Dasiglucagon for use in the treatment of congenital hyperinsulinism

Abstract

The invention relates to dasiglucagon, a glucagon analogue, or a pharmaceutically acceptable salt or solvate thereof, for the treatment of congenital hyperinsulinism.

Description

[0001] DASIGLUCAGON FOR USE IN THE TREATMENT OF CONGENITAL HYPERINSULINISM

[0002] FIELD OF THE INVENTION

[0003] The present invention relates to glucagon analogues, in particular to dasiglucagon and its medical use. Dasiglucagon has utility in the treatment of hypoglycaemia, e.g., in the treatment of congenital hyperinsulinism (CHI).

[0004] BACKGROUND OF THE INVENTION

[0005] Congenital hyperinsulinism (CHI) is a rare disorder with an estimated incidence ranging from approximately 1:25-50,000 (Banerjee et al.). In CHI, pancreatic p-cells secrete insulin irrespective of blood glucose concentration (Banerjee et al. Yau et al.), which causes persistent and often severe hypoglycaemia in neonates and early childhood and results in compromised neurological outcome (brain damage, seizures and neurodevelopmental impairment) in up to 50% of infants and children.

[0006] CHI can be acquired or genetic, with both forms associated with an adverse impact on neurodevelopment in up to 50% of patients (Arnoux et al.; Radcliffe et al.). Other forms of neonatal hyperinsulinism tend to be transient in nature and are often associated with perinatal stress or maternal gestational diabetes (Banerjee et al.). The genetic forms can be single gene defects with symptoms related predominately to hypoglycaemia secondary to hyperinsulinism, or may occur as part of a syndrome where hypoglycaemia secondary to hyperinsulinism is only one manifestation of the syndrome. To date, a number of genes have been identified that cause hyperinsulinism, with many involved in the insulin secretory pathway (De Cosio et al.). The genetic forms of CHI are generally classified as either focal, diffuse, or atypical according to histology (Banerjee et al.).

[0007] Current treatments for CHI include pharmacotherapy, nutritional support, and surgical management. There is only one drug approved for the treatment of hyperinsulinism, approved in 1977. This drug, diazoxide, a potassium channel activator, has significant side effects and complications, is only effective in less than 50% of patients with genetic forms of hyperinsulinism and is ineffective in those with inactivating mutations in the ATP-sensitive K+channel genes (who represent the largest proportion of patients with known genetic cause (De Cosio et al.)). Several unapproved drugs have been utilised for the treatment of CHI as well including calcium channel blockers, and short and long-acting somatostatin analogues, with observational studies reporting variable success. For many patients, treatment involving a near-total pancreatectomy is required after which there is a 95% risk of developing insulindependent diabetes. Despite treatment with diazoxide, off-label therapies and surgery, many patients continue to have plasma glucose below the normal range for 15-25% of the time, suggesting suboptimal clinical management contributing to the risk of neuroglycopaenia and resultant lifelong neurodisability. Hence, a sizeable proportion of children with CHI do not respond sufficiently to existing pharmacotherapies. Many patients continue to experience hypoglycaemia or require nutritional support such as continuous feeding through a nasogastric or gastric tube to prevent hypoglycaemia. In a proportion of patients with diffuse or atypical CHI, medical and nutritional management is inadequate to ensure satisfactory glycaemic stability. In such cases, subtotal or near-total pancreatectomy needs to be undertaken to reduce the frequency of hypoglycaemia. However, such procedures are complicated by the risk of persistent hypoglycaemia in 40-60% patients (Arya et al. Meissner et al.), the need for pancreatic enzyme replacements, and inevitable progression to insulinrequiring diabetes.

[0008] Human preproglucagon is a 158 amino acid precursor polypeptide that is differentially processed in the tissues to form a number of structurally related proglucagon-derived peptides, including glucagon (Glu or GCG), glucagon-like peptide-1 (GLP-1), glucagon-like peptide-2 (GLP-2), and oxyntomodulin (OXM). These molecules are involved in a wide variety of physiological functions, including glucose homeostasis, insulin secretion, gastric emptying and intestinal growth, as well as regulation of food intake.

[0009] Native glucagon is a 29-amino acid peptide that corresponds to amino acids 53 to 81 of preproglucagon. Glucagon helps maintain the level of glucose in the blood by binding to glucagon receptors on hepatocytes, causing the liver to release glucose - stored in the form of glycogen - through glycogenolysis. As these stores become depleted, glucagon also stimulates the liver to synthesize additional glucose by gluconeogenesis. This glucose is released into the bloodstream, preventing the development of hypoglycaemia.

[0010] Reconstituted glucagon is not approved for use in CHI but has been shown to be effective in the treatment of this disease, in particular for short-term treatment. Glucagon is commonly used after diagnosis to stabilise patients before initiation of other medical or surgical treatments and may be administered as an intravenous infusion or as a repeated subcutaneous injection. Furthermore, glucagon is administered as single subcutaneous doses to treat severe hypoglycaemic episodes. For example, the glycogenolytic effect of glucagon and its ability to increase plasma glucose levels has been confirmed in children with CHI (Salomon-Estebanez et al., Cederblad et al.), with transient administration of glucagon (via intravenous (IV) continuous infusion or as bolus subcutaneous (SC) or intramuscular injections) often used during or after diagnosis to stabilise CHI patients before initiation of other medical or surgical treatments.

[0011] However, native glucagon has relatively low physical and chemical stability per se. Hence, it cannot be used for long-term treatment. Long-term glucagon treatment is thus complicated by the fact that currently available glucagon products are unstable in nature and form fibrils within hours after reconstitution. This fibril formation may lead to infusion set clotting, catheter obstruction and dosing errors that may cause acute severe hypoglycaemia. In a home-care setting, this fibril formation and associated risk of dosing errors carry the risk of hypoglycaemic events, which is a major barrier for using currently marketed glucagon products for long-term treatment of patients with CHI. Hence, while glucagon is used for CHI in a hospital setting, as described above, there are currently no approved glucagon products for long-term (home) use.

[0012] Therefore, there is a need for effective therapy for patients with CHI, in particular for longterm use. SUMMARY OF THE INVENTION

[0013] The present inventors have found that a glucagon analogue, dasiglucagon, or a pharmaceutically acceptable salt or solvate thereof, can be efficiently and safely used in subjects with CHI, in particular for long-term treatments.

[0014] Dasiglucagon is a glucagon analogue under development for the prevention and treatment of hypoglycaemia in patients with CHI. WO 2014 / 016300 describes glucagon analogues, in particular dasiglucagon (compound number 21 or SEQ ID NO.: 22 in WO 2014 / 016300). Dasiglucagon is currently approved as a rescue treatment for severe hypoglycaemia in pediatric and adult patients with diabetes (Zealand Pharma, Dasiglucagon (Zegalogue) US Prescribing Information). Like human glucagon, dasiglucagon comprises 29 amino acids, with seven amino acid substitutions introduced to improve stability in aqueous media, enabling dasiglucagon to be formulated as a ready-to-use aqueous solution deliverable via SC injection or SC infusion (Hovelmann et al.).

[0015] In particular, the present inventors found that dasiglucagon or a pharmaceutically acceptable salt or solvate thereof is particularly effective in certain patient subgroups and in combination or absence of certain standard of care therapies. Additionally, it was found that dasiglucagon was more effective in the treatment of hypoglycaemia than could have been anticipated by previous publications. Finally, the inventors found that dasiglucagon was surprisingly effective in the treatment of nocturnal hypoglycaemia.

[0016] Hence, in one embodiment, the present invention provides dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating CHI. In one embodiment, the method of treating CHI does not comprise the administration of diazoxide. In other embodiments, the method of treating CHI additionally comprises coadministration of at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus to a patient suffering from CHI (a CHI patient). In one embodiment, the CHI patient has a body weight of 5 to <10 kg at the start of the treatment, and in preferred embodiments, the CHI patient has not had a pancreatectomy before the start of the treatment. In one embodiment, the present invention provides dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating CHI, wherein the treatment reduces the time in hypoglycaemia, wherein the time in hypoglycaemia is defined as a glucose level of <70 mg / dL measured by continued glucose monitoring (CGM). In other embodiments, the treatment reduces the rate of hypoglycaemic episodes. The rate of hypoglycaemic episodes is defined as the number of CGM-detected episodes per week. A single CGM-detected hypoglycaemic episode is defined as a glucose level of <70 mg / dL measured by continued glucose monitoring (CGM) for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70 mg / dL) was not reached within this time. A new episode of hypoglycaemia begins when the next CGM values below 70 mg / dL was measured for at least 15 minutes.

[0017] The present invention further provides dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating nocturnal hypoglycaemia in CHI patients.

[0018] In one embodiment, the invention provides dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of preventing nocturnal hypoglycaemia in CHI patients.

[0019] The treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof may be for 4 or 8 weeks. Optionally, treatment with the standard of care is concomitant. In one embodiment, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof is administered at a dose of at least 10 pg / h. The dose may be increased by 10 pg / h every two hours from the start of treatment to a maximum rate of 70 pg / h.

[0020] In one preferred embodiment, the method of treatment is used in paediatric patients, optionally wherein the patients are between 3 months and 12 years of age (both inclusive).

[0021] BRIEF DESCRIPTION OF FIGURES

[0022] Figure 1: Visualisation of the sequence of dasiglucagon (SEQ ID NO.: 1).

[0023] Figure 2: Trial scheme as described in Example 1.

[0024] Figure 3: IV glucose infusion rate (GIR) during Part 1 of Example 1.

[0025] Figure 4: Total carbohydrates (g) during part 1 of Example 1.

[0026] Figure 5: Trial scheme as described in Example 2. Figure 6: CGM percent time in hypolgycaemia <70 mg / dL (%) by treatment group of Example 2.

[0027] Figure 7: CGM-detected hypoglycaemic episode rate (per week) by treatment group of Example 2.

[0028] Figure 8: CGM-detected clinically significant hypoglycaemic episode rate (per week) by treatment group of Example 2.

[0029] Figure 9: Subgroup analysis of efficacy of dasiglucagon for Example 1 showing weighted mean IV glucose infusion rate (GIR) (mg / kg / min) by genetic type - part 1 FAS population.

[0030] Figure 10: Subgroup analysis of efficacy of dasiglucagon for Example 2.

[0031] Figure 11: Subgroup analysis of efficacy of dasiglucagon for Example 2 by age groups - week 2-4 FAS population; continuous glucose monitoring (CGM) percent time <70 mg / dL (3.9 mmol / L).

[0032] Figure 12: Subgroup analysis of efficacy of dasiglucagon for Example 2 by baseline body weight groups- week 2-4 FAS population; continuous glucose monitoring (CGM) percent time <70 mg / dL (3.9 mmol / L).

[0033] Figure 13: Subgroup analysis of efficacy of dasiglucagon for Example 2 by baseline diazoxide use - week 2-4 FAS population; continuous glucose monitoring (CGM) percent time <70 mg / dL (3.9 mmol / L).

[0034] Figure 14: Subgroup analysis of efficacy of dasiglucagon for Example 2 by baseline use of a somatostatin analogue - week 2-4 FAS population; continuous glucose monitoring (CGM) percent time <70 mg / dL (3.9 mmol / L).

[0035] Figure 15: Subgroup analysis of efficacy of dasiglucagon for Example 2 by pancreatectomy at baseline- week 2-4 FAS population; continuous glucose monitoring (CGM) percent time <70 mg / dL (3.9 mmol / L).

[0036] BRIEF DESCRIPTION OF SEQUENCES

[0037] SEQ ID NO. 1: amino acid sequence of Dasiglucagon - HSQGTFTSDYSKYLD-Aib- ARAEEFVKWLEST - which corresponds to SEQ ID NO: 22 in WO 2014 / 016300, Hy- HSQGTFTSDYSKYLD-Aib-ARAEEFVKWLEST-OH. A "Hy-" moiety at the / V-terminus of the sequence in question indicates a hydrogen atom, while an "-OH" moiety at the C-terminus of the sequence indicates a hydroxy group. "Aib" stands for 2-methylalanine, also known as alpha-aminoisobutyricacid.

[0038] DETAILED DESCRIPTION

[0039] Definitions and abbreviations

[0040] All terms as used herein, unless otherwise stated, shall be understood in their ordinary meaning as known in the art. Other more specific definitions for certain terms as used in the present application are as set forth below and are intended to apply uniformly throughout the description and claims unless an otherwise expressly set out definition provides a broader definition.

[0041] Throughout the description and claims the word "comprise" and variations of the word, are not intended to exclude other technical features, additives, components, or steps. Furthermore, the word "comprise" encompasses the case of "consisting of". Additional objects, advantages and features of the invention will become apparent to those skilled in the art upon examination of the description or may be learned by practice of the invention.

[0042] Furthermore, the present invention covers all possible combinations of particular aspects and embodiments described herein.

[0043] In this specification and the appended claims, the singular forms "a", "an" and "the" include plural referents unless the context clearly dictates otherwise.

[0044] If the term "about" as used in connection with a numerical value throughout the specification and the claims denotes an interval of accuracy, familiar and acceptable to a person skilled in the art. In general, such interval of accuracy is ± 15 %.

[0045] Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this disclosure is related. For example, the Concise Dictionary of Biomedicine and Molecular Biology, Juo, Pei- Show, 2nd ed., 2002, CRC Press; The Dictionary of Cell and Molecular Biology, 3rd ed., 1999, Academic Press; and the Oxford Dictionary Of Biochemistry And Molecular Biology, Revised, 2000, Oxford University Press, provide one of skill with a general dictionary of many of the terms used in this disclosure. Units, prefixes, and symbols are denoted in their "Systeme International de Unites" (SI) accepted form.

[0046] Throughout the present specification, the conventional one-letter and three-letter codes for naturally occurring amino acids are used. Unless otherwise indicated, reference is made to the L-isomeric forms of the amino acids referred to herein.

[0047] Numeric ranges are inclusive of the numbers defining the range.

[0048] The headings provided herein are not limitations of the various aspects or embodiments of the disclosure.

[0049] The following abbreviations are used throughout the description:

[0050] Table 1. Abbreviations used in the description

[0051] Measurement of hypoglycaemia

[0052] Blood glucose levels

[0053] The primary symptom of CHI is hypoglycaemia. Hypoglycaemia, also referred to as low blood sugar or low blood glucose, is a fall in blood sugar to levels below normal, typically below 70 mg / dL (3.9 mmol / L). Blood sugar levels are generally maintained between 70 and 110 mg / dL (3.9-6.1 mmol / L). Although 70 mg / dL (3.9 mmol / L) is the lower limit of normal glucose, symptoms of hypoglycaemia usually do not occur until 54 mg / dL (3.0 mmol / L) or lower.

[0054] Therefore, in the context of the present invention, hypoglycaemia is defined as a blood glucose level of below 70 mg / dL (3.9 mmol / L). Clinically significant hypoglycaemia is defined as a blood glucose level of 54 mg / dL (3.0 mmol / L) or lower.

[0055] The skilled person is aware that different units can be used to measure the blood sugar level.

[0056] Indicators

[0057] In the context of the present invention, a variety of approaches to determine the extent of hypoglycaemia may be used.

[0058] For example, one may evaluate the percent time in hypoglycaemia or clinically significant hypoglycaemia.

[0059] In some embodiments of the present invention, the "percent time in hypoglycaemia" is defined as the percent time with a glucose level of <70 mg / dL, for example measured with the Continuous Glucose Monitoring method, see below for further details. Similarly, in some embodiments of the present invention, the "percent time in clinically significant hypoglycaemia" is defined as the percent time with a glucose level of <54 mg / dL, for example measured with the Continuous Glucose Monitoring method, see below forfurther details.

[0060] Additionally, one may evaluate the "rate of hypoglycaemic episodes" or the "rate of clinically significant hypoglycaemic episodes".

[0061] In some embodiments of the present invention, the "rate of hypoglycaemic episodes" is defined as the number of episodes per week, wherein a single hypoglycaemic episode is defined as a glucose level of <70 mg / dL for at least 15 minutes and up until 60 minutes from the start of the episode even if normoglycaemia (>70 mg / dL) was not reached within this time, wherein a new episode of hypoglycaemia begins when the next values below 70 mg / dL are measured for at least 15 minutes.

[0062] Similarly, in some embodiments of the present invention, the "rate of clinically significant hypoglycaemic episodes" is defined as the number of episodes per week, wherein a single clinically significant hypoglycaemic episode is defined as a glucose level of <54 mg / dL for at least 15 minutes and up until 60 minutes from the start of the episode even if normoglycaemia (>70 mg / dL) was not reached within this time, wherein a new episode of clinically significant hypoglycaemia begins when the next values below 54 mg / dL are measured for at least 15 minutes.

[0063] Measurement methods

[0064] A variety of methods to measure glucose levels are known in the art.

[0065] SMPG refers to "Self-Monitored Plasma Glucose". The subject's glucose levels are measured at least three times daily, preferably before main meals, and also in case of suspected hypoglycaemia. Readings are typically collected in the subject's diary. SMPG can be carried out with any suitable glucose meter, for example, the StatStrip Xpress2 manufactured by Nova Biomedical, Waltham, MA, USA. CGM refers to "Continuous Glucose Monitoring". The method is primarily distinguished over SMPG in that it offers a continuous readout of the subject's glucose level instead of discrete values. CGM can be carried out by a variety of suitable glucose meters or continuous glucose monitors, for example, the Dexcom G4 or G6 by Dexcom Inc., San Diego, CA, USA. In a preferred embodiment, in the present description, glucose levels are measured with the CGM method.

[0066] The term "mean", also known as the arithmetic mean or arithmetic average, is a measure of central tendency of a finite set of numbers: specifically, the sum of the values divided by the number of values.

[0067] The term "median" expresses the value separating the higher half from the lower half of a data sample, a population, or a probability distribution. For a data set, it may be thought of as "the middle" value.

[0068] Nocturnal hypoglycaemia

[0069] Many episodes of hypoglycaemia occur at night, specifically during sleep.

[0070] In the context of the present invention, "nocturnal hypoglycaemia" is defined as hypoglycaemia occurring between 10 pm (excluded) and 6 am (excluded).

[0071] More specifically, a typical measure for nocturnal hypoglycaemia in the context of the present invention is the mean number of nocturnal hypoglycaemic events (episodes) / week as described above.

[0072] In the specific context of nocturnal hypoglycaemia, a typical measure is the mean number of nocturnal hypoglycaemic events (episodes) / week with onset between 10 pm (excluded) and 6 am (excluded)). A "single CGM-detected hypoglycaemic episode" is defined as CGM <3.9 mmol / L; 70 mg / dL (or <3.0 mmol / L; 54 mg / dL) for 15 minutes and up until 60 minutes from the start of the episode even if normoglycaemia (>3.9 mmol / L) is not reached within this time. A "new episode of nocturnal hypoglycaemia" is defined as when the next CGM value was below 3.9 mmol / L; 70 mg / dL (or <3.0 mmol / L; 54 mg / dL) for at least 15 min.

