Actrii antibodies with extended half life

Abstract

Provided herein are ActRII antibodies exhibiting extended half-life. Also provided are methods of using such antibodies for the treatment of disorders such as obesity and diabetes, cardiovascular disease, liver disease, and muscle wasting.

Description

[0001] Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 ACTRII ANTIBODIES WITH EXTENDED HALF LIFE REFERENCE TO AN ELECTRONIC SEQUENCE LISTING [1] The contents of the electronic sequence listing (VRNS_012_00US_SeqList_ST26.xml; Size: 4,435,673 bytes; and Date of Creation: February 28, 2024) are herein incorporated by reference in its entirety. BACKGROUND [2] Activin type II receptor (ActRII) antibodies have been shown to be useful in the treatment and prevention of chronic diseases, such as obesity, diabetes, muscle wasting diseases, cardiovascular disease, and liver disease, among others. Because of their relatively long circulating half-life, antibodies are particularly effective for treating chronic diseases, as a longer half-life in circulation is associated with reduced administration frequency and / or dosage, and chronic disease patients often require long- term administration. Thus, there is a need for effective ActRII antibodies with longer half-life for use in the treatment of chronic diseases. Provided herein are compositions and methods that address this need. SUMMARY [3] Provided herein are compositions and methods for the administration of ActRII antibodies comprising variants in an Fc domain, e.g., M252Y, S254T, and T256E (interchangeably referred to herein as “YTE”, and “YTE mutations”). The inclusion of modifications provided herein in an Fc domain of ActRII antibodies provided herein extends half-life in circulation in a subject, and may improve the treatment of a disease or disorder, e.g., a metabolic disorder (e.g., obesity and diabetes), cardiovascular disease, liver disease, and muscle wasting. In some embodiments of the present disclosure, an ActRII antibody is co-administered with an agent having glucose dependent insulinotropic polypeptide (GIP) and GLP-1 agonist activity (GIP / GLP-1). In some embodiments, the ActRII antibody is co-administered with an agent having GIP, GLP-1, and glucagon agonist activity (GCG). (e.g., retatrutide). [4] In some exemplary embodiments, the disclosure provides an antibody that specifically binds activin receptor II (ActRII), wherein the antibody comprises a heavy chain (HC) and a light chain (LC), wherein the HC comprises the amino acid sequence of SEQ ID NO: 9, and wherein the LC comprises the amino acid sequence of SEQ ID NO: 10. [5] In other exemplary embodiments provided herein is an antibody that specifically binds activin receptor II (ActRII), wherein the antibody comprises: a) a heavy chain (HC) comprising a heavy chain variable region (VH), wherein the VH comprises the amino acid sequence of SEQ ID NO: 7; and wherein the HC is an IgG1 isotype sequence comprising the M252Y, S254T, and T256E Fc domain variants; and Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 b) a light chain (LC) comprising a light chain variable region (VL), wherein the VL comprises the amino acid sequence of SEQ ID NO: 8. [6] In other exemplary embodiments, provided herein is an antibody that specifically binds activin receptor II (ActRII), wherein the antibody comprises: a) a heavy chain variable region (VH), wherein the VH comprises a CDRH1 of SEQ ID NO: 1, a CDRH2 of SEQ ID NO: 2, and a CDRH3 of SEQ ID NO: 3, wherein the antibody is an IgG1 isotype sequence comprising the substitutions of M252Y, S254T, and T256E; and b) a light chain variable region (VL), wherein the VL comprises a CDRL1 of SEQ ID NO: 4, a CDRL2 of SEQ ID NO: 5, and a CDRL3 of SEQ ID NO: 6. [7] In some embodiments, provided herein is a method of treating a disorder in a subject in need thereof, comprising administering to the subject an activin receptor II (ActRII) antibody with Fc variants. In some embodiments, the disorder to be treated is a metabolic disorder. In some embodiments, the metabolic disorder to be treated is one or more of: obesity, diabetes, metabolic syndrome, anti-psychotic drug-associated obesity, sarcopenic obesity, glucocorticoid-induced obesity, hypothalamic obesity associated with craniopharyngioma, Prader-Willi syndrome, and a monogenetic disorder associated with obesity. In some embodiments, the monogenetic disorder associated with obesity is one of: Bardet-Biedl syndrome or obesity resulting from mutations in one or more of genes of ADCY3, ALMS1, ARL6, BBS1, BBS2, BBS4, BBS5, BBS7, BBS9, BBS10, BBS12, BDNF, CCDC28B,CEP290, CREBBP, EP300, GNAS, IER3IP1, MC3R, MKKS, MKS1, MRAP2, NTRK2, PCSK1, PHF6, POMC, SH2B1, SIM1, TMEM67, TRIM32, TTC8 or VPS13B. [8] In some embodiments, the metabolic disorder to be treated is Type I Diabetes or Type II Diabetes. [9] In some embodiments, the treatments provided herein are useful for an obesity related co- morbidity, wherein the co-morbidity is selected from the group of: glucose intolerance, prediabetes, insulin resistance, high triglycerides, overweight associated physical impairment, renal disease, obstructive sleep apnea, sexual hormones impairment, endocrine reproductive disorders, osteoarthritis, gastrointestinal cancers, dyslipidemia, hypertension, atherosclerotic vascular disease, stroke, and / or gallstones.

[0010] In some embodiments, the treatment provided herein reduces body weight in the subject. In some embodiments, the treatment reduces fat mass in the subject. In some embodiments, the treatment increases or maintains lean mass in the subject. In some embodiments, the treatment improves insulin sensitivity in the subject. In some embodiments, the treatment improves the long-term weight management of a subject administered the ActRII antibody. In some embodiments, the efficacy of the treatment is measured by at least one of the following: body weight; bioelectrical impedance analysis (BIA); dual X-ray absorptiometry (DXA); waist circumference; decreased BMI; waist to hip ratio; waist to height ratio; blood lipids profile; leptin, adiponectin, and adipsin levels; urine biomarkers; hemoglobin Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 c (Hgbc) levels; hand dynamometry demonstrating muscle strength; glucose levels; insulin levels; short physical performance battery (SPPB); Impact of Weight on Quality of Life-Lite (IWQOL-Lite) assessment; Short Form (36) Health Survey (SF-36) assessment; homeostasis model assessment 2 (HOMA2); and physical activity monitoring via actigraphy.

[0011] In some embodiments, the treatments provided herein treat cardiovascular disease. In some embodiments, the treatments provided herein treat liver disease. In some embodiments, the treatments provided herein treat muscle wasting. In some embodiments, the muscle wasting is associated with disease or disuse. In some embodiments, the muscle wasting disease is sarcopenia or cachexia.

[0012] In some embodiments, the treatments provided herein comprise administering to the subject a combination therapy comprising an ActRII antibody and an agent having glucagon-like peptide-1 receptor (GLP-1) agonist activity, wherein the agent having GLP-1 agonist activity is selected from an antibody, a small molecule, an aptamer, polypeptide, or a peptide. In some embodiments, the agent having GLP-1 agonist activity is a peptide. In some embodiments, the agent having GLP-1 activity is selected from the group consisting of exenatide, exenatide extended-release, dulaglutide, liraglutide, lixisenatide, semaglutide, tirzepatide, cotadutide, noiiglutide, oxyntomodulin, retatrutide, survodutide, albiglutide, beinaglutide and PEG-loxenatide, pemvidutide, orforglipron and danuglipron. In some exemplary embodiments, the agent having GLP-1 activity is retatrutide.

[0013] In some embodiments, the ActRII antibody and / or the agent having GLP-1 agonist activity are administered subcutaneously. In some embodiments, the ActRII antibody is administered intravenously. In some embodiments, the ActRII antibody and the agent having GLP-1 agonist activity are administered on the same day. In some embodiments, the ActRII antibody is administered prior to the agent having GLP-1 agonist activity. In some embodiments, the agent having GLP-1 agonist activity is administered prior to the ActRII antibody. In some embodiments, the subject is human.

