Compositions suitable for use in neonates

Abstract

The present invention provides stable, pure, and potent compositions optimized for administration to newborns and / or preterm infants, and their use in methods for treating intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and / or chronic lung disease (CLD) in preterm infants, the methods comprising administering to a subject in need of treatment a pharmaceutical composition comprising insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3), and polysorbate 20 surfactant, at a high effective dose in a low volume in the infant, resulting in high serum IGF-1 exposure and treatment of IVH, BPD, and / or CLD. In some aspects, provided herein are methods for manufacturing compositions comprising a disposable use bag, wherein the composition has improved stability, reduced oxidation, and increased efficacy. In some aspects, the provided methods result in a reduced incidence of intraventricular hemorrhage, bronchopulmonary dysplasia, right ventricular hypertrophy (RVH), pulmonary hypertension (PH), necrotizing enterocolitis, or symptoms and features of chronic lung disease of premature infants.

Description

[Technical Field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority to and the benefit of U.S. Provisional Application No. 63 / 093,696, filed October 19, 2020, the contents of which are incorporated herein by reference in their entirety. [Background technology]

[0002] There is a great need for compositions optimized for therapeutic use in newborns and / or preterm infants, for example, to treat or reduce the incidence of conditions such as intraventricular hemorrhage, bronchopulmonary dysplasia, and chronic lung disease in preterm infants.

[0003] Intraventricular hemorrhage (IVH) is a life-threatening condition in preterm infants characterized by intraventricular and periventricular bleeding, resulting in acute and chronic brain injury and the potential for long-term adverse neurodevelopmental outcomes.

[0004] IVH is a major complication in preterm infants. IVH is associated with severe complications, including periventricular hemorrhagic infarction, posthemorrhagic ventricular dilation, periventricular leukomalacia, and cerebellar hemorrhage, and can result in high mortality and morbidity. Other complications include posthemorrhagic hydrocephalus, cerebral palsy, and mental retardation, as well as long-term neurodevelopmental disabilities.

[0005] IVH can result in mortality and morbidity in preterm infants. The current standard of care is based on early management and stabilization of cerebral hemodynamics and respiratory support. Prognosis is related to the severity of the hemorrhage, damage to the brain parenchyma, the presence of seizures, and the severity of periventricular hemorrhagic infarction.

[0006] Chronic lung disease of preterm infants (CLD) is another serious and life-threatening condition in preterm infants. Extremely preterm infants, in particular, are at high risk for developing CLD. Bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age is typically the earliest sign of CLD, although infants without BPD may also develop CLD. The term "chronic lung disease of preterm infants" encompasses a wide range of symptoms and features that often overlap with those of BPD.

[0007] Current standard treatment and prevention options for BPD and CLD include respiratory support (such as supplemental oxygen via non-invasive nasal flow with continuous positive airway pressure, and mechanical ventilation with endotracheal intubation), pulmonary surfactant administration, bronchodilators to help open the airways, caffeine to help reduce breathing pauses (apneas) and improve respiratory muscle function, and steroids to help reduce inflammation, diuretics to help reduce excess fluid in the lungs, vasodilators to help reduce blood pressure in the lungs, and antibiotics to fight infection. Pulmonary outcomes in extremely preterm infants The long-term trajectory of CLD typically begins with prenatal risk factors, followed by respiratory distress syndrome (RDS) in the first hours or days of life requiring respiratory support, BPD, typically diagnosed at 36 weeks postmenstrual age, and ultimately chronic lung disease in infancy, childhood, adolescence, and even adulthood. CLD can result in more frequent hospital readmissions and ER visits for respiratory causes, the need for respiratory medications, or home respiratory support, and many children suffer from a form of reactive airway disease (asthma) that continues to limit their quality of life.

[0008] Treating premature infants, sometimes weighing approximately 1-2 lbs (450-900 g), presents many challenges, particularly because the amount that can be administered is so small. Delivering precise doses of protein by infusion to this patient population and ensuring compatibility of the pharmaceutical composition with clinical administration components (e.g., infusion devices) is critical.

[0009] Furthermore, this class of patients is extremely weak and vulnerable. The toxicological risks posed by exposure to substances such as excipients during pharmaceutical treatment must be carefully evaluated. Newborns may exhibit different sensitivities to chemicals, such as excipients, used in formulations compared to adults and older children. This creates a significant challenge for those attempting to treat this patient population.

[0010] In addition, each therapeutic protein has different properties, e.g., the balance of hydrophobic and charged moieties on the surface of the folded molecule. Thus, each therapeutic protein requires a formulation specifically optimized for its properties (e.g., properties such that the formulation is compatible with the pharmacological activity and stability of the therapeutic protein) and its suitability for administration. This challenge is even greater when the therapeutic entity is a protein complex. Summary of the Invention [Problem to be solved by the invention]

[0011] The present disclosure relates to compositions optimized for administration to newborns and / or preterm infants, and methods of treatment therewith, e.g., use of the compositions in the treatment of, for example, intraventricular hemorrhage, bronchopulmonary dysplasia, and chronic lung disease in preterm infants, particularly for use in this patient population. In a further independent aspect, a process for manufacturing a formulation of the composition is provided, e.g., using disposable bags that minimize contact of the formulation with stainless steel, particularly to provide a robust process for achieving a formulation with reduced oxidation.

[0012] The compositions provided herein are suitable for use in neonates and possess one or more (such as all) of the following advantages: minimize excipients (minimizing adverse effects and maximizing intolerance / toxicity in the patient population); minimize loss of protein complexes in compositions administered parenterally (e.g., via intravenous (IV) infusion, using tubing, rubber and / or plastic materials and / or filters); are stable (e.g., physically and / or chemically stable, advantageously providing a shelf life of at least 3-6 months); and have the ability to deliver active therapeutic agents at concentration levels appropriate for the neonatal patient population. [Means for solving the problem]

[0013] Thus, in one aspect, a low concentration pharmaceutical composition suitable for administration of a therapeutic protein conjugate to a neonate is provided, which comprises conjugated insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (e.g., equimolar amounts, such as in the range of 0.75-1.25:1 or 1:0.75-1.25), and a non-ionic surfactant (e.g., a polysorbate surfactant such as polysorbate 20 or polysorbate 80, particularly polysorbate 20) in the range of 0.0025% to 0.0075%.

[0014] In one embodiment, the pharmaceutical composition is isotonic.

[0015] In one embodiment, the pharmaceutical composition is a liquid.

[0016] In one embodiment, the concentration of the therapeutic conjugate is in the range of 10-100 mg / L (e.g., 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or 100 mg / L), such as 45-55 mg / L, particularly 50 mg / L).

[0017] In one embodiment, the pharmaceutical composition is aqueous.

[0018] In one embodiment, the formulation is provided as a unit containing a 50 microgram / mL rhIGF-1 / rhIGFBP-3 solution in 50 mM sodium acetate and 105 mM sodium chloride containing 0.005% (v / v) polysorbate 20, pH 5.5, stored at 2°C to 8°C (36°F to 46°F).

[0019] In one embodiment, a pharmaceutical composition according to the present disclosure is provided as a final product in an infusion bag or glass vial containing an extractable volume of about 6.5 mL.

[0020] In one embodiment, the pharmaceutical formulation can be administered parenterally without loss of the therapeutic protein conjugate (eg, without loss of activity of the therapeutic protein conjugate).

[0021] In one embodiment, the composition has a minimum number and / or amount of excipients, for example, 1, 2, 3, 4, or 5 excipients.

[0022] In one embodiment, the activity or another property of the composition is measured by an assay or method disclosed herein, such as in the Examples.

[0023] In one embodiment, the polysorbate surfactant, for example polysorbate 20 or polysorbate 80, particularly polysorbate 20%, is in the range of 0.0025% to 0.0075% v / v.

[0024] In one embodiment, the pH of the composition is in the range of pH 5 to pH 7, such as pH 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, especially pH 5.5, or pH 5.3 to pH 5.8.

[0025] In one embodiment, the formulation delivers at least 80%, e.g., 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99 or 100%, of the dose of the therapeutic protein conjugate to the neonate in active form.

[0026] Thus, in a preferred embodiment, 10 to 1000 micrograms per mL (e.g., 10 to 100 micrograms / mL, i.e., for example, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or 100 micrograms / mL, such as 45 to 55 micrograms / mL, in particular 50 micrograms / mL) of conjugated insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3) (e.g., equimolar amounts, such as 0.75 to 1.25: and a non-ionic surfactant (e.g., a polysorbate surfactant such as polysorbate 20 or polysorbate 80, particularly polysorbate 20) in the range of 0.0025% to 0.0075% (e.g., 0.005%); a buffer (e.g., 50 mM sodium acetate), a salt (e.g., 105 mM sodium chloride), and the pH of the formulation is in the range of pH 5.3 to 5.8 (e.g., pH 5.5).

[0027] In further embodiments, the present invention provides effective treatments for diseases and complications of preterm infants, including, inter alia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and chronic lung disease of preterm infants (CLD). The present invention provides, in part, methods and pharmaceutical compositions comprising a combination of insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3), together with a surfactant (e.g., polysorbate 20), which, when administered intravenously, e.g., shortly after birth, to replace IGF-1 lost from the maternal supply, can ameliorate or reduce intraventricular hemorrhage (IVH), bronchopulmonary dysplasia, and / or chronic lung disease of preterm infants. The present invention is based, in part, on the surprising discovery that the addition of a low concentration (e.g., 0.0025% to 0.0075% v / v) of a surfactant (e.g., polysorbate 20) to an IGF-1 / IGFBP-3 pharmaceutical composition results in improved efficacy and increased stability. Without wishing to be bound by any particular theory, it is contemplated that, for example, such low concentrations of surfactant (e.g., polysorbate 20) minimize adsorption-related product losses and eliminate the need to prime and flush intravenous infusion sets prior to drug administration, significantly reducing drug loss and improving efficacy. The present invention is also based, in part, on improved stability achieved through reduced accumulation of oxidative species and the use of non-stainless steel contact surfaces, such as disposable bags, during mixing of the formulation solution and the complex. Improved stability is achieved during storage at about 25°C (e.g., about 23°C to about 27°C) or about 40°C (e.g., about 38°C to about 42°C), e.g., for about 3 to 6 months. In addition to the benefits of reduced aggregation and increased stability and purity, surfactant-containing formulations allow for accurate dosing and administration of smaller dose volumes to extremely preterm infants at risk for developing preterm complications, such as intraventricular hemorrhage, bronchopulmonary dysplasia, and / or chronic lung disease of preterm infants (see, e.g.,

[0008] ). As used herein, chronic lung disease (CLD) and chronic lung disease of preterm infants are used interchangeably.The formulations of the present invention are stable and exhibit reduced aggregation at concentrations ranging from 10 micrograms / mL to 1000 micrograms / mL (e.g., 20 micrograms / mL, 30, 40, 50 micrograms / mL). In contrast, in the absence of polysorbate and upon exposure to routine stress, high molecular weight species accumulate, contributing to decreased stability, increased aggregation, and potentially increased immunogenicity. In summary, the present invention provides improved formulations of IGF-1 / IGFBP-3 with, among other benefits, increased potency and improved stability during storage, particularly with minimized toxicity, providing a safe and effective product for administration to neonates in the treatment of premature infant diseases.

[0028] In one embodiment, a stable formulation of rIGF-1 / rIGFBP-3 containing a surfactant can be prepared and delivered at a dose of about 400 micrograms / kg / 24 hours, etc. In one embodiment, a stable formulation of rIGF-1 / rIGFBP-3 containing a surfactant can be prepared and delivered at a dose of about 1000 micrograms / kg / 24 hours, etc. The addition of a surfactant also increases product stability by reducing protein loss due to adsorption. In one embodiment, the methods provided herein result in high effective serum IGF-1 exposure by administering a pharmaceutical rIGF-1 / rIGFBP-3 composition at a dose of about 250 micrograms / kg / 24 hours or less in the presence of a surfactant.

[0029] The present application is based, in part, on the advantages that accrue from incorporating a polysorbate surfactant, e.g., polysorbate 20 or polysorbate 80, into pharmaceutical rIGF-1 / rIGFBP-3 compositions. The present application discloses highly potent and stable formulations for the treatment of diseases and complications of premature infants, such as intraventricular hemorrhage, bronchopulmonary dysplasia, and chronic lung disease of premature infants, that result in high rIGF-1 serum exposure levels when rIGF-1 / rIGFBP-3 is administered at concentrations of about 10 micrograms / mL to 1000 micrograms / mL.

[0030] In one aspect of the present disclosure, provided herein is a pharmaceutical composition comprising a protein complex comprising recombinant insulin-like growth factor-1 (rIGF-1), recombinant insulin-like growth factor binding protein-3 (rIGFBP-3), and a polysorbate surfactant at a concentration of about 0.0025% v / v to 0.0075% v / v, wherein the rIGF-1 and rIGFBP-3 are complexed in equimolar amounts, and the rIGF-1 / IGFBP-3 is at a concentration of about 10 micrograms / mL to 1000 micrograms / mL.

[0031] In some aspects, provided herein is a pharmaceutical composition comprising a protein complex comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and a polysorbate surfactant at a concentration of about 0.0025% to 0.0075%, wherein rIGF-1 and rIGFBP-3 are complexed in a ratio of 0.75 to 1.25:1 or 1:0.75 to 1.25, e.g., equimolar amounts. In some embodiments, the polysorbate surfactant is polysorbate 20 or polysorbate 80.

[0032] In some embodiments, the polysorbate surfactant is polysorbate 20. Polysorbate 20 is also known as polyoxyethylene sorbitan monolaurate.

[0033] In some embodiments, the polysorbate surfactant is polysorbate 80. Polysorbate 80 is also known as polyoxyethylene sorbitan monooleate.

[0034] In some embodiments, the polysorbate surfactant is at a concentration of about 0.001% to 2.4% v / v. In some embodiments, the polysorbate surfactant is at a concentration of about 0.2% to 0.4% v / v. In some embodiments, the polysorbate surfactant is at a concentration of about 0.001%, 0.005%, 0.01%, 0.02%, 0.03%, 0.05%, 0.10%, 0.15%, 0.2%, 0.5%, 0.7%, 1.0%, 1.2%, 1.5%, 1.8%, 2.0%, 2.2%, or 2.4% v / v.

[0035] In some embodiments, the polysorbate surfactant is at a concentration of about 0.0025% to 0.0075% v / v. In some embodiments, the polysorbate surfactant is at a concentration of about 0.0025%, about 0.005%, or about 0.0075% v / v. In some embodiments, the polysorbate surfactant is at a concentration of about 0.005% v / v.

[0036] In some embodiments, less than about 20% of the IGF-1 in the composition is present as oxidized species after about 6 months of storage at 25° C. In some embodiments, less than about 15% of the IGF-1 in the composition is present as oxidized species after about 6 months of storage at 25° C. In some embodiments, less than 10% of the IGF-1 is present as oxidized species after about 6 months of storage at 25° C. In some embodiments, less than 5% of the IGF-1 is present as oxidized species after about 6 months of storage at 25° C. In some embodiments, less than 4% of the IGF-1 is present as oxidized species after about 6 months of storage at 25° C. In some embodiments, less than 2% of the IGF-1 is present as oxidized species after about 6 months of storage at 25° C. In some embodiments, less than 4% of the IGF-1 is present as oxidized species after about 3 months of storage at 25° C. In some embodiments, less than 2% of the IGF-1 is present as oxidized species after about 3 months of storage at 25° C.

[0037] In some embodiments, less than 10% of the IGF-1 is present as oxidized species after about 3 months of storage at 40° C. In some embodiments, less than 8% of the IGF-1 is present as oxidized species after about 3 months of storage at 40° C. In some embodiments, less than 6% of the IGF-1 is present as oxidized species after about 3 months of storage at 40° C. In some embodiments, less than 5% of the IGF-1 is present as oxidized species after about 3 months of storage at 40° C. In some embodiments, less than 4% of the IGF-1 is present as oxidized species after about 3 months of storage at 40° C. In some embodiments, less than 10% of the IGF-1 is present as oxidized species after about 3 months of storage at 40° C. In some embodiments, less than 3% of the IGF-1 is present as oxidized species after about 3 months of storage at 40° C. In some embodiments, less than 8% of the IGF-1 is present as oxidized species after about 1 month of storage at 40° C. In some embodiments, less than 6% of the IGF-1 is present as oxidized species after about 1 month of storage at 40° C. In some embodiments, less than 5% of the IGF-1 is present as oxidized species after about 1 month of storage at 40° C. In some embodiments, less than 4% of the IGF-1 is present as oxidized species after about 1 month of storage at 40° C. In some embodiments, less than 3% of the IGF-1 is present as oxidized species after about 1 month of storage at 40° C. In some embodiments, less than 2% of the IGF-1 is present as oxidized species after about 1 month of storage at 40° C.

[0038] In some embodiments, the percentage of oxidized species in the composition is determined by reversed-phase ultra-performance liquid chromatography (RP-UPLC). In some embodiments, the IGFBP-3 contains less than 5% trisulfide variants.

[0039] In some embodiments, the composition further comprises a buffer comprising sodium acetate, acetic acid, and / or sodium chloride. In some embodiments, the composition further comprises a buffer comprising sodium acetate or acetic acid. In some embodiments, the composition further comprises a buffer comprising sodium chloride.

[0040] In some embodiments, the sodium acetate or acetic acid is at a concentration of about 10-100 mM. In some embodiments, the sodium acetate or acetic acid is at a concentration of about 10 mM, 15 mM, 20 mM, 25 mM, 30 mM, 35 mM, 40 mM, 45 mM, 50 mM, 55 mM, 60 mM, 65 mM, 70 mM, 75 mM, 80 mM, 85 mM, 90 mM, 95 mM, or 100 mM. In some embodiments, the sodium acetate or acetic acid is at a concentration of about 50 mM.

[0041] In some embodiments, the sodium chloride is at a concentration of about 20 mM and 200 mM. In some embodiments, the sodium chloride is at a concentration of about 20 mM, 25 mM, 30 mM, 35 mM, 40 mM, 45 mM, 50 mM, 55 mM, 60 mM, 65 mM, 70 mM, 75 mM, 80 mM, 85 mM, 90 mM, about 95 mM, about 100 mM, about 105 mM, about 110 mM, about 115 mM, about 120 mM, about 125 mM, about 130 mM, about 135 mM, about 140 mM, about 145 mM, about 150 mM, about 155 mM, about 160 mM, about 165 mM, about 170 mM, about 175 mM, about 180 mM, about 185 mM, about 190 mM, about 195 mM, or about 200 mM. In some embodiments, the sodium chloride is at a concentration of about 105 mM.