[0073] Dasiglucagon

[0074] In the context of the present invention, the term "native glucagon" refers to native human glucagon. Native glucagon is a 29-amino acid peptide that corresponds to amino acids 53 to 81 of preproglucagon. Glucagon helps maintain the level of glucose in the blood by binding to glucagon receptors on hepatocytes, causing the liver to release glucose - stored in the form of glycogen -through glycogenolysis. As these stores become depleted, glucagon also stimulates the liver to synthesize additional glucose by gluconeogenesis. This glucose is released into the bloodstream, preventing the development of hypoglycaemia. See, e.g., SEQ ID NO.: 1 in WO 2014 / 016300.

[0075] Dasiglucagon is a glucagon analogue, as described above. In particular, it is a modified human glucagon. Dasiglucagon comprises 29 amino acids and is distinct from glucagon through its amino acid sequence. This improves, inter alia, water solubility of dasiglucagon compared to glucagon, as shown in WO 2014 / 016300. Dasiglucagon consists of 29 amino acids, similar to endogenous glucagon:

[0076] His-Ser-GIn-Gly-Thr-Phe-Thr-Ser-Asp-Tyr-Ser-Lys-Tyr-Leu-Asp-Aib-Ala-Arg-Ala-Glu-Glu-Phe- Val-Lys-Trp-Leu-Glu-Ser-Thr (SEQ ID NO.: 1)

[0077] WO 2014 / 016300 describes glucagon analogues, including dasiglucagon (compound 21 or SEQ ID NO.: 22 in WO 2014 / 016300).

[0078] Dasiglucagon has the molecular formula C152H222N38O50. A visualisation illustrating the structure of Dasiglucagon is shown in Figure 1. Dasiglucagon demonstrates in vitro agonist activity at the human glucagon receptor, with EC50 values of 0.0095 nM and 0.030 nM, respectively as reported in WO 2014 / 016300. It should be understood that Dasiglucagon may also be provided in the form of a salt or other derivative (dasiglucagon or a pharmaceutically acceptable salt or solvate thereof). Salts include pharmaceutically acceptable salts, as defined herein.

[0079] Peptide synthesis

[0080] Dasiglucagon may be manufactured by standard chemical synthetic methods, or by using recombinant expression systems, or by any other suitable state-of-the-art method. A nonlimiting example for the synthesis of dasiglucagon is provided in the examples section.

[0081] Thus, dasiglucagon may be synthesized in a number of ways, including, inter alia, methods comprising:

[0082] (a) synthesizing the peptide by means of solid-phase or liquid-phase methodology, either stepwise or by fragment assembly, and isolating and purifying the final peptide product; or

[0083] (b) expressing a nucleic acid construct that encodes the peptide in a host cell, and recovering the expression product from the host cell culture; or

[0084] (c) effecting cell-free in vitro expression of a nucleic acid construct that encodes the peptide, and recovering the expression product; or employing any combination of methods as in (a), (b) and (c) to obtain fragments of the peptide, subsequently joining (e.g., ligating) the fragments to obtain the complete peptide, and recovering the peptide.

[0085] It may be preferable to synthesize dasiglucagon by means of solid-phase or liquid-phase peptide synthesis, the methodology of which is well known to persons of ordinary skill in the art of peptide synthesis. Reference may also be made in this respect to, for example, WO 98 / 11125 and Fields, G.B. et al., 2002, "Principles and practice of solid-phase peptide synthesis", in: Synthetic Peptides (2nd Edition), and examples provided therein. Starting on p. 39 of WO 2014 / 016300, general synthesis procedures for glucagon analogues are provided. For recombinant expression, nucleic acid constructs may be inserted in suitable vectors to form cloning or expression vectors carrying the nucleic acid constructs. The vectors can, depending on purpose and type of application, be in the form of plasmids, phages, cosmids, mini-chromosomes, or viral, but naked DNA which is only expressed transiently in certain cells may also be an important vector. Preferred cloning and expression vectors (plasmid vectors) are capable of replication, thereby enabling high copy-numbers for the purposes of high-level expression or high-level replication for subsequent cloning.

[0086] In general, an expression vector may comprise the following features in the 5'-3' direction and operably linked: a promoter for driving expression of the nucleic acid fragment, optionally a nucleic acid sequence encoding a leader peptide enabling secretion (to the extracellular phase or, where applicable, into the periplasma), the nucleic acid fragment encoding the peptide of the invention, and optionally a nucleic acid sequence encoding a terminator. The expression vector also may comprise additional features such as selectable markers and origins of replication. When operating with expression vectors in producer strains or cell lines, it may be preferred that the vector is capable of integrating into the host cell genome. The skilled person will be familiar with suitable vectors, and will be able to design one according to the specific requirements in question.

[0087] Vectors may be used to transform host cells to produce dasiglucagon. Such transformed cells can be cultured cells or cell lines used for propagation of the nucleic acid fragments and vectors, or may be used for recombinant production of dasiglucagon.

[0088] In some aspects, the transformed cells are micro-organisms such as bacteria (e.g., species of Escherichia (e.g., E. coli), Bacillus (e.g., B. subtilis), Salmonella or Mycobacterium (preferably non-pathogenic, e.g., M. bovis BCG)), yeasts (e.g., Saccharomyces cerevisiae or Pichia pastoris), or protozoans. Alternatively, the transformed cells may be derived from a multicellular organism, e.g., the cells may be fungal cells, insect cells, algal cells, plant cells, or animal cells such as mammalian cells. For the purposes of cloning and / or optimised expression, the transformed cell may be capable of replicating the nucleic acid construct. Cells expressing the nucleic acid constructs are useful and may be used for small-scale or large-scale preparation of dasiglucagon.

[0089] When producing dasiglucagon by means of transformed cells, it will be convenient, although not essential, that the expression product is secreted into the culture medium.

[0090] Pharmaceutically acceptable salts or solvates

[0091] Dasiglucagon as defined above, may be used as a pharmaceutically acceptable salt or solvate in the context of the present invention.

[0092] The term "pharmaceutically acceptable salt" in the context of the invention refers to a salt that is not harmful to the patient or subject to be treated therewith. Such salts are in general acid addition salts or basic salts. Acid addition salts include salts of inorganic acids and salts of organic acids. Non-limiting examples of suitable acid addition salts include hydrochloride salts, phosphate salts, formate salts, acetate salts, trifluoroacetate salts and citrate salts. Examples of basic salts include salts where the cation is selected from alkali metal ions, such as sodium and potassium, alkaline earth metal ions, such as calcium, as well as substituted ammonium ions, e.g. of the type NR(R')s+, where R and R' independently designate optionally substituted Ci-ealkyl, optionally substituted C2-ealkenyl, optionally substituted aryl, or optionally substituted heteroaryl. Other examples of pharmaceutically acceptable salts are described in Remington's Pharmaceutical Sciences, 17th edition. Ed. Alfonso R. Gennaro (Ed.), Mack Publishing Company, Easton, PA, U.S.A., 1985 and more recent editions, and in the Encyclopaedia of Pharmaceutical Technology.

[0093] The term "solvate" in the context of the present invention refers to a complex of defined stoichiometry formed by a solute (in casu a compound, or a pharmaceutically acceptable salt thereof, of the present invention) and a solvent. Relevant solvents (particularly in the case of pharmaceutically acceptable solvates) include, but are not limited to, water, ethanol and acetic acid. Solvates in which the solvent molecule in question is water are generally referred to as "hydrates". Pharmaceutical composition or pharmaceutical formulation

[0094] In the context of the present invention, dasiglucagon (or a pharmaceutically acceptable salt or solvate thereof as described above) may be comprised in a pharmaceutical composition (also referred to as pharmaceutical formulation) further comprising a pharmaceutically acceptable salt and / or excipient as defined herein.

[0095] Such pharmaceutical compositions may be prepared by conventional techniques, e.g., as described in Remington: The Science and Practice of Pharmacy, 19thedition, 1995.

[0096] The term "excipient" refers to a vehicle, diluent or adjuvant that is administered with the active ingredient. Such pharmaceutical excipients can be sterile liquids, such as water and oils, including those of petroleum, animal, vegetable or synthetic origin, such as peanut oil, soybean oil, mineral oil, sesame oil and similar. Water or saline aqueous solutions and aqueous dextrose and glycerol solutions, particularly for injectable solutions, are particularly used as vehicles. Suitable pharmaceutical vehicles are described in Remington's Pharmaceutical Sciences by E.W. Martin, 21st Edition, 2005; or Handbook of Pharmaceutical Excipients, Rowe C. R.; Paul J. S.; Marian E. Q., sixth Edition. Suitable pharmaceutically acceptable vehicles include, e.g., water, salt solutions, alcohol, vegetable oils, polyethylene glycols, gelatin, lactose, amylose, magnesium stearate, talc, surfactants, silicic acid, viscous paraffin, perfume oil, monoglycerides and diglycerides of fatty acids, fatty acid esters petroetrals, hydroxymethyl cellulose, polyvinylpyrrolidone and similars.

[0097] Aqueous solutions are particularly preferred. Therefore, particularly useful embodiments of liquid pharmaceutical compositions are aqueous compositions, i.e., compositions comprising water. Such compositions may be in the form of an aqueous solution or an aqueous suspension. Preferred embodiments of aqueous pharmaceutical compositions are aqueous solutions. In the context of the invention the term "aqueous composition" or "aqueous formulation" will normally refer to a composition comprising at least 50% by weight (50% w / w) of water, preferably at least 75% w / w of water, more preferably at least 80% w / w of water, more preferably at least 85% w / w of water, more preferably at least 90% w / w of water, most preferably at least 95% w / w of water. Likewise, the term "aqueous solution" will normally refer to a solution comprising at least 50 % w / w of water, and the term "aqueous suspension" to a suspension comprising at least 50 % w / w of water.

[0098] As explained in detail in WO 2021 / 185821, stable formulations of glucagon analogues such as dasiglucagon described therein can avoid including a polar aprotic solvent in the liquid formulation, such as the use of dimethyl sulfoxide (DMSO) as used in WO 2017 / 053822 and WO 2014 / 124151 with the disadvantages that this brings to the formulations in use. Hence, in preferred embodiments, aqueous compositions of the present invention substantially do not include aprotic polar solvents, such as dimethyl sulfoxide (DMSO). Substantially in this sense means that the aqueous formulations include less than 5% by volume (v / v) aprotic solvent, more preferably less than 2% by volume (v / v) aprotic solvent and even more preferably less than 1% by volume (v / v) aprotic solvent. Water is the sole solvent used to make the aqueous liquid formulations according to certain embodiments.

[0099] The composition or formulation comprising dasiglucagon is preferably a stable composition or formulation.

[0100] A "stable" composition or formulation is one in which the peptide therein essentially retains its physical stability and / or chemical stability and / or biological activity upon storage. Preferably, the composition or formulation essentially retains its physical and chemical stability, as well as its biological activity upon storage. The storage period is generally selected based on the intended shelf-life of the formulation. The compositions or formulations of the present invention are provided as stable liquid formulations, e.g. stable aqueous liquid formulations. Various analytical techniques for measuring protein stability are available in the art and are reviewed in Peptide and Protein Drug Delivery, 247-301, Vincent Lee Ed., Marcel Dekker, Inc., New York, N.Y., Pubs. (1991) and Jones, A. Adv. Drug Delivery Rev. 10: 29-90 (1993), for example. In the present invention, "stable" formulations include formulations in which at least 80%, more preferably at least 85%, more preferably at least 90%, more preferably at least 95%, more preferably at least 96%, more preferably at least 97%, more preferably at least 98%, and most preferably at least 99% of the glucagon analogue does not degrade in the formulation after it has been stored at 2-8°C for 18 months. It is also possible to test stability under accelerated condition which generally use an increased storage temperature in order to assess stability over reduced time periods. For example, storage at 25^C, sometimes referred to as under accelerated conditions, may be used to assess stability over a period of 13, 26, 39 or 52 weeks. By way of comparison, the use of other buffers such as phosphate buffer or histidine buffer leads to stability levels that are generally less than 80% after storage for a corresponding period.

[0101] Stability can be measured at a selected temperature for a selected time period, for example using elevated temperature to reduce the period over which a formulation is tested. Generally, storage at a temperature between 2 to 8°C denotes storage under normal refrigerated conditions. In certain embodiments, the composition or formulation is stable under such conditions for at least 6 months, more preferably at least 12 months, more preferably at least 18 months, more preferably at least 24 months. Stability can be evaluated qualitatively and / or quantitatively in a variety of different ways, including evaluation of aggregate formation (e.g., using size exclusion chromatography, UV light scattering, dynamic light scattering, circular dichroism, by measuring turbidity, and / or by visual inspection); by assessing charge heterogeneity using cation exchange chromatography, image capillary isoelectric focusing (icIEF) or capillary zone electrophoresis; amino-terminal or carboxyterminal sequence analysis; mass spectrometric analysis; SDS-PAGE analysis to compare reduced and intact antibody; peptide map (for example tryptic or LYS-C) analysis; evaluating biological activity or antigen binding function of the antibody; etc. Instability may involve any one or more of: aggregation, deamidation (e.g., Asn deamidation), oxidation (e.g., Met oxidation), isomerization (e.g., Asp isomeriation), clipping / hydrolysis / fragmentation (e.g. hinge region fragmentation), succinimide formation, unpaired cysteine(s), / V-terminal extension, C-terminal processing, glycosylation differences, adduct formation etc.

[0102] A peptide "retains its physical stability" in a pharmaceutical composition or formulation if it shows no sign (or very little sign) of aggregation, precipitation and / or denaturation upon e.g. visual examination of colour and / or clarity, or as measured by UV light scattering, dynamic light scattering, circular dichroism, or by size exclusion chromatography and is considered to still retain its biological activity. A peptide "retains its chemical stability" in a pharmaceutical composition or formulation, if the chemical stability at a given time is such that the peptide 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 peptide. Chemical alteration may involve isomerization, oxidation, size modification (e.g., clipping) which can be evaluated using HPLC or size exclusion chromatography, SDS-PAGE and / or mass spectrometry, for example. Other types of chemical alteration include charge alteration (e.g., occurring as a result of deamidation) which can be evaluated by HPLC or ion-exchange chromatography or imaged capillary isoelectric focusing (icIEF), for example.

[0103] In some embodiments the aqueous stable liquid pharmaceutical compositions of the present invention comprise dasiglucagon (or a pharmaceutically acceptable salt or solvate thereof as described above), a buffer, a tonicity modifier and are formulated to have a pH that is physiologically compatible with administration to a patient.

[0104] In some embodiments, the stable aqueous liquid pharmaceutical compositions of the present invention further comprise a preservative, for example enabling multi-dose formulations to be produced.

[0105] Stable liquid pharmaceutical compositions comprising dasiglucagon are described in detail in WO 2021 / 185821. For instance, a formulation comprising dasiglucagon or a pharmaceutically acceptable salt and / or derivative thereof may comprise:

[0106] (a) dasiglucagon or a pharmaceutically acceptable salt and / or derivative thereof present at a concentration of about 0.5 mg / mL to about 10 mg / mL, such as 4 mg / mL;

[0107] (b) TRIS, Bis-TRIS, ACES or MES present as a buffer at a concentration of about 25 mM to about 75 mM, and / or citrate, acetate or succinate present as a buffer at a concentration of about 1 mM to about 30 mM;

[0108] (c) sodium chloride present as a tonicity modifier and at a concentration of about

[0109] 50 mM to about 600 mM; and (d) a pH of about 5.6 to about 7.0.

[0110] Certain embodiments of liquid pharmaceutical compositions may comprise dasiglucagon or a pharmaceutically acceptable salt or solvate thereof in a concentration from about 0.01 mg / mL to about 25 mg / mL, such as from about 0.5 mg / mL to about 10 mg / mL, such as from about 1 mg / mL to about 10 mg / mL, e.g., from about 1 mg / mL to about 5 mg / mL. In a particularly preferred embodiment, a liquid pharmaceutical composition comprises dasiglucagon or a pharmaceutically acceptable salt or solvate thereof at a concentration of about 4 mg / mL.

[0111] In other embodiments, the pH of the pharmaceutical composition is a pH selected from the list consisting of 2.0, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 3.0, 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7,

[0112] 3.8, 3.9, 4.0, 4.1, 4.2, 4.3, 4.4, 4.5, 4,6, 4.7, 4.8, 4.9, 5.0, 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9,

[0113] 6.0, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 6.7, 6.8, 6.9, 7.0, 7.1, 7.2, 7.3, 7.4, 7.5, 7.6, 7.7, 7.8, 7.9, 8.0, 8.1,

[0114] 8.2, 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, 8.9, 9.0, 9.1, 9.2, 9.3, 9.4, 9.5, 9.6, 9.8, 9.9, and 10.0.

[0115] Preferably, in the aqueous liquid pharmaceutical compositions of the present invention, the composition has a pH between about 5.6 to about 7.0, preferably between about 5.8 and 6.7, more preferably between about 6.0 and 6.8, and even more preferably a pH of about 6.5.

[0116] The pH may be adjusted using any means known in the art. Preferably, the pH is adjusted using hydrochloric acid (HCI) and / or sodium hydroxide (NaOH).

[0117] The pharmaceutical composition of the invention may also comprise a buffer. The term "buffer" as used herein denotes a pharmaceutically acceptable agent which stabilizes the pH of a pharmaceutical formulation.

[0118] In further embodiments of buffer-containing pharmaceutical compositions, the buffer or buffer substance is selected from the group consisting of: acetate buffers (e.g., sodium acetate), sodium carbonate, citrates (e.g., sodium citrate), glycylglycine, histidine, glycine, lysine, arginine, phosphates (e.g., chosen among sodium dihydrogen phosphate, disodium hydrogen phosphate and trisodium phosphate), TRIS (i.e., tris(hydroxymethyl)aminomethane), HEPES (i.e., 4-(2-hydroxyethyl)-l-piperazine- ethanesulfonic acid), BICINE (i.e., / V, / V-bis(2-hydroxyethyl)glycine), and TRICINE (i.e., N- [tris(hydroxymethyl)methyl]glycine), as well as succinate, malate, maleate, fumarate, tartrate, and aspartate buffers, and mixtures thereof. Preferably, any of these buffers are present at a concentration of about 1 mM to about 30 mM, more preferably about 10 mM to about 30 mM, and more preferably at a concentration of about 15 mM. The actual concentration used may take account of whether the buffers are used individually or in combination.

[0119] Some non-limiting preferred buffers in the context of the present invention are:

[0120] TRIS buffer ((tris(hydroxymethyl)aminomethane or 2-Amino-2-(hydroxymethyl)propane-l,3- diol) in IUPAC nomenclature);

[0121] Bis-TRIS buffer ((Bis-Tris methane or 2-[Bis(2-hydroxyethyl)amino]-2- (hydroxymethyl)propane-l,3-diol) in IUPAC nomenclature);

[0122] ACES buffer (( / V-(2-Acetamido)-2-aminoethanesulfonic acid or 2- (carbamoylmethylamino)ethanesulfonic acid) in IUPAC nomenclature); and

[0123] MES buffer (2-(N-morpholino)ethanesulfonic acid or as 2-morpholin-4-ylethanesulfonic acid in IUPAC nomenclature).