[0014] In exemplary embodiments, provided herein is a combination composition comprising an ActRII antibody and an agent having GLP-1 agonist activity, wherein the agent having GLP-1 agonist activity is selected from the group consisting of exenatide, exenatide extended-release, dulaglutide, liraglutide, lixisenatide, semaglutide, tirzepatide, cotadutide, noiiglutide, oxyntomodulin, retatrutide, survodutide, albiglutide, beinaglutide and PEG-loxenatide, pemvidutide, orforglipron and danuglipron. In some exemplary embodiments, the combination comprises retatrutide. In some embodiments, the combination comprises a pharmaceutically acceptable excipient.

[0015] In some embodiments, is a polynucleotide encoding an ActRII antibody with defined variants in the crystallizable fragment (Fc) domains e.g., YTE (M252Y / S254T / T256E) and LS (M428L / N434S). BRIEF DESCRIPTION OF THE DRAWINGS Attorney Docket No.31014 VRNS-012 / 00US 340953-2263

[0016] FIG.1 illustrates the plasma concentration in cynomolgus monkeys over time of three ActRII antibodies after single intravenous bolus administration: (1) an exemplary ActRII antibody with M252Y, S254T, and T256E (YTE) variants in an Fc domain (N=3) (SEQ ID NO:9); (2) an exemplary ActRII antibody with M428L and N434S (LS) variants in an Fc domain (N=2) (SEQ ID NO:12), and (3) an ActRII antibody with an Fc domain (N=3) (SEQ ID NO:11). The horizontal dotted line at 10 µg / mL represents the approximate serum concentration at which the target receptors are > 95% saturated and the drug is maximally active in muscle tissue.

[0017] FIG.2 illustrates the plasma concentration in individual cynomolgus monkeys over time after single intravenous bolus administration of an exemplary ActRII antibody with the M252Y, S254T, and T256E (YTE) variants in an Fc domain (N=3) (SEQ ID NO:9). The horizontal dotted line at 10 µg / mL represents the approximate serum concentration at which the target receptors are > 95% saturated and the drug is maximally active in muscle tissue.

[0018] FIG.3 illustrates the plasma concentration in cynomolgus monkeys over time after single intravenous bolus administration of an ActRII antibody with M428L and N434S (LS) variants in an Fc domain (N=2) (SEQ ID NO:12). The horizontal dotted line at 10 µg / mL represents the approximate serum concentration at which the target receptors are > 95% saturated and the drug is maximally active in muscle tissue.

[0019] FIG.4 illustrates the plasma concentration in cynomolgus monkeys over time after single intravenous bolus administration of an ActRII antibody with an Fc domain (N=3) (SEQ ID NO:11). The horizontal dotted line at 10 µg / mL represents the approximate serum concentration at which the target receptors are > 95% saturated and the drug is maximally active in muscle tissue.

[0020] FIG.5 shows the average pharmacodynamic effect (body weight change) in cynomolgus monkeys over time after single intravenous bolus administration of three ActRII antibodies: (1) an ActRII antibody with the M252Y, S254T, and T256E (YTE) variants in an Fc domain (N=3) (SEQ ID NO:9), (2) an ActRII antibody with M428L and N434S (LS) variants in an Fc domain (N=2) (SEQ ID NO:12), ActRII antibody-LS; and (3) an ActRII antibody with an Fc domain of SEQ ID NO:11 (N=3). Cynomolgus monkeys have low body fat, thus inhibition of the ActRII pathway results in body weight gain due to muscle hypertrophy. DETAILED DESCRIPTION

[0021] Provided herein are compositions and methods for the administration of ActRII antibodies comprising variants in an Fc domain, e.g., M252Y, S254T, and T256E. The variants in the Fc domain of the ActRII antibodies disclosed herein extends antibody half-life in a subject and may improve the treatment of a disease or disorder, e.g., a metabolic disorder (e.g., obesity and diabetes), cardiovascular Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 disease, liver disease, and muscle wasting. In some embodiments, the variants in the Fc domain of the ActRII antibodies disclosed herein may lower the frequency and / or dosage of the ActRII antibody therapy. The present disclosure describes the surprising effect that variants in an Fc domain, e.g., M252Y, S254T, and T256E, extend the half-life of exemplary ActRII antibodies comprising the L234A and L235A (LALA) Fc domain variants. In some embodiments, ActRII antibodies with the M252Y, S254T, and T256E (YTE) and L234A and L235A (LALA) Fc domain variants show greater half-life extension than ActRII antibodies with M428L and N434S (LS) and L234A and L235A (LALA) Fc domain variants.

[0022] In some embodiments, the ActRII antibodies described herein with the M252Y, S254T, and T256E (YTE) Fc domain variants may be used in combination therapies, for example in combination with an agent having a GLP-1 agonist activity. In some embodiments, the ActRII antibodies provided herein with the M252Y, S254T, and T256E (YTE) Fc domain variants may be used in combination with an agent having GIP / GLP-1 / GCG agonist activity, e.g., retatrutide. I. Definitions

[0023] Unless otherwise defined herein, scientific and technical terms used herein shall have the meanings that are commonly understood by those of ordinary skill in the art. Generally, nomenclature used in connection with, and techniques of, chemistry, molecular biology, cell biology, immunology, pharmacology, and protein chemistry, described herein, are those well-known and commonly used in the art.

[0024] It must be noted that, as used herein and in the appended claims, the singular forms “a,” “and,” and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to “an agent” refers to one or mixtures of such candidates, and reference to “a method” includes reference to equivalent steps and methods known to those skilled in the art, and so forth.

[0025] As used herein, the term “approximately” or “about,” as applied to one or more values of interest, refers to a value that is similar in magnitude and / or within a similar range to a stated reference value. In certain embodiments, the term “approximately” or “about” refers to a range of values that fall within 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, 1%, or less in either direction (greater than or less than) of the stated reference value unless otherwise stated or otherwise evident from the context (except where such number would exceed 100% of a possible value).

[0026] Where a range of values is provided, it is understood that each intervening value, to the tenth of the unit of the lower limit unless the context clearly dictates otherwise, between the upper and lower limit of that range and any other stated or intervening value in that stated range is encompassed within the invention. The upper and lower limits of these smaller ranges may independently be included in the smaller ranges is also encompassed within the disclosure, subject to any specifically excluded limit in the stated Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 range. Where the stated range includes one or both of the limits, ranges excluding either or both of those included limits are also included in the disclosure.

[0027] As used herein, the terms “polypeptide,” “peptide,” and “protein” refer to polymers of amino acids of any length. The terms also encompass an amino acid polymer that has been modified; for example, to include disulfide bond formation, glycosylation, lipidation, phosphorylation, or conjugation with a labeling component.

[0028] As used herein, the terms “identity” and “identical,” when referring to a comparison of two sequences, refers to the percentage of exact matching residues in an alignment of a sequence provided herein to a reference sequence, such as an alignment generated by a BLAST algorithm or other alignment algorithms known in the art. Identity may be calculated based on an alignment of a full-length sequence provided herein and a full-length reference sequence. Identity may also be calculated based on a partial alignment of a sequence provided herein and a reference sequence, if the reference sequence is longer than a sequence provided herein. Identity may also be calculated based on a partial alignment of a sequence provided herein and a reference sequence, if the reference sequence is shorter than a sequence provided herein. Thus, when aligning two sequences, according to the aforementioned, a query sequence “shares at least x % identity to” a subject sequence if in the alignment of the two sequences, at least x % (rounded down) of the residues in the subject sequence are aligned as an exact match to a corresponding residue in the query sequence, wherein the numerator is the number of exact matches and the denominator is the length of the query sequence. In some embodiments, the denominator may alternatively be the length of the query sequence minus any gaps of two or more non-matching residues. Where the subject sequence has variable positions (e.g., residues denoted X), an alignment to any residue in the query sequence is counted as a match.