[0042] In some embodiments, the composition has a pH of about 5.0-7.0. In some embodiments, the pH is about 5.0, about 5.2, about 5.4, about 5.6, about 5.8, about 6.0, about 6.2, about 6.4, about 6.6, about 6.8, or about 7.0. In some embodiments, the composition has a pH of about 5.1, about 5.3, about 5.5, about 5.7, or about 5.9, about 6.1, about 6.3, about 6.5, about 6.7, or about 6.9. In some embodiments, the composition has a pH of about 5.3-5.8. In some embodiments, the composition has a pH of about 5.5.

[0043] In some embodiments, rIGF-1 / IGFBP-3 is at a concentration of about 10 micrograms / mL to 1000 micrograms / mL. In some embodiments, rIGF-1 / IGFBP-3 is at a concentration of about 10 micrograms / mL to 100 micrograms / mL. In some embodiments, rIGF-1 / IGFBP-3 is at a concentration of about 20 micrograms / mL to 100 micrograms / mL. In some embodiments, rIGF-1 / IGFBP-3 is at a concentration of about 10 micrograms / mL, about 20 micrograms / mL, about 30 micrograms / mL, about 40 micrograms / mL, about 50 micrograms / mL, about 60 micrograms / mL, about 70 micrograms / mL, about 80 micrograms / mL, about 90 micrograms / mL, or about 100 micrograms / mL. In some embodiments, rIGF-1 / IGFBP-3 is at a concentration of about 10 micrograms / mL, 25 micrograms / mL, 50 micrograms / mL, 75 micrograms / mL, or 100 micrograms / mL. In some embodiments, rIGF-1 / IGFBP-3 is at a concentration of about 45-55 micrograms / mL. In some embodiments, rIGF-1 / IGFBP-3 is at a concentration of about 50 micrograms / mL. In some embodiments, rIGF-1 / rIGFBP-3 is at a concentration of about 75 micrograms / mL.

[0044] In some embodiments, rIGF-1 / IGFBP-3 is at a concentration of about 100 micrograms / mL to 1000 micrograms / mL, or at a concentration of about 100 micrograms / mL, about 200 micrograms / mL, about 300 micrograms / mL, about 400 micrograms / mL, about 500 micrograms / mL, about 600 micrograms / mL, about 700 micrograms / mL, about 800 micrograms / mL, about 900 micrograms / mL, or about 1000 micrograms / mL.

[0045] In some embodiments, the pharmaceutical composition is suitable for subcutaneous or intravenous injection. In some embodiments, the pharmaceutical composition is suitable for subcutaneous injection. In some embodiments, the pharmaceutical composition is suitable for intravenous injection.

[0046] In some embodiments, the pharmaceutical composition has a shelf life of 20 months or more at a temperature of 2-8°C. In some embodiments, the pharmaceutical composition has a shelf life of at least 24 months at a temperature of 2-8°C. In some embodiments, the pharmaceutical composition is stable at room temperature and / or under ambient light. In some embodiments, the pharmaceutical composition is stable at room temperature and / or under ambient light for at least 8 hours, 12 hours, 24 hours, 36 hours, or 48 hours. In some embodiments, the pharmaceutical composition is stable at room temperature and / or under ambient light for at least 8 hours. In some embodiments, the pharmaceutical composition is stable at room temperature and / or under ambient light for at least 12 hours. In some embodiments, the pharmaceutical composition is stable at room temperature and / or under ambient light for at least 24 hours. In some embodiments, the pharmaceutical composition is stable at room temperature and / or under ambient light for at least 48 hours.

[0047] In some embodiments, the pharmaceutical composition comprises rIGF-1 and rIGFBP-3 complexed in equimolar amounts, e.g., in the range of 0.75-1.25:1 or 1:0.75-1.25. In some embodiments, the IGF-1 is recombinantly produced. In some embodiments, the IGFBP-3 is recombinantly produced. In some embodiments, the IGF-1 and IGFBP-3 are complexed prior to administration to a subject.

[0048] In some embodiments, a pharmaceutical composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and polysorbate 20 is more stable at room temperature than a pharmaceutical composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3) without polysorbate 20.

[0049] In some embodiments, a pharmaceutical composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and polysorbate 20 is less oxidized at room temperature than a pharmaceutical composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3) without polysorbate 20.

[0050] In some embodiments, the percentage of oxidized IGF-1 species does not increase by more than 25% after 3 months when stored at a temperature of about 25° C. In some embodiments, the percentage of oxidized IGF-1 species does not increase by more than 10% after 3 months when stored at a temperature of about 25° C.

[0051] In some embodiments, provided herein are pharmaceutical compositions further comprising a pharmaceutically acceptable carrier.

[0052] In some embodiments, provided herein are methods for treating or preventing intraventricular hemorrhage (IVH), comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1) and recombinant insulin-like growth factor binding protein 3 (rIGFBP-3).

[0053] In some aspects, provided herein are methods for treating or preventing intraventricular hemorrhage, comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and a polysorbate surfactant (e.g., polysorbate 20).

[0054] In some aspects, provided herein are methods for treating or preventing intraventricular hemorrhage (IVH), comprising administering to a subject in need thereof a pharmaceutical composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and a polysorbate surfactant (e.g., polysorbate 20) at a concentration of about 0.0025% v / v to 0.0075% v / v, wherein rIGF-1 and rIGFBP-3 are complexed in a ratio of 0.75 to 1.25:1 or 1:0.75-1.25, e.g., equimolar amounts, and wherein rIGF-1 / IGFBP-3 is at a concentration of about 10 micrograms / mL to 1000 micrograms / mL.

[0055] In some aspects, provided herein are methods for treating or preventing intraventricular hemorrhage (IVH), comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), wherein the subject in need thereof has a gestational age of less than 26 weeks. In some embodiments, provided herein are methods for treating or preventing IVH, comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), wherein the subject in need thereof has a gestational age of about 23 weeks to 25 weeks + 6 days. In some aspects, provided herein are methods for treating or preventing intraventricular hemorrhage (IVH), comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), in a therapeutic amount sufficient to achieve a reduced incidence of intraventricular hemorrhage relative to a control.

[0056] In some embodiments, the reduced incidence is achieved by about 36-40 weeks postmenstrual age (PMA) as assessed by ultrasound or MRI. In some embodiments, the reduced incidence is achieved by about 35-42 weeks postmenstrual age as assessed by ultrasound or MRI. In some embodiments, the reduced incidence is achieved by 35 weeks postmenstrual age as assessed by ultrasound or MRI. In some embodiments, the reduced incidence is achieved by 36 weeks postmenstrual age as assessed by ultrasound or MRI. In some embodiments, the reduced incidence is achieved by 37 weeks postmenstrual age as assessed by ultrasound or MRI. In some embodiments, the reduced incidence is achieved by 38 weeks postmenstrual age as assessed by ultrasound or MRI. In some embodiments, the reduced incidence is achieved by 39 weeks postmenstrual age as assessed by ultrasound or MRI. In some embodiments, the reduced incidence is achieved by 40 weeks postmenstrual age as assessed by ultrasound or MRI. In some embodiments, the reduced incidence is achieved by 41 weeks of postmenstrual age as assessed by ultrasound or MRI, hi some embodiments, the reduced incidence is achieved by 42 weeks of postmenstrual age as assessed by ultrasound or MRI.

[0057] In some embodiments, the reduction in incidence is assessed by ultrasound.

[0058] In some embodiments, the reduction in incidence of IVH is at least about a 30% reduction in the incidence of Grade II, Grade III, or Grade IV IVH. In some embodiments, the reduction in incidence of IVH is at least about a 30% reduction in the incidence of Grade II IVH. In some embodiments, the reduction in incidence of IVH is at least about a 30% reduction in the incidence of Grade III IVH. In some embodiments, the reduction in incidence of IVH is at least about a 30% reduction in the incidence of Grade IV IVH.

[0059] In some embodiments, provided herein are methods for treating or preventing bronchopulmonary dysplasia, comprising administering a composition to a subject in need thereof. In some embodiments, provided herein are methods for treating or preventing chronic lung disease in premature infants, comprising administering a composition to a subject in need thereof.

[0060] In one aspect, provided herein is a method of treating or preventing chronic lung disease in premature infants, the method comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and a surfactant.

[0061] In some embodiments, the surfactant is a polysorbate surfactant. In some embodiments, the polysorbate surfactant is selected from polysorbate 20 (P20) or polysorbate 80 (P80). In some embodiments, the polysorbate surfactant is P20. In some embodiments, the polysorbate surfactant is P80.

[0062] In some embodiments, the polysorbate surfactant is at a concentration of about 0.001% to 2.4% v / v. In some embodiments, the polysorbate surfactant is at a concentration of about 0.2% to 0.4% v / v. In some embodiments, the polysorbate surfactant is at a concentration of about 0.001%, 0.005%, 0.01%, 0.02%, 0.03%, 0.05%, 0.10%, 0.15%, 0.2%, 0.5%, 0.7%, 1.0%, 1.2%, 1.5%, 1.8%, 2.0%, 2.2%, or 2.4% v / v. In some embodiments, the polysorbate surfactant is at a concentration of about 0.0025%, about 0.005%, or about 0.0075% v / v. In some embodiments, the polysorbate is at a concentration of 0.005%.

[0063] In some embodiments, the subject in need of treatment is an infant.

[0064] In some embodiments, the infant is born at least 1 week, 2 weeks, 3 weeks, 4 weeks, 1 month, 2 months, or 3 months premature. In some embodiments, the infant is about 23-34 weeks postmenstrual age (PMA). In some embodiments, the infant is about 23 weeks, about 24 weeks, about 25 weeks, about 26 weeks, about 27 weeks, about 28 weeks, about 29 weeks, about 30 weeks, about 31 weeks, about 32 weeks, about 33 weeks, or about 34 weeks PMA. In some embodiments, the infant is about 23 weeks PMA. In some embodiments, the infant is less than 36 weeks PMA. In some embodiments, the infant is less than 35 weeks PMA. In some embodiments, the infant is less than 34 weeks PMA. In some embodiments, the infant is less than 33 weeks PMA. In some embodiments, the infant is less than 32 weeks PMA. In some embodiments, the infant is less than 31 weeks PMA. In some embodiments, the infant is less than 30 weeks PMA. In some embodiments, the infant is less than 29 weeks PMA. In some embodiments, the infant is less than 28 weeks PMA. In some embodiments, the infant is less than 27 weeks PMA. In some embodiments, the infant is less than 26 weeks PMA. In some embodiments, the infant is less than 25 weeks PMA. In some embodiments, the infant is less than 24 weeks PMA. In some embodiments, the infant is less than 23 weeks PMA.

[0065] In some embodiments, the infant is born at a gestational age (GA) of less than 32 weeks. In some embodiments, the infant is born at a GA of less than 31 weeks. In some embodiments, the infant is born at a GA of less than 30 weeks. In some embodiments, the infant is born at a GA of less than 29 weeks. In some embodiments, the infant is born at a GA of less than 28 weeks. In some embodiments, the infant is born at a GA of between 28 and 32 weeks.

[0066] In some embodiments, the subject in need of treatment is administered a composition that is subcutaneous, intravenous, intramuscular, or oral. In some embodiments, the method includes administering the composition subcutaneously or intravenously. In some embodiments, the composition is administered intravenously.

[0067] In some embodiments, the composition is administered at a dosage of about 100-1000 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of about 100-800 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of about 100-500 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of 100 micrograms / kg / 24 hours to 450 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of 100 micrograms / kg / 24 hours to 400 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of 150 micrograms / kg / 24 hours to 400 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of 200 micrograms / kg / 24 hours to 400 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of about 250-1000 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of about 800 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of about 250-800 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of 250 micrograms / kg / 24 hours to 400 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of about 250 micrograms / kg / 24 hours. In some embodiments, the composition is administered at a dosage of about 400 micrograms / kg / 24 hours.

[0068] In some embodiments, the composition is administered once, twice, three times, or four times during a 24 hour period. In some embodiments, the composition is administered once during a 24 hour period. In some embodiments, the composition is administered by continuous infusion over a 24 hour period.

[0069] In some embodiments, the composition is administered from birth until about 23-34 weeks postmenstrual age (PMA). In some embodiments, the composition is administered from birth until about 23-32 weeks PMA. In some embodiments, the composition is administered from birth until about 29 weeks plus 6 days PMA. "PMA" or "postmenstrual age" refers to gestational age plus chronological age. In some embodiments, treating or preventing chronic lung disease (CLD) in preterm infants results in a reduced incidence of bronchopulmonary dysplasia (BPD), right ventricular hypertrophy (RVH), pulmonary hypertension (PH), necrotizing enterocolitis, or intraventricular hemorrhage. The methods provided herein include embodiments in which administration of IGF-I or an agonist or analog results in a reduced incidence of chronic lung disease (CLD) in preterm infants by 12 months corrected age (CA). An infant's corrected age is the infant's adjusted age based on his or her expected delivery date. Assuming a gestational age of 40 weeks (i.e., the expected delivery date), a premature infant's corrected age (CA) is the infant's chronological age minus the excess time the infant spent outside the mother's body (i.e., the number of weeks the infant was born prematurely). In some embodiments, administration of the pharmaceutical composition results in a reduced incidence of chronic lung disease in premature infants from 23 weeks to 12 months of postmenstrual age (PMA). For example, administration of the pharmaceutical composition results in a reduced incidence of CLD by at least 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, or 52 weeks of PMA. In some other embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of CLD by at least 6, 7, 8, 9, 10, 11, or 12 months PMA. In some embodiments, administration of the composition results in a reduction in the incidence of bronchopulmonary dysplasia (BPD) by 23 weeks to 12 months postmenstrual age (PMA).For example, administration of the pharmaceutical composition results in a reduction in the incidence of BPD by at least 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, or 52 weeks PMA. In some other embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of BPD by at least 6, 7, 8, 9, 10, 11, or 12 months PMA. In some embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of severe intraventricular hemorrhage (IVH) grade II, III or IV by at least 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months or 24 months of postmenstrual age (PMA). In some embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of right ventricular hypertrophy (RVH) by 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 6 months, 8 months, 10 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, or 24 months of postmenstrual age (PMA). In some embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of pulmonary hypertension (PH) by 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 6 months, 8 months, 10 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, or 24 months (PMA).In some embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of necrotizing enterocolitis by 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 6 months, 8 months, 10 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, or 24 months (PMA).

[0070] In some embodiments, the subject has reduced IGF-1 serum levels. In some embodiments, the subject has an IGF-1 level of less than 60 micrograms / L. In some embodiments, the subject has an IGF-1 level of less than 50 micrograms / L. In some embodiments, the subject has an IGF-1 level of less than 40 micrograms / L. In some embodiments, the subject has an IGF-1 level of less than 30 micrograms / L. In some embodiments, the subject has an IGF-1 level of about 30-50 micrograms / L.

[0071] In some embodiments, administration of the pharmaceutical composition results in an increase in IGF-1 serum levels compared to baseline levels. In some embodiments of the present disclosure, the baseline IGF-1 serum level in an untreated infant is less than 60 micrograms / L. In some embodiments, the baseline IGF-1 serum level is less than 50 micrograms / L. In some embodiments, the baseline IGF-1 serum level is less than 40 micrograms / L. In some embodiments, the baseline IGF-1 serum level is less than 30 micrograms / L. In some embodiments, the baseline IGF-1 serum level is about 30-50 micrograms / L.

[0072] In some embodiments, IGF-1 serum levels are increased by at least about 25% to 50% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, or 60% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 10% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 15% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 20% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 25% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 30% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 35% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 40% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 45% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 50% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 55% compared to baseline levels. In some embodiments, IGF-1 serum levels are increased by at least about 60% compared to baseline levels.

[0073] In some embodiments, IGF-1 serum levels remain elevated for at least 24 hours after administration. In some embodiments, IGF-1 serum levels remain elevated for about 48 hours. In some embodiments, IGF-1 serum levels remain elevated for about 72 hours. In some embodiments, IGF-1 serum levels remain elevated for at least about 7 days. In some embodiments, IGF-1 serum levels remain elevated until at least about 23-34 weeks of postmenstrual age (PMA). In some embodiments, IGF-1 serum levels remain elevated until at least about 23-12 months of postmenstrual age (PMA).

[0074] In some embodiments, administration of the pharmaceutical composition results in a reduced incidence of chronic lung disease, bronchopulmonary dysplasia, right ventricular hypertrophy (RVH), pulmonary hypertension (PH), necrotizing enterocolitis, or intraventricular hemorrhage in premature infants up to 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40 weeks, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, or 24 months of postmenstrual age (PMA). The methods provided herein include embodiments in which administration of a pharmaceutical composition results in a reduction in the incidence of chronic lung disease (CLD) in preterm infants by 12 months corrected age (CA). An infant's corrected age is the infant's adjusted age based on their expected due date. Assuming a gestational age of 40 weeks (i.e., the expected due date), a preterm infant's corrected age is calculated by subtracting the excess time the infant spent outside the mother's body from its chronological age. In some embodiments, administration of a pharmaceutical composition reduces the incidence of bronchopulmonary dysplasia (BPD) by 23 to 24 months of postmenstrual age (PMA). For example, administration of a pharmaceutical composition results in a reduction in the incidence of BPD by 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, or 40, 45, 50, or 52 weeks of PMA. In some other embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of BPD by 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, or 24 months PMA. In some embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of intraventricular hemorrhage (IVH) grade I, II, III or IV by 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months or 24 months of postmenstrual age (PMA).In some embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of right ventricular hypertrophy (RVH) by 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, or 12 months of postmenstrual age (PMA). In some embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of pulmonary hypertension (PH) by (PMA) 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, or 24 months. In some embodiments, administration of the pharmaceutical composition results in a reduction in the incidence of necrotizing enterocolitis by (PMA) 23 weeks, 24 weeks, 25 weeks, 26 weeks, 27 weeks, 28 weeks, 29 weeks, 30 weeks, 31 weeks, 32 weeks, 33 weeks, 34 weeks, 35 weeks, 36 weeks, 37 weeks, 38 weeks, 39 weeks, 40 weeks, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 23 months, or 24 months.

[0075] In some embodiments, administration of the pharmaceutical composition results in an increase in functional status as assessed by the PREMature Infant Index (PREMII) by 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40 weeks of postmenstrual age (PMA).

[0076] In some embodiments, administration of the pharmaceutical composition results in an increase in the IGF-1 serum target level of about 28 to 109 micrograms / mL (μg / ml), hi some embodiments, administration of the pharmaceutical composition results in an increase in the IGF-1 serum target level of about 30 μg / ml, about 40 μg / ml, about 50 μg / ml, about 60 μg / ml, about 70 μg / ml, about 80 μg / ml, about 90 μg / ml, about 100 μg / ml, or about 110 μg / ml.

[0077] In some embodiments, the reduction in incidence is at least about 20% to 50% relative to untreated controls, hi some embodiments, the reduction in incidence is about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, or about 70% relative to untreated controls.

[0078] In some embodiments, the reduction in incidence is at least about 20-50% relative to controls receiving standard of care, hi some embodiments, the reduction in incidence is about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, or about 70% relative to controls receiving standard of care.