[0124] Preferably, in the aqueous liquid pharmaceutical composition of the present invention, the TRIS, Bis-TRIS or ACES is present as a buffer at a concentration of about 25 mM to about 75 mM, preferably at a concentration of about 50 mM.

[0125] Other buffers that can be used as alternatives or in addition to these buffers include citrate, acetate or succinate, for example in the form of sodium citrate, sodium acetate or sodium succinate. Preferably, these buffers are present at a concentration of about 1 mM to about 30 mM, more preferably about 10 mM to about 30 mM, and more preferably at a concentration of about 15 mM. The actual concentration used may take account of whether the buffers are used individually or in combination. In further embodiments of pharmaceutical compositions, the composition comprises a pharmaceutically acceptable preservative. Relevant preservatives include preservatives selected from the group consisting of: phenol, o-cresol, m-cresol, p-cresol, methyl p- hydroxybenzoate, ethyl p-hydroxybenzoate, propyl p-hydroxybenzoate, butyl p- hydroxybenzoate, 2-phenoxyethanol, 2-phenylethanol, benzyl alcohol, ethanol, chlorobutanol, thiomerosal, bronopol, benzoic acid, imidurea, chlorhexidine, sodium dehydroacetate, chlorocresol, benzethonium chloride, chlorphenesine [i.e., 3-(p- chlorphenoxy)propane-l,2-diol] and mixtures thereof.

[0126] Meta-cresol (m-cresol) is a preferred pharmaceutically acceptable preservative.

[0127] The preservative may be present in a concentration of from 0.1 mg / ml to 30 mg / ml, such as from 0.1 mg / ml to 20 mg / ml (e.g., from 0.1 mg / ml to 10 mg / ml, or from 2 mg / ml to 8 mg / ml, or from 4 mg / ml to 7 mg / ml) in the final liquid composition. The preferred concentration is about 3.0 mg / ml to 4.0 mg / ml, e.g., about 3.15 mg / ml.

[0128] Preferably the preservative is meta-cresol at a concentration of about 1.0 mg / mL to about 5.0 mg / mL.

[0129] In further embodiments, a pharmaceutical composition comprises a tonicity modifier. The term "tonicity modifier" as used herein denotes pharmaceutically acceptable tonicity agents that are used to modulate the tonicity of the formulation. The pharmaceutical compositions of the present invention are preferably isosmotic, that is they have an osmotic pressure that is substantially the same as human blood serum.

[0130] Relevant tonicity modifiers include agents selected from: salts (e.g., sodium chloride), sugars and sugar alcohols, amino acids (including glycine, arginine, lysine, isoleucine, aspartic acid, tryptophan and threonine), alditols (including glycerol, propyleneglycol (i.e., 1,2-propanediol), 1,3-propanediol and 1,3-butanediol), polyethylene glycols (including PEG400) and mixtures thereof. Suitable sugars include mono-, di- and polysaccharides, and water-soluble glucans, such as fructose, glucose, mannose, sorbose, xylose, maltose, lactose, sucrose, trehalose, dextran, pullulan, dextrin, cyclodextrin, soluble starch, hydroxyethyl starch and carboxymethylcellulose sodium salt.

[0131] The tonicity modifier used in the pharmaceutical compositions is preferably sodium chloride.

[0132] The concentration of the tonicity modifier will be dependent on the concentration of other components of the pharmaceutical compositions, especially where the pharmaceutical compositions is intended to be isosmotic. Typically, sodium chloride will be employed as a tonicity modifier at a concentration of about 50 mM to 600 mM. In certain embodiments, the concentration of sodium chloride present as a tonicity modifier in the present pharmaceutical compositions may be from about 10 mM to about 150 mM, such as about 20 mM to about 130 mM, about 50 mM to about 125 mM, about 75 mM to about 120 mM, about 80 mM to about 100 mM, or about 90 mM. In certain embodiments, the concentration of sodium chloride present as a tonicity modifier in the present pharmaceutical compositions may be from about 150 mM to about 200 mM, optionally about 175 mM. In a preferred embodiment, sodium chloride may be present as a tonicity modifier in pharmaceutical compositions comprising a preservative at concentrations of about 50 mM to about 150 mM, and most preferably at a concentration of about 90 mM.

[0133] As disclosed herein, the stable aqueous liquid pharmaceutical composition of dasiglucagon (or a pharmaceutically acceptable salt or solvate thereof as described above) of the present invention preferably comprises:

[0134] (a) dasiglucagon, or the pharmaceutically acceptable salt or solvate thereof present at a concentration of about 4 mg / mL;

[0135] (b) TRIS, Bis-TRIS, ACES or MES present as a buffer at a concentration of about 50 mM;

[0136] (c) sodium chloride present as a tonicity modifier; and at a concentration of about 90 mM; and

[0137] (d) a pH of about 6.5. The most preferred formulation of dasiglucagon in an aqueous liquid pharmaceutical composition is shown in the below Table 2:

[0138] Table 2: preferred formulation of dasiglucagon

[0139] Medical uses

[0140] The present invention provides dasiglucagon (and pharmaceutically acceptable salts or solvates thereof), as well as pharmaceutical compositions as described above comprising the same for use in the treatment and / or prevention of a variety of conditions or disorders, in particular hypoglycaemia, such as nocturnal hypoglycaemia, more particular CHI. Optionally, the compounds (and pharmaceutically acceptable salts or solvates thereof) may be used in combination with one or more additional therapeutically active substances. Hence, the present invention provides the use of dasiglucagon (and pharmaceutically acceptable salts or solvates thereof), as well as pharmaceutical compositions comprising the same in a method for treating and / or preventing hypoglycaemia, such as nocturnal hypoglycaemia, more particularly CHI. The present invention provides methods for treating and / or preventing hypoglycaemia, such as nocturnal hypoglycaemia, more particularly CHI. The present invention thus provides dasiglucagon (and pharmaceutically acceptable salts or solvates thereof), as well as pharmaceutical compositions comprising the same in the manufacture of a medicament for the treatment and / or prevention of hypoglycaemia, such as nocturnal hypoglycaemia, more particularly CHI.

[0141] The present invention also provides dasiglucagon (and pharmaceutically acceptable salts or solvates thereof), as well as pharmaceutical compositions comprising the same for use in the treatment and / or prevention of hypoglycaemia, such as nocturnal hypoglycaemia, more particularly CHI, wherein the patient is suffering from NME (necrolytic migratory erythema). In one aspect of the invention, the hypoglycaemia is nocturnal hypoglycaemia. In another aspect of the invention, the hypoglycaemia is CHI.

[0142] Also provided is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME).

[0143] Another aspect of the invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of CHI, in a patient suffering from necrolytic migratory erythema (NME).

[0144] A further aspect of the invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of nocturnal hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME).

[0145] Further provided is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising reducing the dose of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0146] Additionally provided is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of CHI, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising reducing the dose of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof. Further provided is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of nocturnal hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising reducing the dose of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0147] Further provided is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising reducing the infusion rate of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0148] Additionally provided is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of CHI, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising reducing the infusion rate of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0149] Further provided is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of nocturnal hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising reducing the infusion rate of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0150] Additionally provided is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising discontinuing the treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof. In one aspect of the invention, the hypoglycaemia is nocturnal hypoglycaemia. In another aspect of the invention, the hypoglycaemia is CHI.

[0151] Further provided is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising interrupting the treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof. The dose may be interrupted for a period of for example 1-2 days, 1-3 days, 1-4 days, 1-5 days, 1-6 days or 1-7 days or more than 7 days. In one aspect of the invention, the hypoglycaemia is nocturnal hypoglycaemia. In another aspect of the invention, the hypoglycaemia is CHI.

[0152] A further aspect of the invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the prevention of hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising reducing the dose of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof. The hypoglycaemia may be nocturnal hypoglycaemia.

[0153] An additional aspect of the invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the prevention of hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising discontinuing the infusion of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof. The hypoglycaemia may be nocturnal hypoglycaemia.

[0154] A further aspect of the invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the prevention of hypoglycaemia, in a patient suffering from necrolytic migratory erythema (NME) by a dosage regimen comprising interrupting the dose of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof. The dose may be interrupted for a period of for example 1-2 days, 1-3 days, 1-4 days, 1-5 days, 1-6 days, 1-7 days or more than 7 days. The hypoglycaemia may be nocturnal hypoglycaemia.

[0155] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating and / or preventing hypoglycaemia, wherein the method comprises the following steps:

[0156] (i) identifying a patient who has developed NME; and

[0157] (ii) reducing the dose of dasiglucagon and / or reducing the dasiglucagon infusion rate and / or interrupting dasiglucagon treatment for a period and / or discontinuing dasiglucagon treatment. A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating congenital hyperinsulinism (CHI), wherein the method comprises the following steps:

[0158] (i) identifying a patient who has developed NME; and

[0159] (ii) reducing the dose of dasiglucagon and / or reducing the dasiglucagon infusion rate and / or interrupting dasiglucagon treatment for a period and / or discontinuing dasiglucagon treatment.

[0160] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating and / or preventing nocturnal hypoglycaemia, wherein the method comprises the following steps:

[0161] (i) identifying a patient who has developed NME; and

[0162] (ii) reducing the dose of dasiglucagon and / or reducing the dasiglucagon infusion rate and / or interrupting dasiglucagon treatment for a period and / or discontinuing dasiglucagon treatment.

[0163] The term "treatment" (as well as "treating" and other grammatical variants thereof) as employed in the context of the invention refers to an approach for preventing and / or for obtaining beneficial or desired clinical results. For the purposes of the present invention, beneficial or desired clinical results include, but are not limited to, alleviation of symptoms, diminishment of extent of disease, stabilization of (i.e., not worsening of) state of disease, delay or slowing of disease progression, amelioration or palliation of disease state, and remission (whether partial or total), whether detectable or undetectable. "Treatment" may also refer to prolongation of survival compared to expected survival in the absence of treatment. "Treatment" is an intervention performed with the intention of preventing the development of, or altering the pathology of, a disorder. Accordingly, "treatment" refers both to therapeutic treatment and to prophylactic or preventative measures. As used in the context of prophylactic or preventative measures, the pharmaceutical formulation need not completely prevent the development of the disease or disorder. Those in need of treatment include those already suffering from the disorder, as well as those in which development of the disorder is to be prevented. "Treatment" also means inhibition or reduction of an increase in pathology or symptoms (e.g., weight gain or hypoglycaemia) compared to the absence of treatment and is not necessarily meant to imply complete cessation of the relevant condition.

[0164] As a general principle, dasiglucagon (and pharmaceutically acceptable salts or solvates thereof), as well as pharmaceutical compositions or formulations comprising the same, may be useful to control blood glucose levels, in particular during long periods of time, such as for example 3 or more hours, or 4 or more hours, or 5 or more hours, or 6 or more hours, or 7 or more hours, or 8 or more hours, or 9 or more hours, or 10 or more hours, preferably during periods of time or more than 6 hours, such as about 6 hours, or more than 7 hours, such as about 7 hours, or more than 8 hours, such as one day, or more, such as 2 days, or 3 days, or 4 days, or 5 days, or 6 days, or 7 days, or more, such as 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks, or 6 weeks, or 7 weeks, or 8 weeks, or three months, or five months, or six months, or one year, or more.

[0165] The terms "patient", "subject", and "individual" may be used interchangeably in the context of the present invention, and refer to either a human or a non-human animal. These terms include mammals such as humans, primates, livestock animals (e.g., bovines, porcines), companion animals (e.g., canines, felines) and rodents (e.g., mice and rats). Preferably, the patient is a human, more particularly a newborn or a child.

[0166] In an embodiment, the patient is 12 years (inclusive) or younger. In another embodiment, the patient is under 12 months (exclusive) of age.

[0167] In an embodiment, the patient is 7 days (inclusive) or older. In another embodiment the patient is 3 months (inclusive) or older.

[0168] In a preferred embodiment, the patient is between the ages of 3 months and 12 years (both inclusive).

[0169] In another preferred embodiment, the patient between the ages of 7 days (inclusive) and 12 months (exclusive). In a further embodiment, the patients have a weight at the beginning of the treatment, i.e., at baseline, of 20 kg or less, more preferably the patients have a weight at the beginning of the treatment, i.e., at baseline, of 10 kg or more but less than 20 kg. In the most preferred embodiment, the patients have a weight of less than 10 kg, optionally of between 5 (inclusive) and 10 (exclusive) kg.

[0170] As is shown in the examples further hereinbelow, patients with a weight of less than 10 kg at the start of the treatment, i.e., at baseline, respond particularly well to treatment with dasiglucagon.

[0171] In a preferred embodiment, the patient is between the ages of 3 months and 12 years (both inclusive and has a bodyweight of between 5 (inclusive) and 10 (exclusive) kg.

[0172] In another preferred embodiment, the patient has not had a pancreatectomy before the start of the treatment. In the context of the present invention, pancreatectomy refers to surgical removal of all or part of the pancreas.

[0173] In a further aspect of the present invention, the patient has an ABCC8 mutation. As shown in Example 1, patients with an ABCC8 mutation (i.e., mutations in the ABCC8 gene, as described herein) have been shown to respond particularly well to treatment with dasiglucagon. The ABCC8 gene (ATP Binding Cassette Subfamily C Member 8, Gene ID: 6833, updated on 4-Dec- 2023) is a protein coding gene. The protein encoded by this gene is a member of the superfamily of ATP-binding cassette (ABC) transporters. ABC proteins transport various molecules across extra- and intra-cellular membranes. ABC genes are divided into seven distinct subfamilies (ABC1, MDR / TAP, MRP, ALD, OABP, GCN20, White). This protein is a member of the MRP subfamily which is involved in multi-drug resistance. This protein functions as a modulator of ATP-sensitive potassium channels and insulin release. Mutations and deficiencies in this protein have been observed in patients with hyperinsulinemic hypoglycemia of infancy, an autosomal recessive disorder of unregulated and high insulin secretion. Mutations have also been associated with non-insulin-dependent diabetes mellitus type II (neonatal diabetes), an autosomal dominant disease of defective insulin secretion, and congenital hyperinsulinism. Thus, a further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of hypoglycaemia, in a patient with an ABCC8 mutation. The hypoglycaemia may be nocturnal hypoglycaemia. In another aspect of the invention, the hypoglycaemia is CHI.

[0174] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the treatment of CHI, in a patient with an ABCC8 mutation.

[0175] An additional aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof, for use in the prevention of hypoglycaemia, in a patient with an ABCC8 mutation. The hypoglycaemia may be nocturnal hypoglycaemia. In another aspect of the invention, the hypoglycaemia is CHI.

[0176] The ABCC8 mutation may be a homozygous mutation, a heterozygous mutation or an unknown ABCC8 mutation type. In one aspect the ABCC8 mutation is a heterozygous mutation.

[0177] In a further aspect, the mutation is a change in an amino acid of the protein sequence of the ABCC8 gene. In another aspect the mutation changes a single amino acid in the SURI protein coded by the ABCC8 gene.

[0178] The terms "therapeutically effective amount" and “therapeutically effective dose" as employed in the context of the present invention (notably in the context of a compound of the invention) refer to an amount or a dose sufficient to cure, alleviate, partially arrest or otherwise promote the cure or healing of a given condition (disorder, disease) or injury and, preferably, complications arising therefrom. An amount or dose effective for a particular purpose will depend on the severity of the condition or injury as well as on the body weight and general state of the subject or patient to be treated. Determination of an amount or dose that is appropriate is within the skills of a trained physician (or veterinarian) of ordinary skill.

[0179] In a preferred embodiment of the invention, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating CHI. Alternatively, the invention relates to a method for treating CHI comprising administering the compound or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition of the invention to a subject in need thereof, as described above.

[0180] In another embodiment of the invention, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating nocturnal hypoglycaemia in CHI patients Alternatively, the invention relates to a method for treating nocturnal hypoglycaemia in CHI patients comprising administering the compound or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition of the invention to a subject in need thereof, as described above.

[0181] In another embodiment, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating CHI and the treatment reduces the percent time in hypoglycaemia, wherein the percent time in hypoglycaemia is defined as the percent time that the patient has a glucose level of <70 mg / dL (or <3.9 mmol / L), measured by continued glucose monitoring (CGM).

[0182] Alternatively, the invention relates to a method for treating CHI comprising administering dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition of the invention to a subject in need thereof and the treatment reduces the percent time in hypoglycaemia as compared with the percent time in hypoglycaemia in patients receiving the standard of care (SoC) treatment, wherein the percent time in hypoglycaemia is defined as the percent time that the patient has a glucose level of <70 mg / dL (or <3.9 mmol / L), measured by CGM.

[0183] In a related embodiment, the treatment reduces the mean percent time in hypoglycaemia during weeks 2-4 by at least 10%, 20%, 30%, or 40%, or more, such as at least 41%, relative to the percent time in hypoglycaemia in patients receiving the SoC treatment. In another embodiment, the mean percent time in hypoglycaemia during weeks 2-4 is reduced by at least 10 - 50%, 20 - 45%, or 30 - 41% relative to the percent time in hypoglycaemia in patients receiving the SoC treatment. In a particularly preferred embodiment, the mean percent time in hypoglycaemia during weeks 2-4 is reduced by at least 41% relative to the percent time in hypoglycaemia in patients receiving the SoC treatment. In another embodiment.

[0184] In another embodiment, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating CHI, and the treatment reduces the rate of hypoglycaemic episodes. The rate of hypoglycaemic episodes can be defined as the number of CGM-detected episodes per week. A single CGM-detected hypoglycaemic episode is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L) measured by CGM for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70 mg / dL or >3.9 mmol / L) was not reached within this time, wherein a new episode of hypoglycaemia begins when the next CGM values below 70 mg / dL (or below 3.9 mmol / L) was measured for at least 15 minutes.

[0185] Alternatively, the invention relates to a method for treating CHI comprising administering the dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition of the invention to a subject in need thereof and the treatment reduces the rate of hypoglycaemic episodes, wherein the rate of hypoglycaemic episodes is defined as the number of CGM-detected episodes per week, wherein a single CGM-detected hypoglycaemia episode is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L) measured by CGM for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70 mg / dL or >3.9 mmol / L) is not reached within this time, and a new episode of hypoglycaemia begins when the next CGM value below 70 mg / dL or below 3.9 mmol / L is measured for at least 15 minutes.