[0029] The terms “treatment”, “treating” and the like are used herein to generally mean obtaining a desired pharmacologic and / or physiologic effect with a therapeutic agent. The effect may be prophylactic in terms of completely or partially preventing a disease or symptom thereof, e.g., reducing the likelihood that the disease or symptom thereof occurs in the subject, and / or may be therapeutic in terms of completely or partially reducing a symptom, or a partial or complete cure for a disease and / or adverse effect attributable to the disease. “Treatment” as used herein covers any treatment of a disease in a mammal, and includes: (a) preventing the disease from occurring in a subject which may be predisposed to the disease but has not yet been diagnosed as having it; (b) inhibiting or slowing the onset or development of the disease; or (c) relieving the disease, e.g., causing regression of the disease or symptoms associated with the disease. The therapeutic agent may be administered before, during or after the onset of disease. The treatment of ongoing disease, where the treatment stabilizes or reduces the undesirable clinical symptoms of the patient, may be of particular interest. In some embodiments, treatment is performed prior to complete loss of function in Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 the affected tissues. In some embodiments, the subject therapy will be administered during the symptomatic stage of the disease, and in some embodiments, after the symptomatic stage of the disease.

[0030] The terms “individual,” “subject,” and “patient” are used interchangeably herein and refer to any subject for whom treatment or therapy is desired. The subject may be a mammalian subject. Mammalian subjects include, e.g., humans, non-human primates, rodents, (e.g., rats, mice), lagomorphs (e.g., rabbits), ungulates (e.g., cows, sheep, pigs, horses, goats, and the like), etc. In some embodiments, the subject is a human. In some embodiments, the subject is a non-human primate, for example a cynomolgus monkey. In some embodiments, the subject is a companion animal (e.g., cats, dogs).

[0031] As used herein, Body Mass Index or “BMI” is calculated as weight in kilograms (kg) divided by height in meters squared (m2), rounded to one decimal place. As used herein, “obesity” in adult humans is defined as a BMI greater than or equal to 30 kg / m2. “Obesity” in human youth is defined as a BMI greater than or equal to the age- and sex-specific 95th percentile of the 2000 CDC growth charts. The term "overweight " is defined as a BMI of greater than or equal to 25 and less than 30. In some other embodiments, a BMI >27 is associated with metabolic-associated co-morbidities.

[0032] The terms “obesity related co-morbidity,” “obesity related condition” and “obesity related disorder” may be used interchangeably and refer to a health condition related to the obesity of the subject. In some embodiments, obesity related co-morbidity or condition increases the mortality risk of the subject. Obesity related co-morbidities include but are not limited to: glucose intolerance, prediabetes, insulin resistance, Type II diabetes, overweight or obesity associated physical impairment, overweight or obesity associated pain, renal disease, obstructive sleep apnea, breathing problems, gastroesophageal reflux disease, sexual hormones impairment, endocrine reproductive disorders, osteoarthritis, hypertension, atherosclerotic vascular disease, stroke, gallstones, gall bladder disease, high LDL cholesterol, low HDL cholesterol, high levels of triglycerides (dyslipidemia), cancer, severe COVID-19, overall mortality, lower quality of life, and mental illness such as clinical depression, anxiety, and other mental disorders. In an embodiment, weight related co-morbidity is at least one selected from the group consisting of hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, and cardiovascular disease.

[0033] As used herein, "antibody" includes reference to an immunoglobulin molecule immunologically reactive with a particular antigen, and includes both polyclonal and monoclonal antibodies. The term includes humanized antibodies, chimeric antibodies, e.g., murine variable region with a human constant region) and conjugated antibodies. The term "antibody" also includes antigen binding forms of antibodies, including fragments that retain antigen-binding capability (e.g., Fab', F(ab')2, Fab, single chain variable fragments (scFv) containing VH and VL sequences linked together in one chain, single chain antibody fragments (scAb), wherein fragment crystallizable regions (Fc) are linked to any of the aforementioned antigen-binding fragments. Attorney Docket No.31014 VRNS-012 / 00US 340953-2263

[0034] The activin receptors Type II B (ActRIIB) and Type IIA (ActRIIA) regulate Exemplary myostatin, activin, and bone morphogenetic proteins (BMPs)Exemplary ActRII that bind to ActRIIA and ActRIIB have been shown to treat metabolic diseases by increasing lean muscle mass, decreasing fat mass and improving glycemic control in human clinical studies (US / 2021 / 0363263, and Heymsfield et al. JAMA Netw Open.2021 Jan; 4(1): e2033457. Administration of ActRII antibodies in combination with agents having GLP-1 activity further decreases fat mass (WO / 2023 / 028606). ActRII antibodies have also been shown to treat muscle wasting, e.g., associated with disease or disuse (US Pat Nos.8,388,968 and 11,357,851), cardiac abnormalities and heart failure (US Pat No.10,982,000), liver disease (US / 2022 / 0340668), and for increasing immune response, e.g., to a vaccine.

[0035] In some embodiments, exemplary antibodies of the disclosure include one or more of the sequences of exemplary ActRII antibodies, further with the Fc domain variants M252Y, S254T, and T256E in the heavy chain (HC) sequence.

[0036] Table 1 provides the complementarity determining regions (CDR), heavy chain variable region (VH), light chain variable region (VL), heavy chain (HC), and light chain (LC) amino acid sequences of an exemplary ActRII antibody. Table 1 Heavy Chain Complementarity Determining Regions (CDRs) CDRH1 - GYTFTSSYIN (SEQ ID NO: 1) CDRH2 - TINPVSGSTSYAQKFQ (SEQ ID NO: 2) CDRH3 - GGWFDY (SEQ ID NO: 3) Light Chain Complementarity Determining Regions (CDRs) CDRL1 – TGTSSDVGSYNYVN (SEQ ID NO: 4) CDRL2 - MIYGVSKRPS (SEQ ID NO: 5) CDRL3 - GTFAGGSYYG (SEQ ID NO: 6) Heavy chain variable region Variable Region (VH) QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSY AQKFQGRVTMTRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSS (SEQ ID NO: 7) Light chain variable region Variable Region (VL) QSALTQPASVSGSPGQSITISCTGTSSDVGSYNYVNWYQQHPGKAPKLMIYGVSKRPSGV SNRFSGSKSGNTASLTISGLQAEDEADYYCGTFAGGSYYGVFGGGTKLTVLGQ (SEQ ID NO: 8) Heavy Chain (HC) L234A / L235A / M252Y / S254T / T256E QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSY AQKFQGRVTMTRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSSASTKG PSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL SSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAPEAAGGPSVFL FPPKPKDTLYITREPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRV VSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQ VSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNV FSCSVMHEALHNHYTQKSLSLSPGK (SEQ ID NO: 9) Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 Light Chain (LC) QSALTQPASVSGSPGQSITISCTGTSSDVGSYNYVNWYQQHPGKAPKLMIYGVSKRPSGV SNRFSGSKSGNTASLTISGLQAEDEADYYCGTFAGGSYYGVFGGGTKLTVLGQPKAAPSV TLFPPSSEELQANKATLVCLISDFYPGAVTVAWKADSSPVKAGVETTTPSKQSNNKYAAS SYLSLTPEQWKSHRSYSCQVTHEGSTVEKTVAPTECS (SEQ ID NO: 10) Heavy Chain (HC) L234A / L235A QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSY AQKFQGRVTMTRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSSASTKG PSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL SSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAPEAAGGPSVFL FPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRV VSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQ VSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNV FSCSVMHEALHNHYTQKSLSLSPGK (SEQ ID NO: 11) Heavy Chain (HC) L234A / L235A / M428L / N434S QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSY AQKFQGRVTMTRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSSASTKG PSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL SSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAPEAAGGPSVFL FPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRV VSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQ VSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNV FSCSVLHEALHSHYTQKSLSLSPGK (SEQ ID NO: 12) Heavy Chain (HC) L234A / L235A / M252Y / S254T / T256E M428L / N434S QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSY AQKFQGRVTMTRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSSASTKG PSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL SSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAPEAAGGPSVFL FPPKPKDTLYITREPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRV VSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQ VSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNV FSCSVLHEALHSHYTQKSLSLSPGK (SEQ ID NO: 13)

