Methods for treating eye diseases

Abstract

Methods are provided for treating patients with neovascular eye diseases.

Description

[Technical Field]

[0001] Sequence Listing This application contains a Sequence Listing that has been submitted electronically in ASCII format and is hereby incorporated by reference in its entirety. The ASCII copy, created on July 28, 2020, is titled PAT058689_SEQ_LISTING_ST25.txt and is 8KB in size.

[0002] The present invention relates to methods for treating ocular diseases with VEGF antagonists. In particular, the present invention relates to treating neovascular ocular diseases such as diabetic retinopathy and proliferative diabetic retinopathy with less frequent dosing than currently approved treatment regimens. [Background technology]

[0003] Diabetes mellitus (DM) is the most common endocrine disorder in developed countries, with prevalence estimates ranging between 2-5% of the world's population. Diabetic retinopathy (DR) and diabetic macular edema (DME) are common microvascular complications in patients with diabetes that can affect and weaken visual acuity (VA) and ultimately lead to blindness.

[0004] DR is the most common cause of vision loss in people with diabetes and the leading cause of visual impairment and blindness in working-age adults. DR occurs when high blood sugar levels cause damage to blood vessels in the retina. These vessels may swell and leak, or they may close, preventing blood from passing through. Sometimes, abnormal new blood vessels grow in the retina. Diabetic retinopathy includes both nonproliferative diabetic retinopathy (nPDR) and the more advanced form of the disease, proliferative diabetic retinopathy (PDR). DME frequently manifests as a symptom of DR (Riordan-Eva, 2004, Eye (Lond). 2004, 18:1161-8) and is the leading cause of visual impairment in patients with DR. Diabetic macular edema (DME) can occur at any stage of DR, but it often appears after severe nPDR and PDR.

[0005] Currently, healthcare providers actively monitor for mild to moderate nPDR and withhold treatment for severe nPDR and PDR. Both LUCENTIS® and EYLEA® have recently received approval for DR in the United States. The recommended dose for EYLEA® to treat DR is 2 mg (0.05 mL) administered every four weeks for five injections, followed by one injection every eight weeks. The recommended dose for LUCENTIS® to treat DR is 0.3 mg (0.05 mL) administered once per month. While two medications are approved to treat DR, the current standard of care is panretinal photocoagulation (PRP) and laser. Despite the availability of such treatment options, there remains a need for treatments that reduce injection frequency, provide better anatomical responses, and avoid invasive laser therapy. Summary of the Invention [Means for solving the problem]

[0006] The present invention provides methods for administering a therapeutic VEGF antagonist to treat proliferative diabetic retinopathy (PDR). In some embodiments, the present invention provides a method for treating PDR comprising administering to a mammal at least two separate doses of a VEGF antagonist at 6-week intervals (q6w) during an induction phase, followed by an additional dose during a maintenance phase, wherein the doses administered during the maintenance phase are separated by at least 6 weeks. In some embodiments, the doses during the maintenance phase are administered once every 12 weeks (q12w) or more. In some embodiments, the dosing frequency is adjusted based on the results of disease activity assessments, e.g., using predefined visual and anatomical criteria. In one embodiment, at any time during the maintenance phase (e.g., after week 48 measured from the initial therapeutic dose), the treatment interval may be extended by 6 weeks at a time, up to a maximum of 24 weeks, at the discretion of the treatment provider based on the assessment of diabetes activity. In another embodiment, the dosing frequency during the maintenance phase can be adjusted by decreasing the dosing interval from once every 12 weeks (q12w) to once every 6 weeks (q6w) if disease activity is detected at any scheduled treatment visit.

[0007] The present invention also provides a VEGF antagonist for use in a method for treating ocular diseases, particularly neovascular ocular diseases, more particularly diabetic retinopathy (DR) and proliferative diabetic retinopathy (PDR), in a patient, wherein the VEGF antagonist is initially provided in an induction phase, during which the patient receives three individual doses of the VEGF antagonist at six-week intervals, followed by a maintenance phase, during which the patient receives additional doses of the VEGF antagonist once every 12 weeks (q12w). In one embodiment, the dosing frequency can be extended by increasing the dosing interval to once every 24 weeks (q24w) at a time, if no disease activity is detected at scheduled treatment visits. In another embodiment, the dosing frequency can be adjusted by decreasing the dosing interval from once every 12 weeks (q12w) to once every 6 weeks (q6w) if disease activity is detected at a scheduled treatment visit.

[0008] The present invention also provides a method for treating DR, comprising administering to a mammal at least two separate doses of a VEGF antagonist at 6-week intervals (q6w) during an induction phase, followed by an additional dose during a maintenance phase, wherein the doses administered during the maintenance phase are separated by at least 6 weeks. In some embodiments, doses during the maintenance phase are administered once every 12 weeks (q12w) or more. In some embodiments, the dosing frequency is adjusted based on the results of disease activity assessments, e.g., using pre-defined visual and anatomical criteria. In one embodiment, at any time during the maintenance phase (e.g., after week 48 measured from the initial treatment dose), the treatment interval may be extended by 6 weeks at a time, up to a maximum of 24 weeks, at the discretion of the treatment provider based on the assessment of diabetes activity. In another embodiment, the dosing frequency during the maintenance phase may be adjusted by decreasing the dosing interval from once every 12 weeks (q12w) to once every 6 weeks (q6w) if disease activity is detected at any scheduled treatment visit. In another embodiment, the patient also has macular edema (eg, diabetic macular edema).

[0009] The present invention further provides a method for preventing the progression of proliferative diabetic retinopathy (PDR) to nonproliferative diabetic retinopathy (NPDR) in a patient, comprising administering to a mammal at least two separate doses of a VEGF antagonist six weeks apart (q6w) during an induction phase, followed by an additional dose during a maintenance phase, wherein the doses administered during the maintenance phase are separated by at least six weeks. In some embodiments, the doses during the maintenance phase are administered once every 12 weeks (q12w) or more. In some embodiments, the dosing frequency is adjusted based on the results of disease activity assessments, e.g., using predefined visual and anatomical criteria. In one embodiment, at any time during the maintenance phase (e.g., after week 48 measured from the initial treatment dose), the treatment interval may be extended by six weeks at a time, up to a maximum of 24 weeks, at the discretion of the treatment provider based on the assessment of diabetes activity. In another embodiment, the dosing frequency during the maintenance phase can be adjusted by decreasing the dosing interval from once every 12 weeks (q12w) to once every 6 weeks (q6w) if disease activity is detected at any scheduled treatment visit. In some embodiments, patients are initially treated for NPDR. In other embodiments, patients are initially treated for DR.

[0010] The present invention also provides a kit comprising a container containing a VEGF antagonist and instructions for use in treating a patient diagnosed with DR, NPDR, or PDR, wherein three doses of the VEGF antagonist are administered at 6-week intervals (q6w), with the final dose followed by additional individual doses of the VEGF antagonist at 12-week intervals (q12w). In one embodiment, the kit contains one or more 6 mg doses of brolucizumab, each dose provided in a single-use vial containing sufficient brolucizumab to deliver a 6 mg dose when administered in a volume of 0.05 mL, or in a pre-filled syringe containing 6 mg of brolucizumab. In another embodiment, the instructions further instruct adjusting the q12w dosing interval to once every 6 weeks if PDR disease activity is observed in the treated eye. In another embodiment, the instructions further instruct to extend the q12w dosing interval to once every 24 weeks if no PDR disease activity is observed in the treated eye. In yet another embodiment, the instructions further instruct that the VEGF antagonist be administered as needed, i.e., on a case-by-case basis (PRN), at the discretion of the treatment provider (e.g., a physician or other qualified healthcare professional) based on visual and / or anatomical results to determine disease activity before or after any q12w dose.

[0011] In some embodiments, the VEGF antagonist used in the methods of the present invention is an anti-VEGF antibody. In certain embodiments, the anti-VEGF antibody is a single-chain antibody (scFv) or a Fab fragment. In particular, the anti-VEGF antibody is brolucizumab.

