was 86 days. Patients who did not have a response were censored at the date of their last visit or study discontinuation.

[0291] FIG. 11 shows complete TMA response status (open circles) over time, including platelet count normalization (open triangles), hematological normalization (+), 25% improvement from baseline in serum creatinine (open squares), and LDH normalization (X).

[0292] There were seven (7) non-responders. Data on non-responders are shown in Table 13.

[0293] Table 13: Key Efficacy Outcomes: Non-Responders (0 / 3 components) During the Primary Evaluation Period [Table 13-1] [Table 13-2]

[0294] As shown in Table 14, 58.6% (17 / 29) of patients on dialysis at baseline were off by the last available follow-up. Of the 27 patients who were off dialysis at baseline, 21 (78%) remained off dialysis at the last follow-up.

[0295] Table 14: Key Efficacy Outcomes: Dialysis Status Over Time [Table 14]

[0296] With regard to pharmacokinetics / pharmacodynamics, 99.53% of all free C5 results obtained from the first dose through the initial evaluation period were below 0.5 mg / mL, the defined threshold for terminal complement inhibition (see Figure 22). Weight-based dosing resulted in predicted maximum steady-state and trough exposures, with no unexpected pharmacokinetic findings (see Figure 8).

[0297] A summary of key safety results is shown in Table 15. Patients evaluated for safety included all patients (N=58) who received at least one dose of study drug. Two of these patients were excluded from the per-protocol efficacy analysis due to ineligibility (identification of STEC-HUS).

[0298] Table 15: Important Safety Results: Summary of Important Safety Results [Table 15-1] [Table 15-2] (1) Overall, four deaths were observed: one due to a pre-procedural AE (cerebral artery thrombosis) and three due to unrelated procedural AEs, including two due to septic shock and one due to intracranial hemorrhage.

[0299] Four deaths occurred: one due to a pre-treatment adverse event (cerebral artery thrombosis) and three due to unrelated procedural adverse events (two due to septic shock and one due to intracranial hemorrhage). Deaths in patients receiving a single minimum dose of ULTOMIRIS are summarized in Table 16.

[0300] Table 16: Summary of deaths in patients receiving a single dose of minimum ULTOMIRIS [Table 16-1] [Table 16-2]

[0301] As shown in Table 17, the most frequent adverse events were headache (N=21), diarrhea (N=18), vomiting (N=15), nausea (N=13), and hypertension (N=13). As shown in Table 18, the most common serious adverse event was pneumonia (N=3). Three subjects discontinued the study due to adverse events. There were no cases of meningococcal disease.

[0302] Table 17: Important Safety Results: Summary of Important Safety [AEs present in at least 4 patients] [Table 17-1] [Table 17-2]

[0303] Table 18: Important Safety Results: Summary of Important Safety Events [SAEs present in at least 2 patients] [Table 18-1] [Table 18-2]

[0304] 71.4% (40 / 56) of subjects achieved a hemoglobin (HGB) response during the initial evaluation period (see Table 19 and Figure 6). Figure 18 shows the observed and model-based mean change from baseline in HGB over time and 95% confidence intervals. Figure 19 shows the observed mean HGB over time and 95% confidence intervals.

[0305] Table 19: Key Efficacy Outcomes: HGB Response (Increase from Baseline in HGB ≥ Confirmed Results) [Table 19]

[0306] Chronic kidney disease (CKD) stages are classified based on the National Kidney Foundation's Chronic Kidney Disease Stages. CKD stages and corresponding estimated glomerular filtration rate (eGFR) values ​​are as follows: Stage 1: eGFR >= 90 (normal), Stage 2: eGFR 60-89, Stage 3A: eGFR 45-59, Stage 3B: eGFR 30-44, Stage 4: eGFR 15-29, and Stage 5: eGFR < 15 (including end-of-life dialysis). Stage 1 is considered the best category. Stage 5 is considered the worst category. An improvement in eGFR (e.g., > 15) corresponds to an improvement in CKD stage (e.g., a lower CKD stage).

[0307] Figure 12 shows the mean eGFR from baseline and 95% confidence intervals. Figure 13 shows the shift in CKD / eGFR category from baseline to day 183. Data are presented as n (%). eGFR categories are mL / min / 1.73m 2Baseline is derived based on the last available eGFR before treatment initiation. The lower triangle (shown as a diagonal black line) represents improvement from baseline to day 183, the upper triangle (shown as a dot) represents deterioration, and white blood cells represent no change.