[0037] In some embodiments, exemplary ActRII antibodies of the disclosure that specifically bind ActRII comprise: a heavy chain variable region (VH), wherein the VH comprises a CDRH1 of SEQ ID NO: 1, a CDRH2 of SEQ ID NO: 2, and a CDRH3 of SEQ ID NO: 3, wherein the antibody is an IgG1 isotype comprising the substitutions of M252Y, S254T, and T256E in an Fc domain; and a light chain variable region (VL), wherein the VL comprises a CDRL1 of SEQ ID NO: 4, a CDRL2 of SEQ ID NO: 5, and a CDRL3 of SEQ ID NO: 6.

[0038] In some embodiments, exemplary ActRII antibodies of the disclosure that specifically bind activin receptor II (ActRII), comprise: a heavy chain (HC) sequence comprising a heavy chain variable region(VH), wherein the VH comprises the amino acid sequence of SEQ ID NO: 7; and wherein the HC is an IgG1 isotype sequence comprising the substitutions of M252Y, S254T, and T256E in an Fc domain; Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 and a light chain (LC) sequence comprising a light chain variable region(VL), wherein the VL comprises the amino acid sequence of SEQ ID NO: 8.

[0039] In some embodiments, exemplary ActRII antibodies of the disclosure that specifically bind activin receptor II (ActRII), comprise a heavy chain (HC) sequence and a light chain (LC) sequence, wherein the HC comprises the amino acid sequence of SEQ ID NO: 9, and wherein the LC comprises the amino acid sequence of SEQ ID NO: 10.

[0040] In some embodiments, the exemplary ActRII antibodies of the disclosure comprising half-life extension substitutions, comprise a heavy chain variable region comprising the amino acid sequence of SEQ ID NO: 7, or an amino acid sequence of at least 80%, at least 81%, at least 82%, at least 83%, at least 84%, at least 85%, at least 86%, at least 87%, at least 88%, at least 89%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least 97%, at least 98%, or at least 99% sequence identity thereto; and / or a light chain variable region comprising the amino acid sequence of SEQ ID NO: 8, or an amino acid sequence of at least 80%, at least 81%, at least 82%, at least 83%, at least 84%, at least 85%, at least 86%, at least 87%, at least 88%, at least 89%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least at least 97%, at least 98%, or at least 99% sequence identity thereto. In some embodiments, an ActRII antibody of the disclosure comprises one or more modifications in the framework region of the heavy chain variable region and / or light chain variable region of the ActRII antibody relative to SEQ ID NO: 7 and SEQ ID NO: 8. In some embodiments, an ActRII antibody of the disclosure comprises one or more modifications in one or more of the complementarity determining regions (CDRs) of the heavy chain variable region relative to SEQ ID NOS: 1-3. In some embodiments, an ActRII antibody of the disclosure comprises one or more modifications in one or more of the complementarity determining regions (CDRs) of the light chain variable region relative to SEQ ID NOS: 4-6.

[0041] In some embodiments, exemplary ActRII antibodies of the disclosure comprise a heavy chain comprising the amino acid sequence of SEQ ID NO: 9, or an amino acid sequence with at least 80%, at least 81%, at least 82%, at least 83%, at least 84%, at least 85%, at least 86%, at least 87%, at least 88%, at least 89%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least at least 97%, at least 98%, or at least 99% sequence identity thereto, and comprising the modifications of M252Y, S254T, and T256E relative to a human IgG1 Fc domain according to the EU numbering scheme; and / or a light chain comprising the amino acid sequence of SEQ ID NO: 10, or an amino acid sequence with at least 80%, at least 81%, at least 82%, at least 83%, at least 84%, at least 85%, at least 86%, at least 87%, at least 88%, at least 89%, at least 90%, at least 91%, at least 92%, at least 93%, at least 94%, at least 95%, at least 96%, at least at least 97%, at least 98%, or at least 99% sequence identity thereto. Attorney Docket No.31014 VRNS-012 / 00US 340953-2263

[0042] In some embodiments, the ActRII antibody comprises one or more of the CDR amino acid sequences of SEQ ID NOS: 14-75, and an Fc domain comprising the substitutions of M252Y, S254T, and T256E. In some embodiments, the ActRII antibody comprises one or more of the CDR amino acid sequences of SEQ ID NOS: 76-81, and an Fc domain comprising the substitutions of M252Y, S254T, and T256E. In some embodiments, the ActRII antibody comprises one or more of the CDR amino acid sequences of SEQ ID NOS: 82-5049, and an Fc domain comprising modifications of M252Y, S254T, and T256E.

[0043] The ActRII antibodies provided herein, exhibit an increased half-life relative to ActRII antibodies without modifications.

[0044] ActRII antibodies provided herein exhibit an increased half-life relative to ActRII antibodies with modifications to M428L and N434S (LS) in an Fc domain.

[0045] In exemplary embodiments, an Fc domain of the ActRII antibodies provided herein is modified to comprise the modifications of M252Y, S254T, and T256E relative to a human IgG1 Fc domain, according to the EU numbering scheme. As provided herein, the ActRII antibodies of the disclosure may be of an IgG1 isotype, and comprise a human IgG1 Fc domain; of an IgG2 isotype, and comprise a human IgG2 Fc domain; of an IgG3 isotype, and comprise a human IgG3 Fc domain; or of an IgG4 isotype and comprise a human IgG4 Fc domain, wherein in each instance the Fc domain is modified to increase serum half-life. In exemplary embodiments, an Fc domain of the ActRII antibody is a human IgG1 Fc domain with modifications of M252Y, S254T, and T256E.

[0046] In exemplary embodiments, an Fc domain of the disclosure comprises the modification of L234A and L235A (LALA), relative to a human IgG1 Fc domain according to the EU numbering scheme, to reduce effector function, namely antibody-dependent cellular cytotoxicity (ADCC) activity. In exemplary embodiments, an Fc domain of the antibodies of the disclosure comprises the variants of M252Y, S254T, and T256E, and L234A and L235A.

[0047] In some embodiments, the ActRII antibodies of the disclosure exhibit an increased half-life of about 1.2-fold, 1.3-fold, 1.4-fold, 1.5-fold, 1.6-fold, 1.7-fold, 1.8-fold, 1.9-fold, 2.0-fold, 2.1-fold, 2.2- fold, 2.3-fold, 2.4-fold, 2.5-fold, 2.6-fold, 2.7-fold, 2.8-fold, 2.9-fold, 3.0-fold, 3.1-fold, 3.2-fold, 3.3- fold, 3.4-fold, 3.5-fold, 3.6-fold, 3.7-fold, 3.8-fold, 3.9-fold, or 4.0-fold relative to an ActRII antibody without modification or with modification of M428L and N434S (LS) in an Fc domain.