[0186] In a related embodiment, the treatment reduces the mean rate of hypoglycaemic episodes during weeks 2-4 of treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein, is reduced by at least 10% such as by at least 20% or, or by at least 30%, or by at least 35%, such as by at least 40%, or more, such as by at least 41% or by at least 42.5%, such by at least 42.9%, or at least about 43%, relative to the mean rate of hypoglycaemic episodes in patients receiving the SoC treatment. In another embodiment, the mean rate of hypoglycaemic episodes during weeks 2-4 is reduced by at least 10 - 60%, 20 - 50%, or 35 - 45 % relative to the mean rate of hypoglycaemic episodes in patients receiving the SoC treatment. In a particularly preferred embodiment, the mean rate of hypoglycaemic episodes during weeks 2-4 is reduced by at least 40%, preferably by at least 41%, or at least 42.5%, such by at least 42.9%, or at least about 43%, relative to the mean rate of hypoglycaemic episodes in patients receiving the SoC treatment. Preferably, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is administered at a dose of at least 10 pg / h. The amount of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same may preferably be increased by 10 pg / h every two hours, to a maximum of 70 pg / h, see below section "Dosage and schedule" for further details.

[0187] In another embodiment, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating CHI, and the treatment reduces the percent time in clinically significant hypoglycaemia, wherein the percent time in clinically significant hypoglycaemia is defined as the percent time that the patient has a glucose level of <54 mg / dL measured by CGM.

[0188] Alternatively, the invention relates to a method for treating CHI comprising administering dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same to a subject in need thereof, and the treatment reduces the percent time in clinically significant hypoglycaemia, wherein the percent time in clinically significant hypoglycaemia is defined as the percent time that the patient has a glucose level of <54 mg / dL measured by continued glucose monitoring (CGM).

[0189] In a related embodiment, the treatment reduces the mean percent time in clinically significant hypoglycaemia during weeks 2-4 of treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein, by at least 10%, such by as at least 20%, or by at least 30%, or by at least 40%, such as by at least 45%, or by at least about 48%, relative to the mean percent time in clinically significant hypoglycaemia in patients receiving the SoC treatment. In another embodiment, the mean percent time in clinically significant hypoglycaemia during weeks 2-4 of treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein, is reduced by at least 10 - 70%, such as by at least20 - 60%, or by at least 30 - 50%, such as by at least 45 - 50% relative to the mean percent time in clinically significant hypoglycaemia in patients receiving the SoC treatment. In a particularly preferred embodiment, the mean percentage time in clinically significant hypoglycaemia during weeks 2-4 is reduced by at least 45%, preferably by at least 48%relative to the mean percent time in clinically significant hypoglycaemia in patients receiving the SoC treatment. Preferably, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is administered at a dose of at least 10 pg / h. The amount of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof ora pharmaceutical composition comprising the same may preferably be increased by 10 pg / h every two hours, to a maximum of 70 pg / h, see below section "Dosage and schedule" for further details.

[0190] In another embodiment, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating CHI and the treatment reduces the rate of clinically significant hypoglycaemic episodes. The rate of clinically significant hypoglycaemic episodes is defined as the number of CGM -detected episodes per week. A single CGM -detected clinically significant hypoglycaemic episode is defined as a glucose level of <54 mg / dL measured by CGM for 15 minutes and up until 60 minutes from the start of the episode, even if normoglycemia (>70 mg / dL) is not reached within this time. A new episode of clinically significant hypoglycaemia begins when the next CGM values below 54 mg / dL is measured for at least 15 minutes.

[0191] Alternatively, the invention relates to a method for treating CHI comprising administering the compound or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition of the invention to a subject in need thereof and the treatment reduces the rate of clinically significant hypoglycaemic episodes. The rate of clinically significant hypoglycaemic episodes is defined as the number of CGM-detected episodes per week. A single CGM- detected clinically significant hypoglycaemic episode is defined as a glucose level of <54 mg / dL measured by CGM for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70 mg / dL) is not reached within this time. A new episode of clinically significant hypoglycaemia begins when the next CGM values below 54 mg / dL is measured for at least 15 minutes.

[0192] In a related embodiment, the treatment reduces the mean rate of clinically significant hypoglycaemic episodes during weeks 2-4 of treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein, by at least 10%, such as by at least 20% or by at least 30%, such as by at least 40%, e.g., at least 41.5%, relative to the mean rate of clinically significant hypoglycaemic episodes during weeks 2-4 in patients receiving the SoC treatment. In another embodiment, the mean rate of clinically significant hypoglycaemic episodes during weeks 2-4 is reduced by at least 10 - 60%, such as by at least 20 - 50%, or by at least 35 - 45% relative to the mean rate of clinically significant hypoglycaemic episodes during weeks 2-4 in patients receiving the SoC treatment. In a particularly preferred embodiment, the mean rate of clinically significant hypoglycaemic episodes during weeks 2-4 is reduced by at least 40%, more preferably by at least 41%, such as by at least 41.5%, relative to the mean rate of clinically significant hypoglycaemic episodes during weeks 2-4 in patients receiving the SoC treatment. Preferably, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is administered at a dose of at least 10 pg / h. The amount of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof ora pharmaceutical composition comprising the same may preferably be increased by 10 pg / h every two hours, to a maximum of 70 pg / h, see below section "Dosage and schedule" for further details.

[0193] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating hypoglycaemia, wherein the treatment reduces the glucose infusion rate (mg / kg / min) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0194] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating CHI, wherein the treatment reduces the glucose infusion rate (mg / kg / min) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0195] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating nocturnal hypoglycemia, wherein the treatment reduces the glucose infusion rate (mg / kg / min) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0196] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of preventing hypoglycaemia, wherein the treatment reduces the glucose infusion rate (mg / kg / min) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0197] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of preventing nocturnal hypoglycemia, wherein the treatment reduces the glucose infusion rate (mg / kg / min) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0198] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating hypoglycaemia, wherein the treatment reduces the total amount of carbohydrates administered per day (g / day) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0199] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating CHI, wherein the treatment reduces the total amount of carbohydrates administered per day (g / day) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L). A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of treating nocturnal hypoglycemia, wherein the treatment reduces the total amount of carbohydrates administered per day (g / day) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0200] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of preventing hypoglycaemia, wherein the treatment reduces the total amount of carbohydrates administered per day (g / day) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0201] A further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is provided for use in a method of preventing nocturnal hypoglycemia, wherein the treatment reduces the total amount of carbohydrates administered per day (g / day) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0202] In one aspect of the invention, the carbohydrates administered per day (g / day) are administered by IV infusion, nasogastric tube, gastrostomy, or the oral route. Preferably the carbohydrate is administered via the oral route.

[0203] The carbohydrate administered via the oral route may be administered in any form, for example as a solid composition, as a liquid composition, or as a gel composition.

[0204] In one aspect of the invention, the carbohydrate comprises one or more sugars selected from the group comprising glucose, sucrose and fructose.

[0205] The standard of care (SoC) treatment is described below in this application. For example, in the context of the present embodiments, the SoC can include most drugs commonly used and / or recommended in treatment of CHI including, but not limited to: application of carbohydrate-rich liquids mainly via NG-tube or gastric infusions, carbohydrate fortification of other feeds (including oral), diazoxide treatment, and somatostatin analogues (e.g., octreotide, octreotide LAR, or lanreotide), including somatostatin.

[0206] In another embodiment, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as disclosed herein, is provided for use in a method of treating nocturnal hypoglycaemia in CHI patients. Alternatively, the invention relates to a method for treating nocturnal hypoglycaemia in CHI patients, the method comprising administering the compound or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition of the invention to a subject in need thereof (to a CHI subject).

[0207] In a related embodiment, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, is provided for use in a method of treating CHI, and the treatment reduces nocturnal hypoglycaemia. "Nocturnal hypoglycaemia" has been described in the present description. Alternatively, the invention relates to a method for treating CHI comprising administering dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same to a subject in need thereof (CHI patient), and the treatment reduces nocturnal hypoglycaemia.

[0208] In one embodiment, the mean number of nocturnal hypoglycaemic episodes is defined as the mean number of CGM-detected hypoglycaemic episodes / week with onset between 10 pm (excluded) and 6 am (excluded), wherein a single CGM-detected hypoglycaemic episode is defined as CGM <3.9 mmol / L for 15 minutes and up until 60 minutes from the start of the episode, even if normoglycemia (>3.9 mmol / L) is not reached within this time. A new hypoglycaemic episode is defined when the next CGM value below 3.9 mmol / L for at least 15 min is detected.

[0209] In a related embodiment, the mean number of nocturnal hypoglycaemic episodes is defined as the mean number of CGM-detected hypoglycaemic episodes / week with onset between 10 pm (excluded) and 6 am (excluded), wherein a single CGM-detected hypoglycaemic episode is defined as CGM <3.0 mmol / L for 15 minutes and up until 60 minutes from the start of the episode, even if normoglycemia (>3.9 mmol / L) is not reached within this time. A new hypoglycaemic episode is defined when the next CGM value below 3.0 mmol / L for at least 15 min is detected.

[0210] In a related embodiment, the method of the present invention reduces the mean number of nocturnal hypoglycaemic episodes by at least 30%, or by at least 40%, or by at least 45%, or by at least 48%, such as by at least 50%, preferably by at least 48%, wherein the mean number of nocturnal hypoglycaemic episodes is defined as the episodes / week with onset between 10 pm (excluded) and 6 am (excluded), wherein a single CGM-detected hypoglycaemic episode is defined as CGM <3.9 mmol / L for 15 minutes and up until 60 minutes from the start of the episode, even if normoglycemia (>3.9 mmol / L) is not reached within this time. A new hypoglycaemic episode is defined when the next CGM value below 3.9 mmol / L for at least 15 min is detected.

[0211] Standard of care

[0212] Current standard medical treatment of congenital hyperinsulinism (CHI) could include most drugs commonly used and / or recommended in treatment of CHI including, but not limited to: application of carbohydrate-rich liquids mainly via NG-tube or gastric infusions, carbohydrate fortification of other feeds (including oral), diazoxide treatment, and somatostatin analogues (e.g., octreotide, octreotide LAR, or lanreotide), including somatostatin.

[0213] In the context of this invention, it is preferred that the patient receives the same standard of care before and during the treatment with the compound or pharmaceutical compositions of the invention. The standard of care can also continue on after the treatment.

[0214] Depending on the context, this application will refer to other therapies that have been carried out before, during or after therapy with the compound of the invention (dasiglucagon) as standard of care or combination therapy. A non-conclusive list of further substances that patients may receive before, during or after treatment with the compound of the invention (dasiglucagon) is described hereinbelow.

[0215] Diazoxide, sold under the brand name Proglycem, is a medication used to treat low blood sugar due to a number of specific causes. Diazoxide has a structure as depicted below:

[0216] Lanreotide and Octreotide are two commonly used somatostatin analogues used in the field.

[0217] Octreotide sold under the brand name Sandostatin, is an octapeptide that mimics natural somatostatin pharmacologically, though it is a more potent inhibitor of growth hormone, glucagon, and insulin than the natural hormone, is depicted below:

[0218] Lanreotide, sold under the brand name Somatuline, is depicted below:

[0219]

[0220] Sirolimus, also known as rapamycin and sold under the brand name Rapamune among others, has the structure depicted below:

[0221] There are many further pharmacologically active substances or agents used as a standard of care in connection with CHI. These are, for example antidiabetic agents, antiobesity agents, appetite-regulating agents, antihypertensive agents, agents for the treatment and / or prevention of complications resulting from or associated with diabetes, and agents for the treatment and / or prevention of complications and disorders resulting from or associated with obesity. In the present context, the expression "antidiabetic agent" includes compounds for the treatment and / or prophylaxis of insulin resistance and diseases wherein insulin resistance is the pathophysiological mechanism. Examples of such pharmacologically active substances are insulin and insulin analogues, GLP- 1 agonists, sulfonylureas (e.g. tolbutamide, glibenclamide, glipizide and gliclazide), biguanides (e.g. metformin), meglitinides, glucosidase inhibitors (e.g. acarbose), glucagon antagonists, dipeptidyl peptidase IV (DPP-IV) inhibitors, inhibitors of hepatic enzymes involved in stimulation of gluconeogenesis and / or glycogenolysis, glucose uptake modulators, thiazolidinediones such as troglitazone and ciglitazone, compounds modifying the lipid metabolism such as antihyperlipidemic agents (e.g. HMG CoA inhibitors (statins)), compounds lowering food intake, RXR agonists and agents acting on the ATP-dependent potassium channel of the p-cells, e.g. glibenclamide, glipizide, gliclazide and repaglinide; cholestyramine, colestipol, clofibrate, gemfibrozil, lovastatin, pravastatin, simvastatin, probucol, dextrothyroxine, neteglinide, repaglinide; p-blockers, such as alprenolol, atenolol, timolol, pindolol, propranolol and metoprolol, ACE (angiotensin converting enzyme) inhibitors such as benazepril, captopril, enalapril, fosinopril, lisinopril, alatriopril, quinapril and ramipril, calcium channel blockers, such as nifedipine, felodipine, nicardipine, isradipine, nimodipine, diltiazem and verapamil, and a-blockers, such as doxazosin, urapidil, prazosin and terazosin; CART (cocaine amphetamine regulated transcript) agonists, NPY (neuropeptide Y) antagonists, MC4 (melanocortin 4) agonists, orexin antagonists, TNF (tumor necrosis factor) agonists, CRF (corticotropin releasing factor) agonists, CRF BP (corticotropin releasing factor binding protein) antagonists, urocortin agonists, |33 agonists, MSH (melanocyte-stimulating hormone) agonists, MCH (melanocyte-concentrating hormone) antagonists, CCK (cholecystokinin) agonists, serotonin re-uptake inhibitors, serotonin and noradrenaline reuptake inhibitors, mixed serotonin and noradrenergic compounds, 5HT (serotonin) agonists, bombesin agonists, galanin antagonists, growth hormone, growth hormone releasing compounds, TRH (thyrotropin releasing hormone) agonists, UCP 2 or 3 (uncoupling protein 2 or 3) modulators, leptin agonists, DA agonists (e.g. bromocryptin, doprexin), lipase / amylase inhibitors, RXR (retinoid X receptor) modulators, TR |3 agonists, and histamine H3 antagonists.

[0222] In an embodiment of the invention, the CHI patient has not been treated with diazoxide as the standard of care before the treatment, i.e., at baseline, with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. Preferably, the patient has never been treated with diazoxide before the treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same.

[0223] As shown in the examples further hereinbelow, patients who have not received diazoxide at baseline, i.e., before treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein, respond particularly well to treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same.

[0224] In another embodiment, the patient has received a somatostatin analogue as the standard of care before the treatment, i.e., at baseline, with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. In these cases, it is preferred that treatment with the somatostatin analogue continues during the treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. The somatostatin analogues can be any or a combination of those listed above. Hence, in a preferred embodiment, the administration of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is performed together with a somatostatin analogue, i.e., dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is coadministered together with a somatostatin analogue. In the context of the present invention, "somatostatin analogue" refers to both analogues of somatostatin as outlined above and known in the art, as well as native somatostatin (somatostatin).

[0225] In another embodiment, the patient has received diazoxide as the standard of care before the treatment, i.e., at baseline, with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. In these cases, it is preferred that treatment with diazoxide continues during the treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. Hence, one embodiment, the administration of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is performed together with diazoxide, i.e., dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is co-administered together with diazoxide.

[0226] In another embodiment, the patient has received glucagon as the standard of care before the treatment, i.e., at baseline, with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. In these cases, it is preferred that treatment with glucagon continues during the treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. Hence, one embodiment, the administration of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is performed together with glucagon, i.e., dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is co-administered together with glucagon.

[0227] In another embodiment, the patient has received sirolimus as the standard of care before the treatment, i.e., at baseline, with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. In these cases, it is preferred that treatment with sirolimus continues during the treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. Hence, one embodiment, the administration of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is performed together with sirolimus, i.e., dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is co-administered together with sirolimus.

[0228] In another embodiment, the patient has received at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus as the standard of care before the treatment, i.e., at baseline, with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. In these cases, it is preferred that treatment with at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus continues during the treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein. Hence, one embodiment, the administration of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is performed together with at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus, i.e., dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same is co-administered together with at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus.

[0229] In a further embodiment, the patients have not had a total pancreatectomy before the start of the treatment. In further embodiments, the patients have not had any pancreatectomy, i.e., "sub-total", "near-total" or "total" pancreatectomy, before the start of the treatment. Total pancreatectomy involves the removal of the entire pancreas. Sub-total pancreatectomy may involve the removal of 95% or less than 95% of the pancreas. Near-total pancreatectomy can be defined as the removal of more than 95% of the pancreas.

[0230] As is shown in the examples further hereinbelow, patients which have not had any pancreatectomy before the start of the treatment, i.e., at baseline, respond particularly well to treatment with dasiglucagon.

[0231] Administration

[0232] Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof and / or pharmaceutical compositions comprising the same may be administered to a patient in need of such treatment at various sites, for example administration at sites which bypass absorption, such as in an artery or vein or in the heart, and at sites which involve absorption, such as in the skin, under the skin, in a muscle or in the abdomen.

[0233] More generally, administration may be performed by a variety of routes, such as or example parenteral, epidermal, dermal or transdermal routes. In some embodiments, other routes such as lingual, sublingual, buccal, oral, vaginal or rectal may be useful.

[0234] In an embodiment, administration of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein, is performed by parenteral administration, for example, by subcutaneous, intramuscular, intraperitoneal or intravenous injection by means of a syringe, suitably a pen-like syringe.

[0235] Subcutaneous administration is preferred.

[0236] Administration can take place by means of an infusion pump, e.g., in the form of a device or system borne by a subject or patient and comprising a reservoir containing a liquid composition of the invention and an infusion pump for delivery / administration of the composition to the subject or patient, or in the form of a corresponding miniaturized device suitable for implantation within the body of the subject or patient.

[0237] Dosage and schedule

[0238] As described above, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof and / or pharmaceutical compositions comprising the same may be administered in various dosage forms, for example solutions, suspensions or emulsions, and are useful in the formulation of controlled-, sustained-, protracted-, retarded- or slow-release drug delivery systems.

[0239] In an embodiment of the invention, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof and / or pharmaceutical compositions comprising the same may be administered continuously.

[0240] In a further embodiment of the invention, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof and / or pharmaceutical compositions comprising the same is administered at a dose of at least 10 pg / h, such as a dose of at least 15 pg / h, or at a dose of at least 20 pg / h, or at a dose of at least 25 pg / h, or at a dose of at least 30 pg / h, or at a dose of at least 40 pg / h, or at a dose of at least 50 pg / h, or at a dose of at least 55 pg / h, or at a dose of at least 60 pg / h, orat a dose of at least 65 pg / h, orat a dose of at least 70 pg / h, such as a dose of about 70 pg / h.

[0241] In some embodiments, dasiglucagon treatment (which includes the administration of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein) is initiated at a dosage of 10 pg / h (i.e., t=0). In some embodiments the dose is increased by 10 pg / h every two hours (i.e., t=2, 4, 6, etc.) until: i. the patient was weaned of entirely from gastric dextrose infusion and / or glucose fortified feeds and / or IV glucose, or ii. Plasma glucose during the last 2 hours was constantly above 120 mg / dL (6.7 mmol / L), or iii. Adverse events emerged that were considered to be related to dasiglucagon (e.g., nausea and vomiting) and limited further dose escalation.