[0012] Non-limiting embodiments of the present disclosure are described in the following embodiments. 1. A method for treating proliferative diabetic retinopathy (PDR) in a patient, comprising: a) administering to the patient three separate doses of a VEGF antagonist at six-week intervals; and b) administering to the patient one or more additional doses of the VEGF antagonist once every 12 weeks (q12w regimen), the first additional dose being administered 12 weeks after the third individual dose of step a). 2. The method of embodiment 1, further comprising assessing the patient for PDR disease activity before or after each q12w dose. 3. The method of embodiment 2, wherein disease activity is assessed based on review of best corrected visual acuity (BCVA), ETDRS DRSS score, retinal neovascularization status, and peripheral vision. 4. The method of embodiment 2 or 3, wherein if worsening of PDR disease activity is confirmed after the q12w dose, the patient is switched to a q6w regimen, with additional doses administered once every 6 weeks instead of once every 12 weeks. 5. The method of embodiment 4, wherein worsening PDR disease activity is the development of new or worsening retinal neovascularization, retinal neovascular reperfusion, an increase in ETDRS DRSS score, loss of peripheral vision, and / or complications affecting vision, compared to any previous assessment. 6. The method of embodiment 2 or 3, wherein at any time during q12w, the treatment interval is extended to 18 weeks (q18w) or 24 weeks (q24w) if disease activity is stable or improving compared to the previous disease activity assessment. 7. The method of any one of embodiments 1-6, wherein the patient is a human. 8. The method of any one of embodiments 1-7, wherein the anti-VEGF antagonist is brolucizumab. 9. The method of any one of embodiments 1-8, wherein the VEGF antagonist is administered by intravitreal injection. 10. The method of any one of embodiments 1-9, wherein the dose of the VEGF antagonist is 3 mg or 6 mg. 11. A method for treating diabetic retinopathy (DR) or proliferative diabetic retinopathy (PDR), comprising administering to a patient three individual doses at 6-week intervals during an induction phase, followed by additional doses every 12 weeks (q12w regimen) during a maintenance phase, for about 3 mg or about 6 mg of a VEGF antagonist that is an anti-VEGF antibody, optionally wherein the DR patient also has macular edema (such as diabetic macular edema). 12. The method of embodiment 11, further comprising assessing the patient's DR or PDR disease activity before or after each q12w dose. 13. The method of embodiment 12, wherein disease activity is assessed based on review of best corrected visual acuity (BCVA), ETDRS DRSS score, retinal neovascularization status, and peripheral vision. 14. The method of embodiment 12 or 13, wherein at any time during the maintenance phase, the dosing interval is extended to 24 weeks (q24w) if disease activity is improving or stable compared to the previous disease activity assessment. 15. The method of embodiments 11-13, wherein if worsening of PDR disease activity is confirmed after the q12w dose, the patient is switched to a q6w regimen, with additional doses administered once every 6 weeks instead of once every 12 weeks. 16. The method of embodiment 15, wherein worsening PDR disease activity is the development of new or worsening retinal neovascularization, retinal neovascular reperfusion, an increase in ETDRS DRSS score, loss of peripheral vision, and / or complications affecting vision, compared to any previous assessment. 17. The method of any one of embodiments 11-16, wherein the patient is a human. 18. The method of any one of embodiments 11-17, wherein the anti-VEGF antagonist is brolucizumab. 19. The method of any one of embodiments 11-18, wherein the VEGF antagonist is administered by intravitreal injection. 20. A VEGF antagonist for use in a method for treating diabetic retinopathy (DR) or proliferative diabetic retinopathy (PDR) in a patient, wherein the VEGF antagonist is: a) 3 individual doses spaced 6 weeks apart and b) Thereafter, once every 12 weeks (q12w regimen) as a booster dose A VEGF antagonist is administered to the patient. 21. The VEGF antagonist for use according to embodiment 20, wherein the method further comprises assessing the patient for DR or PDR disease activity before or after administration of each q12w dose. 22. The VEGF antagonist for use according to embodiment 21, wherein disease activity is assessed based on review of best-corrected visual acuity (BCVA), ETDRS DRSS score, retinal neovascularization status, and peripheral vision. 23. The VEGF antagonist for use according to embodiment 21 or 22, wherein if worsening of disease activity is confirmed after the q12w dose, the patient is switched to a q6w regimen, with additional doses administered once every 6 weeks instead of once every 12 weeks. 24. The VEGF antagonist for use according to embodiment 23, wherein worsening disease activity is the development of new or worsening retinal neovascularization, reperfusion of retinal neovascularization, an increase in ETDRS DRSS score (such as an increase of 2 or more steps), loss of peripheral vision, and / or complications affecting vision, compared to any previous assessment. 25. The VEGF antagonist for use according to any one of embodiments 20-22, wherein at any time during the maintenance phase, the dosing interval is extended to 24 weeks (q24w) if disease activity is improved or stable compared to the previous disease activity assessment. 26. The VEGF antagonist for use according to any one of embodiments 20 to 25, wherein the patient is a human. 27. The VEGF antagonist for use according to any one of embodiments 20 to 26, wherein the anti-VEGF antagonist is brolucizumab. 28. The VEGF antagonist for use according to any one of embodiments 20 to 27, wherein the VEGF antagonist is administered by intravitreal injection. 29. The VEGF antagonist for use according to any one of embodiments 20 to 28, wherein the dose of the VEGF antagonist is from about 3 mg to about 6 mg. 30. A VEGF antagonist for use in a method for treating diabetic retinopathy (DR) or proliferative diabetic retinopathy (PDR) in a patient, wherein the VEGF antagonist is initially provided in an induction phase, during which the patient receives three individual doses of about 3 mg or about 6 mg of the VEGF antagonist, spaced six weeks apart, and then the VEGF antagonist is provided in a maintenance phase, during which the patient receives an additional about 3 mg or about 6 mg dose of the VEGF antagonist once every 12 weeks (q12w regimen). 31. The VEGF antagonist for use according to embodiment 30, wherein the method further comprises assessing the patient for DR or PDR disease activity before or after administration of each q12w dose. 32. The VEGF antagonist for use according to embodiment 31, wherein disease activity is assessed based on a review of best-corrected visual acuity (BCVA), ETDRS DRSS score, retinal neovascularization status, and peripheral vision. 33. The VEGF antagonist for use according to embodiment 31 or 32, wherein worsening disease activity is the development of new or worsening retinal neovascularization, reperfusion of retinal neovascularization, an increase in ETDRS DRSS score (such as an increase of 2 or more steps), loss of peripheral vision, and / or complications affecting vision, compared to any previous assessment. 34. A VEGF antagonist for use according to embodiment 33, wherein worsening PDR disease activity is the development of new or worsening retinal neovascularization, reperfusion of retinal neovascularization, an increase in ETDRS DRSS score, loss of peripheral vision, and / or complications affecting vision compared to any previous assessment. 35. The VEGF antagonist for use according to any one of embodiments 30-32, wherein at any time during the maintenance phase, the dosing interval is extended to 24 weeks (q24w) if disease activity is improved or stable compared to the previous disease activity assessment. 36. The VEGF antagonist for use according to any one of embodiments 30 to 35, wherein the patient is a human. 37. The VEGF antagonist for use according to any one of embodiments 30 to 36, wherein the anti-VEGF antagonist is brolucizumab. 38. The VEGF antagonist for use according to any one of embodiments 30 to 37, wherein the VEGF antagonist is administered by intravitreal injection. 39.a) A drug container containing a VEGF antagonist and b) A kit comprising instructions for using a VEGF antagonist to treat a patient diagnosed with DR or PDR, wherein three doses of the VEGF antagonist are administered at six-week intervals (q6w), the final dose being followed by additional individual doses of the VEGF antagonist at twelve-week intervals (q12w). 40.(a) One or more 6 mg doses of brolucizumab provided in single-use vials or in pre-filled syringes containing 6 mg of brolucizumab, each dose containing sufficient brolucizumab to deliver a 6 mg dose when administered in a volume of 0.05 mL; or b) One or more 3 mg doses of brolucizumab provided in single-use vials containing sufficient brolucizumab to deliver a 3 mg dose when administered in a volume of 0.05 mL or in pre-filled syringes containing 3 mg of brolucizumab 40. The kit of embodiment 39, comprising: 41. The kit of embodiment 39 or 40, wherein the instructions further instruct to adjust the q12w dosing interval to once every 6 weeks if DR or PDR disease activity is observed in the treated eye. 42. The kit of embodiment 39 or 40, wherein the instructions further instruct to extend the q12w dosing interval to 6 weeks at a time, up to once every 24 weeks, if no disease activity is observed in the treated eye. 43. The kit of embodiment 39 or 40, wherein the instructions further instruct that the VEGF antagonist is to be administered as needed, i.e., on a case-by-case basis (PRN), at the discretion of the treatment provider (e.g., a physician or other qualified healthcare professional) based on visual and / or anatomical results to determine disease activity before or after any q12w dose. 44. A method for preventing the progression of proliferative diabetic retinopathy (PDR) to non-proliferative diabetic retinopathy (NPDR) in a patient, comprising: a) administering to the patient three separate doses of a VEGF antagonist at six-week intervals; and b) thereafter administering to the patient an additional dose of the VEGF antagonist once every 12 weeks (q12w regimen). 45. The method of embodiment 44, further comprising assessing the patient for disease activity before or after each q12w dose. 46. ​​The method of embodiment 45, wherein disease activity is assessed based on best corrected visual acuity (BCVA), ETDRS DRSS score, retinal neovascularization status, and peripheral visual field review. 47. The method of embodiment 45 or 46, wherein if worsening disease activity is confirmed after the q12w dose, the patient is switched to a q6w regimen, with additional doses administered once every 6 weeks instead of once every 12 weeks. 48. The method of embodiment 47, wherein worsening disease activity is new or worsening retinal neovascularization, retinal neovascular reperfusion, an increase in ETDRS DRSS score (e.g., an increase of 2 or more steps), loss of peripheral vision, and / or the onset of a complication affecting vision, compared to any previous assessment. 49. The method of any one of embodiments 45-46, wherein at week 48 after the first dose is administered, the q12w treatment interval is extended by 6 weeks at a time to a maximum of 24 weeks (q24w). 50. The method of any one of embodiments 44-49, wherein the patient is a human. 51. The method of any one of embodiments 44 to 50, wherein the anti-VEGF antagonist comprises the sequence of SEQ ID NO: 3. 52. The method of any one of embodiments 44-51, wherein the VEGF antagonist is administered by intravitreal injection. 53. The method of any one of embodiments 44-52, wherein the dose of the VEGF antagonist is from about 3 mg to about 6 mg.