[0048] In some embodiments, an ActRII antibody binds to ActRIIB with a KD of 100 nM or less, 10 nM or less, 1 nM or less. In some embodiments, an ActRII antibody binds to ActRIIB with an affinity of 100 pM or less (i.e., 100 pM, 50 pM, 10 pM, 1 pM or less). In some embodiments, the ActRII antibody binds to ActRIIB with an affinity of between 10 and 20 pM, In some embodiments, the ActRII antibody binds to ActRIIB with an affinity of between 1 and 10 pM. Attorney Docket No.31014 VRNS-012 / 00US 340953-2263

[0049] In some embodiments, an ActRII antibody binds to ActRIIB with a 5-fold greater affinity than to ActRIIA, a 10-fold, a 50-fold, or a 100-fold. In some embodiments, the ActRII antibody binds to ActRIIA with an affinity of 100 pM or more (i.e.250 pM, 500 pM, 1 nM, 5 nM or more). II. Combination Therapies Agents having GLP-1 agonist activity

[0050] The glucagon-like peptide-1 receptor is a pancreatic beta cell receptor that stimulates insulin secretion upon binding of the hormone glucagon-like peptide 1 (GLP-1). GLP-1 is a type of incretin hormone, all of which regulate insulin release in response to blood sugar. Agents having GLP-1 agonist activity mimic the action of GLP-1 peptide and activate the GLP-1 receptor upon binding, stimulating insulin secretion.

[0051] As provided herein, the agent having GLP-1 agonist activity of the disclosure may be a peptide, polypeptide, antibody, small molecule, or an aptamer. In some embodiments, the agent having GLP-1 agonist activity is a peptide or polypeptide, including but not limited to: exenatide, exenatide extended-release, dulaglutide, liraglutide, lixisenatide, semaglutide, tirzepatide, cotadutide, noiiglutide, oxyntomodulin, retatrutide, survodutide, albiglutide, beinaglutide, PEG-loxenatide, and pemvidutide. In some embodiments, the agent having GLP-1 agonist activity is a small molecule non-peptide agonist, e.g., danuglipron. In exemplary embodiments, the agent having GLP-1 agonist activity is a GIP, GLP-1, and glucagon receptor agonist. In exemplary embodiments, the GIP, GLP-1, and glucagon receptor agonist is retatrutide.

[0052] In some embodiments, the agent having GLP-1 agonist activity is a dual agonist that binds and activates or deactivates a second receptor in addition to a GLP-1 receptor, wherein the second receptor is glucose-dependent insulinotropic (GIP) receptor or a glucagon (GCG) receptor. An exemplary dual acting agent having GLP-1 agonist activity that binds both GLP-1 receptor and GIP receptor is tirzepatide. Exemplary dual-acting agent having GLP-1 agonist activity that binds both GLP-1 receptor and GCG receptor are cotadutide, noiiglutide, and oxyntomodulin, and are included in this disclosure as possible therapeutic agents to be used in combination with the ActRII antibodies. In some embodiments, the agent having GLP-1 agonist activity is also a GIP antagonist. In some embodiments, the agent having GLP-1 agonist activity is also a GCG antagonist.

[0053] In some embodiments, the agent having GLP-1 agonist activity is a GIP, GLP-1, and glucagon receptor agonist. In some other embodiments, the agent having GLP-1 agonist activity is a long-acting GIP, GLP-1, and glucagon receptor agonist, e.g., retatrutide.

[0054] In some embodiments, administration of both an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity exhibits a beneficial effect, wherein the ActRII antibody administered as part of a treatment with an agent having GLP-1 agonist activity decreases the dosage of Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 the agent having GLP-1 agonist activity required to see an effect, and / or increases the therapeutic effect of the agent having GLP-1 agonist activity, relative to the agent having GLP-1 agonist activity alone.

[0055] In some embodiments, a beneficial effect is demonstrated wherein an agent having GLP-1 agonist activity decreases the dosage of the ActRII antibody required to see an effect, and / or increases the therapeutic effect of the ActRII antibody, relative to administration of the ActRII antibody alone. In an embodiment, the therapeutic effect of the combination is synergistic when compared to the sum of activity observed from treatment using an ActRII antibody and GLP-1 agonist agent.

[0056] In some embodiments the beneficial effect is increased safety of the combination relative to an ActRII antibody or an agent having GLP-1 agonist activity alone. In some embodiments the beneficial effect is increased efficacy of the combination relative to an ActRII antibody or an agent having GLP-1 agonist activity alone. In some embodiments the beneficial effect is increased tolerability relative to an ActRII antibody or an agent having GLP-1 agonist activity alone.

[0057] In some embodiments, the increased safety and / or tolerability of an agent is determined by 100%, 90%, 80%, 75%, 50%, or 25% lower risk of adverse reactions, side effects, number of warnings and precautions, or number of contraindications. In some embodiments, the level of the patient or physician reported side effects of an agent having GLP-1 agonist activity are reduced at least 1.5x, 2x, 3x, 4x, 5x, or 10x when agent having GLP-1 agonist activity is administered as part of a treatment with an ActRII antibody of the disclosure, relative to the agent having GLP-1 agonist activity alone. In some embodiments the beneficial effect is increased efficacy of the combination of the ActRII antibody of the disclosure and the agent having GLP-1 agonist activity relative to either of an ActRII antibody or an agent having GLP-1 agonist activity alone.

[0058] In some embodiments, a combination treatment of an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity exhibits a synergistic therapeutic effect, wherein administration of both agents increases the efficacy more than the sum of the effect of each agent individually.

[0059] The combination therapy of the disclosure comprising an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity may be administered via any pharmaceutically acceptable route. In some embodiments, the ActRII antibody and / or the agent having GLP-1 agonist activity is delivered orally, subcutaneously, intravenously, intranasally, transdermally, intraperitoneally, intramuscularly, intrapulmonary, vaginally, rectally, or intraocularly. In exemplary embodiments the ActRII antibody is administered intravenously (IV) and / or subcutaneously, and the agent having GLP-1 agonist activity is administered subcutaneously. mTor inhibitors

[0060] In some embodiments, an ActRII antibody of the disclosure may be administered in combination with an mTOR inhibitor. An mTOR inhibitor may refer to a compound or ligand, or a pharmaceutically acceptable salt thereof, which inhibits the mTOR kinase in a cell. In an embodiment an Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 mTOR inhibitor is an allosteric inhibitor. In an embodiment an mTOR inhibitor is a catalytic inhibitor. Allosteric mTOR inhibitors include the neutral tricyclic compound rapamycin (sirolimus), rapamycin- related compounds, that is compounds having structural and functional similarity to rapamycin including, e.g., rapamycin derivatives, rapamycin analogs and other macrolide compounds that inhibit mTOR activity. Rapamycin analogs useful in the invention include, for example, everolimus. In some embodiments, an mTOR inhibitor may be administered in a combination treatment with an ActRII antibody. In some embodiments the mTOR inhibitor is administered in a dosage of about 10 mg / day or about 50 mg / week. III. Subjects and Treatment

[0061] The ActRII antibodies as provided herein may be used to reduce the frequency and / or dosage of an ActRII antibody in the treatment of a chronic disease, including but not limited to metabolic disorders (e.g., obesity and diabetes), cardiovascular disease, liver disease, and muscle wasting. Metabolic disorder treatments

[0062] Metabolic disorders of the disclosure include but are not limited to obesity, for example, glucocorticoid induced obesity, Type II diabetes, metabolic syndrome, anti-psychotic drug-associated obesity, sarcopenic obesity, glucocorticoid-induced obesity, hypothalamic obesity associated with craniopharyngioma, Prader-Willi syndrome, and a monogenetic disorder associated with obesity.

[0063] In some embodiments, a subject in need of an ActRII antibody treatment described herein is a subject who is overweight. In some embodiments, a subject in need of an ActRII antibody treatment described herein includes a subject with a BMI of 30 or greater. In some embodiments, a subject in need of treatment includes a subject with a BMI of 27 or greater with an obesity related co-morbidity.