[0242] Therefore, in some embodiments, the dose is increased by 10 pg / h every two hours from the start of treatment to a maximum dose of 70 pg / h. In case any of the above situations (i) to (iii) occur, the dose is not further increased.

[0243] In some embodiments, the dose of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein administrated to a patient is between 10 - 70 pg / h, such as between 20 - 70 pg / h, or between 30 - 70 pg / h, or between 40 - 70 pg / h, or between 50 - 70 pg / h, between 60 - 70 pg / h.

[0244] In one embodiment, dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein is administered to a patient for at least two weeks, such as for two weeks, or for at least three weeks, such as for three weeks, or for at least four weeks, such as for about four weeks, or for at least five weeks, such as for about five weeks, or for at least six weeks, such as for about six weeks, or for at least seven weeks, such as for about seven weeks, or for at least eight weeks, such as for about eight weeks, or more, such as for 9, 10, 15, 20, 30, 40, 50, 60 or 100 weeks or more.

[0245] Combination therapies

[0246] As already indicated above, treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof and / or pharmaceutical compositions comprising the same may take place in combination with one or more further known therapies against CHI (e.g., included in the standard of care as defined above above).

[0247] Any suitable combination of a compound or compounds according to the invention with one or more of the above-mentioned compounds, and optionally one or more further pharmacologically active substances, is within the scope of the present invention.

[0248] In one embodiment, the patient continues to receive any or a combination of the therapies they received before the start of the treatment, i.e., at baseline, referred to above as standard of care. Hence in one embodiment, the administration of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof or a pharmaceutical composition comprising the same, as defined herein is concomitant with the standard of care.

[0249] In a further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof and a somatostatin analogue for use in a method of treating hypoglycemia.

[0250] In a further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof and a somatostatin analogue for use in a method of treating CHI.

[0251] In a further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof and a somatostatin analogue for use in a method of treating nocturnal hypoglycemia.

[0252] In a further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating hypoglycemia, wherein the patient has previously been treated with a somatostatin analogue, such as where the patient is undergoing treatment with a somatostatin analogue at the onset of treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0253] In a further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating CHI, wherein the patient has previously been treated with a somatostatin analogue, such as where the patient is undergoing treatment with a somatostatin analogue at the onset of treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0254] In a further aspect of the present invention is dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating nocturnal hypoglycemia, wherein the patient has previously been treated with a somatostatin analogue, such as where the patient is undergoing treatment with a somatostatin analogue at the onset of treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0255] Said somatostatin analogue may include somatostatin, octreotide and lanreotide.

[0256] Other embodiments of the invention

[0257] The following items are also embodiments of the invention:

[0258] Item 1. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating and / or preventing hypoglycaemia.

[0259] Item 2. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating and / or preventing nocturnal hypoglycaemia.

[0260] Item 3. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating congenital hyperinsulinism (CHI).

[0261] Item 4. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method according to any of the preceding items, wherein Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof is provided in a composition together with at least one pharmaceutically acceptable excipient.

[0262] Item 5. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the treatment reduces the percentage time in hypoglycaemia, wherein the percent time in hypoglycaemia is defined as a glucose level of <70 mg / dL measured by continued glucose monitoring (CGM), optionally wherein the mean percentage time in hypoglycaemia during weeks 2-4 is reduced by at least 41% relative to the percent time in hypoglycaemia in patients receiving the SoC treatment.

[0263] Item 6. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the treatment reduces the rate of hypoglycaemic episodes, wherein the rate of hypoglycaemic episodes is defined as the number of CGM-detected episodes per week, wherein a single CGM-detected hypoglycaemic episode is defined as a glucose level of <70 mg / dL measured by continued glucose monitoring (CGM) for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70 mg / dL) was not reached within this time, wherein a new episode of hypoglycaemia begins when the next CGM values below 70 mg / dL was measured for at least 15 minutes, optionally wherein the mean rate of CGM-detected hypoglycaemic episodes during weeks 2-4 is reduced by at least 41% relative to the mean rate of CGM-detected hypoglycaemic episodes in patients receiving the SoC treatment.

[0264] Item 7.Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the treatment reduces the percentage time in clinically significant hypoglycaemia, wherein the percent time in clinically significant hypoglycaemia is defined as a glucose level of <54 mg / dL measured by CGM, optionally wherein the mean percentage time in clinically significant hypoglycaemia during weeks 2-4 is reduced by at least 48% relative to the mean percentage time in clinically significant hypoglycaemia in patients receiving the SoC treatment.

[0265] Item 8.Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the treatment reduces the rate of clinically significant hypoglycaemic episodes, wherein the rate of clinically significant hypoglycaemic episodes is defined as the number of CGM-detected episodes per week, wherein a single CGM-detected clinically significant hypoglycaemic episode is defined as a glucose level of <54 mg / dL measured by continued glucose monitoring (CGM) for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70 mg / dL) was not reached within this time, wherein a new episode of clinically significant hypoglycaemia begins when the next CGM values below 54 mg / dL was measured for at least 15 minutes, optionally wherein the mean rate of CGM-detected clinically significant hypoglycaemic episodes during weeks 2-4 is reduced by at least 41% relative to the mean rate of clinically significant hypoglycaemic episodes during weeks 2-4 in patients receiving the SoC treatment.

[0266] Item 9. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the patient has a body weight of 5 to <10 kg at the start of the treatment.

[0267] Item 10. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any one of the preceding items, wherein the method does not comprise administration of diazoxide, optionally wherein the patient has never been treated with diazoxide.

[0268] Item 11. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any one of the preceding items, wherein the method does not comprise administration of diazoxide and wherein the patient has never been treated with diazoxide.

[0269] Item 12. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method additionally comprises coadministration of at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus, optionally wherein the patient has previously been treated with at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus.

[0270] Item 13. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method additionally comprises coadministration of at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus, wherein the patient has previously been treated with at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus.

[0271] Item 14. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method additionally comprises coadministration of a somatostatin analogue, optionally wherein the patient has previously been treated with a somatostatin analogue.

[0272] Item 15. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method additionally comprises coadministration of a somatostatin analogue, wherein the patient has previously been treated with a somatostatin analogue.

[0273] Item 16. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method additionally comprises coadministration of somatostatin, optionally wherein the patient has previously been treated with somatostatin.

[0274] Item 17. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method additionally comprises coadministration of somatostatin, wherein the patient has previously been treated with somatostatin.

[0275] Item 18. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the patient has not had a pancreatectomy before the start of the treatment.

[0276] Item 19. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the patient has an ABCC8 mutation. Item 20. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the patient has a homozygous ABCC8 mutation.

[0277] Item 21. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the patient has a heterozygous ABCC8 mutation.

[0278] Item 22. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the patient has an unknown ABCC8 mutation.

[0279] Item 23. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method according to any of the preceding items, wherein the method reduces nocturnal hypoglycaemia.

[0280] Item 24. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method reduces the mean number of nocturnal hypoglycaemic episodes by at least 50%, wherein the mean number of nocturnal hypoglycaemic episodes is defined as the episodes / week with onset between 10 pm and 6 am, wherein a single CGM-detected hypoglycaemic episode is defined as CGM <3.9 mmol / L for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>3.9 mmol / L) is not reached within this time, a new hypoglycaemic episode is defined as when the next CGM value was below 3.9 mmol / L for at least 15 min, optionally wherein the method reduces the mean number of nocturnal hypoglycaemic episodes by at least 48%, wherein the mean number of nocturnal hypoglycaemic episodes is defined as the episodes / week with onset between 10 pm and 6 am, wherein a single CGM-detected hypoglycaemic episode is defined as CGM <3.0 mmol / L for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>3.9 mmol / L) is not reached within this time, a new hypoglycaemic episode is defined as when the next CGM value was below 3.0 mmol / L for at least 15 min. Item 25. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method reduces the glucose infusion rate (mg / kg / min) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0281] Item 26. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method reduces the total amount of carbohydrates administered per day (g / day) required to avoid hypoglycemia, wherein hypoglycemia is defined as a glucose level of <70 mg / dL (or <3.9 mmol / L).

[0282] Item 27. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to item 26, wherein the carbohydrates administered per day (g / day) are administered by IV infusion, nasogastric tube, gastrostomy, or by the oral route, preferably wherein the carbohydrates are administered via the oral route.

[0283] Item 28. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to item 27, wherein the carbohydrates administered via the oral route are administered as a solid composition, as a liquid composition, or as a gel composition.

[0284] Item 29. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any one of items 26 to 28 wherein the carbohydrate comprises a carbohydrate selected from the group comprising a monosaccharide, a disaccharide, a polyol, an oligosaccharides and a polysaccharide.

[0285] Item 30. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any one of items 26 to 29, wherein the carbohydrate comprises one or more sugars selected from the group comprising glucose, sucrose and fructose. Item 31. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method comprises treatment with dasiglucagon for 4 or 8 weeks, optionally wherein treatment with the standard of care is concomitant.

[0286] Item 32. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein dasiglucagon is administered at a dose of at least 10 pg / h, optionally wherein the dose is increased by 10 pg / h every two hours from the start of treatment to a maximum dose of 70 pg / h, optionally wherein dasiglucagon is administered at a dose of 70 pg / h.

[0287] Item 33. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any one of the preceding items, wherein the method of treatment is used in paediatric patients, optionally wherein the patients are between 3 months and 12 years of age.

[0288] Item 34. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any one of the preceding items, wherein the method of treatment is used in a patient suffering from NME (necrolytic migratory erythema).

[0289] Item 35. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to item 34, wherein the method of treatment comprises reducing the dose of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0290] Item 36. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to item 34, wherein the method of treatment comprises reducing the infusion rate of dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0291] Item 37. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to item 34, wherein the method of treatment comprises discontinuing treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0292] Item 38. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to item 34, wherein the method of treatment comprises interrupting treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof.

[0293] Item 39. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to item 38, wherein treatment with dasiglucagon or a pharmaceutically acceptable salt or solvate thereof is interrupted for a period of 1-2 days, 1-3 days, 1-4 days, 1-5 days, 1-6 days or 1-7 days.

[0294] Item 40. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding items, wherein the method comprises the following steps:

[0295] (i) identifying a patient who has developed NME; and

[0296] (ii) reducing the dose of dasiglucagon and / or reducing the dasiglucagon infusion rate and / or interrupting dasiglucagon treatment for a period and / or discontinuing dasiglucagon treatment.

[0297] EXAMPLES

[0298] The present invention will be further illustrated by the following examples. The following are given by way of illustration and do not limit the scope of the invention in any way.

[0299] Material used

[0300] Synthesis of dasiglucagon

[0301] The glucagon analogues used in the formulations of the present invention can be synthesized using solid phase peptide synthesis techniques well known in the art. By way of example, this may be carried out on a CEM Liberty Peptide Synthesizer using Tentagel S PHB-Thr(tBu) resin (1.13 g, 0.24 mmol / g), COMU as coupling reagent, DMF as the solvent, and Fmoc-chemistry as described above. Pseudoprolines Fmoc-Phe-Thr (MJ Me, Me pro)-OH (in position 6 / 7) and Fmoc-Glu-Ser (MJ, Me, Me pro)-OH (in position 15 / 16) were used in the sequence. Once synthesized, the glucagon analogue may be cleaved from the resin, and the purification was performed on a Gemini-NX column (5 cm, C18, 10 micron) with a 35 ml / min flow of a mixture of buffer A (0.1% aqueous TFA) and buffer B (aqueous solution containing 0.1% TFA and 90% MeCN). Pooled fractions may be lyophilized and re-dissolved in water prior to further purification. The purity of the product may be determined by analytical HPLC and the monoisotopic mass determined by MS.

[0302] Formulation of dasiglucagon

[0303] The below formulation of dasiglucagon (Table 4) is used in the examples described herein. The formulations were be stored in a refrigerator (at a temperature of 2-8°C) until use. pH of the formulation is 6.5.

[0304] Table 4. Formulation of dasiglucagon Example 1:

[0305] This was a combined phase 2 and 3, randomized, multinational trial that evaluated the efficacy and safety of individually titrated dasiglucagon in children >7 days and <12 months of age who had been diagnosed with congenital hyperinsulinism (CHI). The trial comprised 2 parts: a crossover (2 periods, 48 hours each), double-blind, placebo-controlled Part 1, and an openlabel, single-arm Part 2 of 21 days.

[0306] After screening, eligible patients completed a minimum 24-hour Run-in Period to confirm the intravenous (IV) glucose randomization requirement (>10 mg / kg / min). All non-nutritional carbohydrates and carbohydrate fortification of feeds were prohibited during this 24-hour Run-in Period. During Part 1, patients were randomly assigned 1:1 in a double-blind fashion to receive dasiglucagon or placebo for 48 hours, after which they were crossed over to the other trial treatment for an additional 48 hours. At the beginning of Part 1 and at the time of crossover, the investigational medicinal product (IMP, dasiglucagon) was initiated from the starting dose of 10 pg / hour, and the IV glucose infusion rate (GIR) was set to the rate obtained at the end of the Run-in Period and titrated accordingly. After Part 1, patients continued to an open-label Part 2 and received dasiglucagon for 21 days. After Part 2, patients either entered a long-term extension trial to continue dasiglucagon treatment (Trial ZP4207-17106; based on the investigator's discretion) or a 4-week Follow-up Period. The outline of the trial is shown in Figure 2.

[0307] Participants

[0308] Enrolled patients were male or female, >7 days to <12 months of age at screening, with a body weight of >2.0 kg (4.4 lbs), and a diagnosis of CHI based on presence of the following: hyperinsulinemia, hypofattyacidemia, hypoketonemia, and / or glycemic response.

[0309] Exclusion criteria were reviewed at trial entry and before randomization. Patients who were suspected of having a transient form of CHI, born preterm below 34 weeks of gestational age, or with known or suspected brain damage were excluded at trial entry. Patients with hypertension or hypotension, or with metabolic, endocrine, or syndromic causes of hypoglycemia not due to hyperinsulinism were also excluded at trial entry. Additional exclusion criteria were evaluated at the time of randomization, including a mean IV glucose requirement of <10 mg / kg / min to maintain glycemia above 70 mg / dL (3.9 mmol / L) during the 24 hours prior to randomization. Patients were also not randomized if there was use of glucagon or additional enteral glucose within 24 hours prior to randomization.

[0310] Plasma Glucose Monitoring

[0311] As long as the patient received IV glucose, the Glucose Infusion Rate (GIR) was reviewed hourly, based on an hourly Plasma Glucose (PG) check performed by the StatStrip Xpress2 meter. The IV GIR were reviewed, evaluated, and adjusted (if indicated) according to the IV GIR algorithm based on PG levels specified in the Table 5. If IV glucose were stopped, PG will be checked according to local practice, but at least 3 times daily. Blood for PG check were obtained either by finger or heel sticks or by an indwelling peripheral line.

[0312] At each visit, the investigator ensured that Self-Measured Plasma Glucose (SMPG) data were downloaded from the patient's device. The investigator checked for patient compliance in SMPG measurements.

[0313] Table 5. Plasma Glucose levels and action

[0314] Abbreviations: GIR = glucose infusion rate; IV = intravenous Continuous Glucose Monitoring (CGM)

[0315] For Continuous Glucose Monitoring Dexcom G4 and Dexcom G6 were used in the clinical trials described in the examples below.

[0316] Dexcom CGMs (Dexcom G4 and Dexcom G6), configured and labeled for use in the trial, was provided. The Dexcom G4 was be taken off the market by the supplier during 2020 and patients enrolled thereafter were using the Dexcom G6 CGM. Patients using the Dexcom G4 CGM continued using this device throughout the trial and were not switch to the Dexcom G6 device.

[0317] The CGM were started at least 24 hours prior to randomization and were used during Parts 1 and 2 in a blinded mode to evaluate efficacy in terms of hypoglycemic episodes. Short pauses of 1 to 3 days due to skin irritation or discomfort were allowed during Part 2 of the trial after consultation with the investigator. The CGM devices were calibrated and used according to the manufacturer's instructions; the Dexcom G4 were calibrated 2 times per day, the Dexcom G6 did not require calibration.

[0318] At each visit, the investigator ensured that CGM data were downloaded from the patient's device. The procedure for download of CGM data were described in the pharmacy manual / TMM (trial materials manual). The contract research organization (CRO) or delegate handled the device sourcing, configuration for use in this trial, procedures for blinded data extraction, device service, and handling of potential returns.

[0319] Diary

[0320] For patients who were discharged during the trial, the parent(s) / guardian received a paper diary to be completed at home. The investigator instructed the patient's parent(s) / guardian on how to complete the diary. The following information were recorded in the diary:

[0321] • Type and volume of fluid administered through NG tube / gastrostomy

[0322] • Hypoglycaemic events, including related SMPG measurements

[0323] • Concomitant medications

[0324] • AEs Hospitalizations, visits to health care providers or emergency room (ER) / accident & emergency (A&E) department, and visits by paramedics

[0325] Data regarding suspicion of NME and neurological findings

[0326] Diary entries were reviewed at each visit and the review documented in the diary.

[0327] Dosage

[0328] Part 1

[0329] Treatment with investigational medicinal product (IMP, dasiglucagon) was initiated at 10 pg / hour (t = 0). Every 2 hours (t = 2, 4, 6, etc.), the dose was to be increased by an additional 10 pg / hour until either:

[0330] • The patient was totally weaned off IV glucose, or

[0331] • Plasma glucose during the last 2 hours was constantly above 120 mg / dL (6.7 mmol / L), or

[0332] • IV GIR had not decreased despite 2 sequential dose increments of IMP (in this situation, the dose of IMP was to be maintained until the IV GIR could be further decreased or until crossover or the end of Part 1), or

[0333] • The maximum dose of 70 pg / hour was reached, or

[0334] • Adverse events (AEs) emerged that were considered to be related to dasiglucagon (e.g., nausea / change in feeding pattern or increased vomiting) that were limiting further dose escalation.

[0335] The 2-hour dose-adjustment interval allowed IMP levels to approach a steady state before the dose was further increased. The cumulative dose did not exceed 1.26 mg over the first 24 hours and 1.68 mg for the subsequent 24-hour periods. At the time of crossover from the first 48-hour period to the second 48-hour period, the IMP was again to be titrated from the starting dose of 10 pg / hour, and IV GIR was to be set to the rate obtained at the end of the Run-in Period and titrated accordingly. All feedings (administered as parenteral nutrition, by nasogastric [NG] tube, gastrostomy, or normal route), were recorded during this period. Safety assessments were performed throughout the trial. Part 2

[0336] After Part 1, all patients continued in an open-label Part 2 to receive dasiglucagon for an additional 21 days. Since treatment allocation during Part 1 was blinded, all patients were required to initiate dasiglucagon dosing at 10 pg / hour in Part 2, while IV GIR in Part 2 was started at the rate obtained at the end of the Run-in Period. During Part 2, the dasiglucagon dose, the amount and route of administration of carbohydrates (IV GIR, parenteral nutrition, gastric carbohydrate infusions, and carbohydrates from oral feeds) were adjusted at the discretion of the investigator. Plasma glucose was monitored at least hourly to adjust the IV GIR as appropriate and to avoid hypoglycemia. Additional concomitant medications could be introduced at the investigator's discretion if the maximum dose level of dasiglucagon (70 pg / hour) had been reached or if further up-titration was not possible due to undesirable side effects. See below for further details.