[0079] In some embodiments, the increase in functional status is at least about 20% to 50% relative to untreated controls, hi some embodiments, the increase in functional status is about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, or about 70% relative to controls receiving standard of care.

[0080] In some embodiments, the increase in functional status is at least about 20-50% relative to controls receiving standard of care, hi some embodiments, the increase in functional status is about 20%, about 30%, about 40%, about 50%, about 60%, or about 70% relative to controls receiving standard of care.

[0081] In some embodiments, provided herein are methods for treating or preventing chronic lung disease in premature infants, the methods comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and polysorbate 20 surfactant.

[0082] The methods disclosed herein include embodiments wherein administration of the composition results in an increase in functional status as assessed by the PREMature Infant Index (PREMII) by 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, or 40 weeks of postmenstrual age (PMA).

[0083] In some aspects, provided herein are methods for producing a protein complex comprising insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3), the method comprising the use of a contact surface other than stainless steel, such as a disposable bag, during mixing of the complex with a formulation solution, wherein the protein complex produced by such method exhibits an increase in oxidized species of IGF-1 of less than 20% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 18%. In some embodiments, the increase in oxidized species of IGF-1 is less than 16%. In some embodiments, the increase in oxidized species of IGF-1 is less than 15% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 12% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 10% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 8% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 6% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 4% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 3% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 2% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 1% after 6 months of storage at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 0.5% after 6 months of storage at 25° C.

[0084] In some embodiments, the increase in oxidized species of IGF-1 is less than 12% after 3 months of storage at 40°C. In some embodiments, the increase in oxidized species of IGF-1 is less than 10% after 3 months of storage at 40°C. In some embodiments, the increase in oxidized species of IGF-1 is less than 8% after 3 months of storage at 40°C. In some embodiments, the increase in oxidized species of IGF-1 is less than 6% after 3 months of storage at 40°C. In some embodiments, the increase in oxidized species of IGF-1 is less than 5% after 3 months of storage at 40°C. In some embodiments, the increase in oxidized species of IGF-1 is less than 4% after 3 months of storage at 40°C. In some embodiments, the increase in oxidized species of IGF-1 is less than 3% after 3 months of storage at 40°C. In some embodiments, the increase in oxidized species of IGF-1 is less than 2% after 3 months of storage at 40°C. In some embodiments, the increase in oxidized species of IGF-1 is less than 1% after 3 months of storage at 40°C.

[0085] In some embodiments, the disposable bag is further used during the pharmaceutical filtration step. In some embodiments, the method comprises filling at least 30% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling at least 40% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling 40% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling 50% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling 60% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling 70% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling at least 75% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling 80% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling 85% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling 90% of the disposable bag with the protein complex during the mixing and / or filtering steps. In some embodiments, the method comprises filling 95% of the disposable bag with the protein complex during the mixing and / or filtering steps.

[0086] In some embodiments, the method comprises filling 75-95% of the disposable bag with the protein complex during the mixing step and / or the filtering step. In some embodiments, the method comprises filling 75-90% of the disposable bag with the protein complex during the mixing step and / or the filtering step. In some embodiments, the method comprises filling 75-85% of the disposable bag with the protein complex during the mixing step and / or the filtering step. In some embodiments, the method comprises filling 75-80% of the disposable bag with the protein complex during the mixing step and / or the filtering step.

[0087] In some embodiments, the method comprises filling 25-80% of the disposable bag with the protein complex during the mixing step and / or the filtering step. In some embodiments, the method comprises filling 25-75% of the disposable bag with the protein complex during the mixing step and / or the filtering step. In some embodiments, the method comprises filling 25-70% of the disposable bag with the protein complex during the mixing step and / or the filtering step. In some embodiments, the method comprises filling 25-65% of the disposable bag with the protein complex during the mixing step and / or the filtering step. In some embodiments, the method comprises filling 25-60% of the disposable bag with the protein complex during the mixing step and / or the filtering step. In some embodiments, the method comprises filling 25-55% of the disposable bag with the protein complex during the mixing step and / or the filtering step. In some embodiments, the method comprises filling 25-50% of the disposable bag with the protein complex during the mixing step and / or the filtering step.

[0088] In some embodiments, the disposable bag is about 500 L or greater. In some embodiments, the disposable bag is about 10 L or greater. In some embodiments, the disposable bag is about 50 L or greater. In some embodiments, the disposable bag is about 100 L or greater. In some embodiments, the disposable bag is about 150 L or greater. In some embodiments, the disposable bag is about 200 L or greater. In some embodiments, the disposable bag is about 250 L or greater. In some embodiments, the disposable bag is about 300 L or greater. In some embodiments, the disposable bag is about 350 L or greater. In some embodiments, the disposable bag is about 400 L or greater. In some embodiments, the disposable bag is about 450 L or greater. In some embodiments, the disposable bag is about 500 L or greater. In some embodiments, the disposable bag is about 550L or greater than 550L.

[0089] In some embodiments, less than 25% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 6 months. In some embodiments, less than 20% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 6 months. In some embodiments, less than 18% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 6 months. In some embodiments, less than 15% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 6 months. In some embodiments, less than 12% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 6 months. In some embodiments, less than 10% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 6 months. In some embodiments, less than 5% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 6 months.

[0090] In some embodiments, less than 15% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 3 months. In some embodiments, less than 10% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 3 months. In some embodiments, less than 5% of the protein complexes are present as low molecular weight species upon storage at 40° C. for 3 months.

[0091] In some embodiments, less than 15% of the protein complexes are present as low molecular weight species after storage at 40° C. for 1 month. In some embodiments, less than 15% of the protein complexes are present as low molecular weight species after storage at 40° C. for 8 months. In some embodiments, less than 15% of the protein complexes are present as low molecular weight species after storage at 40° C. for 10 months. In some embodiments, less than 15% of the protein complexes are present as low molecular weight species after storage at 40° C. for 12 months.

[0092] In some embodiments, a pharmaceutical composition comprising an isolated protein complex comprising insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3) is produced by the method described in any of the above aspects or embodiments. In some embodiments, the composition comprises a surfactant, e.g., a polysorbate surfactant.

[0093] In some aspects, provided herein is a pharmaceutical composition comprising an isolated protein complex comprising insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3), produced by a method comprising the use of a disposable bag.

[0094] In some embodiments, the pharmaceutical composition comprises 50 mM sodium acetate, 105 mM sodium chloride, and 0.005% (v / v) P20 at pH 5.5.

[0095] In some embodiments, the sodium acetate or acetic acid is at a concentration of about 10-100 mM. In some embodiments, the sodium acetate or acetic acid is at a concentration of about 10 mM, 15 mM, 20 mM, 25 mM, 30 mM, 35 mM, 40 mM, 45 mM, 50 mM, 55 mM, 60 mM, 65 mM, 70 mM, 75 mM, 80 mM, 85 mM, 90 mM, 95 mM, or 100 mM. In some embodiments, the sodium acetate or acetic acid is at a concentration of about 50 mM.

[0096] In some embodiments, the sodium chloride is at a concentration of about 20 mM and 200 mM. In some embodiments, the sodium chloride is at a concentration of about 20 mM, 25 mM, 30 mM, 35 mM, 40 mM, 45 mM, 50 mM, 55 mM, 60 mM, 65 mM, 70 mM, 75 mM, 80 mM, 85 mM, 90 mM, about 95 mM, about 100 mM, about 105 mM, about 110 mM, about 115 mM, about 120 mM, about 125 mM, about 130 mM, about 135 mM, about 140 mM, about 145 mM, about 150 mM, about 155 mM, about 160 mM, about 165 mM, about 170 mM, about 175 mM, about 180 mM, about 185 mM, about 190 mM, about 195 mM, or about 200 mM. In some embodiments, the sodium chloride is at a concentration of about 105 mM.

[0097] In some embodiments, the pharmaceutical composition has a pH of about 5.0 to 7.0. In some embodiments, the pH is about 5.0, about 5.2, about 5.4, about 5.6, about 5.8, about 6.0, about 6.2, about 6.4, about 6.6, about 6.8, or about 7.0. In some embodiments, the composition has a pH of about 5.1, about 5.3, about 5.5, about 5.7, or about 5.9, about 6.1, about 6.3, about 6.5, about 6.7, or about 6.9. In some embodiments, the composition has a pH of about 5.3 to 5.8. In some embodiments, the composition has a pH of about 5.5.

[0098] Provided herein is a pharmaceutical composition comprising a protein complex comprising equimolar amounts of recombinant insulin-like growth factor 1 (rIGF-1) and recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), a polysorbate 20 surfactant at a concentration of about 0.005%, and a buffer comprising sodium acetate, acetic acid, and / or sodium chloride, wherein the pharmaceutical composition has a pH of about 5.3 to 5.8, the rIGF-1 / IGFBP-3 is at a concentration of about 50 micrograms / mL, and less than 2% of the IGF-1 is present as oxidized species.

[0099] Provided herein is a pharmaceutical composition comprising a protein complex comprising recombinant insulin-like growth factor 1 (rIGF-1) and recombinant insulin-like growth factor binding protein 3 (rIGFBP-3) in equimolar amounts, e.g., in the range of 0.75-1.25:1 or 1:0.75-1.25, a polysorbate 20 surfactant at a concentration of about 0.005%, and a buffer comprising sodium acetate, acetic acid, and / or sodium chloride, wherein the composition has a pH of about 5.3-5.8, the rIGF-1 / IGFBP-3 is at a concentration of about 50 micrograms / mL, and less than 1.5% of the IGF-1 is present as an oxidized species. While the present invention has been described in conjunction with certain preferred embodiments thereof, it should be understood that the foregoing description and the following examples are intended to illustrate, but not limit, the scope of the invention. Other aspects, advantages, and modifications within the scope of the invention will be apparent to those skilled in the art to which the present invention pertains.

[0100] The drawings are for purposes of illustration only and not limitation. [Brief explanation of the drawings]

[0101] [Figure 1] Photograph of the components of the Swedish model infusion set used in the IGF-1 / IGFBP-3 infusion study. [Figure 2] 1 is a graph of protein concentration of IGF-1 / IGFBP-3 pharmaceuticals with and without 0.005% polysorbate 20 before and after buffer correction. [Figure 3A] 1 is a graph showing the purity of the samples as determined by SE-HPLC in the absence of polysorbate 20. [Figure 3B] Figure 1 shows the SE-HPLC profile of the sample in the presence of polysorbate 20. Peak area percent is shown for the average of two injection sets. [Figure 4] 1 is a graph of the oxidation of IGF-1 in IGF-1 / IGFBP-3 formulations in the presence and absence of P20 over 48 hours as measured by RP-UPLC. [Figure 5] Graph showing the percentage of oxidized IGF-1 as a function of time, drug and material concentration used. [Figure 6] 1 is a graph of percent oxidized IGF-1 as a function of time and headspace in disposable bags and glass containers. [Figure 7A] 1 is a graph showing the stability (percent main peak) of IGF-1 / IGFBP-3 as a function of time at 2° C. to 8° C. (e.g., 5° C.). [Figure 7B] 1 is a graph showing the stability (percent main peak) of IGF-1 / IGFBP-3 as a function of time at 23° C. to 27° C. (25° C.). [Figure 7C] 1 is a graph showing the stability of IGF-1 / IGFBP-3 (percent main peak) as a function of time at 38°C to 42°C. [Figure 8A] 1 is a graph of percent oxidized IGF-1 plotted as a function of time at 5° C. [Figure 8B] 1 is a graph of percent oxidized IGF-1 plotted as a function of time at 25° C. [Figure 8C] 1 is a graph of percent oxidized IGF-1 plotted as a function of time at 40° C. [Figure 9] Graphs of IGF-1 concentrations over time are shown for samples treated with either 250 micrograms / kg / 24 hours or 400 micrograms / kg / 24 hours of IGF-1 / IGFBP-3 compared to subjects receiving standard of care. [Figure 10] Graphs are shown validating a simulation model based on simulated and observed IGF-1 concentrations in untreated controls, subjects receiving standard therapy, and subjects treated with low dose or 250 micrograms / kg / 24 hours of rIGF-1 / IGFBP-3. [Figure 11] FIG. 1 is a graph showing the results of a clinical trial simulation that determined the probability of a subject developing no bronchopulmonary dysplasia (BPD) or mild BPD based on serum IGF-1 exposure levels as a result of treatment with either 250 micrograms / kg / 24 hours or 400 micrograms / kg / 24 hours of IGF-1 / IGFBP-3 compared to subjects receiving standard of care. [Figure 12] Model of simulated 95% prediction intervals of IGF-1PK concentrations over the treatment period to predict where the mean and 5th and 95th intervals would fall in relation to the target therapeutic range (28 to 109 ng / ml) in subjects treated with either 250 micrograms / kg / 24 hours or 400 micrograms / kg / 24 hours of IGF-1 / IGFBP-3 compared to subjects receiving standard of care at day 7 and end of infusion. [Figure 13A] Graph of serum IGF-1 exposure on day 7 and probability of BPD outcome (mild or no BPD). [Figure 13B] 1 is a graph of serum IGF-1 exposure and probability of BPD outcome (mild or no BPD) at 40 weeks PMA. DETAILED DESCRIPTION OF THE INVENTION

[0102] In some aspects, the present invention provides compositions optimized for administration to newborns and / or preterm infants, as well as methods for treating diseases and complications of preterm birth, including, inter alia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and chronic lung disease in preterm infants. The compositions and methods provided herein are particularly effective for treating intraventricular hemorrhage, bronchopulmonary dysplasia, and / or chronic lung disease in preterm infants, particularly extremely preterm infants. In some embodiments of the present invention, provided herein are low-concentration pharmaceutical compositions suitable for administering to newborns and / or preterm infants a therapeutic conjugate comprising insulin-like growth factor-1 (IGF-1), conjugated insulin-like growth factor binding protein-3 (IGFBP-3), and a non-ionic surfactant (e.g., a polysorbate surfactant such as polysorbate 20 or polysorbate 80, particularly polysorbate 20, at a concentration of about 0.0025% v / v to 0.0075% v / v (e.g., 0.005% v / v)). In some embodiments, the polysorbate surfactant is polysorbate 20 (P20) or polysorbate 80 (P80). In some embodiments, rIGF-1 and rIGFBP-3 are complexed in a ratio of 0.75-1.25:1 or 1:0.75-1.25, e.g., equimolar amounts, with rIGF-1 / IGFBP-3 at a concentration of about 10 micrograms / mL to 1000 micrograms / mL (e.g., 50 micrograms / mL). In some aspects, the methods of the invention comprise administering the aforementioned pharmaceutical composition to a subject (e.g., a premature infant) in need of treatment. In a further, independent aspect, provided herein are processes for manufacturing formulations of the compositions, e.g., using disposable bags that minimize contact of the formulation with stainless steel, particularly to provide a robust process for achieving formulations with reduced oxidation.

[0103] Various aspects of the invention are described in detail in the following sections. The use of the sections is not intended to limit the invention. Each section may be applicable to any aspect of the invention. In this application, the use of "or" means "and / or" unless otherwise stated.

[0104] definition "Preterm" or "preterm birth" or "prematurity" or "premature infant" or "premature baby" or grammatical equivalents refer to the birth of an infant before 37 weeks of gestation or weighing 10% less than average for the infant's gestational age. For example, an infant born between 22 and 37 weeks is considered preterm. "GA" or "gestational age" is a general term that describes how far along a pregnancy has progressed, measured in weeks from the first day of a woman's last menstrual cycle to the current date. In some embodiments, a preterm infant refers to an infant born at least 1 week, 2 weeks, 3 weeks, 4 weeks, 1 month, 2 months, or 3 months early. In some embodiments, a preterm infant refers to an infant born at a gestational age (GA) less than 32 weeks. In some embodiments, a preterm infant refers to an infant born at a gestational age (GA) less than 28 weeks. "PMA" or "postmenstrual age" refers to gestational age plus chronological age. "CA" or "corrected age" is chronological age reduced by the number of weeks born before 40 weeks gestation.

[0105] As used herein, the term "gestational age" (completed weeks) means the time elapsed between the first day of the last menstrual period and the date of delivery. If pregnancy is achieved using assisted reproductive technology, gestational age is calculated by adding two weeks to the conception period.

[0106] As used herein, the term "chronological age" (days, weeks, months, or years) means the time elapsed since birth.

[0107] As used herein, "postmenstrual age" (weeks) means gestational age plus chronological age.

[0108] As used herein, the term "corrected age" (weeks or months) means chronological age reduced by the number of weeks born before 40 weeks of gestation. This term should only be used for children up to age 3 years who were born prematurely.

[0109] During the perinatal neonatal hospitalization, "postmenstrual age" is the preferred term to describe the age of preterm infants. After the perinatal period, "corrected age" is the preferred term.

[0110] "IGF-I" refers to insulin-like growth factor I from any species, including bovine, ovine, porcine, equine, and human, preferably human, and when referring to exogenous administration, from any source, whether natural, synthetic, or recombinant, provided that it binds to an IGF-binding protein at the appropriate site. IGF-I can be recombinantly produced, for example, as described in PCT Publication No. 95 / 04076.

[0111] "IGFBP" or "IGF-binding protein" refers to a protein or polypeptide from the insulin-like growth factor-binding protein family that is normally associated with, bound to, or complexed with IGF-I, regardless of whether it is circulating (i.e., in serum or tissue). Such binding proteins do not include receptors. This definition includes IGFBP-1, IGFBP-2, IGFBP-3, IGFBP-4, IGFBP-5, IGFBP-6, Mac25 (IGFBP-7), and prostate-stimulating factor (PSF) or endothelial cell-specific molecule (ESM-1), as well as other proteins with high homology to IGFBPs. Mac25 is described, for example, in Swisshelm et al., Proc. Natl. Acad. Sci. USA, 92:4472-4476 (1995) and Oh et al., J. Biol. Chem., 271:30322-30325 (1996). PSF is described in Yamauchi et al., Biochemical Journal, 303:591-598 (1994). ESM-1 is described in Lassalle et al., J. Biol. Chem., 271:20458-20464 (1996).Other identified IGFBPs are described, for example, in EP 375,438 published June 27, 1990, EP 369,943 published May 23, 1990, WO 89 / 09268 published October 5, 1989, Wood et al., Molecular Endocrinology, 2:1176-1185 (1988), Brinkman et al., The EMBO J., 7:2417-2423 (1988), Lee et al., Mol. Endocrinol., 2:404-411 (1988), Brewer et al., BBRC, 152:1289-1297 (1988), EP 294,021 published December 7, 1988, Baxter et al. See, for example, WO 89 / 08667 published September 21, 1989, WO 89 / 09792 published October 19, 1989, and Binkert et al., EMBO J., 8:2497-2502 (1989).