[0013] Specific preferred embodiments of the present invention will become apparent from the following more detailed description of certain preferred embodiments and from the claims. DETAILED DESCRIPTION OF THE INVENTION

[0014] definition The following definitions and explanations are meant and intended to control any future interpretation unless expressly and unambiguously changed in the examples below or unless application of meaning would make any interpretation incomprehensible or inherently incomprehensible. In the event that interpretation of a term would make it incomprehensible or inherently incomprehensible, the definition shall be in accordance with Webster's Dictionary, 3 rd The dictionary should be taken from dictionaries known to those skilled in the art, such as the Oxford Dictionary of Biochemistry and Molecular Biology (Ed. Anthony Smith, Oxford University Press, Oxford, 2004), or the Oxford Dictionary of Biochemistry and Molecular Biology (Ed. Anthony Smith, Oxford University Press, Oxford, 2004).

[0015] As used herein, all percentages are by weight unless otherwise specified.

[0016] As used herein and unless otherwise indicated, the terms "a" and "an" shall be understood to mean "one," "at least one," or "one or more." Unless otherwise required by context, singular terms used herein shall include pluralities and plural terms shall include the singular term.

[0017] The contents of any patents, patent applications, and references cited throughout this specification are hereby incorporated by reference in their entirety.

[0018] The term "VEGF" refers to the 165-amino acid vascular endothelial cell growth factor as described by Leung et al., Science 246:1306 (1989) and Houck et al., Mol. Endocrin. 5:1806 (1991), as well as the related 121-, 189-, and 206-amino acid vascular endothelial cell growth factors, along with naturally occurring allelic and processed forms of those growth factors.

[0019] The term "VEGF receptor" or "VEGFr" refers to a cellular receptor for VEGF, a cell surface receptor typically found on vascular endothelial cells, and variants thereof that retain the ability to bind hVEGF. One example of a VEGF receptor is the fms-like tyrosine kinase (flt), a transmembrane receptor in the tyrosine kinase family. DeVries et al., Science 255:989 (1992); Shibuya et al., Oncogene 5:519 (1990). The flt receptor contains an extracellular domain, a transmembrane domain, and an intracellular domain with tyrosine kinase activity. The extracellular domain is involved in VEGF binding, while the intracellular domain is involved in signal transduction. Another example of a VEGF receptor is the flk-1 receptor (also known as KDR). Matthews et al., Proc. Nat. Acad. Sci. 88:9026 (1991); Terman et al., Oncogene 6:1677 (1991); Terman et al., Biochem. Biophys. Res. Commun. 187:1579 (1992). Binding of VEGF to the flt receptor results in the formation of at least two high molecular weight complexes with apparent molecular weights of 205,000 and 300,000 daltons. The 300,000 dalton complex is thought to be a dimer containing two receptor molecules bound to a single molecule of VEGF.

[0020] As used herein, "VEGF antagonist" refers to a compound that can reduce or inhibit VEGF activity in vivo. A VEGF antagonist can bind to a VEGF receptor or prevent a VEGF protein from binding to a VEGF receptor. A VEGF antagonist can be, for example, a small molecule capable of specifically binding to one or more VEGF proteins or one or more VEGF receptors, an anti-VEGF antibody or an antigen-binding fragment thereof, a fusion protein (such as aflibercept or other such soluble decoy receptors), an aptamer, an antisense nucleic acid molecule, an interfering RNA, a receptor protein, and the like. Some VEGF antagonists are described in WO 2006 / 047325.

[0021] In preferred embodiments, the VEGF antagonist is an anti-VEGF antibody (such as brolucizumab or ranibizumab or bevacizumab or a bispecific antibody such as faricimab) or a soluble VEGF receptor (such as aflibercept).

[0022] As used herein, the term "antibody" includes whole antibodies and any antigen-binding fragments thereof (i.e., "antigen-binding portion," "antigen-binding polypeptide," or "immunobinder") or single chains thereof. An "antibody" includes a glycoprotein or antigen-binding portion thereof comprising at least two heavy (H) chains and two light (L) chains interconnected by disulfide bonds. Each heavy chain contains a heavy chain variable region (V H The heavy chain constant region is composed of three domains, CH1, CH2, and CH3. Each light chain comprises a light chain variable region (V L The light chain constant region is composed of one domain, CL. H Area and V LThe regions can be further subdivided into regions of hypervariability, termed complementarity determining regions (CDRs), interspersed with more conserved regions, termed framework regions (FRs). H and V L consists of three CDRs and four FRs arranged from the amino terminus to the carboxy terminus in the following order: FR1, CDR1, FR2, CDR2, FR3, CDR3, FR4. The variable regions of the heavy and light chains contain binding domains that interact with antigens. The constant region of the antibody may mediate the binding of the immunoglobulin to host tissues or host factors, including various cells of the immune system (e.g., effector cells) and the first component (C1q) of the classical complement system.

[0023] The term "single-chain antibody," "single-chain Fv," or "scFv" refers to antibody heavy chain variable domains (or regions; V H ) and an antibody light chain variable domain (or region; V L ) Such scFv molecules can have the general structure: NH2-V L -Linker-V H -COOH or NH2-V H -Linker-V L -COOH.

[0024] The term "antigen-binding portion" of an antibody (or simply "antibody portion") refers to one or more fragments of an antibody that retain the ability to specifically bind to an antigen (e.g., VEGF). It has been shown that the antigen-binding function of an antibody can be performed by fragments of a full-length antibody. Examples of binding fragments encompassed within the term "antigen-binding portion" of an antibody include: (i) V L , V H (ii) a Fab fragment, which is a monovalent fragment consisting of the V, CL, and CH1 domains; (iii) a F(ab')2 fragment, which is a bivalent fragment containing two Fab fragments linked by a disulfide bridge at the hinge region; H and an Fd fragment consisting of the CH1 domain; (iv) a V of a single arm of an antibody. L and V H Fv fragment consisting of domains; (v) VH and (vi) an isolated complementarity-determining region (CDR) or (vii) a combination of two or more isolated CDRs, optionally joined by a synthetic linker. Additionally, the two domains of the Fv fragment, V, L and V H Although the V are encoded by separate genes, they can be joined using recombinant methods by synthetic linkers that allow them to be made as a single protein chain. L Area and V H The domains pair to form a monovalent molecule (known as a single-chain Fv (scFv); see, e.g., Bird et al. (1988) Science 242:423-426; and Huston et al. (1988) Proc. Natl. Acad. Sci. USA 85:5879-5883). Such single-chain antibodies are also intended to be encompassed within the term "antigen-binding portion" of an antibody. These antibody fragments are obtained using conventional techniques known to those of skill in the art, and the fragments are screened for utility in the same manner as intact antibodies. Antigen-binding portions can be produced by recombinant DNA techniques or by enzymatic or chemical cleavage of intact immunoglobulins. Antibodies can be of various isotypes, such as IgG (e.g., IgG1, IgG2, IgG3, or IgG4 subtypes), IgA1, IgA2, IgD, IgE, or IgM antibodies.

[0025] As used herein, "mammal" includes any animal classified as a mammal, including, but not limited to, humans, domestic animals, livestock, and companion animals.

[0026] "Ocular diseases" or "neovascular ocular diseases" that can be treated using the methods of the present invention include conditions, diseases, or disorders associated with ocular neovascularization, including, but not limited to, abnormal angiogenesis, choroidal neovascularization (CNV), retinal vascular permeability, retinal edema, diabetic retinopathy (particularly proliferative diabetic retinopathy (PDR) and nonproliferative diabetic retinopathy (NPDR)), diabetic macular edema (DME), neovascular (exudative) age-related macular degeneration (AMD), including CNV associated with nAMD (neovascular AMD), sequelae associated with retinal ischemia, central retinal vein occlusion (CRVO), branch retinal vein occlusion (BRVO), and posterior segment neovascularization. In a preferred embodiment, the disease is PDR. In another preferred embodiment, the disease is NPDR.

[0027] As used herein, the term "subject" or "patient" refers to humans and non-human mammals, including, but not limited to, primates, pigs, horses, dogs, cats, sheep, and cows. Preferably, the subject or patient is a human.

[0028] Treatment regimen In one aspect, the present invention provides methods for treating patients with diabetic retinopathy (DR), nonproliferative diabetic retinopathy (NPDR), and proliferative diabetic retinopathy (PDR), comprising administering to the patient a VEGF antagonist in a treatment schedule comprising an induction phase and a maintenance phase as described herein. In certain embodiments, the present invention provides methods for preventing progression of NPDR to PDR, comprising administering to the patient a VEGF antagonist in a treatment schedule comprising an induction phase and a maintenance phase as described herein.

[0029] In one embodiment, the patient is at least 18 years old and has been diagnosed with diabetes mellitus (DM) type 1 or 2 and HbA1c≦12%. In another embodiment, the patient has PDR as assessed by a care provider and has a BCVA≧ETDRS letters 34 (Snellen equivalent 20 / 200). The patient is diagnosed with PDR by a care provider using, for example, standard or wide-field color fundus photographs (CFP), optionally with fluorescein angiography (FA). In another embodiment, the patient has not undergone panretinal photocoagulation (PRP) laser treatment.