[0337] The maximum trial duration for each patient was approximately 81 days, including screening (up to 28 days, including a 24-hour Run-in Period), Part 1 (2x 48-hour period; 96 hours in total), Part 2 (21 days), and the Follow-up Period (28 days). If the patient entered the long-term extension trial (Trial ZP4207-17106) instead of this trial's 4-week Follow-up Period, their maximum trial duration was 54 days. The maximum treatment duration for each patient was 25 days.

[0338] IV glucose infusion rate (GIR)

[0339] The primary efficacy endpoint was the weighted mean IV GIR (glucose infusion rate) in the last 12 hours of each treatment period during Part 1 (Day 1 to 4) (dasiglucagon or placebo administration). The detailed results of the weighted mean IV GIR in the last 12 hours of each treatment period during Part 1 for the FAS Population are given in Table 6.

[0340] The baseline weighted mean (SD) IV GIR in the FAS population at the end of the Run-in Period was 15.71 mg / kg / min (4.538). At Day 2 after dasiglucagon treatment, the weighted mean (SD) IV GIR was 4.33 mg / kg / min (4.922) which represents a mean (SD) CFB of -11.38 mg / kg / min (2.770). At Day 2 after placebo treatment, the weighted mean (SD) IV GIR was 9.51 mg / kg / min

[0341] (5.655) which represents a mean (SD) CFB of -6.20 mg / kg / min (4.574).

[0342] The primary analysis showed that the difference between dasiglucagon (LS mean 4.32 mg / kg / min [95% Cl: 1.04 to 7.60]) and placebo (LS mean 9.53 mg / kg / min [95% Cl : 6.24 to 12.81]) was statistically significant (P = 0.0037; LS means difference -5.21 mg / kg / min [95% Cl: -8.29 to -2.13]). Results are also shown in Figure 3.

[0343] Table 6. Weighted Mean IV GIR (mg / kg / min over the Last 12-Hour Treatment Period) - Part 1

[0344] - Description (FAS Population)

[0345] Abbreviations: FAS =Ful I Analysis Set; GIR = glucose infusion rate; IV = intravenous;

[0346] Max = maximum; Min = minimum; n =number of observations; N = number of patients;

[0347] NA = not applicable; SD = standard deviation a Baseline is IV GIR just before first exposure (Day 1). b Weighted mean calculated from the last 12 hours. Note: Patients are summarized by planned treatment. No imputation of missing data for those descriptive statistics. Day 2 is the second day reported in each treatment period of the crossover.

[0348] Total amount of carbohydrate administered per day

[0349] The key secondary efficacy endpoint was the total amount (g) of carbohydrates administered (regardless of the route) per day during Part 1 of the trial (Day 1 to 4, for each 48-hour treatment period). The total amount (g) of carbohydrates administered per day during Part 1 in the FAS population (Figure 4).

[0350] The mean (SD) total amount of carbohydrates administered during Part 1 after dasiglucagon treatment was 106.7 g / day (53.72) with median of 99.3 g / day. After placebo treatment, the mean (SD) total amount of carbohydrates administered was 139.1 g / day (57.35) with median of 134.2 g / day.

[0351] The LS mean treatment difference (95% Cl) was -30.93 g / day (-56.80 to -5.05) in favour of dasiglucagon, which was statistically significant (P = 0.0238).

[0352] Table 7. Total Amount of Carbohydrates Administration (g / Day) - Part 1 - Description (FAS Population)

[0353] Part 1

[0354] Statistic Dasiglucagon Placebo

[0355] (N = 12) (N = 12)

[0356] N 12 12

[0357] Mean (SD) 106.7 (53.72) 139.1 (57.35)

[0358] Median 99.3 134.2

[0359] Min, Max 45, 239 34, 244

[0360] Abbreviations: FAS = Full Analysis Set; n = number of observations; N = number of patients; SD = standard deviation Part 1

[0361] Statistic Dasiglucagon Placebo

[0362] _ (N = 12) _ (N = 12) _

[0363] Note: Patients were summarized by planned treatment. No imputation of missing data for those descriptive statistics. The total amount of carbohydrates administered was the sum of the last 48 hours of the period divided by the number of days followed.

[0364] Time to Complete Weaning Off IV GIR

[0365] Time to complete weaning off IV GIR (time from first exposure during Part 2 to stop of IV glucose infusion) in the FAS population is displayed in Table . Complete weaning off IV GIR was defined as the first point in time when the patient had been off IV GIR for 12 hours. This definition was based on clinical considerations by CHI experts that 12 hours off IV GIR is considered a reasonable indication that patients can manage without IV GIR, even though some of them may need re-initiation of IV glucose at later point. Only patients without complete weaning off IV GIR at the start of Part 2 were included in this analysis.

[0366] The median (95% Cl) time to complete weaning off IV GIR was 5.8 days (1.0; 7.9) with 2 patients censored at the end of Week 3. At the end of Week 1, 7 patients (58.3%) had weaned off IV GIR; at the end of Week 2 and Week 3, 10 patients (83.33%) had weaned off IV GIR for at least 12 hours.

[0367] Out of the 10 patients,

[0368] • 7 patients had weaned off at trial completion

[0369] • 2 patients had weaned off for at least 12 hours before pancreatectomy (1 of the patients was completely weaned off after the pancreatectomy)

[0370] • 1 patient was on IV glucose at trial completion

[0371] Table 8: Time to Complete Weaning Off IV GIR (Days) - Part 2 - Kaplan-Meier

[0372] Estimates (FAS Population) Statistic Dasiglucagon

[0373] (N = 12)

[0374] Median 95% Cl 5.8 [1.0; 7.9]

[0375] Cumulative Patients Censored, n (%)

[0376] End of Week 1 0 (0.00)

[0377] End of Week 2 0 (0.00)

[0378] End of Week 3 2 (100.0)

[0379] Cumulative Number of Patients with Weaning off IV

[0380] GIR Within Week, n (%)

[0381] End of Week 1 7 (58.33)

[0382] End of Week 2 10 (83.33)

[0383] End of Week 3 10 (83.33)

[0384] Abbreviations: Cl = confidence interval; FAS = Full Analysis Set; GIR = glucose infusion rate;

[0385] IV = intravenous; N= number of patients in analysis population

[0386] Note: Time to complete weaning off IV glucose defined as the first point in time when the patient had been off IV GIR for 12 hours. It was censored at time of pancreatectomy. Start time was first day of Part 2. Percentages calculated by KM estimates.

[0387] Subgroup analysis

[0388] The authors conducted further analysis of a subgroup of the enrolled patients to identify whether patients with an ABCC8 mutation had a reduced glucose infusion rate compared to patients with no CHI mutation. This subgroup was analysed by statistical analysis based on the weighted mean IV glucose infusion rate (GIR) (mg / kg / min). The results are shown in Figure 9.

[0389] Concomitant medication

[0390] Prior and concomitant medications were noted by the parent(s) / guardian in the diary. At least 1 prior medication was reported for 11 patients (91.7%). Prior medications by ATC level 4 (or higher) were most frequently reported as:

[0391] • Solutions for parenteral nutrition, namely glucose (8 patients [66.7%])

[0392] • Drugs for treatment of hypoglycemia, namely diazoxide (7 patients [58.3%])

[0393] • Glucogenolytic hormones, namely glucagon (7 patients [58.3%])

[0394] • Carbohydrates (4 patients [33.3%]): o Glucose (3 patients [25.0%]) o Maltodextrin (1 patient [8.3%])

[0395] Concomitant medications that were ongoing at the start of the trial were reported in 12 patients (100.0%). By ATC level 4 (or higher), the most commonly reported concomitant medications were:

[0396] • Heparin group (9 patients [75.0%])

[0397] • Vitamin D and analogs (5 patients [41.7%])

[0398] • Other drugs for functional gastrointestinal disorders, namely simethicone (4 patients [33.3%])

[0399] • Thiazides, plain, namely chlorothiazide (4 patients [33.3%])

[0400] Concomitant medications which were started or changed during the trial were administered to 3 patients (25.0%) when receiving dasiglucagon during Part 1, 4 patients (33.3%) when receiving placebo during Part 1, and to 12 patients (100.0%) during Part 2.

[0401] During Part 1, only soft paraffin and fat products belonging to ATC level 3 of emollients and protectives, were administered to 2 patients (16.7%) while they were taking placebo. All other drugs were administered to 1 patient (8.3%).

[0402] During Part 2, the most commonly administered concomitant medications by ATC level 4 (or higher) were:

[0403] Anilides, namely paracetamol (9 patients [75.0%])

[0404] Corticosteroids, weak (group I), which groups dermatological preparations, namely hydrocortisone (7 patients [58.3%]) • First-generation cephalosporins (6 patients [50.0%]), mainly cefazolin (5 patients [41.7%])

[0405] • Amides (5 patients [41.7%]), mainly bupivacaine (4 patients [33.3%])

[0406] • Opioid anesthetics (5 patients [41.7%]), mainly fentanyl (4 patients [33.3%])

[0407] • Other general anesthetics (5 patients [41.7%]), mainly propofol (5 patients [41.7%])

[0408] • Other quaternary ammonium compounds (5 patients [41.7%]), such as vecuronium (3 patients [25.0%]) and rocuronium (2 patients [16.7%])

[0409] Other concomitant medications were administered to <4 patients during Part 2.

[0410] Safety

[0411] All 12 enrolled patients developed 1 or more adverse events (AEs) during the trial; 10 patients (83.33%) developed a total of 66 treatment emergent adverse events (TEAEs) while receiving dasiglucagon during Part 1 and Part 2.

[0412] The incidence of all TEAEs reported during the trial during Part 1 was higher during administration of placebo, when 7 patients (58.33%) developed at least 1 TEAE, than during administration of dasiglucagon, where 3 patients (25.00%) developed at least 1 TEAE.

[0413] During Part 2, where all patients received only dasiglucagon, 10 patients (83.33%) developed at least 1 TEAE.

[0414] The majority of the AEs were mild (63 events out of a total of 76 for both parts and both treatment groups) and considered unrelated to the IMP (65 events out of a total of 76 for both parts and both treatment groups).

[0415] The most frequently reported TEAEs were in system organ class:

[0416] Gastrointestinal disorders: 1 patient (8.33%) in Part 1 during dasiglucagon, 1 patient (8.33%) in Part 1 during placebo, 6 patients (50.00%) in Part 2. These were mainly vomiting, constipation and gastrooesophageal reflux disease. Skin and subcutaneous tissue disorders: 1 patient (8.33%) in Part 1 during placebo, 7 patients (58.33%) in Part 2. These were mainly rash papular and dermatitis diaper.

[0417] Metabolism and nutrition disorders: 1 patient (8.33%) in Part 1 during placebo, 5 patients (41.67%) in Part 2. These were mainly hypokalaemia and hyponatraemia.

[0418] During the course of the trial, 1 patient (8.33%) experienced a total of 2 serious adverse events (SAEs) (acute respiratory failure and respiratory distress), which were considered severe and not related to the trial treatment.

[0419] No deaths occurred during this trial. During the course of the trial, no patient discontinued the IMP due to an AE.

[0420] A total of 6 adverse events of special interest (AESIs) were reported in 4 patients. Of these, 4 were related to suspicion of NME (necrolytic migratory erythema, none were confirmed) and 2 were related to hemodynamic changes. During Part 1, while receiving dasiglucagon treatment, no patients experienced an AESL Two patients (16.67%) developed 2 AESIs while receiving placebo during Part 1 (1 event of suspicion of NME, 1 event of post-dose hemodynamic changes). During Part 2, 3 patients (25.00%) experienced 4 AESIs (3 events of suspicion of NME, 1 event of post-dose hemodynamic changes).

[0421] No remarkable abnormalities were found in the biochemistry, hematology, vital signs, ECG, echocardiography and neurological exams. A few cases of clinically significant changes in hemoglobin, electrolytes, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were noted.

[0422] None indicated any trends in aggregated change from baseline (CFB).

[0423] Local tolerability reactions, assessed only for patients during receiving dasiglucagon, were mostly mild and attributed to the adhesive dressing. None of the local reactions were severe, and none were attributed to the trial intervention. At baseline and during the trial, no patients, among those tested, had antidrug antibody (ADA)-positive results.

[0424] Example 2:

[0425] This 2-part, open-label, randomised trial evaluating the efficacy and safety of dasiglucagon in children with CHI was conducted at 11 sites in 4 countries (USA, UK, Germany, and Israel) between Jan 7, 2019, and Oct 5, 2020. Patients were randomly assigned to continue receiving standard of care alone (SoC), or SoC plus dasiglucagon (10-70 pg / hour via an infusion pump) for 4 weeks (Part 1). In Part 2, all patients received SoC plus dasiglucagon for 4 weeks (Figure 5). Participants completing the trial were given the opportunity to continue dasiglucagon treatment in an ongoing long-term extension trial (ZP4207-17106; www.clinicaltrials.gov NCT03941236) conditional on investigator confirmation of a continued positive benefit-risk balance. Patients not continuing into the extension trial attended a follow-up visit 4 weeks after stopping dasiglucagon treatment.

[0426] The trial protocol, consent form and other information provided to participants and parents / legal representatives were approved by independent ethics committees or institutional review boards at participating sites, and by competent authorities. The trial was conducted according to the Declaration of Helsinki and Good Clinical Practice with written informed consent obtained from pa re nts / ca regivers and assent from participants (as required) before trial enrolment. The trial is registered with www.clinicaltrials.gov (NCT03777176).

[0427] Participants

[0428] Eligible participants were aged between 3 months and 12 years (both inclusive), had a body weight >4 kg, a documented diagnosis of CHI, and were experiencing >3 episodes of hypoglycaemia / week (self-measured plasma glucose [SMPG] <3.9 mmol / L) according to the investigator's evaluation. Patients could either have undergone near-total pancreatectomy (>95%) or be treated non-surgically. Patients requiring exogenous insulin, or who had documented HbAic>7% (53 mmol / mol) after near-total pancreatectomy (and within 6 months prior to screening) were excluded. Patients were also excluded if there were significant changes to SoC medications during screening or they had received glucagon in the 24 hours prior to randomization. Doses of all SoC medications were to remain stable throughout the trial. If the participant was receiving octreotide or lanreotide, these must have been used for at least 8 and 16 weeks prior to screening, respectively.

[0429] Table 9: Baseline and demographic characteristics Values are mean (SD) unless otherwise specified; n: number of patients; SoC: standard of care; weight Z-scores (based on the World Health Organization growth charts) were derived using a subject's age and sex.

[0430] Plasma Glucose Monitoring

[0431] During the trial, Self-Measured Plasma Glucose (SMPG) assessments (StatStrip XpressZ) were be performed regularly (at least 3 times daily, preferably before meals, as instructed by the investigator) to evaluate efficacy.

[0432] At each visit, the investigator ensured that SMPG data were downloaded from the patient's devices. The investigator checked for patient compliance in number of daily SMPG measurements and that hypoglycemic episodes are recorded in the diary.

[0433] Continuous Glucose Monitoring (CGM)

[0434] Additionally, CGM were used (Dexcom G4) in a blinded manner to evaluate efficacy in terms of hypoglycemic episodes. The CGM were supplied for use throughout the trial, and continuous glucose monitoring was required for the 2 weeks up to randomization, during Week 2-4 of Treatment Period 1, and during Week 6-8 of Treatment Period 2. Short pauses of 1-3 days due to skin irritation or discomfort were allowed after consultation with the investigator.

[0435] At each visit, the investigator ensured that CGM data were downloaded from the patient's devices. Dexcom G4 CGMs configured and labeled for use in this trial were provided. Each CGM device were calibrated and used according to the manufacturer's instructions.

[0436] The contract research organization (CRO) or delegate handled device sourcing, configuration for use in the trial, procedures for blinded data extraction, device service, and return handling.

[0437] Diary

[0438] The patient's parent(s) / guardian was provided with a paper diary at all visits except at Visit 7 and the Follow-up Visit. The investigator instructed the patient's parent(s) / guardian on how to complete the diary. The diary was completed throughout the trial until the end of treatment visit (Visit 7). The following information was recorded in the diary:

[0439] • Type and volume of fluid administered through NG tube / gastrostomy (if applicable)

[0440] • Hypoglycemic events, including related SMPG measurements

[0441] • Concomitant medications

[0442] • AEs

[0443] • Hospitalizations, visits to health care providers or ER, and visit by paramedics

[0444] • Data regarding suspicion of NME and neurological findings

[0445] Diary entries were reviewed at each visit and the review documented in the diary.

[0446] Randomisation

[0447] Patients were randomly assigned (using an interactive web response system) in a 1:1 ratio using a block randomisation scheme stratified by region (US / non-US) to continue receiving SoC alone, or SoC plus dasiglucagon for 4 weeks (Part 1). In Part 2, all patients received SoC plus dasiglucagon for 4 weeks (Figure 1). Stratification addressed regional differences in CHI treatment (e.g., differences between North America and Europe in the frequency of sub-total pancreatectomy (<95%) for diffuse CHI). The trial was open label apart from continuous glucose monitoring (CGM) results which were blinded to all patients, pa re nts / ca regivers, and trial personnel until after database lock.

[0448] Procedures

[0449] Following screening, eligible patients underwent a 2-week blinded CGM period using a Dexcom G4 device (Dexcom Inc., San Diego, CA, USA) to establish baseline glycemic profiles. This period was also used to confirm eligibility criteria frequency of >3 episodes of hypoglycaemia (SMPG <3.9 mmol / L) per week via SMPG measurements using a StatStrip Xpress 2 glucose meter (Nova Biomedical, Waltham, MA, USA).

[0450] At the beginning of Part 1 (Week 1), all patients were admitted as inpatients for 1-2 days. Patients assigned to SoC plus dasiglucagon treatment received dasiglucagon infusion (4 mg / mL: Zealand Pharma, Spborg, Denmark) via an Accu-Chek Spirit Combo infusion pump (Hoffman-La Roche AG, Basel, Switzerland). Infusion was initiated at 10 pg / h, with the dose increased by 10 pg / h every 2 hours to a maximum rate of 70 pg / h unless the patient was weaned off gastric dextrose infusion and / or glucose fortified feeds, PG levels during the previous 2 hours were consistently >6.7 mmol / L, or adverse events considered related to dasiglucagon (e.g., nausea and vomiting) limited further dose escalation. The dose increase in dasiglucagon was restricted to achieve the treatment objectives of obtaining a SMPG value between 3.9-6.7 mmol / L while approaching a normal feeding regimen according to age.