[0112] "IGFBP-3" refers to insulin-like growth factor binding protein 3. IGFBP-3 is a member of the insulin-like growth factor binding protein family. IGFBP-3 can be from any species, including bovine, ovine, porcine, and human, in native sequence or variant forms, including, but not limited to, naturally occurring allelic variants. IGFBP-3 can be from any source, whether natural, synthetic, or recombinant, provided that it binds to IGF-I at the appropriate site. IGFBP-3 can be produced recombinantly, as described in PCT Publication No. 95 / 04076.

[0113] As used herein, a "therapeutic composition" is defined as comprising IGF-I, its analogs, or IGF-I in combination with its binding protein, IGFBP-3 (IGF-I / IGFBP-3 complex). Therapeutic compositions may also contain other substances, such as carriers, such as water, minerals, proteins, and other excipients known to those skilled in the art. In some embodiments, the therapeutic composition includes a surfactant, such as polysorbate 20 (P20) or polysorbate 80 (P80).

[0114] An "analog" of IGF-I is a compound that has the same therapeutic effect as IGF-I in humans or animals. These can be either naturally occurring analogs of IGF-I (e.g., truncated IGF-I) or known synthetic analogs of IGF-I. See, for example, U.S. Patent No. 5,473,054 for analog compounds of IGF-I.

[0115] An "agonist" of IGF-I is a compound, including peptides, that can increase serum and tissue levels of IGF, particularly IGF-I, in mammals and particularly humans. See, e.g., U.S. Patent No. 6,251,865 for a review of IGF agonist molecules.

[0116] As used herein, "developmental delay" refers to abnormal neurogenesis that may lead to delayed mental progression in achieving developmental milestones. Developmental delay may, in some cases, be determined by electroencephalography.

[0117] As used herein, "subject" refers to any mammal, including a human. In certain embodiments of the invention, the subject is an adult, adolescent, or infant. Also contemplated by the present invention is the administration of pharmaceutical compositions and / or performance of treatment methods in utero.

[0118] As used herein, the term "treatment" (also "treat" or "treating") refers to any administration of a therapeutic composition (e.g., IGF-1 / IGFBP-3) that partially or completely alleviates, improves, relieves, inhibits, delays the onset of, prevents, reduces the severity of, and / or reduces the incidence of one or more symptoms or characteristics of a particular disease, disorder, and / or condition (e.g., intraventricular hemorrhage, bronchopulmonary dysplasia, chronic lung disease of premature infants). Such treatment may be in subjects who do not exhibit signs of the associated disease, disorder, and / or condition and / or in subjects who exhibit only early signs of the disease, disorder, and / or condition. Alternatively, or in addition, such treatment may be in subjects who exhibit one or more established signs of the associated disease, disorder, and / or condition. Thus, in some embodiments, treatment refers to preventing the onset or progression of a disease.

[0119] "Baseline level of IGF-1" refers to the serum level of IGF-1 in a subject before receiving any treatment.

[0120] "Shelf life" or "shelf life" refers to the period of storage of a pharmaceutical product while retaining characteristics and properties suitable for therapeutic use. For example, in some embodiments, the amount of undesirable species, including oxidized species, high molecular weight species, and degradation products, is reduced (e.g., less than 10%) during the shelf life of the formulation. Shelf life may be described, for example, at a particular storage temperature (e.g., 5°C, 25°C, 40°C, etc.).

[0121] "Stability" or "stable" refers to the degree to which a pharmaceutical product retains the characteristics and properties suitable for therapeutic use that it possessed at the time of manufacture during storage and use. Stability includes aspects related to its formulation, the stability of the IGF-1 and IGFBP3 components, the integrity and stability of the IGF-1 / IGFBP3 complex, containers and closures, manufacturing and processing conditions, packaging components, storage and shipping conditions, temperature, light, and humidity, as well as the expected duration and conditions of pharmacy shelf life and patient use. In some embodiments, stability refers to a reduction in the amount of undesired species, including oxidized species, which results in a reduction in aggregation and / or low molecular weight species represented by degradation products, and reduced high molecular weight species. In some embodiments, stability refers to less than 10% undesired species. In some embodiments, stability refers to less than 5% undesired species. In some embodiments, stability refers to less than 2% undesired species.

[0122] "Standard neonatal care" or "standard of care" refers to the standard of care in a Level III neonatal intensive care unit (NICU) as described by the American Academy of Pediatrics for infants born at a gestational age less than 32 weeks.

[0123] "Standard of care for CLD and / or BPD" refers to therapeutic measures that include respiratory support such as supplemental oxygen, continuous positive airway pressure, and mechanical ventilation with endotracheal intubation. Symptoms are managed with medications such as bronchodilators to help open the airways, steroids to help reduce inflammation, diuretics to help reduce excess fluid in the lungs, bronchodilators to help reduce blood pressure in the lungs, and antibiotics to fight infection.

[0124] "Standard of care for IVH" refers to preventive and / or therapeutic measures, including early administration and stabilization of cerebral hemodynamics and respiratory support, as well as antenatal steroids. IVH treatment refers to supportive management of symptoms with medications to reduce bleeding and brain damage and prevent seizures.

[0125] As used herein, the terms "improve," "increase," or "reduce," or grammatical equivalents, refer to a value that is relative to a baseline measurement, such as a measurement in the same individual prior to initiation of a treatment described herein, or a measurement in a control individual (or control individuals) in the absence of a treatment described herein or historical reference or data. A "control individual" is an individual who is afflicted with the same form of preterm infant disease (e.g., IVH, BPD, CLD, among others) as the individual being treated, and who is approximately the same age as the individual being treated (to ensure that the stage of disease in the treated and control individuals is comparable).

[0126] IGF-1 / IGFBP-3 The present invention can be practiced using IGF-1 or its agonists or analogs. IGF-I is a well-known regulator of postnatal growth and metabolism. See Baker J, Liu JP, Robertson EJ, Efstratiadis A. It has a molecular weight of approximately 7.5 kilodaltons (Kd). Most circulating IGFs are bound to IGF-binding proteins, more particularly IGFBP-3. IGF-I can be measured in serum to diagnose abnormal growth-related conditions.

[0127] Typically, therapeutic compositions suitable for treating the disorders described herein, including, for example, IVH, BPD, or CLD, comprise IGF-1 and an IGF-1 binding protein, such as an IGF binding protein (IGFBP). At least six different IGF binding proteins (IGFBPs) have been identified in various tissues and body fluids. In some embodiments, suitable therapeutic compositions according to the present invention contain IGF-1 and IGFBP-3. IGF-1 and IGFBP-3 may be used as a protein complex or separately. In some embodiments, IGF-1 and IGFBP-3 are complexed in equimolar amounts. In some embodiments, a therapeutic composition comprises mecasermin rinfabate. In some embodiments, a therapeutic composition comprises mecasermin rinfabate and a surfactant. In some embodiments, a therapeutic composition comprises mecasermin rinfabate and polysorbate 20. In some embodiments, a therapeutic composition comprises mecasermin rinfabate and polysorbate 80.

[0128] IGF-I and IGF-I binding proteins such as IGFBP-3 may be purified from natural sources or produced by recombinant means. For example, the purification of IGF-I from human serum is well known in the art (Rinderknecht et al. (1976) Proc. Natl. Acad. Sci. USA 73:2365-2369). The production of IGF-I by a recombinant process is shown in EP 0128733 published in December 1984. IGFBP-3 can be produced from natural sources using a process such as that shown by Baxter et al. (1986, Biochem. Biophys. Res. Comm. 139:1256-1261). Alternatively, IGFBP-3 can be synthesized recombinantly as discussed by Sommer et al., pp. 715-728, in Modern Concepts of Insulin-Like Growth Factors (E.S. Pencer, ed., Elsevier, NY, 1991). Recombinant IGFBP-3 binds to IGF-I in a 1:1 molar ratio (equimolar amounts).

[0129] Pharmaceutical Compositions and Therapeutic Uses The present invention provides a pharmaceutical composition suitable for administering a therapeutic protein conjugate to a neonate, comprising conjugated insulin-like growth factor 1 and insulin-like growth factor binding protein 3 (e.g., equimolar amounts, e.g., in the range of 0.75-1.25:1 or 1:0.75-1.25) and 0.0025%-0.0075% non-ionic surfactant (e.g., a polysorbate surfactant such as polysorbate 20 or polysorbate 80, particularly polysorbate 20). In one embodiment, the pharmaceutical composition is isotonic. In one embodiment, the pharmaceutical composition is liquid. In one embodiment, the pharmaceutical composition is aqueous.

[0130] The present invention also provides methods for treating (e.g., alleviating or reducing the risk of) diseases and complications in preterm infants, such as intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), or chronic lung disease (CLD), such as CLD, associated with preterm infants. For example, in some embodiments, the present invention may be used to treat preterm infants, e.g., to ameliorate or reduce the risk of IVH or IVH-related complications. In some other embodiments, the present invention may be used to treat preterm infants, e.g., to ameliorate or reduce the risk of CLD or CLD-related complications. In further embodiments, the present invention may be used to treat preterm infants, e.g., to ameliorate or reduce the risk of BPD or BPD-related complications. In some embodiments, the present invention may be used to treat infants born at least 1 week, 2 weeks, 3 weeks, 4 weeks, 1 month, 2 months, or 3 months premature. In some embodiments, the present invention may be used to treat extremely premature infants.

[0131] In one embodiment of the present invention, a pharmaceutical composition comprising IGF-I is administered in combination with an IGF binding protein capable of binding to IGF-I and a surfactant. In some embodiments, the IGF binding protein capable of binding to IGF-I is IGF binding protein 3 (IGFBP-3). In some embodiments, the composition comprises a surfactant selected from polysorbate 20 or polysorbate 80.

[0132] In some embodiments, the concentration of the therapeutic complex comprising rIGF-1 / IGFBP-3 is in the range of 10 to 1000 micrograms / mL (e.g., 10 to 100 micrograms / mL, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or 100 micrograms / mL), such as 45 to 55 micrograms / mL, particularly 50 micrograms / mL.

[0133] In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 has a concentration of about 10 micrograms / mL to 1000 micrograms / mL. In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 has a concentration of about 10 micrograms / mL to 100 micrograms / mL. For example, in some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 has a pharmaceutical concentration of about 45 to 55 micrograms / mL. In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 has a concentration of about 50 micrograms / mL. In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 at a pharmaceutical concentration of about 10 to 100 micrograms / mL is suitable for intravenous administration. In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 at a concentration of about 45 to 55 micrograms / mL is suitable for intravenous administration. In some embodiments, a pharmaceutical composition comprising rIGF-1 / IGFBP-3 at a concentration of about 50 micrograms / mL is suitable for intravenous administration.

[0134] In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 has a concentration of about 1000 micrograms / mL to 5000 micrograms / mL. For example, in some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 has a concentration of 2000 micrograms / mL to 3000 micrograms / mL. In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 has a concentration of about 2500 micrograms / mL. In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 at a concentration of about 1000 to 5000 micrograms / mL is suitable for subcutaneous administration. In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 at a concentration of about 2000 micrograms / mL to 3000 micrograms / mL is suitable for subcutaneous administration. In some embodiments, the pharmaceutical composition comprising rIGF-1 / IGFBP-3 at a concentration of about 2500 micrograms / mL is suitable for subcutaneous administration.

[0135] In some embodiments, pharmaceutical compositions containing IGF-I and IGFBP-3 in a ratio of 0.75-1.25:1 or 1:0.75-1.25, e.g., equimolar amounts of IGF-I and IGF binding protein 3, may be used. In some embodiments, IGF-I and IGF binding protein 3 are complexed prior to administration. The complex may be formed, for example, by mixing approximately equimolar amounts of IGF-I and IGF binding protein 3 dissolved in a physiologically compatible carrier, such as normal saline or phosphate-buffered saline solution. In some embodiments, concentrated solutions of recombinant human IGF-I and concentrated solutions of recombinant human IGF binding protein 3 are mixed for a time sufficient to form a complex in a ratio of 0.75-1.25:1 or 1:0.75-1.25, e.g., an equimolar complex. In some embodiments, recombinant human IGF-I and recombinant human IGF binding protein 3 are combined to form the complex during purification, as described in International Patent Application No. WO 96 / 40736.

[0136] In some embodiments, a pharmaceutical composition is provided comprising a composition described herein and one or more suitable pharmaceutical excipients. In one embodiment, the composition has a minimal number and / or amount of excipients, e.g., 1, 2, 3, 4, or 5 excipients.

[0137] In some embodiments, the pharmaceutical composition comprises polysorbate 20. In some embodiments, the polysorbate 20 surfactant is at a concentration of about 0.001% to 2.4% v / v. In some embodiments, the polysorbate 20 surfactant is at a concentration of about 0.2% to 0.4% v / v. In some embodiments, the polysorbate 20 surfactant is at a concentration of about 0.001%, 0.005%, 0.01%, 0.02%, 0.03%, 0.05%, 0.10%, 0.15%, 0.2%, 0.5%, 0.7%, 1.0%, 1.2%, 1.5%, 1.8%, 2.0%, 2.2%, or 2.4% v / v. In some embodiments, the polysorbate 20 surfactant is at a concentration of about 0.0025%, about 0.005%, or about 0.0075% v / v. In some embodiments, the polysorbate 20 is at a concentration of 0.005%.

[0138] In some embodiments, the pharmaceutical composition comprises polysorbate 80. In some embodiments, the polysorbate 80 surfactant is at a concentration of about 0.001% to 2.4% v / v. In some embodiments, the polysorbate 80 surfactant is at a concentration of about 0.2% to 0.4% v / v. In some embodiments, the polysorbate 80 surfactant is at a concentration of about 0.001%, 0.005%, 0.01%, 0.02%, 0.03%, 0.05%, 0.10%, 0.15%, 0.2%, 0.5%, 0.7%, 1.0%, 1.2%, 1.5%, 1.8%, 2.0%, 2.2%, or 2.4% v / v. In some embodiments, the polysorbate 80 surfactant is at a concentration of about 0.0025%, about 0.005%, or about 0.0075% v / v. In some embodiments, the polysorbate 80 is at a concentration of 0.005%.

[0139] In some embodiments, the % surfactant is w / w.

[0140] In one embodiment, the % surfactant is w / v, ie, weight of composition to volume of surfactant, or weight of surfactant to volume of composition.

[0141] In one embodiment, the % surfactant is v / v.

[0142] In some embodiments, the pharmaceutical composition further comprises a buffer comprising sodium acetate, acetic acid, and / or sodium chloride. In some embodiments, the composition further comprises a buffer comprising sodium acetate or acetic acid. In some embodiments, the composition further comprises a buffer comprising sodium chloride.

[0143] In some embodiments, the sodium acetate or acetic acid is at a concentration of about 10-100 mM. In some embodiments, the sodium acetate or acetic acid is at a concentration of about 10 mM, 15 mM, 20 mM, 25 mM, 30 mM, 35 mM, 40 mM, 45 mM, 50 mM, 55 mM, 60 mM, 65 mM, 70 mM, 75 mM, 80 mM, 85 mM, 90 mM, 95 mM, or 100 mM. In some embodiments, the sodium acetate or acetic acid is at a concentration of about 50 mM.

[0144] In some embodiments, the sodium chloride is at a concentration of about 20 mM and 200 mM. In some embodiments, the sodium chloride is at a concentration of about 20 mM, about 25 mM, 30 mM, 35 mM, 40 mM, 45 mM, 50 mM, 55 mM, 60 mM, 65 mM, 70 mM, 75 mM, 80 mM, about 90 mM, about 95 mM, about 100 mM, about 105 mM, about 110 mM, about 115 mM, about 120 mM, about 125 mM, about 130 mM, about 135 mM, about 140 mM, about 145 mM, about 150 mM, about 155 mM, about 160 mM, about 165 mM, about 170 mM, about 175 mM, about 180 mM, about 185 mM, about 190 mM, about 195 mM, or about 200 mM. In some embodiments, the sodium chloride is at a concentration of about 105 mM.

[0145] In some embodiments, the composition has a pH of about 5.0-6.0. In some embodiments, the pH is about 5.0, about 5.2, about 5.4, about 5.6, about 5.8, about 6.0, about 6.2, about 6.4, about 6.6, about 6.8, or about 7.0. In some embodiments, the composition has a pH of about 5.1, about 5.3, about 5.5, about 5.7, about 5.9, about 6.1, about 6.3, about 6.5, about 6.7, or about 6.9. In some embodiments, the composition has a pH of about 5.3-5.8, e.g., 5.3, 5.4, 5.5, 5.6, 5.7, or 5.8, particularly pH 5.5.

[0146] Pharmaceutical compositions of the present invention include those suitable for oral, nasal, topical (including buccal and sublingual), or parenteral (including subcutaneous, intramuscular, intravenous, and intradermal) administration. Formulations may conveniently be provided in unit dosage form, e.g., tablets and sustained-release capsules, and liposomes, and may be prepared by any method well known in the art of pharmacy. See, e.g., Remington's Pharmaceutical Sciences, Mack Publishing Company, Philadelphia, Pa. (17th ed. 1985). In some embodiments, the compositions are administered intravenously.

[0147] Such preparative methods include the step of bringing into association the molecule to be administered with ingredients such as the carrier which constitutes one or more accessory ingredients. In general, the compositions are prepared by uniformly and intimately bringing into association the active ingredients with liquid carriers, liposomes or finely divided solid carriers, or both, and then, if necessary, shaping the product.

[0148] Compositions of the present invention suitable for oral administration may be presented as discrete units such as capsules, cachets, or tablets each containing a predetermined amount of the active ingredient; as a powder or granules; as a solution or suspension in an aqueous liquid or a non-aqueous liquid, or as an oil-in-water or water-in-oil liquid emulsion; or filled into liposomes, boluses, and the like.

[0149] Tablets can be made by compression or molding, optionally with one or more accessory ingredients. Compressed tablets can be prepared by compressing the active ingredient in a free-flowing form, such as a powder or granules, mixed with an optional binder, lubricant, inert diluent, preservative, surfactant, or dispersant in a suitable machine. Molded tablets can be made by molding a mixture of powdered compounds moistened with an inert liquid diluent in a suitable machine. Tablets can optionally be coated or scored, and can be formulated to provide a slow or controlled release of the active ingredient therein.

[0150] Compositions suitable for parenteral administration include aqueous and non-aqueous sterile injection solutions which may contain antioxidants, buffers, bacteriostats, and solutes so that the formulation is isotonic with the blood of the intended recipient, as well as aqueous and non-aqueous sterile suspensions which may contain suspending agents and thickening agents. The formulations may be presented in unit-dose or multi-dose containers, for example, sealed ampoules and vials, and may be stored in a freeze-dried (lyophilized) condition requiring only the addition of a sterile liquid carrier, for example, water for injection, immediately prior to use. Extemporaneous injection solutions and suspensions may be prepared from sterile powders, granules, and tablets.