[0064] In some embodiments, a subject in need of treatment lacks glycemic control.

[0065] Subjects can be of any age, including youth. In some embodiments, the subject is over 20 years old, over 30 years old, over 40 years old, over 45 years old, over 50 years old, over 60 years old, or over 80 years old. In exemplary embodiments the subject is 45 or older. In some embodiments, the subject is 18 or older.

[0066] In some embodiments, the obesity related co-morbidity includes but is not limited to one or more of: glucose intolerance, prediabetes, insulin resistance, high triglycerides, overweight associated physical impairment, renal disease, obstructive sleep apnea, sexual hormone impairment, endocrine reproductive disorders, osteoarthritis, gastrointestinal cancers, dyslipidaemia, hypertension, atherosclerotic vascular disease, stroke, gastroesophageal reflux disease and / or gallstones.

[0067] In some embodiments, administration of an ActRII antibody of the disclosure treats one or more of a metabolic disorder, cardiovascular disease, liver disease or muscle wasting. In some embodiments, administration of an ActRII antibody, together with an agent having GLP-1 agonist Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 activity treats one or more of a metabolic disorder, cardiovascular disease, liver disease or muscle wasting.

[0068] In some embodiments, administration of an ActRII antibody of the disclosure improves glycemic control and / or treats Type II Diabetes. In some embodiments, administration of an ActRII antibody of the disclosure together with an agent having GLP-1 agonist activity improves glycemic control and / or treats Type II Diabetes.

[0069] As provided herein, administration of an ActRII antibody of the disclosure may reduce fat mass in a subject. In some embodiments, the treatment of an ActRII antibody reduces fat mass in a subject (relative to pre-treatment) by at least 5%, at least 6%, at least 7%, at least 8%, at least 9%, at least 10%, at least 11%, at least 12%, at least 13%, at least 14%, at least 15%, at least 16%, at least 17%, at least 18%, at least 19%, at least 20%, at least 21%, at least 22%, at least 23%, at least 24%, at least 25%, at least 26%, at least 27%, at least 28%, at least 29%, at least 30%, at least 31%, at least 32%, at least 33%, at least 34% at least 35%, at least 36%, at least 37%, at least 38%, at least 39%, at least 40%, at least 41%, at least 42%, at least 43%, at least 44%, at least 45%, at least 46%, at least 47%, at least 48%, at least 49%, at least 50%, over the treatment period.

[0070] In some embodiments, the combined treatment of an ActRII antibody and an agent having GLP-1 agonist activity further reduces fat mass in an additive or synergistic manner.

[0071] In some embodiments, administration of an ActRII antibody of the disclosure maintains or increases lean mass in the subject. In some embodiments, an ActRII antibody treatment increases lean mass in a subject by at least 5%, at least 6%, at least 7%, at least 8%, at least 9%, at least 10%, at least 11%, at least 12%, at least 13%, at least 14%, at least 15%, at least 16%, at least 17%, at least 18%, at least 19%, at least 20%, at least 21%, at least 22%, at least 23%, at least 24%, at least 25%, at least 26%, at least 27%, at least 28%, at least 29%, at least 30%, at least 31%, at least 32%, at least 33%, at least 34% at least 35%, at least 36%, at least 37%, at least 38%, at least 39%, at least 40%, at least 41%, at least 42%, at least 43%, at least 44%, at least 45%, at least 46%, at least 47%, at least 48%, at least 49%, or at least 50% over the treatment period.

[0072] In some embodiments, the combined treatment of an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity increases lean mass to a greater extent than a treatment with an agent having GLP-1 agonist activity alone. In some embodiments, a combination treatment of an ActRII antibody and an agent having GLP-1 agonist activity reduces fat mass and increases lean mass in an additive or synergistic manner. In some embodiments, the treatment reduces fat mass in a subject by at least 5% (e.g., 5%-50%) and increases lean mass by at least 5% (e.g., 5%-50%) over the treatment period.

[0073] In some embodiments, a combination treatment of an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity maintains lean mass in a subject. In some embodiments, a combined treatment of an ActRII antibody and an agent having GLP-1 agonist activity reduces fat mass and Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 maintains lean mass in the subject in an additive or synergistic manner. In some embodiments, the combination treatment reduces fat mass in a subject by at least 5% (e.g., 5%-50%) and maintains lean mass over the treatment period.

[0074] In some embodiments, administration of an ActRII antibody of the disclosure reduces body weight in the subject. In some embodiments, a combination treatment of an ActRII antibody and an agent having GLP-1 agonist activity reduces body weight in the subject. In some embodiments, the treatment reduces body weight in a subject by at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% over the treatment period. In some embodiment, the combined treatment reduces body weight to a greater extent relative to treatment with either alone.

[0075] In some embodiments, administration of an ActRII antibody of the disclosure reduces the BMI of the subject. In some embodiments, a combination treatment of an ActRII antibody and an agent having GLP-1 agonist activity reduces the BMI of the subject. In some embodiments, the treatment reduces BMI in a subject by at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% over the treatment period. In some embodiment, the combined treatment reduces BMI to a greater extent relative to treatment with either alone.

[0076] In some embodiments, a combined treatment of an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity reduces body weight in a synergistic manner. In some embodiments, administration of an ActRII antibody reduces central adiposity in the subject. In some embodiments, a combined treatment of an ActRII antibody and an agent having GLP-1 agonist activity reduces central adiposity in the subject. In some embodiments, the treatment reduces central adiposity in a subject by at least 5% (e.g., 5%-50%) over the treatment period. In some embodiment, the combined treatment reduces central adiposity to a greater extent relative to treatment with either alone. In some embodiments, a combined treatment of an ActRII antibody and an agent having GLP-1 agonist activity reduces central adiposity in a synergistic manner.

[0077] In some embodiments, administration of an ActRII antibody of the disclosure reduces waist circumference in the subject. In some embodiments, a combined treatment of an ActRII antibody and an agent having GLP-1 agonist activity reduces waist circumference in the subject. The average waist circumference of a woman in the United States is 38.7 inches, and the average waist circumference of a man is 40.2 inches, according to the United States Centers for Disease Control and Prevention (CDC). In some embodiments, the waist circumference may be decreased at least 5%, at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% over the treatment period.

[0078] In some embodiments, fat mass in response to either an ActRII antibody treatment of the disclosure or the combined treatment of an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity is measured with BIA and / or DXA. Attorney Docket No.31014 VRNS-012 / 00US 340953-2263

[0079] In some embodiments, administration of an ActRII antibody of the disclosure improves glycemic control in the subject. In some embodiments, a combined treatment of an ActRII antibody and an agent having GLP-1 agonist activity improves glycemic control in the subject. In some embodiments, the combined treatment improves glycemic control to a greater extent relative to treatment with either alone. In some embodiments, a combined treatment of an ActRII antibody and an agent having GLP-1 agonist activity improves glycemic control in a synergistic manner.

[0080] In some embodiments, glycemic control in response to the combined treatment of an ActRII antibody and an agent having GLP-1 agonist activity is measured by glucose and insulin levels, and the HOMA2 model is applied (www.dtu.ox.ac.uk / homacalculator / ).