[0451] In Part 2, patients originally assigned to receive SoC alone in Part 1 were admitted as inpatients for the first 1 to 2 days of Part 2 (Week 5) and had dasiglucagon infusion initiated and titrated as described above. Regardless of whether dasiglucagon was initiated during Part 1 or 2, SoC medications for CHI were to be kept constant throughout the trial. Adjustments to gastric and oral feeds were permitted.

[0452] All patients and / or their parent(s) / guardian were trained and supervised in the use of the infusion pump, CGM device and hand-held glucose meter, with SMPG measurements recorded in a patient diary. Each patient was required to have a SMPG measurement at least 3-times / day (preferably before main meals) and when hypoglycaemia was suspected. CGM was used in a blinded manner with glucose measurements not available to patients or investigators during the study period. The blinded CGM device was worn by patients during the entire trial including the 2-week period prior to randomization. Short periods of CGM discontinuation for 1-3 days were allowed on investigator discretion in the event of skin irritation, discomfort, or other valid reasons.

[0453] Dosage

[0454] Dasiglucagon treatment was initiated at 10 pg / hour (t=0). Every 2 hours (t=2, 4, 6, etc.), the dose was increased by an additional 10 pg / hour until either:

[0455] (i) The patient was weaned off entirely from gastric dextrose infusion and / or glucose fortified feeds. Plasma glucose during the previous 2 hours was consistently above 120 mg / dL

[0456] (6.7 mmol / L).

[0457] (iii) The maximum investigational medicinal product infusion rate of 70 pg / hour was reached.

[0458] (iv) Adverse events emerged that were considered to be related to dasiglucagon (e.g., nausea and vomiting) and limited further dose escalation.

[0459] The dose of dasiglucagon was not escalated beyond reaching the treatment objectives of PG in the range of 70-120 mg / dL (3.9-6.7 mmol / L) while approaching a normal feeding regimen according to age.

[0460] The 2-hour dose-adjustment interval allowed plasma drug levels to approach approximately steady state before the dose was further increased. The maximum cumulative dose over the first 24 hours was 1.26 mg.

[0461] After the first 24 hours, the dose of dasiglucagon could still be modified to optimize each patient's treatment and to reduce gastric dextrose infusions. The maximum dose of dasiglucagon was 70 pg / hr, corresponding to a maximum of 1.68 mg per day.

[0462] Percent time in hypoglycemia

[0463] The percent time in CGM-detected hypoglycaemia defined as <70 mg / dL was expressed for the full analysis set (FAS) population. At baseline, the mean (SD) results were similar for both treatment groups: 20.74% (8.855) in the dasiglucagon + standard of care group, and 22.17% (13.382) in the standard of care only group.

[0464] During Treatment Period 1 (Weeks 2-4), the CGM percent time in hypoglycaemia decreased in the dasiglucagon + standard of care group by mean (SD) change from baseline -9.91% (10.119) to a mean (SD) of 11.77% points (9.248), i.e., by 47.78%, and in the standard of care only group there was a mean (SD) change from baseline -1.95% (10.186) to a mean (SD) of 20.22% (10.034). During Treatment Period 2, when all patients received dasiglucagon + standard of care, the percent time in hypoglycemia further decreased during Weeks 6-8 by mean (SD) -13.27% (10.120) to mean (SD) 8.64% (6.011).

[0465] Posthoc analysis using generalized linear model with log link and normal distribution showed that the difference between dasiglucagon + standard of care (LS mean 10.28% [95% Cl of LS mean: 7.18 to 14.72]) and the standard of care only group (LS mean 19.26% [95% Cl of LS mean: 15.61 to 23.77]) showed strong evidence with low P value (P = 0.0017) and an estimate of LS means ratio of 0.53 (95% Cl of LS means ratio: 0.36 to 0.79) in Treatment Period 1. The results are also displayed in Figure 6 and the table below. Of note, patients switching to dasiglucagon in Treatment Period 2 appear to achieve similar reductions during Treatment Period 2 as those achieved for patients on dasiglucagon + standard of care during Treatment Period 1.

[0466] Table 10. CGM Percent Time in Hypoglycemia by Treatment Period (FAS Population)

[0467] Abbreviations: CGM = continuous glucose monitoring; FAS = full analysis set; n = number of observations; N = number of patients; NA = not applicable; SD = standard deviation

[0468] For both treatment periods, baseline was the value assessed during 14 days before randomization. Note: Patients are summarized by planned treatment. No imputation of missing data.

[0469] Hypoglycemia was defined as CGM <70 mg / dL.

[0470] Hypoglycaemia event rates

[0471] Rate of CGM-detected hypoglycemic episodes, defined as CGM <70 mg / dL for 15 minutes or more per week, was descriptively analyzed for the full analysis set (FAS) population is summarized below. The mean (SD) baseline values were 36.17 (13.263) in the dasiglucagon + standard of care group and 43.16 (23.314) in the standard of care only group.

[0472] During Treatment Period 1, the rate over Weeks 2-4 decreased in both groups, but the decrease was less pronounced in the standard of care only group when compared to the dasiglucagon + standard of care: in the dasiglucagon + standard of care group, the mean (SD) change from baseline was -14.37 (21.184) to the mean (SD) rate of 21.71 (14.179), i.e., 39.73%; in the standard of care only group, the mean (SD) change from baseline was -6.28 (20.565) to the mean (SD) rate of 36.88 (15.023).

[0473] Results of the posthoc negative binomial regression analysis show strong evidence of the difference between the treatment groups after Treatment Period 1 with low P value (P = 0.0029) and event rate ratio (0.57 [95% Cl of event rate ratio 0.39 to 0.83]); the event rate for the dasiglucagon + standard of care was 25.97 (95% Cl of event rate: 19.83 to 34.02), the event rate for the standard of care only group was 45.49 (95% Cl of event rate: 35.36 to 58.52). Results are displayed in Figure 7 and the table below. Of note, patients switching to dasiglucagon in Treatment Period 2 appear to achieve similar reduction during Treatment Period 2 as those achieved for patients on dasiglucagon + standard of care during Treatment Period 1.

[0474] Table 11. Rate of CGM-detected Hypoglycemic Episodes (events) - Treatment Period 1 (FAS Population) Trial Visit Dasiglucagon + Standard of Care Standard of Care Only

[0475] (N = 16) (N = 16)

[0476] Statistic Change from Change from

[0477] Observed baseline Observed baseline

[0478] Baseline n 15 NA 16 NA

[0479] Mean (SD) 36.17 (13.263) NA 43.16 (23.314) NA Median 34.50 NA 38.75 NA

[0480] Min, Max 16.0, 68.0 NA 12.0, 89.5 NA

[0481] Week l n 15 15 16 16

[0482] Mean (SD) 24.33 (12.028) -11.83 (17.802) 39.94 (19.126) -3.22 (21.384) Median 23.00 -14.00 36.00 -1.00

[0483] Min, Max 2.0, 44.0 -47.0, 16.0 10.0, 78.0 -68.0, 25.0

[0484] Week 2 n 15 15 15 15

[0485] Mean (SD) 21.60 (16.093) -14.57 (22.007) 36.40 (16.847) -4.43 (21.735) Median 16.00 -10.50 34.00 -5.00

[0486] Min, Max 3.0, 51.0 -58.0, 20.5 14.0, 78.0 -67.5, 25.0

[0487] Week 3 n 16 15 16 16

[0488] Mean (SD) 20.94 (20.888) -14.30 (27.022) 37.75 (16.937) -5.41 (21.876) Median 15.50 -18.50 36.50 -3.50

[0489] Min, Max 3.0, 77.0 -50.0, 46.5 4.0, 66.0 -41.5, 41.0

[0490] Week 4 n 16 15 16 16 Trial Visit Dasiglucagon + Standard of Care Standard of Care Only

[0491] (N = 16) (N = 16)

[0492] Statistic Change from Change from

[0493] Observed baseline Observed baseline

[0494] Mean (SD) 23.94 (13.626) -14.23 (18.104) 38.75 (18.314) -4.41 (17.434)

[0495] Median 19.00 -16.50 34.50 -4.00

[0496] Min, Max 5.0, 54.0 -49.0, 9.5 2.0, 73.0 -47.5, 26.5

[0497] Weeks 2-4 n 16 15 16 16

[0498] Mean (SD) 21.71 (14.179) -14.37 (21.184) 36.88 (15.023) -6.28 (20.565)

[0499] Median 16.83 -15.50 31.67 -4.50

[0500] Min, Max 5.7, 56.0 -52.3, 25.5 6.7, 69.0 -52.2, 25.2

[0501] Abbreviations: CGM = continuous glucose monitoring; FAS = full analysis set; n = number of observations; N = number of patients; NA = not applicable; PG = plasma glucose; SD = standard deviation

[0502] Baseline was the value recorded during the 14 days before randomization.

[0503] Note: Patients are summarized by planned treatment. No imputation of missing data. Rate of hypoglycemic episodes were defined as number of CGM -detected episodes perweek. A single CGM-detected hypoglycemia episode was defined as CGM <70 mg / dL for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70mg / dL) was not reached within this time. A new episode of hypoglycemia was reported when the next CGM values below 70 mg / dL was measured for at least 15 minutes.

[0504] Percent time in clinically significant hypoglycemia

[0505] A posthoc analysis of the percent time in CGM-detected clinically significant hypoglycaemia defined as <54 mg / dL was expressed for the full analysis set (FAS) population. The baseline was calculated as average percent time <54 mg / dL during 14 days before randomization. The mean (SD) baseline time <54 mg / dL was 5.90% (4.022) in the dasiglucagon + standard of care group and 7.42% (5.076) in the standard of care only group.

[0506] During Treatment Period 1 in the time period of Weeks 2-4, the CGM percent time <54 mg / dL decreased from baseline to the mean (SD) 3.23% (2.609) for the dasiglucagon + standard of care group corresponding to a mean (SD) change from baseline of -2.78% (4.846), i.e., 47.12%; for the standard of care only group there was a decrease from baseline to a mean (SD) of 6.27% (3.435) with a mean (SD) change from baseline of -1.15% (4.663).

[0507] The posthoc generalized linear model with log link and normal distribution analysis of the data found strong evidence of the difference between treatment groups (LS mean [95% Cl of LS mean]: 2.99 [1.86 to 4.80] for dasiglucagon + standard of care; 6.09 [4.82 to 7.69] for standard of care only) with low P value (P = 0.0061) and low estimate of LS means ratio (0.49 [95% Cl of LS means ratio: 0.30 to 0.82]).

[0508] Table 12. Posthoc CGM Percent Time in Clinically Significant Hypoglycemia During Treatment

[0509] Period 1 (FAS Population)

[0510] Trial Visit Dasiglucagon + Standard of Care Standard of Care Only

[0511] (N = 16) (N = 16)

[0512] Statistic Change from Change from

[0513] Observed baseline (CFB) Observed baseline (CFB)

[0514] Baseline3n 15 NA 16 NA

[0515] Mean (SD) 5.90 (4.022) NA 7.42 (5.076) NA

[0516] Median 4.82 NA 6.83 NA

[0517] Min, Max 1.3, 15.0 NA 0.7, 16.8 NA

[0518] Week lbn 15 15 16 16

[0519] Mean (SD) 3.70 (2.510) -2.20 (3.473) 7.16 (4.802) -0.26 (5.152) Trial Visit Dasiglucagon + Standard of Care Standard of Care Only

[0520] (N = 16) (N = 16)

[0521] Statistic Change from Change from

[0522] Observed baseline (CFB) Observed baseline (CFB)

[0523] Median 3.34 -1.38 6.98 -0.85

[0524] Min, Max 0.1,10.2 -8.3, 5.3 0.0,15.4 -8.1,11.7

[0525] Week 2bn 15 15 15 15

[0526] Mean(SD) 3.51(3.661) -2.40(5.461) 6.78(4.224) -0.59(5.016)

[0527] Median 1.92 -1.66 6.10 0.23

[0528] Min, Max 0.2, 11.7 -13.5, 5.0 0.9, 14.5 -14.9, 6.7

[0529] Week 3bn 16 15 16 16

[0530] Mean(SD) 3.20(3.392) -2.64(5.222) 5.12(2.803) -2.30(4.754)

[0531] Median 1.84 -2.13 4.77 -1.76

[0532] Min, Max 0.0, 12.2 -14.5, 7.4 0.3, 9.8 -10.9, 9.1

[0533] Week 4bn 16 15 16 16

[0534] Mean(SD) 2.95(1.752) -3.11(4.371) 6.68(5.027) -0.74(5.847)

[0535] Median 2.41 -1.98 5.16 -1.15

[0536] Min, Max 0.9, 6.4 -12.2, 2.6 0.5, 17.2 -9.9, 13.5

[0537] Week 2-4cn 16 15 16 16

[0538] Mean(SD) 3.23(2.609) -2.78(4.846) 6.27(3.435) -1.15(4.663)

[0539] Median 2.16 -1.41 4.88 -0.67

[0540] Min, Max 0.7, 9.1 -13.4,4.2 1.3,12.6 -11.3,6.6 Trial Visit Dasiglucagon + Standard of Care Standard of Care Only

[0541] (N = 16) (N = 16)

[0542] Statistic Change from Change from

[0543] Observed baseline (CFB) Observed baseline (CFB)

[0544] Abbreviations: CGM = continuous glucose monitoring; FAS = full analysis set; n = number of observations; N = number of patients; NA = not applicable; SD = standard deviation a Baseline was average percent time below 54 mg / dL during 14 days before randomization. b Weekly value was percent time below 54 mg / dL during the corresponding week. c Average weekly percent time below 54 mg / dL across the last 3 weeks of treatment period.

[0545] Note: Patients are summarized by planned treatment. Percent time below 54 mg / dL (3.0 mmol / L) as measured with CGM. No imputation of missing data. Average weekly value is calculated as summing time below 54 mg / dL and dividing by number of weeks in corresponding period.

[0546] Clinically significant hypoglycemia event (episode) rates

[0547] Rate of clinically significant CGM-detected hypoglycemic episodes, defined as CGM <54 mg / dL for 15 minutes or more per week, was descriptively analyzed for the FAS population in Treatment Period 1 as a posthoc analysis, and in Treatment Period 2 when all patients received dasiglucagon + standard of care, as a preplanned analysis.

[0548] The mean (SD) baseline values were 13.87 (8.800) in the dasiglucagon + standard of care group and 18.22 (11.125) in the standard of care only group. During Treatment Period 1, the rate over Weeks 2-4 decreased in both groups. In the dasiglucagon + standard of care group, the mean (SD) change from baseline was -5.11 (12.565), i.e., by 36.84%, to the mean (SD) rate of 8.48 (6.556); in the standard of care only group, the mean (SD) change from baseline was - 3.72 (10.787) to the mean (SD) rate of 14.50 (6.248). During Treatment Period 2, when all patients received dasiglucagon + standard of care, during Weeks 6-8 the rate of clinically significant CGM-detected hypoglycemic episodes decreased by mean (SD) - 8.51 (9.941) to the mean (SD) rate of 7.78 (5.226).

[0549] Posthoc negative binominal regression analysis showed that the difference between the treatment groups (dasiglucagon + standard of care event rate of 10.58 [95% Cl of event rate: 7.79 to 14.37]; standard of care only event rate of 18.74 [95% Cl of event rate: 14.09 to 24.93]) showed strong evidence with low P value (P = 0.0075) and low event rate ratio (0.56 [95% Cl of event rate ratio 0.37 to 0.86]).

[0550] Results are displayed in Figure 8 and the table below.

[0551] Table 13. Posthoc CGM event rate in Clinically Significant Hypoglycemia During Treatment Period 1 (FAS Population)

[0552] Trial Visit Dasiglucagon + Standard of Care Standard of Care Only

[0553] (N = 16) (N = 16)

[0554] Statistic Change from Change from

[0555] Observed baseline Observed baseline

[0556] Baseline3n 15 NA 16 NA

[0557] Mean (SD) 13.87 (8.800) NA 18.22 (11.125) NA

[0558] Median 11.00 NA 18.25 NA

[0559] Min, Max 4.5, 33.0 NA 3.0, 38.5 NA

[0560] Week l n 15 15 16 16

[0561] Mean (SD) 10.13 (5.514) -3.73 (8.938) 16.38 (10.601) -1.84 (10.285) Median 9.00 -3.00 14.50 -2.75

[0562] Min, Max 0.0, 22.0 -21.0, 10.5 0.0, 40.0 -20.0, 19.5 Trial Visit Dasiglucagon + Standard of Care Standard of Care Only

[0563] (N = 16) (N = 16)

[0564] Statistic Change from Change from

[0565] Observed baseline Observed baseline

[0566] Week 2 n 15 15 15 15

[0567] Mean (SD) 8.67 (7.650) -5.20 (13.485) 15.60 (9.006) -2.50 (11.885)

[0568] Median 6.00 -5.00 13.00 -1.50

[0569] Min, Max 1.0, 29.0 -30.0, 17.5 3.0, 34.0 -35.5, 12.5

[0570] Week 3 n 16 15 16 16

[0571] Mean (SD) 9.00 (9.423) -4.33 (14.375) 13.06 (6.875) -5.16 (12.964)

[0572] Median 6.50 -5.00 12.50 -4.75

[0573] Min, Max 0.0, 36.0 -30.0, 24.5 1.0, 29.0 -25.5, 26.0

[0574] Week 4 n 16 15 16 16

[0575] Mean (SD) 8.31 (4.453) -5.80 (10.951) 15.81 (9.759) -2.41 (12.099)

[0576] Median 6.50 -4.00 13.50 -1.50

[0577] Min, Max 3.0, 21.0 -26.0, 9.5 1.0, 35.0 -24.5, 23.5

[0578] Weeks 2-4 n 16 15 16 16

[0579] Mean (SD) 8.48 (6.556) -5.11 (12.565) 14.50 (6.248) -3.72 (10.787)

[0580] Median 6.17 -3.17 13.00 -2.33

[0581] Min, Max 3.0, 28.7 -28.7, 17.2 3.0, 27.0 -28.5, 13.3

[0582] Abbreviations: CGM = continuous glucose monitoring; FAS = full analysis set; n = number of observations; N = number of patients; NA = not applicable; PG = plasma glucose; SD = standard deviation a Baseline was the value recorded during the 14 days before randomization.

[0583] Note: Patients are summarized by planned treatment. No imputation of missing data. Rate of clinically significant hypoglycemic episodes were defined as number of CGM-detected episodes per week. A single CGM-detected clinically significant hypoglycemia episode was defined as CGM <54 mg / dL for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70 mg / dL) was not reached within this time. A new episode of hypoglycemia was reported when the next CGM value below 54 mg / dL was measured for at least 15 minutes.

[0584] Nocturnal hypoglycaemia

[0585] Many episodes of hypoglycaemia occur at night, specifically during sleep. The investigators have conducted further analysis to identify how dasiglucagon affects nocturnal hypoglycaemia.

[0586] CGM demonstrates dasiglucagon-associated reduction in the risk of nocturnal hypoglycaemia, see Table 14 below.