[0151] In some embodiments, the methods disclosed herein provide for parenteral administration to infants in need of such treatment of a low concentration isotonic pharmaceutical composition suitable for administering to newborns a therapeutic protein complex (particularly in activated form) comprising IGF-I complexed with IGF binding protein 3 in the presence of a non-ionic surfactant, e.g., 0.005% polysorbate 20 or polysorbate 80.

[0152] In one embodiment, the pharmaceutical formulation can be administered parenterally without loss of the therapeutic protein conjugate (e.g., without loss of activity of the therapeutic protein conjugate). In one embodiment, activity is measured by an assay disclosed herein, such as in the Examples. In one embodiment, the formulation delivers at least 80%, e.g., 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100%, of the dose of the therapeutic protein conjugate to the neonate in active form.

[0153] Parenteral administration includes, but is not limited to, intravenous (IV), intramuscular (IM), subcutaneous (SC), intraperitoneal (IP), intranasal, and inhalation routes. In some embodiments, the IGF-I / IGFBP-3 pharmaceutical composition is administered intravenously. IV, IM, SC, and IP administration can be by bolus or infusion, and can also be by sustained-release implantable devices, including, but not limited to, pumps, sustained-release formulations, and mechanical devices. The formulation, route and method of administration, and dosage will depend on the disorder being treated and the patient's medical history. Thus, in some embodiments, the methods disclosed herein provide for intravenously administering to an infant in need of such treatment a pharmaceutical composition comprising IGF-I complexed with IGF binding protein 3 in the presence of a surfactant, e.g., 0.005% v / v polysorbate 20 or polysorbate 80. In some embodiments, the methods disclosed herein provide for subcutaneous administration of a pharmaceutical composition comprising IGF-I complexed with IGF binding protein 3 in the presence of a surfactant, e.g., 0.005% v / v polysorbate 20 or polysorbate 80, to an infant in need of such treatment.

[0154] The pharmaceutical composition according to the present invention can be administered in various doses. For example, a suitable dosage may be in the range of about 100 to 1000 micrograms / kg / 24 hours. In some embodiments, a suitable dosage may be about 100 micrograms / kg / 24 hours, 150 micrograms / kg / 24 hours, 200 micrograms / kg / 24 hours, 250 micrograms / kg / 24 hours, 300 micrograms / kg / 24 hours, 350 micrograms / kg / 24 hours, 400 micrograms / kg / 24 hours, 450 micrograms / kg / 24 hours, 500 micrograms / kg / 24 hours, 550 micrograms / kg / 24 hours, 600 micrograms / kg / 24 hours, 650 micrograms / kg / 24 hours, 700 micrograms / kg / 24 hours, 750 micrograms / kg / 24 hours, 800 micrograms / kg / 24 hours, 850 micrograms / kg / 24 hours, 900 micrograms / kg / 24 hours, 950 micrograms / kg / 24 hours, or 1000 micrograms / kg / 24 hours. In some embodiments, a suitable dose is about 250 micrograms / kg / 24 hours. In some embodiments, a suitable dose is about 400 micrograms / kg / 24 hours. In some embodiments, a suitable dose is about 750 micrograms / kg / 24 hours. In some embodiments, a suitable dose is about 1000 micrograms / kg / 24 hours. In some embodiments, a pharmaceutical composition according to the present invention is administered from birth until about 23-34 weeks postmenstrual age (PMA), until about 28-32 weeks PMA, or until about 29 weeks plus 6 days PMA.

[0155] The methods provided herein include embodiments in which administration of a pharmaceutical IGF-I / IGFBP-3 composition results in a reduced incidence of chronic lung disease in preterm infants by 12 months corrected age (CA). In some embodiments, administration of a pharmaceutical IGF-I / IGFBP-3 composition results in a reduced incidence of bronchopulmonary dysplasia (BPD) by 23, 26, 30, 34, 36, 40 weeks, 6 months, 8 months, 10 months, or 12 months of postmenstrual age (PMA). In some embodiments, administration of a pharmaceutical IGF-I / IGFBP-3 composition results in a reduced incidence of severe intraventricular hemorrhage (IVH) grade III or IV by 23, 26, 30, 34, 36, 40 weeks, 6 months, 8 months, 10 months, or 12 months of postmenstrual age (PMA). In some embodiments, administration of a pharmaceutical IGF-I / IGFBP-3 composition results in a reduced incidence of right ventricular hypertrophy (RVH) by 23, 26, 30, 34, 36, 40 weeks, 6 months, 8 months, 10 months, or 12 months of postmenstrual age (PMA). In some embodiments, administration of a pharmaceutical IGF-I / IGFBP-3 composition results in a reduced incidence of pulmonary hypertension (PH) by 23, 26, 30, 34, 36, 40 weeks, 6 months, 8 months, 10 months, or 12 months of postmenstrual age (PMA). In some embodiments, administration of a pharmaceutical IGF-I / IGFBP-3 composition results in a reduced incidence of necrotizing enterocolitis by 23, 26, 30, 34, 36, 40 weeks, 6 months, 8 months, 10 months, or 12 months of postmenstrual age (PMA).

[0156] In some embodiments, the methods disclosed herein include those in which administration of a pharmaceutical IGF-I / IGFBP-3 composition results in an increase in functional status as assessed by the PREMature Infant Index (PREMII) by 36 or 40 weeks of postmenstrual age (PMA).

[0157] For parenteral or oral administration, the conjugate composition can be a liquid preparation, such as a semi-solid or liquid, suspension, etc. Physiologically compatible carriers are non-toxic to recipients at the dosages and concentrations used and are compatible with the other ingredients of the formulation. For example, the formulation preferably does not contain oxidizing agents and other compounds known to be harmful to polypeptides. Thus, physiologically compatible carriers include, but are not limited to, normal saline, serum albumin, 5% dextrose, plasma preparations, and other protein-containing solutions. Optionally, the carrier can also contain a detergent or surfactant.

[0158] In yet another aspect of the present invention, there is provided the use of an IGF-I / IGFBP-3 pharmaceutical composition in the manufacture of a therapeutic composition for treating complications of preterm birth.

[0159] In one preferred embodiment, 10 to 1000 micrograms per mL (e.g., 10 to 100 micrograms / mL, i.e., for example, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, or 100 micrograms / mL, such as 45 to 55 micrograms / mL, especially 50 micrograms / mL) of conjugated insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3) (e.g., equimolar amounts, e.g., 0.75 to 1.25:1 or Provided is a low-concentration isotonic pharmaceutical composition suitable for administering a therapeutic protein conjugate (particularly in an active form) to neonates, the composition comprising a non-ionic surfactant (e.g., a polysorbate surfactant such as polysorbate 20 or polysorbate 80, particularly polysorbate 20) in a ratio of 1:1 in the range of 0.75 to 1.25; and a non-ionic surfactant in the range of 0.0025% to 0.0075% (e.g., 0.005%); a buffer (e.g., 50 mM sodium acetate), and a salt (e.g., 105 mM sodium chloride), the pH of the formulation being in the range of pH 5.3 to 5.8 (e.g., pH 5.5).

[0160] chronic lung disease Chronic lung disease in premature infants Extremely preterm babies are at a very high risk of developing chronic preterm lung disease. Preterm babies may need a breathing machine (ventilator) and extra oxygen to breathe. Chronic preterm lung disease can occur if the breathing machine or oxygen injures the preterm baby's lungs. In lung injury, the tissue lining the baby's lungs becomes inflamed. The tissue can be destroyed and cause scarring. Scarring can cause breathing difficulties and the baby may need more oxygen. Lung injury can be caused by: Premature babies: Their lungs are not fully formed, especially their air sacs. ● Small amounts of surfactant: This is a substance in the lungs that helps keep the tiny air sacs open. ●Oxygen use: Large amounts of oxygen can be harmful to lung cells. Respiratory (mechanical ventilation): Air pressure can be harmful to the lungs. This pressure can come from a ventilator, suctioning the airway, and the use of an endotracheal (ET) tube. An ET tube is a tube placed in a baby's windpipe (trachea) and connected to a ventilator.

[0161] The long-term trajectory of pulmonary outcomes in infants born extremely preterm generally begins with prenatal risk factors, followed by respiratory distress syndrome (RDS) requiring respiratory support in the first hours or days of life, often leading to a diagnosis of BPD in those who survive to a comparable age, and finally, chronic lung disease in preterm infants as they grow into infancy, toddlerhood, and often school age or adolescence, resulting in more frequent hospital readmissions and ER visits for respiratory causes, the need for respiratory medications or home respiratory support, and many suffering from a form of reactive airway disease that continues to limit their quality of life.

[0162] Chronic lung disease in preterm infants is a broad term that includes infants diagnosed with bronchopulmonary dysplasia, but may also include infants who have not been diagnosed with bronchopulmonary dysplasia after extremely preterm birth and who have developed persistent lung disease. While chronic lung disease in preterm infants may be diagnosed by a long time to weaning from oxygen support, clinical endpoints of chronic lung disease in preterm infants may actually include, but are not limited to, persistent oxygen dependence, symptoms of cough and wheezing, respiratory illness and hospitalization, dependence on continuous airway pressure, dependence on mechanical ventilation and respiratory medications, and a diagnosis of pulmonary hypertension (PH). In some embodiments, chronic lung disease (CLD) in preterm infants may persist into adulthood. In some embodiments, CLD encompasses a wide range of diseases and disorders, including, but not limited to, COPD (emphysema and chronic bronchitis), asthma, cystic fibrosis, restrictive lung disease, and persistent infections.

[0163] In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD. In some embodiments, the compositions and methods described herein are used to treat CLD.

[0164] In some aspects, methods are described herein for treating or reducing the incidence of CLD, comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and a surfactant (e.g., a polysorbate surfactant, e.g., polysorbate 20).

[0165] In some aspects, described herein are methods for treating or reducing the incidence of CLD, comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and a polysorbate surfactant at a concentration of about 0.0025% to 0.0075% (e.g., 0.005%), wherein the rIGF-1 and rIGFBP-3 are complexed in a ratio of 0.75 to 1.25:1 or 1:0.75-1.25, e.g., equimolar amounts, and wherein the rIGF-1 / IGFBP-3 is at a concentration of about 10 micrograms / mL to 1000 micrograms / mL (e.g., 50 micrograms / mL). In some aspects, methods are described herein for treating or reducing the incidence of CLD, comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), in a therapeutic amount sufficient to achieve a reduction in the incidence of CLD relative to a control.

[0166] In some embodiments, reduction in incidence of or treatment of CLD is assessed by time from respiratory technology support (RTS) from day 1 to 12 months corrected age (CA) to final weaning (time frame: baseline to 12 months corrected age (CA)). In this context, RTS is defined as any one of the following: (1) supplemental oxygen at less than (<) 2 liters per minute (L / min) without positive pressure (including nasal cannula); (2) positive pressure support (including continuous positive airway pressure [CPAP], nasal cannula oxygen >2 L / min); (3) positive pressure ventilation (techniques involving positive pressure tidal breaths, such as high frequency oscillatory ventilation and mechanical ventilation, nasal intermittent positive pressure ventilation [NIPPV]). In some embodiments, the compositions and methods described herein result in a reduction in incidence of CLD as assessed by time to weaning from RTS compared to baseline controls.

[0167] In some embodiments, reduction in the incidence of or treatment of CLD is assessed by the incidence of bronchopulmonary dysplasia (BPD) or death by 36 weeks postmenstrual age (PMA) (time frame: baseline to 36 weeks postmenstrual age (PMA)). BPD can be assessed, for example, by a modified National Institute of Child Health and Human Development (NICHD) severity grading system and standardized by an oxygen challenge test. In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by the incidence of bronchopulmonary dysplasia (BPD) or death by 36 weeks postmenstrual age (PMA) compared to baseline controls.

[0168] In some embodiments, reduction in the incidence of or treatment of CLD is assessed by the total number of days of respiratory technical support (RTS) from birth to 12 months corrected age (CA) (time frame: birth to 12 months CA). In this context, RTS may be defined as any one of the following: (1) any fraction of inspired oxygen (FiO2) greater than (>) 21 percent (%), (2) non-invasive respiratory support delivered via a nasal interface (e.g., continuous positive airway pressure [CPAP], bi-stage positive airway pressure [BiPAP], high-flow therapy, nasal intermittent positive pressure ventilation [NIPPV], nasal cannula), or (3) invasive respiratory support (mechanical ventilation) via an endotracheal tube or tracheostomy. The total number of days of RTS from birth to 12 months CA will be reported. In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by total days of respiratory technology support (RTS) from birth to 12 months corrected age (CA) (time frame: birth to 12 months CA) compared to baseline controls.

[0169] In some embodiments, the reduction in incidence of or treatment of CLD is measured by the duration of readmission (time frame: Neonatal Intensive Care Unit (NICU) discharge to 12 months CA). In some embodiments, the compositions and methods described herein result in a reduction in incidence of CLD as measured by the duration of readmission compared to baseline controls.

[0170] In some embodiments, the reduction in incidence of or treatment of CLD is measured by emergency room visits (time frame: NICU discharge to 12 months CA). In some embodiments, the compositions and methods described herein result in a reduction in incidence of CLD as measured by emergency room visits.

[0171] In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by days of respiratory medication use (time frame: NICU discharge to 12 months CA). In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by days of respiratory medication use compared to baseline controls. Respiratory medication use can include, for example, bronchodilators, steroids, leukotriene inhibitors, and diuretics.

[0172] In some embodiments, the reduction in incidence of or treatment of CLD is assessed by the incidence of signs and / or symptoms of respiratory disease as assessed by a 28-day caregiver-administered diary completed at 12 months corrected age (CA) (time frame: 11 months CA to 12 months CA). In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by a 28-day caregiver-administered diary completed at 12 months corrected age (CA) compared to baseline controls.

[0173] In some embodiments, reduction in the incidence of or treatment of CLD is assessed by the incidence of chronic respiratory morbidity (CRM1) by 12 months corrected age (CA) (time frame: NICU discharge to 12 months CA). Subjects are defined as having CRM1 if they experienced / required at least one of the following three clinical / treatment events as reported by parents / caregivers and captured by pulmonary morbidity assessments in at least two 3-month quarters over a 12-month period: 1. Emergency room visit or hospitalization related to a respiratory diagnosis, 2. Home RTS, 3. Daily use of respiratory medications (e.g., bronchodilators, steroids, leukotriene inhibitors, diuretics) as reported by caregivers on pulmonary morbidity assessments. Incidence from CRM1 to 12 months CA will be reported. In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by chronic respiratory morbidity (CRM1) by 12 months corrected age (CA) compared to baseline controls.

[0174] In some embodiments, reduction in the incidence of or treatment of CLD is assessed by the incidence of chronic respiratory morbidity, including symptoms of respiratory disease by 12 months corrected age (CA) (CRM2) (time frame: NICU discharge to 12 months CA). Subjects are defined as having CRM2 if they experienced / required at least one of the following four clinical / treatment events, as reported by parents / caregivers and captured by pulmonary morbidity assessments in at least two 3-month quarters over a 12-month period: 1. Emergency room visit or hospitalization related to a respiratory diagnosis; 2. Home RTS; 3. Daily use of respiratory medications (e.g., bronchodilators, steroids, leukotriene inhibitors, diuretics) reported by caregivers on pulmonary morbidity assessments; 4. Symptoms of respiratory disease, as defined by the presence of a cough without cold or wheezing at least once a week. Incidence from CRM2 to 12 months CA will be reported. In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by the incidence of chronic respiratory disease, including symptoms of respiratory disease (CRM2), by 12 months corrected age (CA) compared to baseline controls.

[0175] In some embodiments, the reduction in incidence of or treatment of CLD is assessed by the severity of chronic respiratory morbidity (CRM3) by 12 months corrected age (CA) as determined by the Infant Chronic Lung Disease (CLD) Severity Score (time frame: NICU discharge to 12 months CA). This is determined by the Infant CLD Severity Score, which includes components such as respiratory hospitalizations, RTS use, and respiratory medication use. In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by the severity of chronic respiratory morbidity (CRM3) by 12 months corrected age (CA) as determined by the Infant Chronic Lung Disease (CLD) Severity Score compared to baseline controls.

[0176] In some embodiments, the reduction in incidence of or treatment of CLD is assessed by the incidence of intraventricular hemorrhage (IVH) by 40 weeks postmenstrual age (PMA) as assessed by cranial ultrasound (time frame: baseline to 40 weeks PMA). In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by the incidence of intraventricular hemorrhage (IVH) by 40 weeks postmenstrual age (PMA) as assessed by cranial ultrasound compared to baseline controls.

[0177] In some embodiments, the reduction in incidence of or treatment of CLD is assessed by the incidence of intraventricular hemorrhage (IVH) by about 36-40 weeks postmenstrual age (PMA) as assessed by cranial ultrasound (time frame: baseline to 36-40 weeks PMA). In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by the incidence of intraventricular hemorrhage (IVH) by 36-40 weeks postmenstrual age (PMA) as assessed by cranial ultrasound compared to baseline controls.

[0178] In some embodiments, the reduction in incidence of or treatment of CLD is assessed by the incidence of intraventricular hemorrhage (IVH) by 36 weeks postmenstrual age (PMA) as assessed by cranial ultrasound (time frame: baseline to 36 weeks PMA). In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by the incidence of intraventricular hemorrhage (IVH) by 36 weeks postmenstrual age (PMA) as assessed by cranial ultrasound compared to baseline controls.

[0179] In some embodiments, the reduction in incidence of or treatment of CLD is assessed by motor function at 12 months corrected age (CA) as measured by the Alberta Infant Motor Scale (AIMS) (time frame: at 12 months CA). The AIMS is a measure of early motor maturity used to assess infants at risk for motor delay and focuses on achieving motor milestones and developing postural control. It consists of 58 items, including assessments of four positions: prone (21 items), supine (9 items), sitting (12 items), and standing (16 items). Each item is scored as "observed" or "not observed." The scorer identifies the smallest and most mature item observed. In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by motor function at 12 months corrected age (CA) as measured by the Alberta Infant Motor Scale (AIMS) compared to baseline controls.

[0180] In some embodiments, the reduction in incidence of or treatment of CLD is assessed by functional status as assessed by the PREMature Infant Index (PREMII) at 36 weeks postmenstrual age (PMA) (time frame: at 36 weeks PMA). PREMII is a Clinician-Reported Outcomes (ClinRO) assessment used to capture the overall functional maturation of extremely preterm infants. Functional status reflects the infant's overall health and development and is defined as what the infant is able to do in eight key areas of function (feeding, weight gain, thermoregulation, respiratory support, apnea, bradycardia, desaturation events, and oxygen administration). In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by functional status as assessed by the PREMature Infant Index (PREMII) at 36 weeks postmenstrual age (PMA) compared to baseline controls.

[0181] In some embodiments, the reduction in incidence of or treatment of CLD is assessed by the incidence of death (time frame: birth to 12 months CA). In some embodiments, the compositions and methods described herein result in a reduction in the incidence of CLD as assessed by the incidence of death compared to baseline controls.