[0030] In one embodiment, the induction phase consists of at least two individual doses administered six weeks apart (q6w), e.g., on day 0, week 6, and week 12. In one embodiment, the maintenance phase begins with a dosing regimen in which the VEGF antagonist is administered once every 12 weeks (q12w), and the dosing interval is adjusted by plus or minus six weeks, depending on disease activity assessments performed before the doses are administered. In one embodiment, if disease activity is observed before administering the q12w dose, the patient will receive the q12w dose as planned, followed by the next dose six weeks later, thus remaining on the q6w dosing regimen until no disease activity is observed. If disease activity is no longer observed, the dosing regimen will be adjusted back to a q12w schedule. In another embodiment, if no disease activity is observed at any time during the maintenance phase, the treatment interval may be extended by six weeks, up to q18w, and then another six weeks, up to 24-week intervals (q24w). If disease activity is observed in patients on a q24w dosing regimen, the treatment interval may be adjusted back to a q18w or q12w dosing regimen.

[0031] In one aspect, the present invention provides a method for treating neovascular ocular diseases, including PDR, in a mammal, comprising administering multiple doses of a VEGF antagonist (e.g., an anti-VEGF antibody or fragment thereof) to the mammal at various intervals for at least two years. In some embodiments, doses are administered two or three times at six-week intervals during an "induction phase," followed by additional doses at 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24-week intervals during a "maintenance phase." Disease activity assessments are conducted at least at every additional scheduled dose during the maintenance phase. If disease activity is confirmed as described herein, the treatment regimen may be changed from every 12 weeks to every 6 weeks (i.e., q6w). The present invention provides specific criteria established by the inventors based on disease activity assessment to determine when to use 6-week intervals and when to continue 12-week intervals.In some cases, patients will receive a 12-week interval regimen for a while, then switch to a 6-week interval, and then switch back to a 12-week interval.Therefore, patients do not need to continue one interval regimen, and can switch back and forth depending on the evaluation according to the criteria described herein.

[0032] In one embodiment, if no disease activity is detected over multiple consecutive treatment visits, the treatment provider may extend treatment for an additional 1 to 24 weeks. For example, if a patient is treated every 12 weeks, the treatment provider may extend treatment to every 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 weeks; or if a patient is treated every 6 weeks, the treatment provider may extend treatment to every 7, 8, 9, 10, 11, or 12 weeks. If disease activity is identified at any treatment visit, the treatment schedule may be adjusted back to a 12-week or 6-week treatment regimen. As used herein, "disease activity" refers to a worsening of an ocular disease based on the criteria provided herein.

[0033] In one embodiment, the present invention provides a method for treating an ocular disease, particularly an ocular neovascular disease, more particularly PDR, comprising administering a VEGF antagonist to a mammal in need thereof according to the following schedule: an "induction phase" of 3 doses administered at 6-week (i.e., "q6" or "q6w") intervals (e.g., day 0, week 6, week 12); and A "maintenance phase" of additional doses administered at 12-week (i.e., "q12" or "q12w") intervals.

[0034] In one embodiment, the "maintenance phase" can be additional doses at 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 week intervals, and can be adjusted as described herein based on disease activity assessments as described herein.

[0035] In some embodiments, the "induction phase" can be 2, 3, 4, 5, or 6 doses administered at q6w intervals. In other embodiments, the "induction phase" can be 2, 3, 4, 5, or 6 doses administered once every 4 weeks (q4w intervals).

[0036] In certain embodiments, disease activity assessments ("DAA") are performed at all scheduled treatment visits. In one embodiment, patients are reassigned to a q6w or q12w dosing regimen based on the presence of disease activity as determined by the treatment provider, for example, new or worsening retinal neovascularization, retinal neovascular reperfusion, an increase in ETDRS DRSS score (e.g., an increase of 2 or more steps in DR disease activity), loss of peripheral vision, and / or the onset of a complication affecting vision, compared to any previous assessment.

[0037] At the week of assessment, the patient may be currently receiving, for example, a 6-week, 12-week, or 24-week interval regimen, and the assessment may therefore determine whether the patient should continue with the current interval or switch to a different interval.

[0038] In one embodiment, the VEGF antagonist used in the methods of the invention is brolucizumab and is administered as an intravitreal injection at a dose of 1, 2, 3, 4, 5, or 6 mg (eg, 6 mg / 0.05 mL).

[0039] The evaluations described herein preferably include one or more of the following tests to assess the activity of a VEGF antagonist (e.g., brolucizumab) on visual function, retinal structure, and leakage. Best corrected visual acuity at 4 meters using an ETDRS-like chart ETDRS DRSS score based on 7-field stereo color fundus photography (CFP) Anatomical retinal assessment by optical coherence tomography (OCT), standard or wide-field fluorescein angiography (FA), OCT angiography, and / or wide-field CFP / FA Peripheral vision assessed by perimetry Contrast Sensitivity

[0040] Visual acuity can be assessed using best correction (BCVA) determined from protocol refraction. BCVA measurements can be taken in a sitting position using a visual acuity chart such as the ETDRS.

[0041] Optical coherence tomography (OCT), color fundus photography, and fluorescein angiography can be evaluated according to methods known to those skilled in the art.

[0042] Further criteria for assessing disease activity include, but are not limited to, changes in central retinal thickness (CST). CST is the average thickness of a 1 mm circular area centered on the fovea, measured from the retinal pigment epithelium (RPE) to the internal limiting membrane (ILM). CST can be measured, for example, using spectral domain optical coherence tomography (SD-OCT).

[0043] The means for performing the above tests are well understood and commonly used by those of skill in the art.

[0044] Disease activity is assessed for clinically significant improvement in BCVA, reduction in central retinal thickness (CST), reduction in fluid accumulation (e.g., retinal fluid), and / or reduction in the severity of diabetic retinopathy. If disease activity worsens (e.g., a letter decrease as measured by BCVA, an increase in CST, an increase in fluid accumulation, and / or an increase in the severity of diabetic retinopathy compared to the patient's baseline record or any previous assessment), more frequent dosing intervals are prescribed thereafter. If improvement in disease activity is observed, less frequent dosing intervals are prescribed. If there is no worsening or improvement in disease activity (i.e., the patient's disease is stable), the dosing interval is maintained or extended (less frequent). The fluid measured in the eye can be intraretinal fluid and / or subretinal fluid.

[0045] Assessment of disease activity status can be based on, for example, acute changes (e.g., a decrease in measurement compared to a previous assessment, such as a baseline assessment) in the severity of diabetic retinopathy (e.g., retinal neovascularization) based on ophthalmoscopy, standard or wide-field color fundus photography and / or standard or wide-field fluorescein angiography (FA) and / or OCT angiography, BCVA, ETDRS DRSS score based on 7-field stereo color fundus photography (CFP), anatomical retinal assessment by optical coherence tomography (OCT), peripheral visual field assessed by perimetry, and / or contrast sensitivity. Guidance can then be based, for example, on BCVA regression due to disease activity compared to a previous assessment. It should be understood that the treating clinician can make a decision based on clinical opinion, which can include more than just visual acuity criteria. Disease activity assessment can include both visual acuity and anatomical criteria. In one embodiment, disease activity is assessed when the following are observed: new or worsening retinal neovascularization, reperfusion of retinal neovascularization, an increase in ETDRS DRSS score (e.g., an increase of 2 or more steps in DR disease activity), loss of peripheral vision, and / or the onset of a complication affecting vision compared to any previous assessment.

[0046] In one embodiment, disease activity assessment to establish the patient's disease status is performed at baseline (week 0; first treatment). Disease activity assessment (DAA) during a treatment regimen is at the discretion of the assessor (e.g., treatment provider) and is based on changes in visual, anatomical, morphological, and clinical parameters relative to the patient's baseline (week 0) disease status.

[0047] In certain other embodiments, during the maintenance phase, the VEGF antagonist is administered as needed, i.e., on a case-by-case basis (PRN), at the discretion of the treatment provider (e.g., a physician or other qualified healthcare professional) based on visual and / or anatomical results to determine disease activity.

[0048] Anti-VEGF antagonists In certain embodiments, the VEGF antagonist used in the methods of the present invention is an anti-VEGF antibody, particularly an anti-VEGF antibody described in WO 2009 / 155724, the entire contents of which are hereby incorporated by reference.