[0587] Table 14. CGM measures of hypoglycaemia

[0588] Measure Mean observed values Ratioc

[0589] (Weeks 2-4: Dasiglucagon + SoC / SoC)

[0590] Dasiglucagon Dasiglucagon SoC SoC

[0591] + SoC + SoC (Baseline) (Weeks

[0592] (Baseline) (Weeks 2-4) n = 16 2-4) n = 15 n = 16 n = 16

[0593] Nocturnal 11.9 5.9 11.8 9.5 0.39 [0.21; hypoglycaemia 0.75],

[0594] <3.9 mmol / Lbp=0.0047f

[0595] (70 mg / dL) Nocturnal 3.9 2.0 4.9 3.5 0.63 [0.32; hypoglycaemia 1-24],

[0596] <3.0 mmol / Lbp=0.1775f

[0597] (54 mg / dL)

[0598] Abbreviations: SoC: standard of care; CGM: continuous glucose monitoringbMean number of nocturnal hypoglycaemia events / week (events with onset between 10 pm (excluded) and 6 am (excluded)); a single CGM-detected hypoglycaemia episode is defined as CGM <3.9 mmol / L; 70 mg / dL (or <3.0 mmol / L; 54 mg / dL) for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>3.9 mmol / L) is not reached within this time. A new episode of hypoglycaemia is defined as when the next CGM value was below 3.9 mmol / L; 70 mg / dL (or <3.0 mmol / L; 54 mg / dL) for at least 15 min;cpost-hoc analyses: dEstimate of least squares (LS) means ratio;eEstimate of geometric mean ratio;fEstimate of event rate ratio.

[0599] Subgroup analysis

[0600] The authors have conducted further analysis of subgroups of the enrolled patients to identify which patients benefit the most from treatment with dasiglucagon. Subgroups were analysed by statistical analysis based on the patients involved and the percent time <70 mg / dL (<3.9 mmol / L) measured by continuous glucose monitoring (CGM). The results are shown in Figures 11-15. A forest plot of the results is shown in Figure 10.

[0601] Subgroups included:

[0602] • Groups defined by age (figure 11).

[0603] • Groups defined by body weight (figure 12).

[0604] • Groups defined by whether the patients received diazoxide treatment at baseline (figure 13). For the analysis depicted in figure 13 the term SOC did not include treatment with diazoxide, i.e., the treatment groups "no" received SOC at baseline which did not include diazoxide treatment. The treatment groups "yes" received diazoxide treatment at baseline.

[0605] • Groups defined by whether the patients received treatment with a somatostatin analogue at baseline (figure 14). For the analysis depicted in figure 14 the term SOC did not include treatment with diazoxide. Le., the treatment groups "no" received SOC at baseline which did not include diazoxide treatment. The treatment groups "yes" received treatment with a somatostatin analogue at baseline. Somatostatin analogue in the present context include octreotide and lanreotide.

[0606] • Groups defined by pancreatectomy at baseline (figure 15).

[0607] Concomitant medication

[0608] Prior and concomitant medications were noted by the parent(s) / guardian in the diary.

[0609] At least 1 prior medication was reported for 16 patients (50.00%) overall, roughly equally between the 2 treatment groups; dasiglucagon + standard of care: 9 patients (56.30%), standard of care only: 7 patients (43.80%). The frequencies of prior medications were largely similar between the treatment groups. Prior medications by ATC level 4 (or higher) were most frequently reported as:

[0610] • propionic acid derivatives (5 patients [15.60%]), namely ibuprofen (5 patients [15.60%])

[0611] • somatostatin and analogues (5 patients [15.60%]) with octreotide having been taken by 5 patients (15.60%) and lanreotide by 2 patients (6.30%)

[0612] • Other frequent prior medications each administered with overall frequency 9.40% (3 patients) included: o anilides (namely paracetamol) o drugs for treatment of hypoglycemia (namely diazoxide) o glycogenolytic hormones (namely glucagon) o selective immunosuppressants (namely sirolimus)

[0613] Concomitant medications that were ongoing at the start of the trial were reported in almost all patients (31 patients [96.90%]). By ATC level 4 (or higher), the most commonly reported concomitant medications were: somatostatin analogues including octreotide and lanreotide (20 patients [62.50%]) drugs for treatment of hypoglycemia (10 patients [31.30%]) glycogenolytic hormones (8 patients [25.00%]) proton pump inhibitors (8 patients [25.00%])

[0614] The frequencies of concomitant medications ongoing at the start of the trial were mostly comparable between treatment groups. The exceptions were in administration of:

[0615] • proton pump inhibitors: 6 patients (37.50%) in the dasiglucagon + standard of care group; 2 patients (12.50%) in the standard of care only group

[0616] • thiazides, plain: 4 patients (25.00%) in the dasiglucagon + standard of care group;

[0617] 1 patient (6.30%) in the standard of care only group

[0618] Concomitant medications which were started or changed during the trial were administered to 27 patients (84.4%). Most of these belong to ATC level 4 (or higher):

[0619] • propionic acid derivatives (namely ibuprofen), 8 patients (25.00%)

[0620] • anilides (namely paracetamol), 6 patients (18.80%)

[0621] • corticosteroids, weak (group 1), namely hydrocortisone, 6 patients (18.80%)

[0622] • glycogenolytic hormones (specifically glucagon), 3 patients (9.40%) overall (the patients were in the dasiglucagon + standard of care group [18.80%]); these include patient 102506 who received glucagon 0.25 mg intramuscularly as needed before the study and the dose has changed to 0.5 mg on Treatment Day 41, patient 103501 who received glucagon 5 mg subcutaneously once to treat hypoglycemic episode on Treatment Day 5, and patient 203501 who received glucagon 250 pg intramuscularly once to treat hypoglycemic episode on Treatment Day 47

[0623] • somatostatin and analogues (namely octreotide) 2 patients (6.30%) overall, 1 in each treatment group (6.30% per group)

[0624] Largely, the frequencies of concomitant medications starting during the trial were similar, although the overall numbers were rather small. A notable exception can be seen in hydrocortisone administration, which was given to 5 patients (31.30%) in the dasiglucagon + standard of care group and only 1 patient in the standard of care only group (6.30%).

[0625] Safety

[0626] Of all 32 patients who received dasiglucagon during both treatment periods, 27 patients (84.38%) developed a total of 128 treatment emergent adverse events (TEAEs). During Treatment Period 1, 50 TEAEs were reported for 87.50% of patients in the dasiglucagon + standard of care group versus 11 events reported for 50% of patients in the standard of care group. Vomiting was reported more frequently in the dasiglucagon treatment group compared with those receiving standard of care treatment, consistent with this gastrointestinal event being well-known side effect of glucagon treatment. More cases of skin and subcutaneous tissue disorders (including 2 confirmed cases of necrolytic miratory erythema, NME) were reported for dasiglucagon relative to standard of care treatment. No skin-related events led to permanent discontinuation of dosing. An imbalance of events was noted within the MedDRA system organ class (SOC) of infections and infestations during the initial 4-week trial period; 12 events in the dasiglucagon + standard of care group versus 4 events in the standard of care group.

[0627] During the course of the trial, 4 patients experienced a total of 6 SAEs. During Treatment Period 1, serious adverse events (SAEs) were reported for 2 (12.5%) patients in the dasiglucagon + standard of care group and 1 (6.25%) patient in the standard of care only group. During Treatment Period 2, 2 (6.25%) patients developed a total of 3 SAEs. None of the reported SAEs were considered related to dasiglucagon treatment.

[0628] No deaths occurred during this trial.

[0629] One patient discontinued the investigational medicinal product prematurely due to a TEAE of hyperglycaemia. This moderate, non-serious TEAE developed on trial Day 46 during Treatment Period 2 and was considered probably related to the investigational medicinal product.

[0630] A total of 8 adverse events of special interest (AESIs) were reported in 7 patients. Of these, 5 were related to suspicion of necrolytic migratory erythema (NME) (of these 2 were later confirmed) and 3 were related to neurological events (1 of them was reported before the start of the investigational medicinal product).

[0631] No remarkable abnormalities were found in the biochemistry, hematology, vital signs, ECG, echocardiography and neurological exams. A few cases of clinically significant increases in ALT and AST were noted for dasiglucagon + standard of care; all were assessed as not / unlikely related to investigational medicinal product.

[0632] Local tolerability reactions, assessed only for patients in dasiglucagon + standard of care group, were mostly mild and attributed to the adhesive dressing. None of the local reactions were severe, and none were attributed to the trial intervention.

[0633] At baseline, 1 patient (3.3%) had ADA-positive results, and this patient's titer increased during the trial (treatment-boosted ADA). Additionally, 6 patients (20.7%) had treatment-induced ADA found during the trial.

[0634] Example 3: Dasiglucagon safety in paediatric participants with CHI

[0635] Background: Congenital hyperinsulinism (CHI) is a rare disorder, which causes persistent and severe hypoglycaemia in infants and children. CHI can be treated with glucagon, but long-term use is challenging owing to its instability in aqueous solution. Dasiglucagon, a stable glucagon analogue designed for long-term use as a subcutaneous continuous infusion, is in clinical development. Here, we present dasiglucagon safety results in participants treated for up to 8 weeks from 2 completed trials.

[0636] Methods: Trial 17103 (NCT04172441) (Example 1) included neonates and infants with CHI aged 7-364 days. In Part 1 (Pl), participants were randomized to receive dasiglucagon or placebo (48 hours each) in a double-blind, crossover design. In open-label Part 2 (P2), all participants received dasiglucagon for 21 days. Open-label trial 17109 (NCT03777176) (Example 2) included children with CHI aged 3 months to 12 years. In Pl participants were randomized to receive standard of care (SoC) or dasiglucagon+SoC for 4 weeks. In P2 all participants received dasiglucagon+SoC for 4 weeks. Safety analysis comprised treated participants.

[0637] Results: In trials 17103 (n=12) and 17109 (n=32) respectively, participants' median age was 1.3 months and 4.3 years; 83.3% and 50.0% were male. Most participants had not had a pancreatectomy (17103: 91.7%; 17109: 65.6%). Table 15 summarizes safety results. In both trials, most treatment-emergent adverse events (TEAEs) were mild. Hemodynamic events were infrequent; no clinically relevant abnormalities were observed for blood pressure and heart rate. Necrolytic migratory erythema (NME) was confirmed in 2 participants.

[0638] Table 15. Summary of safety results aAcute respiratory failure;bvascular device infection, localised infection;Chypoglycemia;dfolliculitis, H1N1 influenza, hyperglycemia;ehyperglycemia

[0639] Conclusions: Dasiglucagon was well tolerated over 8 weeks, with a good and expected safety profile, confirming known class effects; no new safety concerns were identified. A trial investigating dasiglucagon's long-term safety profile is ongoing.

[0640] REFERENCES

[0641] Arnoux JB, Verkarre V, Saint-Martin C, et al. Congenital hyperinsulinism: current trends in diagnosis and therapy. Orphanet J Rare Dis 2011; 6: 63.

[0642] Arya VB, Senniappan S, Demirbilek H, et al. Pancreatic endocrine and exocrine function in children following near-total pancreatectomy for diffuse congenital hyperinsulinism. PLoS One 2014; 9(5): e98054.

[0643] Banerjee I, Raskin J, Arnoux JB, et al. Congenital hyperinsulinism in infancy and childhood: challenges, unmet needs and the perspective of patients and families. Orphanet J Rare Dis 2022; 17(1): 61.

[0644] Cederblad F, Ewald U, Gustafsson J. Effect of glucagon on glucose production, lipolysis, and gluconeogenesis in familial hyperinsulinism. Harm Res 1998; 50(2): 94-8.

[0645] Concise Dictionary of Biomedicine and Molecular Biology, Juo, Pei-Show, 2nd ed., 2002, CRC Press

[0646] De Cosio AP, Thornton P. Current and Emerging Agents for the Treatment of Hypoglycemia in Patients with Congenital Hyperinsulinism. Paediatr Drugs 2019; 21(3): 123-36. De Leon DD, Banerjee I, Kendall DM, Birch S, B0ge E, Ivkovic J, Thornton PS. Dasiglucagon significantly reduces requirement for intravenous glucose in children with congenital hyperinsulinism ages 7 days to 12 months. Harm Res Paediatr 2022; 95(suppl 2): 61

[0647] "Handbook of Pharmaceutical Excipients", Rowe C. R.; Paul J. S.; Marian E. Q., sixth Edition

[0648] Hovelmann U, Bysted BV, Mouritzen U, et al. Pharmacokinetic and Pharmacodynamic Characteristics of Dasiglucagon, a Novel Soluble and Stable Glucagon Analog. Diabetes Care 2018; 41(3): 531-7.

[0649] Lord K, Radcliffe J, Gallagher PR, Adzick NS, Stanley CA, De Leon DD. High risk of diabetes and neurobehavioral deficits in individuals with surgically treated hyperinsulinism. J Clin Endocrinol Metab 2015; 100(11): 4133-9.

[0650] Meissner T, Wendel U, Burgard P, Schaetzle S, Mayatepek E. Long-term follow-up of 114 patients with congenital hyperinsulinism. Eur J Endocrinol 2003; 149(1): 43-51.

[0651] Remington's Pharmaceutical Sciences, 17th edition. Ed. Alfonso R. Gennaro (Ed.), Mack Publishing Company, Easton, PA, U.S.A., 1985

[0652] "Remington's Pharmaceutical Sciences" by E.W. Martin, 21st Edition, 2005

[0653] Salomon-Estebanez M, Yau D, Dunne MJ, et al. Efficacy of Dose-Titrated Glucagon Infusions in the Management of Congenital Hyperinsulinism: A Case Series. Front Endocrinol (Lausanne) 2020; 11: 441.

[0654] The Dictionary of Cell and Molecular Biology, 3rd ed., 1999, Academic Press; and the Oxford Dictionary Of Biochemistry And Molecular Biology, Revised, 2000, Oxford University Press Zealand Pharma. Dasiglucagon (Zegalogue) US Prescribing Information. Available at: https: / / www.accessdata.fda.gov / drugsatfda docs / label / 2021 / 214231s000lbl.pdf. 2021. Yau D, Laver TW, Dastamani A, et al. Using referral rates for genetic testing to determine the incidence of a rare disease: The minimal incidence of congenital hyperinsulinism in the UK is 1 in 28,389. PLoS One 2020; 15(2): e0228417.

Claims

CLAIMS1. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method of treating congenital hyperinsulinism (CHI).

2. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method according to claim 1, wherein Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof is provided in a composition together with at least one pharmaceutically acceptable excipient.

3. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein the treatment reduces the percentage time in hypoglycaemia, wherein the percent time in hypoglycaemia is defined as a glucose level of <70 mg / dL measured by continued glucose monitoring (CGM), optionally wherein the mean percentage time in hypoglycaemia during weeks 2-4 is reduced by at least 41% relative to the percent time in hypoglycaemia in patients receiving the SoC treatment.

4. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein the treatment reduces the rate of hypoglycaemic episodes, wherein the rate of hypoglycaemic episodes is defined as the number of CGM-detected episodes per week, wherein a single CGM-detected hypoglycaemic episode is defined as a glucose level of <70 mg / dL measured by continued glucose monitoring (CGM) for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70 mg / dL) was not reached within this time, wherein a new episode of hypoglycaemia begins when the next CGM values below 70 mg / dL was measured for at least 15 minutes, optionally wherein the mean rate of CGM-detected hypoglycaemic episodes during weeks 2-4 is reduced by at least 41% relative to the mean rate of CGM-detected hypoglycaemic episodes in patients receiving the SoC treatment.

5. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein the treatment reduces the percentage time in clinically significant hypoglycaemia, wherein the percent time in clinically significant hypoglycaemia is defined as a glucose level of <54 mg / dL measured by CGM,optionally wherein the mean percentage time in clinically significant hypoglycaemia during weeks 2-4 is reduced by at least 48% relative to the mean percentage time in clinically significant hypoglycaemia in patients receiving the SoC treatment.6 Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein the treatment reduces the rate of clinically significant hypoglycaemic episodes, wherein the rate of clinically significant hypoglycaemic episodes is defined as the number of CGM-detected episodes per week, wherein a single CGM-detected clinically significant hypoglycaemic episode is defined as a glucose level of <54 mg / dL measured by continued glucose monitoring (CGM) for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>70 mg / dL) was not reached within this time, wherein a new episode of clinically significant hypoglycaemia begins when the next CGM values below 54 mg / dL was measured for at least 15 minutes, optionally wherein the mean rate of CGM-detected clinically significant hypoglycaemic episodes during weeks 2-4 is reduced by at least 41% relative to the mean rate of clinically significant hypoglycaemic episodes during weeks 2-4 in patients receiving the SoC treatment.

7. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein the patient has a body weight of 5 to <10 kg at the start of the treatment.

8. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any one of the preceding claims, wherein the method does not comprise administration of diazoxide, optionally wherein the patient has never been treated with diazoxide.

9. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein the method additionally comprises coadministration of at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus, optionally wherein the patient has previously been treated with at least one of diazoxide, a somatostatin analogue, glucagon and / or sirolimus.

10. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein the patient has not had a pancreatectomy before the start of the treatment.

11. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in a method according to any of the preceding claims, wherein the method reduces nocturnal hypoglycaemia.

12. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein the method reduces the mean number of nocturnal hypoglycaemic episodes by at least 50%, wherein the mean number of nocturnal hypoglycaemic episodes is defined as the episodes / week with onset between 10 pm (excluded) and 6 am (excluded), wherein a single CGM-detected hypoglycaemic episode is defined as CGM <3.9 mmol / L for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>3.9 mmol / L) is not reached within this time, a new hypoglycaemic episode is defined as when the next CGM value was below 3.9 mmol / L for at least 15 min, optionally wherein the method reduces the mean number of nocturnal hypoglycaemic episodes by at least 48%, wherein the mean number of nocturnal hypoglycaemic episodes is defined as the episodes / week with onset between 10 pm (excluded) and 6 am (excluded), wherein a single CGM-detected hypoglycaemic episode is defined as CGM <3.0 mmol / L for 15 minutes and up until 60 minutes from the start of the episode even if normoglycemia (>3.9 mmol / L) is not reached within this time, a new hypoglycaemic episode is defined as when the next CGM value was below 3.0 mmol / L for at least 15 min.

13. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein the method comprises treatment with dasiglucagon for 4 or 8 weeks, optionally wherein treatment with the standard of care is concomitant.

14. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any of the preceding claims, wherein dasiglucagon is administered at adose of at least 10 pg / h, optionally wherein the dose is increased by 10 pg / h every two hours from the start of treatment to a maximum dose of 70 pg / h, optionally wherein dasiglucagon is administered at a dose of 70 pg / h.

15. Dasiglucagon or a pharmaceutically acceptable salt or solvate thereof for use in the method according to any one of the preceding claims, wherein the method of treatment is used in paediatric patients, optionally wherein the patients are between 3 months and 12 years of age (both inclusive).

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