[0182] In some embodiments, the reduction in incidence of or treatment of CLD is assessed by insulin-like growth factor 1 (IGF-1) exposure response (time frame: up to 12 months CA). IGF-1 is assessed, for example, using IGF-1's relationship (pharmacokinetics / pharmacodynamics [PK / PD]) between respiratory and neurological endpoints. In some embodiments, the compositions and methods described herein result in a reduction in incidence of CLD as assessed by insulin-like growth factor exposure response.

[0183] Intraventricular hemorrhage Intraventricular hemorrhage (IVH) is a life-threatening condition in preterm infants characterized by bleeding in and around the ventricles, the spaces in the brain that contain cerebrospinal fluid. Intraventricular hemorrhage is most common in preterm infants, especially those born before 28 weeks gestation.

[0184] Babies with respiratory problems such as respiratory distress syndrome (RDS) or other complications of premature babies are more likely to have IVH.

[0185] IVH is associated with severe complications, including periventricular hemorrhagic infarction, posthemorrhagic ventricular dilation, periventricular leukomalacia, and cerebellar hemorrhage, resulting in mortality and morbidity. Other complications include posthemorrhagic hydrocephalus, cerebral palsy, and mental retardation, as well as long-term neurodevelopmental disabilities.

[0186] The current standard of care for the prevention and / or treatment of IVH is based on early management and stabilization with antenatal steroids and cerebral hemodynamic and respiratory support. Prognosis is related to the severity of the hemorrhage, damage to the brain parenchyma, the presence of seizures, and the severity of periventricular hemorrhagic infarction. IVH treatment involves supportive management of symptoms with medications to reduce hemorrhage and brain damage and prevent seizures.

[0187] In some aspects, methods are described herein for treating or preventing IVH, comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and a surfactant (e.g., a polysorbate surfactant, e.g., polysorbate 20).

[0188]

[0001] In some aspects, described herein are methods for treating or preventing intraventricular hemorrhage (IVH), comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and a polysorbate surfactant at a concentration of about 0.0025% to 0.0075%, wherein rIGF-1 and rIGFBP-3 are complexed in equimolar amounts, and wherein rIGF-1 / IGFBP-3 is at a concentration of about 10 micrograms / mL to 1000 micrograms / mL.

[0002] In some aspects, described herein are methods for treating or preventing intraventricular hemorrhage, comprising administering to a subject in need thereof a composition comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), in a therapeutic amount sufficient to achieve a reduction in the incidence of intraventricular hemorrhage relative to a control.

[0189] IVH grades are classified as follows: Grade I - bleeding in the region of the germinal matrix, very little bleeding, or no bleeding within the ventricles; Grade II - bleeding filling 10-50% of the ventricles; Grade III - bleeding filling more than 50% of the ventricles; and Grade IV (PVHI) - periventricular echodensity. This bleeding, formerly called Grade IV, is now classified as periventricular hemorrhagic infarction (PVI). Grades I and II are defined as mild grades, while Grade III and PVHI are defined as advanced grades. Table 1 shows the cranial ultrasound grading of IVH. [Table 1]

[0190] In some embodiments, the compositions and methods described herein result in a reduced incidence of Grade II IVH, Grade III IVH, and Grade IV IVH or PVHI. In some embodiments, the compositions and methods described herein result in a reduced incidence of Grade II IVH. In some embodiments, the compositions and methods described herein result in a reduced incidence of Grade III IVH. In some embodiments, the compositions and methods described herein result in a reduced incidence of PVHI. In some embodiments, the compositions and methods described herein are used to treat Grade II IVH, Grade III IVH, and Grade IV IVH or PVHI. In some embodiments, the compositions and methods described herein are used to treat Grade II IVH. In some embodiments, the compositions and methods described herein are used to treat Grade III IVH. In some embodiments, the compositions and methods described herein are used to treat Grade IV IVH or PVHI.

[0191] In some embodiments, the incidence of IVH is assessed by cranial ultrasound or ultrasound. Screening is performed at various intervals, including, for example, in some embodiments, days 0, 1, 2, 3, 7, 14, and 21, to detect and evaluate cerebral hemorrhage. In some embodiments, ultrasound is further performed at 32 weeks PMA, 33 weeks PMA, 34 weeks PMA, 35 weeks PMA, 36 weeks PMA, 37 weeks PMA, 38 weeks PMA, 39 weeks PMA, or 40 weeks PMA. In some embodiments, ultrasound is further performed at 36 weeks PMA. In some embodiments, ultrasound is further performed at 40 weeks PMA. In some embodiments, a single reader (masked to treatment) is used to evaluate all ultrasound images for the highest grade of GMH-IVH according to the method of Papile and Bowerman. (Papile LA, et al.Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J.Roentgenol.(1984)143:1041-52.)

[0192] In some embodiments, no IVH and grade I IVH are grouped together. In some embodiments, two independent readers were used in a post-hoc analysis masked to treatment to assess periventricular hemorrhagic infarction (PVHI), and discrepancies were resolved by consensus. IVH was graded based on severity according to Volpe. In some embodiments, PHI was graded according to the Dudink method by assessing the localization of caudate, temporal, anterior terminal vein, and complete terminal vein infarction. (Dudink J. et al., Venous subtypes of preterm periventricular hemorrhagic infarction. Arch Dis Child Fetal Neonatal Ed. (2008) 93:F201-6.)

[0193] In some embodiments, limited PHI is assessed when only the caudate or temporal veins are affected, or when small anterior terminal venous infarction is observed on cranial ultrasound. In some embodiments, extensive PHI is assessed with complete terminal venous infarction or a combination of caudate, temporal, and anterior venous infarction. Cranial ultrasound imaging is also used to detect posthemorrhagic ventricular dilation (PHVD) and white matter injury (WMI). (Davies, MW et al., Reference ranges for the linear dimensions of the intracranial ventricles in preterm neonates. Arch. Dis. Child Fetal Neonatal Ed., 2000 82:F218-23; Govaert P. et al., An Atlas of Neonatal Brain Sonography. 2 nd Ed. London: Mac Keith Press, 2010). In some embodiments, WMI is scored using a 4-grade scale as shown in Table 2. [Table 2]

[0194] In some embodiments, IVH is assessed by magnetic resonance imaging (MRI), which assesses the size and location of white matter lesions and hemorrhages that are associated with neurodevelopmental outcomes.

[0195] In some embodiments, a consensus IVH grade is assigned to each subject based on the highest grade of IVH observed by a single, or in the case of multiple readers, collaborative masked readers.

[0196] In some embodiments, a reduced incidence of IVH relates to assessing a subject as exhibiting a lower grade of IVH compared to the grade of IVH in the absence of treatment. In some embodiments, for example, a reduced incidence refers to grade I IVH instead of grade II, grade III, or grade IV IVH before treatment. In some embodiments, a reduced incidence refers to grade II IVH instead of grade III or grade IV IVH before treatment. In some embodiments, a reduced incidence refers to grade III IVH instead of grade IV IVH before treatment.

[0197] In some embodiments, the severity of IVH by treatment group was determined from the maximum grade of bleeding observed for each infant in the population. In some embodiments, a reduction in the incidence of IVH refers to a 20-50% reduction in the incidence of IVH in the population. In some embodiments, a reduction in the incidence of IVH refers to a 20% reduction in the incidence of IVH in the population. In some embodiments, a reduction in the incidence of IVH refers to a 30% reduction in the incidence of IVH in the population. In some embodiments, a reduction in the incidence of IVH refers to a 40% reduction in the incidence of IVH in the population. In some embodiments, a reduction in the incidence of IVH refers to a 50% reduction in the incidence of IVH in the population.

[0198] In some embodiments, a reduction in the incidence of IVH refers to a 20-50% reduction in the incidence of grade IV IVH (or PHVI) in a population. In some embodiments, a reduction in the incidence of IVH refers to a 20% reduction in the incidence of grade IV IVH (or PHVI) in a population. In some embodiments, a reduction in the incidence of IVH refers to a 30% reduction in the incidence of grade IV IVH (or PHVI) in a population. In some embodiments, a reduction in the incidence of IVH refers to a 40% reduction in the incidence of grade IV IVH (or PHVI) in a population. In some embodiments, a reduction in the incidence of IVH refers to a 50% reduction in the incidence of grade IV IVH (or PHVI) in a population.

[0199] In some embodiments, a reduction in the incidence of IVH refers to a 20-50% reduction in the incidence of Grade III IVH in a population. %. In some embodiments, a reduction in the incidence of IVH refers to a 20% reduction in the incidence of Grade III IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 30% reduction in the incidence of Grade III IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 40% reduction in the incidence of Grade III IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 50% reduction in the incidence of Grade III IVH in a population.

[0200] In some embodiments, a reduction in the incidence of IVH refers to a 20-50% reduction in the incidence of Grade II IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 20% reduction in the incidence of Grade II IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 30% reduction in the incidence of Grade II IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 40% reduction in the incidence of Grade II IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 50% reduction in the incidence of Grade II IVH in a population.

[0201] In some embodiments, a reduction in the incidence of IVH refers to a 20-50% reduction in the incidence of Grade I IVH in a population. %. In some embodiments, a reduction in the incidence of IVH refers to a 20% reduction in the incidence of Grade I IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 30% reduction in the incidence of Grade I IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 40% reduction in the incidence of Grade I IVH in a population. In some embodiments, a reduction in the incidence of IVH refers to a 50% reduction in the incidence of Grade I IVH in a population.

[0202] In some embodiments, treating IVH refers to the administration of a therapeutic composition (e.g., IGF-1 / IGFBP-3) to partially or completely alleviate, ameliorate, reduce, inhibit, delay the onset of, prevent, reduce the severity of, and / or reduce the incidence of one or more symptoms or characteristics of intraventricular hemorrhage. In some embodiments, the subject being treated does not exhibit signs of IVH and / or exhibits only early or mild signs of IVH. In some other embodiments, the subject being treated exhibits one or more established signs of IVH. Thus, in some embodiments, treating refers to preventing the onset or progression of IVH from mild to severe forms.

[0203] In some embodiments, the compositions and methods described herein result in a reduced incidence of IVH, hi some embodiments, the compositions and methods described herein are used to treat IVH.

[0204] Bronchopulmonary dysplasia Bronchopulmonary dysplasia (BPD) is a serious lung condition that affects newborns. BPD primarily affects premature infants and is a breathing disorder in which an infant's lungs become irritated and do not develop normally. BPD primarily affects premature infants who require oxygen therapy, which is oxygen given through a nasal cannula, mask, or breathing tube. It occurs most frequently in low-birth-weight infants born 10 weeks or more early or weighing less than 2 pounds at birth.

[0205] Since its first description in 1967, the definition of BPD has evolved. The original definition included infants with a 28-day oxygen requirement with associated radiographic changes. This definition of BPD was subsequently refined as infants with a birth weight less than 1,500 g requiring oxygen support at 36 weeks PMA. In 2001, the NIH defined BPD as follows: "For those born at <32 weeks' gestational age, BPD refers to the requirement for oxygen support (>21%) for at least 28 days and thereafter at 36 weeks' PMA or at discharge evaluation, whichever occurs first. For those born at >32 weeks' gestational age, BPD refers to the requirement for oxygen supplementation (<21%) for at least 28 days and thereafter at 56 days' postnatal age or at discharge evaluation, whichever occurs first." Infants who did not require oxygen were classified as having mild BPD. Moderate BPD was diagnosed in those requiring positive pressure ventilation / continuous positive airway pressure and / or oxygen requirements >30%, and severe BPD in those requiring less than 30% oxygen. The "physiologic definition" of BPD proposed in 2003 classified infants with BPD as those requiring positive pressure and oxygen ≥0.3 at 36 weeks PMA. In contrast, those requiring FiO2 <0.3 required up to a 2-week oxygen reduction trial based on oxygen saturation. However, the physiological definition remained less popular than the functional criterion, whereby preterm infants were diagnosed with BPD if they still required oxygen therapy by the time they reached 36 weeks postmenstrual age.

[0206] Babies who develop BPD are often born with respiratory distress syndrome (RDS). Although bronchopulmonary dysplasia is often referred to interchangeably as chronic lung disease in preterm infants, BPD is actually a single-time point assessment at 36 weeks, and CLD broadly refers to chronic and long-term or persistent lung disease, sometimes in infants previously diagnosed with BPD or in infants who have not yet been diagnosed with BPD. For practical purposes, BPD is more clearly defined and therefore provides a relevant, easily measured clinical endpoint for measuring the outcome of CLD. Thus, in some embodiments, the methods described herein result in a reduction in the incidence of BPD. In some embodiments, the methods described herein are used to treat BPD. In some embodiments, the methods described herein result in absent, mild, or less severe BPD.

[0207] Some newborns may require long-term oxygen or breathing support from nasal continuous positive airway pressure (NCPAP) machines, ventilators, and medications such as bronchodilators. They may continue to suffer from breathing problems due to chronic lung disease in premature infants into childhood and even adulthood.

[0208] In some embodiments, the compositions and methods described herein result in a reduced incidence of bronchopulmonary dysplasia. In some embodiments, the compositions and methods described herein are used to treat bronchopulmonary dysplasia.

[0209] Pulmonary hypertension Prenatal factors such as chorioamnionitis (CA) and preeclampsia (PE), as well as postnatal insults including exposure to high levels of supplemental oxygen, are strongly associated with an increased risk of bronchopulmonary dysplasia (BPD) and pulmonary hypertension (PH) after preterm birth.

[0210] Persistent pulmonary hypertension in newborns occurs when a newborn's circulatory system does not adapt to breathing outside the womb. In the womb, the fetus receives oxygen through the umbilical cord, so the lungs require little blood supply. This can lead to symptoms such as rapid breathing, difficulty breathing, and / or low oxygen saturation.

[0211] In some embodiments, the compositions and methods described herein result in a reduced incidence of pulmonary hypertension. In some embodiments, the compositions and methods described herein are used to treat pulmonary hypertension.

[0212] right ventricular hypertrophy Right ventricular hypertrophy (RVH) is an abnormal enlargement or pathological increase in muscle mass of the right ventricle in response to pressure overload, most commonly resulting from severe pulmonary disease. The right ventricle is significantly smaller than the left ventricle and produces power that is largely obscured by the power generated by the larger left ventricle.

[0213] In some embodiments, the compositions and methods described herein result in a reduced incidence of RVH. In some embodiments, the compositions and methods described herein are used to treat RVH.

[0214] Necrotizing enterocolitis Necrotizing enterocolitis (NEC) is a complication of preterm infants that can also occur in infants with chronic preterm lung disease. Necrotizing enterocolitis primarily affects the intestine of preterm infants. The intestinal wall is invaded by bacteria, causing local infection and inflammation that can ultimately destroy the bowel (intestine) wall.

[0215] In some embodiments, the compositions and methods described herein result in a reduced incidence of NEC. In some embodiments, the compositions and methods described herein are used to treat NEC.

[0216] In yet another aspect, methods are provided for producing a protein complex comprising insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3), the methods comprising the use of a contact surface other than stainless steel, such as a disposable bag, during mixing of the complex with a formulation solution, wherein the protein complex produced by such methods exhibits an increase in oxidized species of IGF-1 of less than 20%, e.g., after storage for 6 months at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 5% after storage for 6 months at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 2% after storage for 6 months at 25° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 10%, e.g., after storage for 3 months at 40° C. In some embodiments, the increase in oxidized species of IGF-1 is less than 2%, e.g., after storage for 3 months at 40° C. In some embodiments, less than about 5-25% (e.g., less than about 10%) of the protein complex exists as low molecular weight species upon storage for 6 months at 40° C. In some embodiments, less than 5-15% (e.g., less than about 10%) of the protein complex exists as low molecular weight species upon storage for 3 months at 40° C. In some embodiments, the formulation solution includes a surfactant (e.g., polysorbate 20) at a concentration of about 0.0025 v / v to 0.0075 v / v (e.g., 0.0025% v / v).

[0217] The disposable bag is a disposable process vessel that includes an inert contact surface other than stainless steel. In some embodiments, the disposable bag is made of a high-purity, medical-grade composite film, which is strong, flexible, provides excellent gas barrier properties, is suitable for bioprocessing of pharmaceuticals under aseptic conditions, and results in reduced oxidative species, improving pharmaceutical efficacy and stability. In some embodiments, the disposable bag is used during mixing, blending, and preparation of an IGF-1 / IGFBP-3 drug substance in a formulation solution containing excipients (sodium chloride, sodium acetate, acetic acid, and polysorbate 20) to obtain an IGF-1 / IGFBP-3 formulation, the composition having a pH of about 5.3-5.8. In some embodiments, the disposable bag is further used during a pharmaceutical filtration step. The method includes, for example, filling about 20-80% of the disposable bag with the protein complex during the mixing and / or filtration steps. In some embodiments, the disposable bag is about 500 L or greater.

[0218] In some embodiments, the storage and transportation are additionally performed in a disposable bag. In some embodiments, the disposable bag has a thickness ranging from 0.1 mm to about 0.5 mm. In some embodiments, the disposable bag has a thickness ranging from 0.25 mm to about 0.35 mm.

[0219] In some embodiments, the disposable bag comprises ultra-low density polyethylene (ULDPE) that contacts the fluid. In some embodiments, the disposable bag comprises a gas barrier comprising polyethylene vinyl alcohol copolymer (EVOH). In some embodiments, the outer layer of the disposable bag comprises polyethylene vinyl acetate (EVA) and ULDPE. In some embodiments, the disposable bag comprises polyethylene vinyl acetate (EVA) that contacts the fluid surface. In some embodiments, the gas barrier comprises polyethylene vinyl alcohol copolymer (EVOH). In some embodiments, the outer layer of the disposable bag comprises linear low density polyethylene (LLDPE). In some embodiments, kits are provided for carrying out the methods described herein. In certain embodiments, the kits comprise a composition comprising rIGF-1, rIGFBP-3, and a polysorbate surfactant, such as polysorbate 20 or polysorbate 80. In some embodiments, the kits contain a composition described herein in a glass vial or other suitable material.

[0220] In some embodiments, an article of manufacture is also provided that includes packaging material and a pharmaceutical product contained within the packaging material. The packaging material includes a label indicating that the pharmaceutical product can be administered at an effective dose and for a sufficient period of time to treat and / or prevent complications associated with preterm birth. The pharmaceutical product includes an IGF-I / IGFBP-3 composition together with a pharmaceutically acceptable carrier.

[0221] In one embodiment, the formulation is provided as a unit containing a 50 microgram / mL rhIGF-1 / rhIGFBP-3 solution in 50 mM sodium acetate and 105 mM sodium chloride containing 0.005% (v / v) polysorbate 20, pH 5.5, stored at 2°C to 8°C (36°F to 46°F).

[0222] In one embodiment, a pharmaceutical composition according to the present disclosure is provided as a final product in an infusion bag or glass vial containing an extractable volume of about 6.5 mL.

[0223] The present invention is further characterized by the following examples which are intended to be exemplary of the invention.

