Treatment agent for disease caused by intervertebral disk degeneration

Abstract

The purpose of the present invention is to use MMP as an active ingredient in a treatment agent for a disease caused by intervertebral disk degeneration even when the subject is a human.　The present invention provides a treatment agent for a disease caused by intervertebral disk degeneration. The treatment agent comprises MMP as an active ingredient, and the dose of the MMP per administration is 100-700 μg.

Description

Treatment for diseases caused by intervertebral disc degeneration

[0001] The present invention relates to a therapeutic agent for diseases caused by intervertebral disc degeneration, and more specifically to a therapeutic agent for diseases caused by intervertebral disc degeneration selected from the group consisting of intervertebral disc herniation, low back pain, discopathy, spinal deformity, and spondylosis deformans.

[0002] Lumbar disc herniation occurs most frequently in young and middle-aged people between the ages of 20 and 40, and in the acute phase, it is accompanied by severe lower back and leg pain and neurological disorders, significantly limiting socioeconomic activities. However, it has been reported that approximately 70% of patients with lumbar disc herniation experience relief of pain within six weeks of onset (Non-Patent Document 1). Since 60% of symptomatic disc herniations are resorbed within three months of onset, pain and neurological symptoms may improve.

[0003] Conservative therapy is the standard of treatment for lumbar disc herniation. Pharmacotherapy, including analgesics, muscle relaxants, and medications for peripheral neuropathic pain, is commonly used around the world. However, the effectiveness of specific medications for improving pain and physical function in patients with lumbar disc herniation has not been clearly demonstrated (Non-Patent Document 1). Furthermore, the effectiveness of physical therapy and alternative therapies, such as exercise therapy, traction therapy, ultrasound therapy, and corsets, has not been fully demonstrated, and their therapeutic effects are considered limited (Non-Patent Document 1). In other words, conservative treatment currently practiced in Japan is symptomatic and not a definitive treatment for the pathology of this disease, in which degenerated discs bulge or prolapse outside the spinal canal or intervertebral foramen, compressing nerve roots and the dural canal and causing inflammation. Meanwhile, evidence for surgical treatment is established, particularly in the short term, and surgery is beneficial when appropriate. However, past evidence has conflicting opinions in the long term, and determining whether surgery is appropriate is crucial (Non-Patent Document 1). Condoliase is available on the market as an intradiscal treatment alternative to surgery, but because it is a heterologous protein, it carries the risk of serious side effects such as shock and anaphylaxis (Non-Patent Documents 2 to 3). Furthermore, its indication is limited to "lumbar disc herniation under the posterior longitudinal ligament where sufficient improvement cannot be achieved with conservative treatment," and only a single administration into the high disc that is the cause of the symptoms is permitted, and the drug cannot be administered again.

[0004] KTP-001 is a novel chemonucleolytic agent containing recombinant human matrix metalloproteinase-7 (MMP-7) (rhMMP-7) as its active ingredient, developed based on the inventor's basic research. MMP-7 enzymatically cleaves proteoglycans, the main component of the extracellular matrix produced by intervertebral disc nucleus pulposus cells. Expression of MMP-7 has been confirmed in the spontaneous regression mechanism of herniated discs, and intradiscal administration of MMP-7 is thought to physiologically promote the spontaneous regression mechanism in a similar manner.

[0005] Patent Document 1 discloses the use of MMP-7 as a therapeutic agent for intervertebral disc degeneration. Patent Document 2 discloses a method for producing MMP-7 that enables mass production in Escherichia coli. Patent Document 3 discloses a method for producing an MMP-7 formulation with improved storage stability in vial formulations, etc.