[0049] In one embodiment, the anti-VEGF antibody used in the methods of the invention comprises a variable heavy chain having the sequence set forth in SEQ ID NO:1 and a variable light chain having the sequence set forth in SEQ ID NO:2. VH: SEQ ID NO: 1 EVQLVESGGGLVQPGGSLRLSCTASGFSLTDYYYMTWVRQAPGKGLEWVGFIDPDDDPYYATWAKGRFTISRDNSKNTLYLQMNSLRAEDTAVYYCAGGDHNSGWGLDIWGQGTLVTVSS VL: SEQ ID NO: 2 EIVMTQSPSTLSASVGDRVIITCQASEIIHSWLAWYQQKPGKAPKLLIYLASTLASGVPSRFSGSGSGAEFTLTISSLQPDDFATYYCQNVYLASTNGANFGQGTKLTVLG

[0050] In another embodiment, the anti-VEGF antibody used in the methods of the invention comprises the sequence set forth in SEQ ID NO:3. [ka]

[0051] In a preferred embodiment, the anti-VEGF antibody used in the methods of the invention (e.g., methods for treating DR or PDR or preventing progression of nPDR to PDR) is brolucizumab (comprising the sequence of SEQ ID NO: 3). The sequence of brolucizumab is set forth in SEQ ID NO: 4. The methionine from the start codon in the expression vector will be present in the final protein if not cleaved post-translationally, as follows: [ka]

[0052] In another embodiment, the anti-VEGF antibody used in the methods of the invention comprises three light chain CDRs (CDRL1, CDRL2, and CDRL3) and three heavy chain CDRs (CDRH1, CDRH2, CDRH3), as follows: [ka]

[0053] Brolucizumab is a humanized single-chain Fv (scFv) antibody fragment inhibitor of VEGF with a molecular weight of approximately 26 kDa. RTH258 is an inhibitor of VEGF-A, acting by binding to the receptor binding site of the VEGF-A molecule, thereby preventing VEGF-A from interacting with its receptors VEGFR1 and VEGFR2 on the surface of endothelial cells. Increased levels of signaling through the VEGF pathway are associated with pathological ocular angiogenesis and retinal edema. Inhibition of the VEGF pathway has been shown to inhibit the growth of neovascular lesions and resolve retinal edema in patients with nAMD.

[0054] Pharmaceutical preparations In one aspect, the methods of the invention involve the use of a pharmaceutical formulation comprising an anti-VEGF antibody. The term "pharmaceutical formulation" refers to a preparation that is in a form that allows the biological activity of the antibody or antibody derivative to be effectively manifested and that does not contain additional components that are toxic to the subject to which the formulation is administered. A "pharmaceutically acceptable" excipient (vehicle, additive) is an excipient that can be suitably administered to a mammalian subject to provide an effective dose of the active ingredient employed.

[0055] A "stable" formulation is one in which a therapeutic agent, e.g., an anti-VEGF antibody or antibody derivative thereof, essentially retains its physical stability and / or chemical stability and / or biological activity upon storage. Various analytical techniques for measuring protein stability are available in the art and are reviewed, for example, in Peptide and Protein Drug Delivery, 247-301, Vincent Lee Ed., Marcel Dekker, Inc., New York, NY, Pub. (1991) and Jones, A. Adv. Drug Delivery Rev. 10:29-90 (1993). Stability can be measured for a selected time and at a selected temperature. Preferably, the formulation is stable for at least one week at room temperature (about 30°C) or 40°C and / or for at least three months to two years at about 2-8°C. Furthermore, the formulation is preferably stable after freezing (e.g., to -70°C) and thawing the formulation.

[0056] An antibody or antibody derivative "retains its physical stability" in a pharmaceutical formulation if it meets established release specifications for aggregation, degradation, precipitation, and / or denaturation as measured upon visual examination of color and / or clarity, or by UV light scattering, or by size exclusion chromatography or other suitable art-recognized method.

[0057] An antibody or antibody derivative "retains its chemical stability" in a pharmaceutical formulation if the chemical stability over a given time period is such that the protein is considered to still retain its biological activity, as defined below. Chemical stability can be assessed by detecting and quantifying chemically altered forms of the protein. Chemical alterations may include size changes (e.g., clipping), which can be determined, for example, using size exclusion chromatography, SDS-PAGE, and / or matrix-assisted laser desorption / ionization / time-of-flight mass spectrometry (MALDI / TOF MS). Other types of chemical alterations include charge changes (e.g., resulting from deamidation), which can be determined, for example, by ion exchange chromatography.

[0058] An antibody or antibody derivative "retains its biological activity" in a pharmaceutical formulation if the biological activity of the antibody over a given time period, as determined, for example, in an antigen binding assay, is within about 10% (within the error of the assay) of the biological activity exhibited when the pharmaceutical formulation was prepared. Other "biological activity" assays for antibodies are described in more detail herein below.

[0059] By "isotonic" it is meant that the formulation of interest has essentially the same osmotic pressure as human blood. An isotonic formulation will generally have an osmotic pressure of about 250-350 mOsm. Isotonicity can be measured, for example, using a vapor pressure or ice-freezing type osmometer.

[0060] A "polyol" is a substance containing multiple hydroxyl groups, including sugars (reducing and non-reducing sugars), sugar alcohols, and sugar acids. Preferred polyols herein have a molecular weight of less than about 600 kD (e.g., in the range of about 120 to about 400 kD). A "reducing sugar" is a reducing sugar containing a hemiacetal group capable of reducing metal ions or covalently reacting with lysine and other amino groups in proteins, while a "non-reducing sugar" is a non-reducing sugar that does not possess these properties of a reducing sugar. Examples of reducing sugars are fructose, mannose, maltose, lactose, arabinose, xylose, ribose, rhamnose, galactose, and glucose. Non-reducing sugars include sucrose, trehalose, sorbose, melezitose, and raffinose. Mannitol, xylitol, erythritol, threitol, sorbitol, and glycerol are examples of sugar alcohols. With regard to sugar acids, these include L-gluconate and its metal salts. If it is desired that the formulation be freeze-thaw stable, the polyol is preferably one that does not crystallize at freezing temperatures (e.g., −20° C.) such that the antibody in the formulation would be destabilized. Non-reducing sugars such as sucrose and trehalose are preferred polyols herein, with trehalose being preferred over sucrose due to trehalose's superior solution stability.

[0061] As used herein, "buffer" refers to a buffered solution that resists changes in pH through the action of its acid-base conjugate components. Buffers of the present invention have a pH ranging from about 4.5 to about 8.0, preferably from about 5.5 to about 7. Examples of buffers that control the pH within this range include acetate (e.g., sodium acetate), succinate (e.g., sodium succinate), gluconate, histidine, citrate, and other organic acid buffers. If a freeze-thaw stable formulation is desired, the buffer is preferably not phosphate.

[0062] In the pharmacological sense, in the context of the present invention, a "therapeutically effective amount" of a therapeutic agent, e.g., an anti-VEGF antibody or antibody derivative, refers to a therapeutically effective amount in which the antibody or antibody derivative is effective in the prevention or treatment of a disorder, including chronic and acute disorders or diseases, including pathological conditions that predispose a mammal to the disorder in question.

[0063] A "preservative" is a compound that can be included in a formulation to substantially reduce bacterial activity therein, thus facilitating, for example, the production of a multi-purpose formulation. Examples of possible preservatives include octadecyldimethylbenzyl ammonium chloride, hexamethonium chloride, benzalkonium chloride (a mixture of alkylbenzyldimethylammonium chlorides in which the alkyl groups are long-chain compounds), and benzethonium chloride. Other types of preservatives include aromatic alcohols such as phenol, butyl, and benzyl alcohol, alkyl parabens such as methyl or propyl paraben, catechol, resorcinol, cyclohexanol, 3-pentanol, and m-cresol. The most preferred preservative herein is benzyl alcohol.

[0064] Pharmaceutical compositions used in the present invention comprise a VEGF antagonist, preferably an anti-VEGF antibody (e.g., an anti-VEGF antibody comprising the variable light chain sequence of SEQ ID NO: 1 and the variable heavy chain sequence of SEQ ID NO: 2, such as brolucizumab), together with at least one physiologically acceptable carrier or excipient. Pharmaceutical compositions may include, for example, one or more of water, buffer (e.g., neutral buffered saline or phosphate buffered saline), ethanol, mineral oil, vegetable oil, dimethyl sulfoxide, carbohydrate (e.g., glucose, mannose, sucrose, or dextran), mannitol, protein, adjuvant, polypeptide or amino acid such as glycine, antioxidant, chelating agent such as EDTA or glutathione, and / or preservative. As noted above, other active ingredients may (but need not) be included in the pharmaceutical compositions provided herein.

[0065] Carriers are substances that may be associated with an antibody or antibody derivative prior to administration to a patient, often for the purpose of controlling the stability or bioavailability of the compound. Carriers for use in such formulations are generally biocompatible and may also be biodegradable. Carriers include, for example, serum albumin (e.g., human or bovine), ovalbumin, peptides, polylysine, and monovalent or polyvalent molecules such as polysaccharides and polyamidoamines, such as aminodextran. Carriers also include solid support materials, such as beads and microparticles comprising polylactic acid, polyglycolic acid, poly(lactide-co-glycolide), polyacrylic acid, latex, starch, cellulose, or dextran. Carriers may carry compounds in a variety of ways, including covalent bonding (directly or via a linker group), noncovalent interactions, or admixture.

[0066] Pharmaceutical compositions may be formulated for any suitable method of administration, including, for example, topical, intraocular, oral, nasal, rectal, or parenteral administration. In some embodiments, compositions in a form suitable for intraocular injection, such as intravitreal injection, are preferred. Other forms include, for example, pills, tablets, troches, lozenges, aqueous or oily suspensions, dispersible powders or granules, emulsions, hard or soft capsules, or syrups or elixirs. In yet other embodiments, the compositions provided herein may be formulated as a lyophilizate. As used herein, the term parenteral includes subcutaneous, intradermal, intravascular (e.g., intravenous), intramuscular, spinal, intracranial, intrathecal, and intraperitoneal injections, as well as any similar injection or infusion technique.