[0224] In the context of this specification, comprising is intended to mean "including".

[0225] Where technically appropriate, embodiments of the invention may be combined, and in particular where a method describes composition elements, this combination of features may be used to define the composition itself, and vice versa.

[0226] The background contains technical information that can be used as a basis for revisions.

[0227] Embodiments are described herein as comprising particular features / elements. The disclosure also extends to separate embodiments consisting of, or consisting essentially of, those features / elements.

[0228] Technical references, such as patents and applications, are incorporated herein by reference.

[0229] Any embodiment specifically and explicitly described herein may form the basis of a disclaimer, either alone or in combination with one or more further embodiments.

[0230] This application claims priority from U.S. Provisional Application No. 63 / 093,696, filed October 19, 2020, which is incorporated herein by reference. These documents may be used as the basis for any correction.

[0231] The invention will now be described with reference to the following examples, which are merely illustrative and should not be construed as limiting the scope of the invention. [Example]

[0232] While the particular compounds, compositions, and methods described herein have been specifically described with specificity according to particular embodiments, the following examples serve only to illustrate the compounds of the invention and are not intended to limit them.

[0233] Example 1. Evaluation of the in-use stability of mecasermin rinfabate drug product in the presence and absence of 0.005% (v / v) polysorbate 20 (P20) This example demonstrates the in-use stability and / or compatibility of rhIGF-1 / rhIGFBP-3 pharmaceutical products in the presence and absence of 0.005% polysorbate 20 (P20) during a worse-case administration simulation in a Phase 2 Swedish model infusion set over a 48-hour period at room temperature.

[0234] Briefly, two drug formulations were evaluated: a Phase 2 (Process A) drug formulation in the absence of polysorbate 20 (50 μg / mL mecasermin rinfabate, 50 mM sodium acetate, 105 mM sodium chloride, pH 5.5), and a Phase 3 (Process B) drug formulation consisting of a Phase 2 formulation containing 0.005% (v / v) polysorbate 20.

[0235] During the Phase 2 clinical study, infusion sets had to be primed and flushed with medication for at least 1 hour to prevent loss of adsorption-related products to the infusion set and to ensure that preterm infants received the administered dose of 250 μg / kg / 24 hours of medication. It was observed that loss of adsorption-related products occurred to the infusion set when a "dry" infusion set was used without any priming or flushing with formulation or any other solution prior to administration ("worse case administration").

[0236] Since the drug concentration was very low (50 μg / mL) and the Phase 2 formulation buffer did not contain any surfactants that would prevent or reduce protein adsorption to different polymeric surfaces, a study was conducted to investigate the effect of inclusion of 0.005% P20 in the drug product on adsorption-related product losses during administration, and on the overall quality attributes of the drug product, such as purity, pH, appearance, and potency.

[0237] The experimental infusion set used as a model for this study was previously used in a Phase 2 study at Karolinska, Sweden. Approximately 19 mL of medication in either formulation, with or without P20, was placed in a 20 mL syringe and labeled with the appropriate formulation for each infusion set. The medication volume in the syringe was selected to accommodate the study requirements. The syringe was then connected to a pre-assembled (dry) infusion set (Figure 1). Approximately 3 mL of medication was immediately dispensed from the infusion set and collected in a clean glass vial. This sample served as a baseline medication that had not spent extended time in the infusion set.

[0238] Two independent infusion sets were prepared for each drug product (with and without P20). Two control infusion sets were prepared to serve as buffer backgrounds used for protein concentration correction. Due to the low protein concentrations of the drug products and the use of variable pathlength technology for protein concentration determination, it was necessary to overcome possible absorption interference from leachates. To do this, the corresponding buffer controls for this study were generated and processed exactly as formulated. The buffers were placed in syringes and kept in the infusion sets for 0, 1, 4, 8, 24, and 48 hours. The buffer controls were then used to correct for the protein concentration of unknown light-absorbing species that contribute to the background.

[0239] The data demonstrated that the addition of 0.005% (v / v) P20 reduced adsorption-related product losses and improved other quality attributes of the drug product (e.g., potency) during administration of a model infusion set over a 48-hour period, eliminating the need to prime and flush the infusion set prior to drug administration.

[0240] The results of the study demonstrated that the quality of the drug product in the Phase 3 formulation was maintained in the infusion set for up to 48 hours when stored at room temperature and exposed to ambient light and temperature after including 0.005% P20 in the drug product formulation buffer.

[0241] After collection of the syringe-exposed drug baseline sample, the drug was retained in the infusion set and sampled at 1, 4, 8, 24, and 48 hours with exposure to ambient light and temperature (Table 3). Samples were observed visually immediately after sampling. Samples were refrigerated until ready to be tested at the end of the 48-hour study for pH, protein concentration (A276 nm), RP-UPLC, and SE-HPLC. Samples were also selectively tested for potency (at baseline and 48 hours) using a low-throughput cell proliferation potency assay. An additional drug vial was prepared and set aside to serve as a non-syringe-exposed drug control (baseline) for all assays. [Table 3]

[0242] Visual observations of the drug product and formulation buffer controls for both formulations (with and without P20) were made at each time point. The drug product and formulation samples showed no trends for the presence of particulates or fibers. No changes in pH of either drug product formulation (with or without P20) were observed at any time during the study.

[0243] The protein concentration of the drug product was measured over the 48-hour study before and after buffer correction (Figure 2). During protein concentration measurement, an increase in concentration was observed at later time points, which was attributed to potential unknown species that interfered with the protein concentration measurement. Therefore, formulation controls with and without P20 were also generated to correct for the protein concentration of unknown species.

[0244] The data showed that less adsorption-related protein loss was observed when P20 was present in the formulation. For example, after correcting protein content for unknown light-absorbing species over a 4-hour initial infusion period, three-fold less protein loss was observed for drug product in formulations containing P20 compared to drug product in formulations that did not contain P20. The increase in protein concentration at 48 hours, even after buffer correction, is due to background leachate.

[0245] Overall, the results demonstrated that the addition of P20 prevented adsorption-related product loss in model infusion sets over a 48-hour period at room temperature. This improvement was seen when the drug product was initially exposed to a "dry" infusion set for up to 4 hours. After including 0.005% polysorbate 20 in the drug formulation, priming and flushing of the infusion set prior to drug administration was not required.

[0246] In-line filter compatibility was evaluated for two exemplary in-line filters: an average dose of approximately 5.5 mL for a neonate weighing approximately 1 kg was tested. [Table 4]

[0247] In the absence of polysorbate 20, significant loss of pharmaceutical agent was observed in both cases of the exemplary in-line filters.

[0248] The loss of protein content observed in the absence of P20 is undesirable because it is not possible to increase the dose volume in neonates to deliver a higher effective dose due to the limited daily fluid intake in neonates.

[0249] Example 2. Determination of Purity of Mecasermin Rinfabate Drug Product in Formulations with and without 0.005% (v / v) Polysorbate 20 (P20) by SE-HPLC and RP-UPLC This example demonstrates the purity of the drug product in the formulation in the presence and absence of 0.005% (v / v) polysorbate 20 (P20).

[0250] A size-exclusion high-performance liquid chromatography (SE-HPLC) assay was performed to compare the purity of the drug product in the presence and absence of 0.005% (v / v) polysorbate 20 (P20). The assay was characterized by optimizing the column packing for best profile and signal detection. [Table 5] TIFF0007827315000006.tif73170 [Table 6] TIFF0007827315000008.tif74170

[0251] The data showed that less adsorption-related protein loss was observed when the SE-HPLC data for P20 demonstrated similar purity (percent conjugate peak area) for drug product in formulations held at set injections for up to 48 hours (Tables 5 and 6). Three high molecular weight (HMW) species were observed and summed to report the qualitative values ​​of HMW species in formulations in the absence (Figure 3A) and presence (Figure 3B) of P20. HMW is undesirable because it contributes to reduced product stability, increased aggregation, and increased immunogenicity.

[0252] Example 3. Measurement of mecasermin rinfabate drug product degradation in formulations with and without 0.005% (v / v) polysorbate 20 (P20) by RP-UPLC This example shows exemplary degradation of mecasermin rinfabate by oxidation.

[0253] To investigate the extent of degradation of mecasermin rinfabate, reversed-phase ultra-performance chromatography (RP-UPLC) was performed to monitor the oxidation of IGF1 in the IGF-1 / IGF1-BP3 protein complex.

[0254] RP-UPLC data showed a slight increase in percent oxidized IGF1 after a 48 hour hold time in the infusion set when compared to baseline in both formulations (Figure 4).

[0255] The assay also monitored the percent peak area of ​​IGF-1 and IGFBP-3 proteins separately, and the increase in IGF-1 oxidation coincided with a decrease in the percent IGF-1 peak area, while the percent IGFBP-3 did not change significantly. The decrease in percent IGFBP-3 was approximately 0.6% in formulations without P20, compared to 0.1% when P20 was present in the formulation. Tables 5 and 6 report the percent oxidized IGF-1 and the sum of the IGF-1 and IGFBP-3 peak areas, the latter reported as the percent major peak area.

[0256] Example 4. Determination of the potency of mecasermin rinfabate drug product in formulations with and without 0.005% (v / v) polysorbate 20 (P20) This example illustrates an exemplary effect of the presence of 0.005% (v / v) polysorbate 20 (P20) in a mecasermin rinfabate formulation on the efficacy of the drug product.

[0257] To investigate the effect of the presence or absence of 0.005% (v / v) polysorbate 20 (P20) in the formulation on the efficacy of mecasermin rinfabate drug product, selected samples were tested for efficacy in a formulation containing 0.005% (v / v) P20 or in the absence of 0.005% P20 at baseline and a 48-hour hold time.

[0258] In a worst-case scenario where the infusion set was not primed and flushed with pharmaceutical product, there was a 25% reduction in potency when the formulation buffer did not contain P20, compared to only an 8% reduction in potency when polysorbate 20 was present (Table 7). Both values ​​can be considered within the range of typical cell-based assay variability (70%-130%), although approximately 3-fold lower potency is observed when polysorbate 20 was not present in the pharmaceutical product formulation. [Table 7]

[0259] The addition of polysorbate 20 improved the overall quality of the product as higher potency was observed in the presence of polysorbate 20 in the drug product.

[0260] Collectively, the results of these studies demonstrated that the quality of the Phase 3 drug product is maintained in the infusion set for up to 48 hours when stored at room temperature and exposed to ambient light and temperature.

[0261] Example 5. Mecasermin Rinfabate Drug in Formulations with and without 0.005% (v / v) Polysorbate 20 (P20) or Polysorbate 80 (P80) This example compares the safety and toxicity of polysorbate 20 and polysorbate 80 exposure in the formulation of mecasermin rinfabate drug product.

[0262] Nonclinical data for polysorbates 20 and 80 were used to derive IV tolerable exposure values ​​of 0.02 mg / kg body weight / day for preterm infants and 0.08 mg / kg body weight / day for full-term infants and children up to 1 year of age (Table 8). [Table 8]

[0263] Based on these comparisons, there are no toxicological concerns associated with the small additional amount of polysorbate 20 that patients would receive from rhIGF-1 / rhIGFBP-3 pharmaceutical products relative to the amount of polysorbate 20 and polysorbate 80 that patients already receive from total parenteral nutrition products.

[0264] Example 6. Preparation of mecasermin rinfabate in disposable bags This example demonstrates the role of contact material in the percent oxidation and stability of IGF-1 / IGFBP-3.

[0265] Drug products manufactured using stainless steel vessels or disposable bags were analyzed for oxidation. Briefly, excipients (sodium chloride, sodium acetate, acetic acid, and polysorbate 20) were mixed. The excipients were then filtered and mixed with the thawed drug substance, which was then mixed into the drug product IGF-1 / IGFBP-3 complex. The buffer-mixed bulk drug product was collected in either a 1000 L stainless steel vessel or a 500 L disposable bag (Mobius MIX0500L Bag Gold, including a magnetic stirrer) and filtered through a filter (Opticap XL10 0.22 μm, Durapore PVDF membrane) into the receiving stainless steel vessel or bag (including a magnetic stirrer). Two batches of drug product were analyzed for the percent oxidized IGF-1 by RP-UPLC at release and during storage.

[0266] Figure 5 shows the percentage of oxidized IGF-1 as a function of time and concentration of pharmaceuticals in stainless steel in a small-scale model. Pharmaceuticals without any contact with stainless steel were observed to be less likely to cause oxidation of IGF-1 across all concentrations.

[0267] The same experiment was repeated by mixing the formulation in a glass container and comparing it to the formulation mixed in a disposable bag. Figure 6 summarizes the percent oxidized IGF-1 as a function of time and headspace for the disposable bag and glass containers. The drug mixed in the disposable bag resulted in the lowest oxidation, followed by the formulation mixed in glass with a 20% fill. Next, IGF-1 stability was tested by plotting the percentage of the main peak (non-oxidized IGF-1) as a function of time at different temperatures. It was observed that the formulation produced in the disposable bag maintained IGF-1 stability across all temperatures tested compared to the formulation produced in the stainless steel container. Stability (plotted as percent of the main peak) is shown in Figures 7A-7C. Additionally, the percent oxidized IGF-1 was plotted as a function of time. It was observed that the formulation produced in the disposable bag had a lower percent oxidized IGF-1 across all temperatures tested compared to the formulation produced in the stainless steel container. The percent oxidized IGF-1 plotted as a function of time is shown in Figures 8A-8C.

[0268] Example 7. Treatment of CLD in extremely preterm infants An investigational drug containing the insulin-like growth factor-1 / insulin-like growth factor binding protein-3 (rhIGF-1 / rhIGFBP-3) complex was studied for its therapeutic efficacy in CLD. The pharmaceutical formulation used was 50 μg / mL mecasermin rinfabate in 50 mM sodium acetate with 105 mM sodium chloride, pH 5.5, containing 0.005% (v / v) polysorbate 20.

[0269] This study is designed as a multicenter, randomized, open-label, controlled, three-arm trial to evaluate the clinical efficacy and safety of a therapeutic composition in preventing human chronic lung disease in preterm infants. The study will be conducted in subjects up to 12 months corrected age (CA) compared with standard neonatal care in extremely preterm infants. The study has been reviewed and approved by the Institutional Review Board (IRB) / Independent Ethics Committee (IEC) of the responsible institution.

[0270] Objective: The objective of this study was to determine whether an investigational drug containing rhIGF-1 / rhIGFBP-3 (hereafter referred to as the therapeutic composition) can reduce respiratory complications in extremely preterm infants up to 12 months corrected age (CA) compared with extremely preterm infants receiving standard neonatal care alone.

[0271] Study Subjects: Subjects will be between 23 weeks + 0 days and 27 weeks + 6 days of gestational age (GA). Subjects will include both genders. The study will include at least 50 subjects.

[0272] Exclusion Criteria: Exclusion criteria include detectable gross malformations, known or suspected chromosomal abnormalities, genetic disorders, or syndromes, as determined by the investigator. Exclusion criteria also include a persistent blood glucose level less than (<) 2.5 millimoles per liter (mmol / L) at the baseline visit to exclude severe congenital abnormalities of glucose metabolism; clinically significant neurological disease in the investigator's opinion; monozygotic multiples; and any other condition that may pose a risk to the subject or interfere with the subject's ability to comply with the protocol or interfere with the interpretation of results. Subjects will be excluded if they are participating in or planning to participate in a clinical trial of another investigational drug, device, or procedure (participation in observational studies will be permitted on a case-by-case basis). Subjects will also be excluded if they or their parents or legally authorized representatives are unable to comply with the protocol or are unlikely to be available for long-term follow-up as determined by the investigator.

[0273] Study Design Details: The primary objective of this study is the prevention of bronchopulmonary dysplasia and chronic lung disease in preterm infants. This is an open-label study, and the intervention model will be parallel allocation. The conditions monitored will be BPD and CLD.

[0274] One group of participants (Group A) will receive 250 micrograms / kg / 24 hours of the therapeutic composition via intravenous (IV) administration from birth to 29 weeks + 6 days of postmenstrual age (PMA). Another group of participants (Group B) will receive 400 micrograms / kg / 24 hours of the therapeutic composition via intravenous (IV) administration from birth to 29 weeks + 6 days of postmenstrual age (PMA). A third group (Group C or control group) will receive standard neonatal treatment only.

[0275] The primary outcome measured was the incidence of chronic lung disease (CLD) in preterm infants by 12 months corrected age (CA) [time frame: baseline to 12 months corrected age (CA)]. CLD is a common adverse event of preterm birth, resulting in recurrent respiratory symptoms requiring treatment with pulmonary medications such as bronchodilators, the need for assisted home oxygen, and frequent emergency room visits or hospital readmissions, particularly during the first year of life. CLD is measured by respiratory health care utilization and respiratory symptoms.

[0276] Secondary outcomes included the incidence of bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (PMA) [time frame: 36 weeks PMA]. BPD is a chronic lung disease characterized by lung immaturity, undifferentiated alveoli with the presence of hyaline membranes and atelectasis, dilated capillaries immersed in mesenchyme, and distorted deposition of extracellular matrix. BPD has residual effects on lung function and is associated with neurodevelopmental problems in later childhood.

[0277] Secondary outcomes also included: Incidence of severe intraventricular hemorrhage (IVH) grade III or IV up to 40 weeks postmenstrual age (PMA) [Time frame: baseline to 40 weeks PMA] ●Incidence of bronchopulmonary dysplasia (BPD) even at 40 weeks postmenstrual age (PMA) [Time frame: 40 weeks PMA] Incidence of chronic lung disease (CLD) or death by 6 months corrected age (CA) [Time frame: baseline to 6 months corrected age (CA)]. CLD is a common adverse event of preterm birth, resulting in recurrent respiratory symptoms requiring treatment with pulmonary medications such as bronchodilators, the need for assisted home oxygen, and frequent emergency room visits or hospital readmissions, particularly during the first year of life. CLD is measured by respiratory health care utilization and respiratory symptoms. Functional status assessed by the PREMature Infant Index (PREMII) at 40 weeks postmenstrual age (PMA) [Timeframe: 36 weeks PMA]. PREMII is a Clinician-Reported Outcomes (ClinRO) assessment used to capture the overall functional maturation of extremely preterm infants. Functional status reflects the infant's overall health and development and is defined as what the infant is able to do in eight major areas of function (feeding, weight gain, temperature regulation, respiratory support, apnea, bradycardia, desaturation events, and oxygen administration).

[0278] Example 8. Treatment of intraventricular hemorrhage (IVH) in extremely preterm, low-gestational-age infants An investigational drug containing insulin-like growth factor-1 / insulin-like growth factor binding protein-3 (rhIGF-1 / rhIGFBP-3) complex (50 μg / mL mecasermin rinfabate in 50 mM sodium acetate with 105 mM sodium chloride, pH 5.5, containing 0.005% (v / v) polysorbate 20) will be studied for its therapeutic efficacy in intraventricular hemorrhage (IVH). This study is designed as a multicenter, randomized, open-label, controlled, three-arm trial to evaluate the clinical efficacy and safety of the therapeutic composition in preventing intraventricular hemorrhage. The study will be conducted in subjects up to 36 weeks PMA compared with standard neonatal care (SNC) in extremely preterm infants less than 26 weeks gestation. The study has been reviewed and approved by the responsible institution's Institutional Review Board (IRB) / Independent Ethics Committee (IEC).