[0006] Patent No. 4512038 Patent No. 5602635 Patent No. 6755793

[0007] Nanzando, Lumbar Disc Herniation Treatment Guidelines, Revised 3rd Edition (Published May 2021); Seikagaku Corporation, Hernicore (Registered Trademark) 1.25 Units for Discopathy, Appropriate Use Guide, 1st Edition (Created June 2018); Seikagaku Corporation, Hernicore (Registered Trademark) 1.25 Units for Discopathy, Post-Marketing Surveillance Report (April 2019); Haro H, et al. Experimental chemonucleolysis with recombinant human matrix metalloproteinase 7 in human herniated discs and dogs. Spine J. 2014; 14(7): 1280-1290. Ikeda T, et al. Development of a scoring method for the Japanese version of the EQ-5D-5L. Health and Medical Science. 2015; 64(1): 47-55. Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP, et al. al. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain. 2005; 113(1-2):9-19.

[0008] Patent Document 1 describes that when MMP-7 is used as a therapeutic agent for intervertebral disc degeneration, the dosage per administration is approximately 1 μg to 100 mg, preferably 100 μg to 1 mg. However, the examples in Patent Document 1 only describe administration of 10 μg / 100 μl or 40 μg / 100 μl of human recombinant MMP-7 to rabbit intervertebral discs (Example 2), administration of 20 μg / 200 μl or 10 μg / 100 μl of MMP-7 to dog intervertebral discs (Example 3), and administration of 20 μg / 200 μl of MMP-7 to dog intervertebral discs (Example 4). Therefore, it is unclear whether MMP-7 can be used as a therapeutic agent for intervertebral disc degeneration at dosages other than these. Furthermore, Patent Document 1 does not describe the administration of MMP-7 to human intervertebral discs, and it was unclear whether MMP-7 could be used as a therapeutic agent for human intervertebral disc degeneration.

[0009] In fact, in a clinical trial of this MMP-7 preparation (KTP-001) conducted by the present inventors in the United States, 5 μg of MMP-7 was administered to humans, but with one exception, no effect was observed as a therapeutic effect by intradiscal injection. Also, when 15 μg of MMP-7 was administered to humans, all cases were herniated discs, which simply progressed naturally, and no clear therapeutic effect was observed. Therefore, it was suspected that MMP-7 cannot be used as a therapeutic agent for intervertebral disc degeneration in humans, unlike in rabbits and dogs.

[0010] Therefore, an object of the present invention is to use MMP as an active ingredient in a therapeutic agent for diseases caused by intervertebral disc degeneration, even when the subject is humans.

[0011] After extensive research, the present inventors have unexpectedly discovered that, by setting the dose of MMP per administration to a specific amount, MMP can be used as an active ingredient in a treatment for diseases caused by intervertebral disc degeneration, even in humans.

[0012] As mentioned above, in a clinical trial of the present MMP-7 preparation (KTP-001) in the United States, when 5 μg of MMP-7 was administered to humans, no effect of intervertebral disc injection therapy was observed, except in one exceptional case, and when 15 μg of MMP-7 was administered to humans, all cases developed prolapse herniation, which was merely a natural progression, and no clear therapeutic effect was obtained.In light of these facts, even if the dose of MMP-7 per administration was changed in humans, MMP-7 could not be used as an active ingredient in a treatment for diseases caused by intervertebral disc degeneration, and the findings of the present inventors are completely unexpected.