[0067] Pharmaceutical compositions may be prepared as sterile injectable aqueous or oleaginous suspensions in which the active agent (i.e., VEGF antagonist) is suspended or dissolved in the vehicle, depending on the vehicle and concentration used. Such compositions may be formulated according to known techniques using suitable dispersing agents, wetting agents, and / or suspending agents, such as those mentioned above. Among the acceptable vehicles and solvents that may be used are water, 1,3-butanediol, Ringer's solution, and isotonic saline. Additionally, sterile, fixed oils may be used as a solvent or suspending medium. For this purpose, any bland, fixed oil may be used, including synthetic mono- or diglycerides. Moreover, fatty acids such as oleic acid may be used in the preparation of injectable compositions, and adjuvants such as local anesthetics, preservatives, and / or buffering agents may be dissolved in the vehicle.

[0068] dosage The dosage used in the methods of the present invention is based on the specific disease or condition being treated. The term "therapeutically effective dose" is defined as an amount sufficient to achieve or at least partially achieve the desired effect (e.g., partial or complete regression of retinal neovascularization, a change in BCVA of >1, >2, >3, >4, or >5 letters, or a DRSS score of <61). A therapeutically effective dose need only result in a gradual change in the symptoms or condition associated with the disease. A therapeutically effective dose need not completely cure the disease or completely eliminate the symptoms. Preferably, a therapeutically effective dose can at least partially prevent the disease and / or its complications in patients already suffering from the disease. Amounts effective for this use will depend on the severity of the disorder being treated and the general condition of the patient's own immune system.

[0069] Dosages can be readily determined by a physician of ordinary skill in treating diseases or conditions using known dose-adjustment techniques. The therapeutically effective amount of a VEGF antagonist used in the methods of the present invention is determined, for example, by taking into account the desired dosage and mode of administration. Typically, therapeutically effective compositions are administered at doses ranging from 0.001 mg / ml to about 200 mg / ml per dose. Preferably, the dose used in the methods of the present invention is about 60 mg / ml to about 120 mg / ml (e.g., the dose is 60, 70, 80, 90, 100, 110, or 120 mg / ml). In a preferred embodiment, the dose of an anti-VEGF antibody used in the methods of the present invention (e.g., a method for treating DR or PDR or preventing the progression of nPDR to PDR) is 60 mg / ml or 120 mg / ml.

[0070] In certain embodiments, the dose is administered directly to the patient's eye. In one embodiment, the dose per eye is at least about 0.5 mg to no more than about 6 mg. Preferred doses per eye include about 0.5 mg, 0.6 mg, 0.7 mg, 0.8 mg, 0.9 mg, 1.0 mg, 1.2 mg, 1.4 mg, 1.6 mg, 1.8 mg, 2.0 mg, 2.5 mg, 3.0 mg, 3.5 mg, 4.0 mg, 4.5 mg, 5.0 mg, 5.5 mg, and 6.0 mg. In one embodiment, the dose per eye is at least about 3 mg to no more than about 6 mg, particularly about 3 mg or about 6 mg. The dose can be administered in various volumes suitable for ophthalmic administration, such as 50 μl or 100 μl, including 3 mg / 50 μl or 6 mg / 50 μl. Smaller volumes, including 20 μl or less, such as about 20 μl, about 10 μl, or about 8.0 μl, can also be used. In some embodiments, a dose of 2.4 mg / 20 μl, 1.2 mg / 10 μl, or 1 mg / 8.0 μl (e.g., 1 mg / 8.3 μl) is delivered to a patient's eye to treat or ameliorate one or more of the diseases and disorders described above. Delivery can be, for example, by intravitreal injection.

[0071] As used herein, the term "about" is inclusive of and describes the value or parameter itself. For example, "about x" is inclusive of and describes "x" itself. As used herein, the term "about," when used in connection with a measurement or to modify a value, unit, constant, or set of values, refers to a variation of ±1-10% in addition to including the value or parameter itself. In some embodiments, the term "about," when used in connection with a measurement or to modify a value, unit, constant, or set of values, refers to a variation of ±1, ±2, ±3, ±4, ±5, ±6, ±7, ±8, ±9, or ±10%.

[0072] Aqueous formulations of anti-VEGF antibodies used in the methods of the present invention are prepared in a pH buffer. Preferably, the buffer for such aqueous formulations has a pH in the range of about 4.5 to about 8.0, preferably about 5.5 to about 7.0, and most preferably about 6.75. In one embodiment, the pH of the aqueous pharmaceutical composition of the present invention is about 7.0 to 7.5, or about 7.0 to 7.4, about 7.0 to 7.3, about 7.0 to 7.2, about 7.1 to 7.6, about 7.2 to 7.6, about 7.3 to 7.6, or about 7.4 to 7.6. In one embodiment, the aqueous pharmaceutical composition of the present invention has a pH of about 7.0, about 7.1, about 7.2, about 7.3, about 7.4, about 7.5, or about 7.6. In a preferred embodiment, the aqueous pharmaceutical composition has a pH of ≥7.0. In a preferred embodiment, the aqueous pharmaceutical composition has a pH of about 7.2. In another preferred embodiment, the aqueous pharmaceutical composition has a pH of about 7.4. In another preferred embodiment, the aqueous pharmaceutical composition has a pH of about 7.6. Examples of buffers that control the pH within this range include acetic acid (e.g., sodium acetate), succinic acid (e.g., sodium succinate), gluconic acid, histidine, citric acid, and other organic acid buffers. The buffer concentration can be about 1 mM to about 50 mM, preferably about 5 mM to about 30 mM, depending, for example, on the buffer and the desired isotonicity of the formulation.

[0073] Polyols, which act as tonicifiers, may be used to stabilize antibodies in aqueous formulations. In a preferred embodiment, the polyol is a non-reducing sugar such as sucrose or trehalose. If desired, the polyol is added to the formulation in an amount that may vary based on the desired tonicity of the formulation. Preferably, the aqueous formulation is isotonic, in which case a suitable concentration of the polyol in the formulation is, for example, in the range of about 1% to about 15% w / v, preferably about 2% to about 10% w / v. However, hypertonic or hypotonic formulations may also be suitable. The amount of polyol added may also vary based on the molecular weight of the polyol. For example, a smaller amount of a monosaccharide (e.g., mannitol) may be added compared to a disaccharide (e.g., trehalose).

[0074] A surfactant may also be added to the aqueous antibody formulation. Exemplary surfactants include non-ionic surfactants such as polysorbates (e.g., polysorbate 20, 80, etc.) or poloxamers (e.g., poloxamer 188). The amount of surfactant added is such that it reduces aggregation of the formulated antibody / antibody derivative and / or minimizes particle formation and / or reduces adsorption in the formulation. For example, the surfactant may be present in the formulation in an amount of about 0.001% to about 0.5%, preferably about 0.005% to about 0.2%, and most preferably about 0.01% to about 0.1%.

[0075] In one embodiment, the aqueous antibody formulation used in the methods of the invention is essentially free of one or more preservatives, such as benzyl alcohol, phenol, m-cresol, chlorobutanol, and benzethonium Cl. In another embodiment, a preservative may be included in the formulation, particularly if the formulation is a multidose formulation. The concentration of the preservative may range from about 0.1% to about 2%, most preferably from about 0.5% to about 1%. One or more other pharmaceutically acceptable carriers, excipients, or stabilizers, such as those described in Remington's Pharmaceutical Sciences 21st edition, Osol, A. Ed. (2006), may also be included in the formulation, provided that they do not adversely affect the desired characteristics of the formulation. Acceptable carriers, excipients, or stabilizers are nontoxic to recipients at the dosages and concentrations employed, and further include buffers, cosolvents, antioxidants including ascorbic acid and methionine, chelating agents such as EDTA, metal complexes (e.g., Zn-protein complexes), biodegradable polymers such as polyesters, and / or counterions that form salts such as sodium.

[0076] The formulations to be used for in vivo administration must be sterile, which is readily accomplished by filtration through sterile filtration membranes, prior to, or following, preparation of the formulation.

[0077] In one embodiment, the VEGF antagonist is administered to the eye of the mammal that needs treatment according to known methods for ocular delivery.Preferably, the mammal is human, and the VEGF antagonist is an anti-VEGF antibody (preferably brolucizumab), and the antibody is administered directly to the eye.Administering to the patient can be achieved, for example, by intravitreal injection.

[0078] The VEGF antagonists in the methods of the present invention can be administered as the sole treatment or in conjunction with other agents or therapies useful in treating the condition in question.

[0079] A preferred formulation of brolucizumab for intravitreal injection contains about 4.5% to 11% (w / v) sucrose, 5 to 20 mM sodium citrate, and 0.001% to 0.05% (w / v) polysorbate 80, with a pH of about 7.0 to about 7.4. One such formulation contains 5.9% (w / v) sucrose, 10 mM sodium citrate, 0.02% (w / v) polysorbate 80, a pH of 7.2, and 6 mg of brolucizumab. Another such formulation contains 6.4% (w / v) or 5.8% sucrose, 12 mM or 10 mM sodium citrate, 0.02% (w / v) polysorbate 80, a pH of 7.2, and 3 mg of brolucizumab. Preferred concentrations of brolucizumab are about 120 mg / ml and about 60 mg / ml. Doses can be delivered, for example, at concentrations of 6 mg / 50 μL and 3 mg / 50 μL.