[0279] Objective: The objective of this study was to determine whether an investigational drug containing rhIGF-1 / rhIGFBP-3 (hereafter referred to as the therapeutic composition) could reduce the incidence of intraventricular hemorrhage in extremely preterm infants up to 36 weeks PMA compared with extremely preterm infants receiving standard neonatal care alone.

[0280] Study Subjects: Subjects are infants with a gestational age (GA) of less than 26 weeks or less than 25 weeks + 6 days. Subjects include both genders. The study will include at least 50 subjects.

[0281] Study Design: One group of participants (Group A) will receive 250 micrograms / kg / 24 hour of the therapeutic composition via intravenous (IV) administration from birth to 29 weeks + 6 days of postmenstrual age (PMA). Another group of participants (Group B) will receive 400 micrograms / kg / 24 hour of the therapeutic composition via intravenous (IV) administration from birth to 29 weeks + 6 days of postmenstrual age (PMA). A third group (Group C or control group) will receive standard neonatal treatment only.

[0282] Infants of low gestational age, who have a higher incidence of IVH, the incidence of IVH II / III / PHVI is assessed.

[0283] The primary outcome measured was the incidence and severity of intraventricular hemorrhage at 36 weeks postmenstrual age (PMA) [time frame: 36 weeks PMA]. IVH is a common adverse event of preterm birth and is monitored by cranial ultrasound.

[0284] Secondary outcomes included the severity and incidence of bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (PMA) [time frame: 36 weeks PMA]. BPD is a chronic lung disease characterized histologically by lung immaturity, undifferentiated alveoli with the presence of hyaline membranes and atelectasis, dilated capillaries immersed in mesenchyme, and distorted deposition of extracellular matrix. BPD has residual effects on lung function and is associated with neurodevelopmental disorders in later childhood.

[0285] Efficacy analyses are performed in infants under 26 weeks GA at 36 weeks PMA. The relative reduction in IVH grade II / III / IV (PHVI) is assessed. In some embodiments, subjects are followed to about 40 weeks, 12 months, or 24 months CA.

[0286] Example 9. Prevention of BPD in extremely preterm infants A randomized, parallel-allocation intervention study was conducted to evaluate the effects of IGF-1 / IGFBP-3 on complications in extremely preterm infants, including BPD prevention.The study was conducted between June 18, 2010, and March 30, 2016, at multiple centers in Italy, the Netherlands, Poland, Sweden, the United Kingdom, and the United States.

[0287] The drug mecasermin rinfabate, or IGF-1 / IGFBP-3, was administered as a continuous intravenous infusion to subjects from study day 0 (day of birth) through and including 29 weeks +6 days postmenstrual age (PMA), provided the subject's endogenous IGF-1 production was deemed sufficient to maintain physiological serum IGF-1 levels. After discontinuing the study drug infusion, each subject was followed until 40 weeks ±4 days postmenstrual age (PMA). This study was intended to determine the dose of rhIGF-1 / rhIGFBP-3 administered as a continuous infusion (CI) required to establish and maintain longitudinal serum IGF-1 levels within physiological levels in preterm infants to prevent preterm retinopathy. This was a phase 2, randomized, controlled, assessor-blinded, dose-confirming, pharmacokinetic, safety, and efficacy study of rhIGF-1 / rhIGFBP-3. Sixty-one participants received 250 micrograms per kilogram (mcg / kg) of insulin-like growth factor I (rhIGF-I) / insulin-like growth factor binding protein-3 (rhIGFBP-3) for 24 hours via continuous intravenous (IV) infusion from day 0 to 29 weeks 6 days postmenstrual age (PMA). As a control group, 60 participants received standard care only. Table 3 shows the overall study participant flow. [Table 9] [Table 10]

[0288] Other parameters include secondary outcomes: Time to discharge from neonatal intensive care (TDNIC) [time frame: day 0 to 40 weeks postmenstrual age (EOS)] Number of participants with bronchopulmonary dysplasia (BPD) [Time frame: 36 weeks postmenstrual age] The severity of BPD—mild, moderate, or severe—was based on the National Institute of Child Health and Human Development (NICHD) guidelines for preterm infants born at less than 32 weeks' gestational age. Mild: Requires oxygen for the first 28 days, but on room air at 36 weeks PMA or discharge home, whichever comes first. Moderate BPD: Oxygen required for the first 28 days, but oxygen <30 percent (%) at 36 weeks PMA or discharge home, whichever occurs first. • Severe BPD: Requires oxygen for the first 28 days, but ≥30% (≥) oxygen via head hood or nasal cannula, or continuous positive airway pressure, or mechanical ventilation, or high-flow nasal cannula ≥2 L / min at 36 weeks PMA or discharge home, whichever occurs first. ● Weight change rate [Time frame: Day 0 to 40 weeks postmenstrual age (EOS)] Rate of change is the specific weight change rate in kilograms (kg) per day. Percent change in length [Time frame: Day 0 to 40 weeks postmenstrual age (EOS)] Percentage change is expressed as change in length in centimeters (cm) per day. Number of participants experiencing treatment-emergent adverse events (TEAEs) and treatment-emergent serious adverse events (TESAEs) [Time frame: Day 0 to 40 weeks postmenstrual age (EOS)] An adverse event (AE) was an untoward medical occurrence in a participant receiving an investigational product without consideration of possible causality. A serious adverse event (SAE) was an AE that resulted in any of the following outcomes or was considered serious for any other reason: death, initial or prolonged hospital stay; life-threatening experience (immediate risk of death); persistent or significant disability / incapacity; congenital anomaly. A treatment-emergent adverse event was defined as the onset of any AE or a worsening in severity of a pre-existing AE after the first day of study drug administration. Percentage of serum IGF-1 concentrations falling within the target range after rhIGF-1 / rhIGFBP-3 infusion [time frame: day 0 to 40 weeks postmenstrual age (EOS)] Serum samples were collected from treated and control participants for IGF-1 quantification using a validated immunoassay. The target range for serum IGF-1 was 28-109 mcg / L. The percentage of treated participants overall with serum IGF-1 levels was reported to be within range. Serum concentrations of IGFBP-3 after intravenous (IV) infusion of rhIGF-1 / rhIGFBP-3 [Time frames: Day 0 and 40 weeks postmenstrual age] Serum concentrations of acid-labile subunit (ALS) after intravenous (IV) infusion of rhIGF-1 / rhIGFBP-3 [Time frame: 7 days and 40 weeks postmenstrual age] [Table 11]

[0289] No statistical analysis was provided on the number of participants with bronchopulmonary dysplasia (BPD).

[0290] Example 10. Exposure-Response Analysis of IGF-1 Following Administration of IGF-1 and IGFBP-3 in Preterm Infants This example shows the exposure response of IGF-1 in serum of extremely preterm infants treated with IGF-1 / IGFBP-3.

[0291] Briefly, a human recombinant form of the naturally occurring protein complex of IGF-1 and insulin-like growth factor binding protein-3 (rhIGF-1 / rhIGFBP-3) is administered to preterm infants.

[0292] Approximately 96 preterm infants received daily intravenous infusions of rhIGF-1 / rhIGFBP-3, beginning within 24 hours of birth and ending at 30 weeks postmenstrual age (PMA). Control subjects received standard neonatal care (SOC). The occurrence of BPD was assessed by oxygen challenge testing at 36 weeks PMA.

[0293] The median gestational age at birth was 25.9 weeks (range 23.1-27.9 weeks). The median birth weight was 0.790 (range 0.425-1.22). A logistic regression model was constructed to assess the relationship between IGF-1 exposure criteria and the probability of developing BPD (i.e., no BPD / mild BPD vs. moderate / severe BPD). Sources of variability in BPD response, including gestational age, birth weight, sex, oxygen saturation on day 1, APGAR score at 1 minute, and study group, were assessed and considered.

[0294] Clinical trial simulations were then conducted to identify dosing regimens that would result in serum IGF-1 levels that correlated with BPD prevention or improvement, i.e., provided a high probability of no / mild BPD symptoms in treated preterm infants versus standard of care. Based on a population PK model, a total of 500 trials of 75 subjects treated in a 1:1:1 ratio with rhIGF-1 / rhIGFBP-3 at 250 and 400 micrograms / kg / day or no dose (SOC) were simulated.

[0295] The results of these simulations showed that higher observed mean IGF-1 levels at day 7 (CavD7) were associated with a higher probability of no / mild BPD, demonstrating a statistically significant exposure-response relationship. The probability of no / mild or moderate / severe BPD was determined based on the simulated CavD7 for each study according to the exposure-response model described above.

[0296] Furthermore, the effects of other variables were observed. For example, a statistically significant effect of weight at birth and sex was observed, whereby larger women predicted a higher probability of no / mild BPD. Neither oxygen saturation at birth nor APGAR score at 1 minute was a predictor of no / mild BPD.

[0297] Simulation results showed that treatment with rhIGF-1 / rhIGFBP-3 treatment increased the probability of developing no or mild BPD versus standard of care for treating CLD (Figure 9, Table 12). A comparison of subjects treated with 250 micrograms / kg / day rhIGF-1 / rhIGFBP-3 or no dose (SOC) versus 400 micrograms / kg / day is shown in Figure 11.

[0298] Based on the IGF-1 concentration-time data in preterm infants, the pharmacokinetic properties of infused (or exogenous) IGF-1 were evaluated. Overall, a one-component disposition model with linear elimination, combined with a baseline model that considered changes in weight over time, adequately characterized the concentration-time profiles of infused and endogenous IGF-1, respectively. Furthermore, the model included intersubject variability (BSV) for the volumes of distribution and clearance, as well as BSV for the endogenous model (IGF-1 concentration at birth (C)). endo、0 ), and the initial decrease (C endo、mat (Infants with a longer IGF-1 half-life for IGF-1 were included.) Because age and weight are important components for endogenous production of IGF-1 and clearance of IGF-1 after IV infusion of rhIGF-1 / rhIGFBP-3, a maturation model was developed to characterize weight gain as a function of PMA in preterm infants. The model was validated as shown by graphs of IGF-1 concentrations over time for subjects receiving 250 micrograms / kg / day of rIGF-1 / rIGFBP-3 or lower doses versus control subjects receiving standard of care or untreated controls (Figure 10). [Table 12]

[0299] For the rIGF-1 / rIGFBP-3 400 micrograms / kg / 24-hour regimen, a population PK model was developed using standard of care and IGF-1 data. This model was used to simulate the 95% prediction intervals for IGF-1 PK concentrations over the treatment period and to predict where the mean, 5th, and 95th intervals would fall in relation to the target therapeutic range (Figure 12).

[0300] Results showed that mean IGF-1 levels were higher with the 400 microgram / kg / 24 hour dose than with the 250 microgram / kg / 24 hour dose. By Day 7, approximately 95% of subjects receiving the 400 microgram / kg / 24 hour dose are expected to be within the therapeutic range. At EOI, 90% of subjects are expected to be below 109 ng / ml and 95% of subjects are expected to be above 28 ng / ml. The majority of subjects receiving the 400 microgram / kg / 24 hour dose are expected to achieve target IGF-1 levels (28-109 ng / ml) by Day 7, with a low risk of overshooting target IGF-1 levels by the end of the infusion. The end of the infusion can be, for example, about 28, 29, 30, 31, or 32 weeks postmenstrual age (PMA). In some embodiments, the end of the infusion is about 28 weeks postmenstrual age (PMA). In some embodiments, the end of the infusion is 29 weeks postmenstrual age (PMA). In some embodiments, the end of infusion is about 30 weeks postmenstrual age (PMA). In some embodiments, the end of infusion is about 31 weeks postmenstrual age (PMA). In some embodiments, the end of infusion is about 32 weeks postmenstrual age (PMA).

[0301] To assess whether earlier or higher IGF-1 serum exposure resulted in better BPD outcomes, IGF-1 serum exposure was measured at day 7 (FIG. 13A) and 40 weeks PMA (FIG. 13B).

[0302] Exploratory logistic regression analyses were performed to investigate the relationship between serum IGF-1 exposure at different time points and BPD outcomes. At earlier time points, higher IGF-1 exposure was significantly associated with better BPD outcomes (mild or no BPD). To reduce bias, mean IGF-1 concentrations over 7 days were selected for model development. Birth weight (higher WT, better outcome) and gender (female, better outcome) were identified as covariates affecting BPD outcomes.

[0303] Simulation results further showed that rhIGF-1 / rhIGFBP-3 administered at a 400 microgram / kg / 24-hour regimen was associated with a higher probability of no or mild BPD versus the 250 microgram / kg / 24-hour regimen. Based on the simulation study, we found that the high dose of 400 microgram / kg / 24-hour was highly correlated with BPD prevention and CLD improvement.

[0304] While the particular compounds, compositions, and methods described herein have been specifically described with specificity according to particular embodiments, the following examples serve only to illustrate the compounds of the invention and are not intended to limit them.

[0305] As used herein in the specification and claims, the articles "a" and "an" should be understood to include plural referents unless clearly indicated to the contrary. A claim or specification containing "or" between one or more members of a group is deemed satisfied if one, more than one, or all of the group members are present in, employed in, or otherwise relevant to a given product or process, unless the context indicates otherwise or is otherwise clear. The invention includes embodiments in which exactly one member of a group is present in, employed in, or otherwise relevant to a given product or process. The invention also includes embodiments in which two or more, or all, group members are present in, employed in, or otherwise relevant to a given product or process. Furthermore, the invention should be understood to encompass all variations, combinations, and permutations of one or more limitations, elements, clauses, descriptive language, etc. from one or more of the recited claims that are introduced into another claim that relies on the same base claim (or any other related claim) unless otherwise indicated or unless a contradiction or inconsistency would arise. Where elements are presented as a list (e.g., in a Markush group or similar format), it is understood that each subgroup of the elements is also disclosed, and that any element can be deleted from the group. Generally, when the invention or aspects of the invention are referred to as comprising particular elements, features, etc., it is understood that particular embodiments of the invention or aspects of the invention consist of, or consist essentially of, such elements, features, etc. For the sake of brevity, these embodiments have not always been specifically described in so many words herein. It is also understood that any embodiment or aspect of the invention may be explicitly excluded from the scope of the claims, regardless of whether a specific exclusion is set forth herein. Publications, websites, and other reference materials referred to herein to describe the background of the invention and to provide additional details regarding its practice are incorporated herein by reference.

Claims

1. 1. A liquid pharmaceutical composition suitable for administration to a neonate, comprising a protein complex comprising recombinant insulin-like growth factor 1 (rIGF-1), recombinant insulin-like growth factor binding protein 3 (rIGFBP-3), and a polysorbate surfactant at a concentration of 0.0025% to 0.0075%, a. the rIGF-1 and rIGFBP-3 are complexed; b. the rIGF-1 and rIGFBP-3 complex is at a concentration of 45-55 micrograms / mL; c. A liquid pharmaceutical composition, wherein the composition has a pH of 5.0 to 7.

0.

2. 2. The composition of claim 1, wherein the rIGF-1 and rIGFBP-3 complex is at a concentration of 50 micrograms / mL.

3. 3. The composition of claim 1, wherein the polysorbate surfactant is selected from polysorbate 20 (P20) or polysorbate 80 (P80).

4. 4. The composition of claim 3, wherein the polysorbate surfactant is P20.

5. 4. The composition of claim 1, wherein the polysorbate surfactant is present in the composition at a concentration of 0.005%.

6. The composition of any one of claims 1 to 5, further comprising a buffering agent comprising sodium acetate, acetic acid, and / or sodium chloride.

7. 7. The composition of claim 6, wherein the sodium acetate or acetic acid is at a concentration of 10 to 100 mM.

8. 7. The composition of claim 6, wherein the sodium acetate or acetic acid is at a concentration of 50 mM.

9. The composition of any one of claims 6 to 8, wherein the sodium chloride is at a concentration of 20 mM to 200 mM.

10. 10. The composition of claim 9, wherein the sodium chloride is at a concentration of 105 mM.

11. The composition according to any one of claims 1 to 10, wherein the pH is from 5.3 to 5.

8.

12. The composition of any one of claims 1 to 11, wherein the composition is suitable for intravenous administration.

13. The composition of any one of claims 1 to 12, wherein the composition has a shelf life of at least 24 months at a temperature of 2 to 8°C.

14. The composition of any one of claims 1 to 13, wherein the composition is stable at room temperature and / or ambient light for at least 8 hours, 12 hours, 24 hours, 36 hours, or 48 hours.

15. 3. The composition of claim 1, wherein less than 20% of the rIGF-1 is present as oxidized species after storage at 25°C for 6 months.

16. 3. The composition of claim 1, wherein less than 10% of the rIGF-1 is present as oxidized species after storage at 40°C for 3 months.

17. 17. The composition of any one of claims 1 to 16, wherein the % of oxidized species is determined by reversed-phase ultra-performance liquid chromatography (RP-UPLC).

18. The composition of any one of claims 1 to 17, wherein the rIGFBP-3 contains less than 5% trisulfide variants.

19. a protein complex comprising equimolar amounts of recombinant insulin-like growth factor 1 (rIGF-1) and recombinant insulin-like growth factor binding protein 3 (rIGFBP-3); a polysorbate 20 surfactant at a concentration of 0.005% (v / v); and a buffer comprising sodium acetate, acetic acid, and / or sodium chloride; 10. The composition of claim 1, wherein the composition has a pH of 5.3 to 5.8, the rIGF-1 and rIGFBP-3 complex is at a concentration of 50 micrograms / mL, and less than 1.5% of the rIGF-1 is present as an oxidized species upon product release.

20. A pharmaceutical composition comprising the composition of any one of claims 1 to 19 and a pharmaceutically acceptable carrier.

21. 21. The composition of any one of claims 1 to 20 for use in the treatment or prevention of intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), or chronic lung disease of premature infants (CLD) in a subject in need thereof.

22. 22. The composition of claim 21, wherein the subject in need of treatment is an infant.

23. 23. The composition of claim 21 or 22, wherein the composition is administered intravenously.

24. 24. The composition of any one of claims 21 to 23, wherein the composition is administered at a dosage of 100 to 1000 micrograms / kg / 24 hours.

25. 25. The composition of claim 24, wherein the composition is administered at a dosage of 400 micrograms / kg / 24 hours.

26. 25. The composition of claim 24, wherein the composition is administered at a dosage of 250 micrograms / kg / 24 hours.

27. The composition of any one of claims 21 to 26, wherein the composition is administered by continuous infusion for a period of 24 hours.

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