[0081] In some embodiments, the increased efficacy of the combination effect of an ActRII antibody and an agent having GLP-1 agonist activity in a subject is determined by an at least 1.5-fold, at least 2- fold, at least 2.5 fold, at least 3-fold, at least 3.5 fold, at least 4-fold, at least 4.5 fold, at least 5-fold, at least 10-fold, or at least 20-fold improvement in at least one of the following measurements, relative to either treatment alone: body weight; bioelectrical impedance analysis (BIA) of lean mass and / or fat mass; waist to hip ratio; waist to height ratio; dual X-ray absorptiometry (DXA) of lean mass and / or fat mass; waist circumference; decreased BMI; blood lipids profile; leptin, adiponectin, and adipsin levels; IL-8 and / or IL-6 levels; urine biomarkers; hemoglobin A1c (HgbA1c) levels; hand dynamometry demonstrating muscle strength; glucose levels; insulin levels; short physical performance battery (SPPB); Impact of Weight on Quality of Life (IWQoL-Lite for CT) assessment; Short Form (36) Health Survey (SF-36) assessment; the homeostasis model assessment 2 (HOMA2); and physical activity monitoring via actigraphy. Cardiovascular disease treatments

[0082] In some embodiments, an ActRII antibody of the disclosure treats or prevents a cardiac abnormality or cardiovascular disease, e.g., ischemic coronary disease or heart failure, in a subject. In some embodiments, a combined treatment of an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity treats or prevents cardiovascular disease or a cardiac abnormality in a subject.

[0083] In some embodiments, an ActRII antibody of the disclosure or a combination treatment of the disclosure treats comprising an ActRII antibody and an agent having GLP-1 agonist activity treats or prevents a cardiac abnormality or cardiovascular disease comprising reduced ejection fraction.

[0084] In some embodiments, an ActRII antibody of the disclosure or a combination treatment of the disclosure treats comprising an ActRII antibody and an agent having GLP-1 agonist activity improves ejection fraction and / or systolic function in a subject with cardiovascular disease or a cardiac abnormality. Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 Liver disease treatments

[0085] In some embodiments, an ActRII antibody of the disclosure treats or prevents a chronic liver disease or disorder, e.g., nonalcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), or liver fibrosis. In some embodiments, a combined treatment of an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity treats or prevents a chronic liver disease or disorder, e.g., nonalcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), or liver fibrosis. In some embodiments treatment with an ActRII antibody of the disclosure or with the combination treatment of an ActRII antibody of the disclosure and an agent having GLP-1 agonist activity reduces fat mass in the liver of the subject. Muscle wasting disease / disorder treatments

[0086] In some embodiments, administration of an ActRII antibody of the disclosure treats or prevents muscle wasting in a subject in need thereof, e.g., muscle wasting associated with disease or disuse. In some embodiments, administration of an ActRII antibody of the disclosure in combination with an mTOR inhibitor treats or prevents muscle wasting in a subject in need thereof. VI. Pharmaceutical Compositions

[0087] In some embodiments, the ActRII antibody is combined with another agent, e.g. an agent having GLP-1 agonist activity in a pharmaceutical composition. In exemplary embodiments, the composition includes an ActRII antibody with variants M252Y, S254T, and T256E in the Fc domain and an agent having GLP-1 agonist, e.g., retatrutide. In some embodiments the composition includes an excipient, or carrier, e.g., an aqueous carrier. EXAMPLES Example 1: Effects of half-life extension mutations in exemplary ActRII antibodies

[0088] The study objective was to compare the pharmacokinetic and pharmacodynamic (PK and PD) effects of the heavy chain modifications of M252Y, S254T, and T256E (SEQ ID NO: 9) and the heavy chain modifications of M428L and N434S (LS) (SEQ ID NO:12), in an exemplary ActRII antibody in cynomolgus monkeys. The exemplary ActRII antibody with heavy chain modifications of M252Y, S254T, and T256E (SEQ ID NO: 9) showed improved PK and PD effects relative to an ActRII antibody with LS modifications (SEQ ID NO:12) or an ActRII antibody with no mutations in the Fc domain in cynomolgus monkeys (SEQ ID NO:11).

[0089] Methods: A single intravenous bolus of 20 mg / kg was administered to three groups of 8 cynomologous monkeys receiving one of: (1) an exemplary ActRII antibody with M252Y, S254T, and T256E (YTE) variants in an Fc domain (SEQ ID NO: 9); (2) an exemplary ActRII antibody with M428L and N434S (LS) variants in an Fc domain (SEQ ID NO: 12); and (3) an ActRII antibody with an Fc domain (SEQ ID NO: 11). The monkeys were naïve to biologic drug candidates to avoid cross-reaction Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 of any drug induced antibodies with the tested human antibody drug candidates. Body weight was measured weekly. Blood was collected as follows: pre-dose, 1 hour, 8 hour, 1 day, 3 days, 7 days, 10 days, 14 days, 17 days, 21 days, 24 days and 28 days post administration. To determine systemic exposure, plasma concentrations of human IgG1 and monkey activin A was also determined (data not shown).

[0090] Results: The volume cleared per unit time (µg / ml), as shown in log scale in FIGS.1-4, of an ActRII antibody with M252Y, S254T, and T256E (YTE) variants in an Fc domain (SEQ ID NO: 9) was significantly decreased relative to ActRII antibody with M428L and N434S (LS) variants in an Fc domain (SEQ ID NO: 12); and (3) an ActRII antibody with an Fc domain (SEQ ID NO: 11).

[0091] The average pharmacodynamic effect (in this case, body weight change) in cynomolgus monkeys over time after single intravenous bolus administration of the three exemplary ActRII antibodies was also measured (FIG.5). Cynomolgus monkeys are low in body fat, thus inhibition of the ActRII pathway with the exemplary ActRII antibodies in this system was associated with increased body weight, likely due to increased muscle mass. Administration of bimagrumab modified with the YTE substitutions (N=3) (SEQ ID NO: 9) was associated with a significantly greater increase in body weight relative to ActRII antibody with M428L and N434S (LS) variants in an Fc domain (N=2) (SEQ ID NO: 12); and an ActRII antibody with an Fc domain (N=3) (SEQ ID NO: 11). Thus, the YTE mutation exhibited a surprising improvement in PD (FIG.5) in addition to a significant half-life extension (FIGS. 1-4).

[0092] In addition, model simulations of half-life in humans were performed. The model predicts that an increase in the half-life of an ActRII antibody from 22.5 days to 40-80 days (for M252Y, S254T, and T256E heavy chain modification) (SEQ ID NO: 9), and would be sufficient to increase plasma exposure such that the same body fat decrease would be accomplished with a 2-fold decrease in dosing frequency (e.g., from every 2 weeks to every 4 weeks).

[0002] Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 SEQUENCES >Heavy Chain Complementarity Determining Regions (CDRs) CDRH1 -GYTFTSSYIN (SEQ ID NO: 1) CDRH2 -TINPVSGSTSYAQKFQ (SEQ ID NO: 2) CDRH3 -GGWFDY (SEQ ID NO: 3) >Light Chain Complementarity Determining Regions (CDRs) CDRL1 – TGTSSDVGSYNYVN (SEQ ID NO: 4) CDRL2 - MIYGVSKRPS (SEQ ID NO: 5) CDRL3 - GTFAGGSYYG (SEQ ID NO: 6) >Heavy chain variable region Variable Region (VH) QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSY AQKFQGRVTMTRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSS (SEQ ID NO: 7) >Light chain variable region Variable Region (VL) QSALTQPASVSGSPGQSITISCTGTSSDVGSYNYVNWYQQHPGKAPKLMIYGVSKRPSGV SNRFSGSKSGNTASLTISGLQAEDEADYYCGTFAGGSYYGVFGGGTKLTVLGQ (SEQ ID NO: 8) >Heavy Chain (HC) L234A / L235A / M252Y / S254T / T256E QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSY AQKFQGRVTMTRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSSASTKG PSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL SSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAPEAAGGPSVFL FPPKPKDTLYITREPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRV VSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQ VSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNV FSCSVMHEALHNHYTQKSLSLSPGK (SEQ ID NO: 9) >Light Chain (LC) QSALTQPASVSGSPGQSITISCTGTSSDVGSYNYVNWYQQHPGKAPKLMIYGVSKRPSGV SNRFSGSKSGNTASLTISGLQAEDEADYYCGTFAGGSYYGVFGGGTKLTVLGQPKAAPSV TLFPPSSEELQANKATLVCLISDFYPGAVTVAWKADSSPVKAGVETTTPSKQSNNKYAAS SYLSLTPEQWKSHRSYSCQVTHEGSTVEKTVAPTECS (SEQ ID NO: 10) >Heavy Chain (HC) L234A / L235A QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSY AQKFQGRVTMTRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSSASTKG PSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 SSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAPEAAGGPSVFL FPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRV VSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQ VSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNV FSCSVMHEALHNHYTQKSLSLSPGK (SEQ ID NO: 11) >Heavy Chain (HC) L234A / L235A / M428L / N434S QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSY AQKFQGRVTMTRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSSASTKG PSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSL SSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAPEAAGGPSVFL FPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRV VSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQ VSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNV FSCSVLHEALHSHYTQKSLSLSPGK (SEQ ID NO: 12) >Heavy Chain (HC) L234A / L235A / M252Y / S254T / T256E / M428L / N434S QVQLVQSGAEVKKPGASVKVSCKASGYTFTSSYINWVRQAPGQGLEWMGTINPVSGSTSYAQKFQGRVTM TRDTSISTAYMELSRLRSDDTAVYYCARGGWFDYWGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAAL GCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSSLGTQTYICNVNHKPSNTKVD KRVEPKSCDKTHTCPPCPAPEAAGGPSVFLFPPKPKDTLYITREPEVTCVVVDVSHEDPEVKFNWYVDGV EVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLP PSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNV FSCSVLHEALHSHYTQKSLSLSPGK (SEQ ID NO: 13)