[0080] kit The present invention also provides kits that include a medication container (e.g., a vial or prefilled syringe) containing a VEGF antagonist drug (e.g., brolucizumab) and instructions for using the medication to treat a patient diagnosed with PDR. In one embodiment, the instructions direct that the medication be administered to the patient's eye as needed as follows: three doses of about 6 mg of a VEGF antagonist administered at six-week intervals, followed by additional doses of about 6 mg of the VEGF antagonist every 12 weeks. In some embodiments, the instructions direct that the first three doses be administered in an "induction phase" and additional doses be administered during a "maintenance phase."

[0081] In one embodiment, the kit includes one or more 6 mg doses of brolucizumab, each dose provided in a single-use vial containing sufficient brolucizumab to deliver a 6 mg dose when a volume of 0.05 mL is administered, or in a pre-filled syringe containing 6 mg of brolucizumab.

[0082] In one embodiment, the instructions further instruct the treatment provider (e.g., a physician or other qualified healthcare professional) to adjust the dosing interval from once every 12 weeks to once every 6 weeks during the maintenance phase if disease activity is observed in the treated eye.

[0083] In another embodiment, the instructions further instruct the treatment provider (e.g., a physician or other qualified healthcare professional) to extend the dosing interval to 6 weeks at a time, from once every 12 weeks to once every 24 weeks during the maintenance phase if no disease activity is observed in the treated eye.

[0084] In yet another embodiment, the instructions further instruct that the VEGF antagonist be administered as needed, i.e., on a case-by-case basis (PRN), during the maintenance phase, at the discretion of the treatment provider (e.g., a physician or other qualified healthcare professional) based on visual and / or anatomical results to determine disease activity.

[0085] The following examples are included to demonstrate preferred embodiments of the invention. It should be appreciated by those of skill in the art that the techniques disclosed in the examples which follow represent techniques discovered by the inventors to function well in the practice of the invention, and therefore can be considered to constitute preferred modes for its practice. However, those of skill in the art should, in light of the present disclosure, appreciate that many changes can be made in the specific embodiments which are disclosed and still obtain a like or similar result without departing from the spirit and scope of the invention. [Example]

[0086] The clinical trial was specifically designed to determine the efficacy and safety of brolucizumab compared with panretinal laser photocoagulation (PRP) in patients with proliferative diabetic retinopathy (PDR).

[0087] The study will be a 96-week, two-arm, randomized, single-blind, multicenter, active-controlled, non-inferiority trial in patients with proliferative diabetic retinopathy (PDR).

[0088] Consenting patients will undergo a screening assessment to determine their eligibility based on certain inclusion and exclusion criteria. Subjects who meet all inclusion criteria and none of the exclusion criteria will be randomized 1:1 to: Brolucizumab 6 mg: 3x q6w induction, then q12w maintenance until week 90, with optional extension of treatment interval by 6 weeks per dose from week 48 onwards, up to a maximum of 24 weeks. PRP: 1-3 initial treatments up to 12 weeks, then additional PRP treatments as needed up to 90 weeks.

[0089] Patients will visit the clinic every 6 weeks throughout the study, regardless of whether they are receiving treatment or not.

[0090] Brolucizumab group: During the induction phase, treatment with brolucizumab will be administered every 6 weeks for three consecutive injections (day 0 (baseline), week 6, and week 12).

[0091] Treatment intervals during the maintenance phase will be as follows: Patients will receive q12w injections during the maintenance phase, i.e., at weeks 24, 36, and 48, during the first year of treatment. During the maintenance phase, additional visits (e.g., week 30) are scheduled for disease monitoring, not for treatment administration. However, additional injections may be administered at these visits at the discretion of the treatment provider only if the disease worsens compared to the previous visit, e.g., there are new or expanding retinal neovascularization. If retinal neovascularization is stable, no injections should be administered. Week 48 and beyond Treatment intervals may be extended by 6 weeks at a time up to a maximum of 24 weeks, at the discretion of the provider, based on the provider's assessment of disease activity and whether the disease is stable or regressing, e.g., whether retinal neovascularization is regressing or stable, since the previous injection visit. Thus, at week 48, the provider may choose to extend the treatment interval from 12 weeks to 18 weeks, and may treat the subject eye at week 66 if the disease has not worsened between weeks 36 and 48 and there were no injections at week 42. At week 66, the provider may choose to further extend the treatment interval from 18 weeks to 24 weeks, and may treat the subject eye at week 90 if the disease has not worsened between weeks 48 and 66 and there were no injections at weeks 54 and 60. If, in the provider's opinion based on disease activity assessment, the patient requires more frequent treatment, the provider may decide to switch back to q12w injections.

[0092] Brolucizumab is provided in a single-use sterile glass vial or in a pre-filled syringe (PFS) containing sufficient brolucizumab to deliver a 6 mg dose when a volume of 0.05 mL is administered.

[0093] Brolucizumab will be administered to the diseased eye on Day 0 (baseline). If evaluation and treatment occur on the same day, treatment must occur after completing the efficacy evaluations described below.

[0094] PRP group: Patients in the PRP group received the first treatment at baseline. Treatment may be divided into 2-3 doses up to week 12, according to local clinical practice. If the disease worsens, additional PRP may be administered in the study eye at the investigator's discretion, according to local practice.

[0095] Selection Criteria Subjects eligible for inclusion in this study must meet all of the following criteria: 1. A signed consent form must be obtained prior to participation in this study. 2. Patient is ≥ 18 years of age at screening. 3. Participants cooperate adequately with appropriate fundus photographs and retinal images. 4. Patients have been diagnosed with diabetes mellitus (DM) type 1 or 2 and HbA1c ≦12% at screening. 5. If medication for DM is being used, medication for the management of diabetes must have been stable within 3 months prior to randomization and is expected to remain stable throughout the study as medically tolerated. test eye 6. PDR assessed by the investigator using standard or wide-field CFP, FA, with no evidence of prior PRP, and in the opinion of the investigator, requires treatment with anti-VEGF or PRP. 7. BCVA ≥ ETDRS letter count 34 (Snellen visual acuity chart 20 / 200).

[0096] Exclusion criteria Subjects who meet any of the following criteria are not eligible for inclusion in this study. Eye conditions 1. In the opinion of the investigator, any of the following concomitant conditions or ocular disorders in the study eye at screening or baseline: a. May interfere with the functional or structural response to treatment with the test drug; or b. may confuse the interpretation of test results or c. May impair vision or d. Requiring a planned medical or surgical intervention during the initial 54-week study period. 2. Presence of center-involved diabetic macular edema in the study eye at screening or baseline as assessed by the investigator. 3. Any active intraocular or periocular infection or active intraocular inflammation (e.g., infectious conjunctivitis, keratitis, scleritis, infectious blepharitis, uveitis) in the study eye at screening or baseline. 4. Uncontrolled glaucoma in the study eye, defined as intraocular pressure (IOP) >25 mmHg on medical therapy at screening or baseline, or according to the investigator's opinion. 5. Moderate or dense preretinal or vitreous hemorrhage that interferes with clear visualization of the macula and / or optic disc or interferes with PRP treatment in the study eye at baseline. 6. Fibrotic vascular proliferation or tractional retinal detachment in the posterior pole of the subject eye. 7. Iris or anterior chamber angle neovascularization or neovascular glaucoma in the study eye. 8. Presence of amblyopia, amaurosis, or ocular disorder in the fellow eye with BCVA <20 / 200 at screening (except due to conditions where VA may be improved by surgery, e.g., cataract). Ocular treatment in the test eye 9. PRP at any time prior to baseline. 10. Intravitreal anti-VEGF treatment within 6 months prior to baseline. 11. Need for vitreoretinal surgery at any time prior to baseline or anticipated need for vitreoretinal surgery within the next 12 months. 12. Macular laser treatment within 3 months prior to baseline. 13. Treatment with fluocinolone acetonide intravitreal implant (e.g., ILUVIEN® or RETISERT®) at any time prior to baseline. Other intraocular corticosteroid treatment within 6 months prior to baseline. 14. Aphakia due to absence of posterior capsule. 15. Need for intraocular surgery within 3 months prior to baseline or anticipated cataract extraction within the next 12 months. General condition and treatment 16. Stroke or myocardial infarction during the 6-month period prior to baseline. 17. End-stage renal disease requiring dialysis or kidney transplant. 18. Uncontrolled blood pressure, defined as a systolic value ≥ 180 mmHg or a diastolic value ≥ 100 mmHg at screening or baseline. (Elevated blood pressure readings should be repeated after 20 minutes. If the repeated readings are elevated, the patient is not eligible to enroll in the study.) 19. Systemic anti-VEGF therapy at any time. 20. Systemic medications known to be toxic to the lens, retina, or optic nerve (e.g., deferoxamine, chloroquine / hydroxychloroquine, tamoxifen, phenothiazines, and ethambutol) used during the 6-month period prior to baseline. 21. History of hypersensitivity to the study drug or any of its excipients or to drugs in a similar class or clinically significant hypersensitivity to fluorescein dye as assessed by the investigator. 22. History of malignancy of any organ system (other than localized basal cell carcinoma of the skin or cervical intraepithelial carcinoma), treated or untreated, within the past 5 years, with or without evidence of local recurrence or metastasis. 23. History of any medical condition (e.g., metabolic dysfunction, physical examination findings, or clinical laboratory findings other than type 1 or 2 diabetes mellitus) that, in the opinion of the investigator, would interfere with scheduled study visits, completion of the study, or safe administration of the investigational drug. 24. Use of any systemic investigational drug within 5 half-lives of baseline or within 30 days / until expected pharmacological effect returns to baseline, whichever is longer; or longer if required by local regulations (observational clinical trials requiring only over-the-counter vitamins, supplements, or foods are not excluded). others 25. Pregnant or nursing (lactating) women, where pregnancy is defined as a woman's state from conception through the end of pregnancy, confirmed by a positive human chorionic gonadotropin (hCG) pregnancy test. 26. Females of childbearing potential, defined as any female who is physiologically capable of becoming pregnant unless using highly effective contraception during study drug administration and for 22 days after stopping the study drug.