[0308] Additionally, as shown in Table 20 and Figure 13, 32 of the 47 subjects experienced improvement in CKD stage change from baseline to Day 183 (6 stages 5, 7 stages 4, 5 stages 3, 4 stages 2, and 10 stages 1). Thirteen of the 47 subjects remained the same. Two of the 13 subjects worsened.

[0309] Table 20: Key Safety Results: Minor CKD Shifts [Table 20] (a) Compared with CKD stage at baseline. (b) Subjects with stage 1 at baseline were excluded because they failed to improve. (c) Subjects with stage 5 at baseline were excluded because they could not worsen. (d) The 95% confidence intervals (95% CI) of proportions were based on exact confidence limits using the Clopper-Pearson method.

[0310] Table 21 and Figure 20 show the change in fatigue over time. Data in Figure 20 are presented as means (error bars, 95% CI). Rapid improvement in fatigue was observed, i.e., a median 9-point improvement by Day 8. Clinically meaningful improvement in fatigue (≥ 3 points) was observed in 84.1% (37 / 44) of patients at Day 183. The median increase was 20 points from baseline to Day 183.

[0311] Table 21: Key Safety Outcomes: FACIT-3 point improvement from baseline [Table 21-1] [Table 21-2]

[0312] The EQ-5D-3L is assessed using an index scored according to the United States Time Trade-Off Value Set (US TTO) and responses to questions on a visual analog scale (VAS). A US TTO > 0.94 indicates perfect health. Baseline is from the value on Day 1. Figure 21 shows the mean EQ-5D-3L and 95% confidence interval. Regarding immunogenicity, one patient had a positive result observed during treatment for anti-drug antibodies (ADA), with no clear effect on neutralizing antibodies and pharmacokinetics / pharmacodynamics (see Table 22).

[0313] Table 22: Key Safety Results: Safety Summary: Immunogenic Anti-Drug Antibodies [Table 22]

[0314] Figure 22 shows serum free complement C5 concentrations over time (semi-log scale). The dashed horizontal line indicates a serum free C5 concentration of 0.5 μg / mL, and complete inhibition of terminal complement was defined as a serum free C5 concentration of 0.5 μg / mL or less. The following Day 1 free C5 sample was excluded because it was deemed biologically unacceptable. Because the PK and free C5 samples were collected from the same blood draw, the exclusion was supported by the versus PK data. [N=2, Day 1 pre-dose samples / N=1, Day 1 end of infusion sample]. As can be seen in Figure 22, ULTOMIRIS demonstrated immediate, complete, and sustained terminal complement inhibition over the 8-week dosing interval.

[0315] Finally, the study populations between this ULTOMIRIS study (ALXN1210-aHUS-311) and the adult eculizumab study (C10-004) were similar at Day 183. However, as shown in Figure 23, ULTOMIRIS resulted in improved readouts compared with eculizumab for the following secondary clinical parameters: a) eGFR category / chronic kidney disease (CKD) stage and (b) estimated glomerular filtration rate (eGFR) increase. Specifically, of patients treated with ULTOMIRIS in this study, 68% achieved an improvement in eGFR category / CKD stage of at least one stage, with a mean increase in eGFR of 35±35. In contrast, of patients treated with eculizumab in study C10-004, only 63% achieved an improvement in eGFR category / CKD stage of at least one stage, with a mean increase in eGFR of 29±24. A "complete TMA response" in this study is equivalent to a "modified complete TMA response" in C10-004.

[0316] In summary, ULTOMIRIS provided immediate and complete inhibition of C5, which was maintained over an 8-week dosing interval. Complete TMA responses were achieved in 54% of patients, similar to the data for eculizumab (56% in Study C10-004). There was rapid improvement in platelet counts. Furthermore, renal function improved substantially. Specifically, 58.6% of patients on dialysis at baseline did not require dialysis at the end of the study. Furthermore, no unexpected safety concerns were identified. Therefore, the results from this study support the use of ULTOMIRIS at an 8-week dosing interval in adult patients with complement-mediated TMA.

[0317] Sequence overview [Table 23-1] [Table 23-2] [Table 23-3] Table 23-4 Table 23-5 Table 23-6 Table 23-7

Claims

1. 1. A pharmaceutical composition comprising an anti-C5 antibody for treating atypical hemolytic uremic syndrome (aHUS) in a human adult patient 18 years of age or older, wherein the anti-C5 antibody is ravulizumab, and the anti-C5 antibody comprises: (a) once on day 1 at a dose of 2400 mg for patients weighing ≥ 40 to < 60 kg, 2700 mg for patients weighing ≥ 60 to < 100 kg, or 3000 mg for patients weighing ≥ 100 kg; (b) on day 15, and every 8 weeks thereafter for a period of 2 years, at a dose of 3000 mg for patients weighing ≥ 40 to < 60 kg, 3300 mg for patients weighing ≥ 60 to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg A pharmaceutical composition that is administered intravenously.