Claims

Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 CLAIMS 1. An antibody that specifically binds activin receptor II (ActRII), wherein the antibody comprises a heavy chain (HC) and a light chain (LC), wherein the HC comprises the amino acid sequence of SEQ ID NO: 9, and wherein the LC comprises the amino acid sequence of SEQ ID NO:

10.

2. An antibody that specifically binds activin receptor II (ActRII), wherein the antibody comprises: a. a heavy chain (HC) comprising a heavy chain variable region (VH), wherein the VH comprises the amino acid sequence of SEQ ID NO: 7; and wherein the HC is an IgG1 isotype comprising the substitutions of M252Y, S254T, and T256E in an Fc domain; and b. a light chain (LC) comprising a light chain variable region (VL), wherein the VL comprises the amino acid sequence of SEQ ID NO:

8.

3. An antibody that specifically binds activin receptor II (ActRII), wherein the antibody comprises: a. a heavy chain variable region(VH), wherein the VH comprises a CDRH1 of SEQ ID NO: 1, a CDRH2 of SEQ ID NO: 2, and a CDRH3 of SEQ ID NO: 3, wherein the antibody is an IgG1 isotype comprising the substitutions of M252Y, S254T, and T256E in an Fc domain; and b. a light chain variable region (VL), wherein the VL comprises a CDRL1 of SEQ ID NO: 4, a CDRL2 of SEQ ID NO: 5, and a CDRL3 of SEQ ID NO:

6.

4. A method of treating a disorder in a subject in need thereof, comprising administering to the subject an activin receptor II (ActRII) antibody of anyone of claims 1-3.

5. The method of claim 4, wherein the disorder is a metabolic disorder.

6. The method of claim 5, wherein the metabolic disorder is one or more of: obesity, diabetes, metabolic syndrome, anti-psychotic drug-associated obesity, sarcopenic obesity, glucocorticoid-induced obesity, hypothalamic obesity associated with craniopharyngioma, Prader-Willi syndrome, and a monogenetic disorder associated with obesity.

7. The method of claim 6, wherein the monogenetic disorder associated with obesity is one of: Bardet- Biedl syndrome or obesity resulting from mutations in one or more of genes of ADCY3, ALMS1, ARL6, BBS1, BBS2, BBS4, BBS5, BBS7, BBS9, BBS10, BBS12, BDNF, CCDC28B,CEP290, CREBBP, EP300, GNAS, IER3IP1, MC3R, MKKS, MKS1, MRAP2, NTRK2, PCSK1, PHF6, POMC, SH2B1, SIM1, TMEM67, TRIM32, TTC8 or VPS13B.

8. The method of claim 6, wherein the diabetes in Type I Diabetes or Type II Diabetes.Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 9. The method of claim 6, wherein the treatment treats an obesity related co-morbidity, wherein the co- morbidity is selected from the group of: glucose intolerance, prediabetes, insulin resistance, high triglycerides, overweight associated physical impairment, renal disease, obstructive sleep apnea, sexual hormones impairment, endocrine reproductive disorders, osteoarthritis, gastrointestinal cancers, dyslipidemia, hypertension, atherosclerotic vascular disease, stroke, and gallstones.

10. The method of claim 4, wherein the disorder is a cardiovascular disease.

11. The method of claim 4, wherein the disorder is a liver disease.

12. The method of claim 4, wherein the disorder is muscle wasting.

13. The method of claim 12, wherein the muscle wasting is associated with disease or disuse.

14. The method of claim 13, wherein the disease is sarcopenia or cachexia.

15. The method of any one of claims 4-14, wherein the ActRII antibody is subcutaneously administered in a dose of about 25 mg to about 600 mg.

16. The method of any one of claims 4-14, wherein the ActRII antibody is intravenously administered in a dose of about 10 mg / kg to about 30 mg / kg.

17. The method of any one of claims 4-16, comprising administering to the subject an agent having glucagon-like peptide-1 receptor (GLP-1) agonist activity, wherein the agent is selected from the group consisting of an antibody, a small molecule, an aptamer, protein, and a peptide.

18. The method of claim 17, wherein the agent is selected from the group consisting of exenatide, exenatide extended-release, dulaglutide, liraglutide, lixisenatide, semaglutide, tirzepatide, cotadutide, noiiglutide, oxyntomodulin, retatrutide, survodutide, albiglutide, beinaglutide and PEG-loxenatide, pemvidutide, orforglipron, and danuglipron.

19. The method of claim 18, wherein the peptide is retatrutide.

20. The method of any one of claims 17-19, wherein the agent is administered in a dose of about 0.005 mg to about 3.0 mg, weekly.

21. The method of claim 18 or claim 19, wherein the agent exhibits dual GLP-1 agonist and gastric inhibitory polypeptide (GIP) agonist activity.Attorney Docket No.31014 VRNS-012 / 00US 340953-2263 22. The method of claim 18 or claim 19, wherein the agent exhibits dual GLP-1 agonist and glucagon (GCG) agonist activity.

23. The method of claim 18 or claim 19, wherein the agent exhibits GLP-1 agonist activity, GIP agonist, and GCG agonist activity.

24. The method of any one of claims 17-23, wherein the ActRII antibody and / or the agent having GLP-1 agonist activity are administered subcutaneously.

25. The method of any one of claims 17-24, wherein the ActRII antibody is administered intravenously.

26. The method of any one of claims 1-25, wherein the subject is human.

27. A composition comprising: a. an ActRII antibody of any one of claims 1-3; b. an agent having GLP-1 agonist activity, wherein the agent is selected from the group consisting of exenatide, exenatide extended-release, dulaglutide, liraglutide, lixisenatide, semaglutide, tirzepatide, cotadutide, noiiglutide, oxyntomodulin, retatrutide, survodutide, albiglutide, beinaglutide and PEG-loxommatid, pemvidutide, and danuglipron.

28. A composition comprising an ActRII antibody of any one of claims 1-3 and retatrutide.

29. A composition comprising an ActRII antibody of any one of claims 1-3 and tirzepatide.

30. A composition containing an ActRII antibody of any one of claims 1-3 and survodutide.

31. A polynucleotide encoding the ActRII antibody of any of claim 1-3.

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