[0097] Efficacy (disease activity assessment) The following assessments will be performed to determine the effect of brolucizumab on visual function, diabetic retinopathy status, retinal and vascular structure. Best corrected visual acuity at 4 meters using an ETDRS-like chart ETDRS DRSS score based on 7-field stereo color fundus photography (CFP) Anatomical retinal assessment using SD-OCT, FA, OCT angiography, and wide-field CFP / FA Peripheral vision assessed by perimetry

[0098] All efficacy assessments are performed prior to any administration of treatment.

[0099] eyesight Visual acuity (VA) will be assessed in the study eye at all study visits and in the fellow eye at screening, Week 54, and Week 96 / EOS visits using best correction (BCVA) determined from protocol refraction. BCVA measurements will initially be taken in the sitting position at a 4-meter testing distance using an acuity chart such as the ETDRS. Details of refractive techniques and VA testing, as well as training materials, are provided in the associated manuals. Assessment procedures and rater certification will occur prior to any assessment of study subjects.

[0100] Color fundus photography and fluorescein angiography Seven-field stereo color fundus photography (CFP) will be performed in both eyes at baseline, 54 weeks, and 96 weeks, and in the treated eye at 18 and 72 weeks.

[0101] At sites with applicable facilities, optional wide-field (at least 100 degrees) color fundus photography (WFCFP) should be performed in both eyes at baseline, weeks 54, and 96, and in the treated eye at weeks 18 and 72. If WFCFP images are not taken at baseline, they should not be used at subsequent visits. WFCFP images are not a substitute for 7-field CFP images.

[0102] Standard or wide-field fluorescein angiography (FA) will be performed in the treated eye at the baseline, week 54, and week 96 visits and in the fellow eye at the baseline visit. FA may also be performed at other visits at the discretion of the treatment provider. The model of FA camera used for an individual subject should not be changed for the duration of treatment.

[0103] For screening purposes, FA images taken at a previous routine assessment may be used, as long as the FA is performed within 3 days of the baseline visit.

[0104] The treatment provider will interpret the images according to standard clinical practice and may use any of the CFP, WFCFP, and FA imaging findings to inform his / her treatment decisions.

[0105] Optical coherence tomography Spectral domain optical coherence tomography (SD-OCT) images are obtained and evaluated in both eyes at the baseline, week 54, and week 96 visits, and in the treated eye at all other visits.

[0106] These assessments are performed on-site by a trained technician or provider and should be performed after the BCVA assessment and before any treatment. The provider will review the SD-OCT images to assess the status of macular edema.

[0107] Only SD-OCT equipment may be used (i.e., no time-domain or swept-wavelength OCT). The model of SD-OCT used for an individual subject should not be changed for the duration of treatment.

[0108] Central retinal thickness (CSFT) was measured by SD-OCT. CSFT was determined as the average retinal thickness in a circular area within a 1 mm diameter around the fovea.

[0109] In addition to standard SD-OCT evaluation, wide-field or standard OCT angiography may be performed at each visit in the treated eye, if available. If OCT angiography is not assessed at baseline, it should not be employed at subsequent visits. OCT angiography may be used by treatment providers to supplement the assessment of retinal neovascularization as part of disease activity assessment.

[0110] The treatment provider interprets the OCT images according to clinical practice.

[0111] peripheral vision Visual field testing in the treated eye will be performed using automated perimetry at baseline, weeks 18, 54, 72, and 96. Visual field testing should be performed before treatment if treatment is administered at a clinic visit. Accepted testing methods are full-threshold and the Swedish Interactive Thresholding Algorithm (SITA) standard Humphrey 24-2, 30-2, and 60-4.

[0112] The present invention and its embodiments have been described in detail. However, the scope of the present invention is not intended to be limited to the particular embodiments of any process, manufacture, composition, compound, means, methods, and / or steps described herein. Various modifications, substitutions, and changes can be made to the disclosed components without departing from the spirit and / or essential characteristics of the invention. Accordingly, those skilled in the art will readily recognize from this disclosure that subsequent modifications, substitutions, and / or changes that perform substantially the same function or achieve substantially the same result as the embodiments described herein may be utilized in accordance with such related embodiments of the invention. Accordingly, the following claims are intended to include within their scope such modifications, substitutions, and changes to the process, manufacture, composition, compound, means, methods, and / or steps disclosed herein. The claims should not be construed as limited to the described order or elements, unless specifically stated to that effect. It should be understood that various changes in form and details may be made without departing from the scope of the appended claims.

Claims

1. 1. A pharmaceutical composition comprising a VEGF antagonist for use in a method for treating proliferative diabetic retinopathy (PDR) in a patient, the method comprising: The pharmaceutical composition, wherein the VEGF antagonist consists of the sequence of SEQ ID NO: 3 or SEQ ID NO: 4 and is initially provided in an induction phase, during which the patient receives three individual doses of about 6 mg of the VEGF antagonist, spaced six weeks apart, and then the VEGF antagonist is provided in a maintenance phase, during which the patient receives an additional dose of about 6 mg of the VEGF antagonist once every twelve weeks (q12w regimen).

2. 10. The pharmaceutical composition of claim 1, wherein the method further comprises assessing the patient for PDR disease activity before or after each 12-week dose.

3. 3. The pharmaceutical composition of claim 2, wherein the disease activity is assessed based on checking best corrected visual acuity (BCVA), ETDRS DRSS score, retinal neovascularization status, and peripheral visual field.

4. 4. The pharmaceutical composition of claim 2 or 3, wherein if worsening disease activity is confirmed after 12 weeks of dosing, the patient is switched to once every 6 weeks (q6w regimen) and additional doses are administered once every 6 weeks instead of once every 12 weeks.

5. 5. The pharmaceutical composition of claim 4, wherein worsening disease activity is new or worsening retinal neovascularization, retinal neovascular reperfusion, increased ETDRS DRSS score, loss of peripheral vision, and / or the development of complications affecting vision compared to any previous assessment.

6. 6. The pharmaceutical composition of any one of claims 1 to 5, wherein at any time during the maintenance phase, the dosing interval is extended to 24 weeks if disease activity is improved or stable compared to the previous disease activity assessment.

7. The pharmaceutical composition according to any one of claims 1 to 6, wherein the patient is a human.

8. The pharmaceutical composition of any one of claims 1 to 7, wherein the VEGF antagonist is brolucizumab.

9. The pharmaceutical composition of any one of claims 1 to 8, wherein the VEGF antagonist is administered by intravitreal injection.

10. 10. The pharmaceutical composition of any one of claims 1 to 9, wherein each dose of the VEGF antagonist is administered as a 50 μL intravitreal injection.

11. a) a drug container containing a VEGF antagonist consisting of the sequence of SEQ ID NO: 3 or SEQ ID NO: 4; and b) A kit for treating proliferative diabetic retinopathy (PDR), comprising instructions for using the VEGF antagonist to treat a patient diagnosed with PDR, wherein three doses of about 6 mg of the VEGF antagonist are administered six weeks apart, the final dose being followed by additional individual doses of about 6 mg of the VEGF antagonist at twelve-week intervals.

12. 12. The kit of claim 11, wherein (a) each dose comprises one or more 6 mg doses of brolucizumab provided in a single-use vial containing sufficient brolucizumab to deliver a 6 mg dose when a volume of 0.05 mL is administered or in a pre-filled syringe containing 6 mg of brolucizumab.

13. 13. The kit of claim 11 or 12, wherein the instructions further instruct to adjust the 12-week dosing interval to once every 6 weeks if PDR disease activity is observed in the treated eye.

14. 13. The kit of claim 11 or 12, wherein the instructions further instruct to extend the 12-week dosing interval to 6 weeks at a time, up to once every 24 weeks, if no disease activity is observed in the treated eye.

15. 13. The kit of claim 11 or 12, wherein the instructions further instruct that the VEGF antagonist be administered as needed, at the discretion of a care provider based on visual and / or anatomical results to determine disease activity before or after any 12-week dose.

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