2. 10. The pharmaceutical composition of claim 1, wherein the patient has been previously treated with eculizumab.

3. (a) the treatment begins at least two weeks after the patient's last dose of eculizumab; (b) the patient has been treated with eculizumab for at least 6 months prior to Day 1 of the treatment; and / or (c) the patient has previously been treated with eculizumab at a dose of 900 mg every two weeks; The pharmaceutical composition of claim 2.

4. The pharmaceutical composition of claim 1 , wherein the patient has not been previously treated with a complement inhibitor.

5. 5. The pharmaceutical composition of claim 4, wherein the complement inhibitor is eculizumab.

6. 6. The pharmaceutical composition of any one of claims 1 to 5, wherein the treatment continues at a dose of 3000 mg for patients weighing ≥ 40 to < 60 kg, 3300 mg for patients weighing ≥ 60 to < 100 kg, or 3600 mg for patients weighing ≥ 100 kg every 8 weeks for the life of the patient.

7. The anti-C5 antibody is administered to a patient weighing ≧40 to <60 kg, (a) at a dose of 2400 mg once on day 1; (b) at a dose of 3000 mg on day 15 and every 8 weeks thereafter The pharmaceutical composition according to any one of claims 1 to 6, wherein the composition is administered intravenously.

8. The anti-C5 antibody is administered to a patient weighing ≥ 60 to < 100 kg, (a) at a dose of 2700 mg once on day 1; (b) at a dose of 3300 mg on day 15 and every 8 weeks thereafter The pharmaceutical composition according to any one of claims 1 to 6, wherein the composition is administered intravenously.

9. The anti-C5 antibody is administered to a patient weighing ≥ 100 kg, (a) at a dose of 3000 mg once on day 1; (b) at a dose of 3600 mg on day 15 and every 8 weeks thereafter The pharmaceutical composition according to any one of claims 1 to 6, wherein the composition is administered intravenously.

10. (a) said treatment maintains a serum trough concentration of said anti-C5 antibody of 100 μg / ml or greater, or 200 μg / ml or greater during said treatment; (b) the treatment maintains a free C5 concentration of 0.309-0.5 μg / mL or less; and / or (c) the treatment reduces free C5 levels by greater than 99%, or greater than 99.5%, throughout the treatment period; The pharmaceutical composition according to any one of claims 1 to 6.

11. The treatment (a) terminal complement inhibition; (b) reduced hemolysis compared to baseline as assessed by lactate dehydrogenase (LDH) levels; (c) normalization of LDH levels; and / or (d) disappearance of breakthrough hemolysis during said treatment period. resulting in The pharmaceutical composition according to any one of claims 1 to 6.

12. The treatment (a) a shift toward normal levels of hemolysis-related hematological biomarkers selected from the group consisting of free hemoglobin, haptoglobin, reticulocyte count, PNH red blood cell (RBC) clones, and D-dimers; (b) a shift toward normal levels of factor Ba, soluble tumor necrosis factor receptor 1 [sTNFR1], soluble vascular adhesion molecule 1 [sVCAM1], thrombomodulin, D-dimer, and cystatin C; (c) an increase in hemoglobin stabilization compared to baseline; (d) a reduction in the need for blood transfusions compared to baseline; (e) reduction in major adverse vascular events (MAVE); (f) change from baseline in quality of life as assessed via the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale, version 4 and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 scale; and / or (g) Improvement in the condition requiring dialysis The pharmaceutical composition according to any one of claims 1 to 6,

13. 7. The pharmaceutical composition of any one of claims 1 to 6, wherein the treatment produces at least one therapeutic effect selected from the group consisting of a reduction or cessation of severe hypertension, proteinuria, uremia, lethargy, fatigue, irritability, thrombocytopenia, microangiopathic hemolytic anemia, renal dysfunction, and an improvement in the need for dialysis compared to baseline.

14. The treatment (a) Platelet normalization; (b) ≥ 25% improvement from baseline in serum creatinine; (c) complete TMA response; and / or (d) modified complete TMA response The pharmaceutical composition according to any one of claims 1 to 6, which results in

15. The pharmaceutical composition of any one of claims 1 to 6, wherein the patient's chronic kidney disease (CKD) improves by one or more stages after initiation of treatment.

16. The treatment (a) a shift in eGFR towards normal levels; and / or (b) EQ-5D-3L US Time Trade-Off Value Set (US TTO) > 0.94 The pharmaceutical composition according to any one of claims 1 to 6, which results in

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