[0013] That is, the present invention provides the following. [Aspect A-1] A therapeutic agent for a disease caused by intervertebral disc degeneration, comprising an MMP as an active ingredient, wherein the dose of MMP per administration is 300 μg to 600 μg. [Aspect A-2] The therapeutic agent according to Aspect A-1, wherein the disease caused by intervertebral disc degeneration is selected from the group consisting of herniated disc, lower back pain, discopathy, spinal deformity, and spondylosis deformans, all of which are caused by intervertebral disc degeneration. [Aspect A-3] The therapeutic agent according to Aspect A-2, wherein the spinal deformity is kyphoscoliosis. [Aspect A-4] The therapeutic agent according to Aspect A-3, wherein the kyphoscoliosis is kyphoscoliosis. [Aspect A-5] The therapeutic agent according to Aspect A-1, wherein the disease caused by intervertebral disc degeneration is selected from the group consisting of herniated disc, discopathy, kyphoscoliosis, and spondylosis deformans, all of which are caused by intervertebral disc degeneration. [Aspect A-6] The treating agent according to Aspect A-1, wherein the MMP is a recombinant human MMP. [Aspect A-7] The treating agent according to Aspect A-1, which is to be administered directly to the affected area of ​​the disease. [Aspect A-8] The treating agent according to Aspect A-1, which is to be administered multiple times to a patient with the disease. [Aspect A-9] The treating agent according to Aspect A-1, which is to be administered to a patient with the disease who has not received conservative treatment for the disease. [Aspect A-10] The treating agent according to Aspect A-1, which is to be administered to a patient with the disease immediately after a diagnosis that confirms the disease. [Aspect A-11] The treating agent according to Aspect A-10, wherein the diagnosis that confirms the disease is made using MRI. [Aspect A-12] The treating agent according to Aspect A-1, which is an injectable preparation, and the amount administered per dose is 2 cc or more. [Aspect A-13] The treating agent according to Aspect A-1, which contains 300 μg to 600 μg of MMP. [Aspect A-14] The treating agent according to Aspect A-1, which is a unit dosage form. [Aspect A-15] The treating agent according to Aspect A-1, which is to be administered once per day to a patient with the disease. [Aspect B-1] A treating agent for a disease caused by intervertebral disc degeneration, which contains MMP as an active ingredient, and the dose of MMP per administration is 100 μg to 700 μg.[Aspect B-2] The therapeutic agent according to Aspect B-1, wherein the disease caused by intervertebral disc degeneration is selected from the group consisting of herniated disc, lower back pain, discopathy, spinal deformity, and spondylosis deformans, all of which are caused by intervertebral disc degeneration. [Aspect B-3] The therapeutic agent according to Aspect B-2, wherein the spinal deformity is kyphoscoliosis. [Aspect B-4] The therapeutic agent according to Aspect B-3, wherein the kyphoscoliosis is kyphoscoliosis. [Aspect B-5] The therapeutic agent according to Aspect B-1, wherein the disease caused by intervertebral disc degeneration is selected from the group consisting of herniated disc, discopathy, kyphoscoliosis, and spondylosis deformans, all of which are caused by intervertebral disc degeneration. [Aspect B-6] The therapeutic agent according to Aspect B-1, wherein the dose of MMP per administration is 250 μg to 500 μg. [Aspect B-7] The treating agent according to Aspect B-1, wherein the dose of MMP per administration is 300 μg to 450 μg. [Aspect B-8] The treating agent according to Aspect B-1, wherein the MMP is a recombinant human MMP. [Aspect B-9] The treating agent according to Aspect B-1, for administration directly to the affected area of ​​the disease. [Aspect B-10] The treating agent according to Aspect B-1, for administration once per day to a patient with the disease. [Aspect B-11] The treating agent according to Aspect B-1, for administration multiple times to a patient with the disease. [Aspect B-12] The treating agent according to Aspect B-1, for administration to a patient with the disease who has not received conservative treatment for the disease. [Aspect B-13] The treating agent according to Aspect B-1, for administration to a patient with the disease immediately after a definitive diagnosis of the disease. [Aspect B-14] The treating agent according to Aspect B-13, wherein the definitive diagnosis of the disease is performed using MRI. [Aspect B-15] The treating agent according to Aspect B-1, which is an injection and has a single dose of 2 cc or more. [Aspect B-16] The treating agent according to Aspect B-1, which contains 100 μg to 700 μg of MMP. [Aspect B-17] The treating agent according to Aspect B-1, which contains 250 μg to 500 μg of MMP. [Aspect B-18] The treating agent according to Aspect B-1, which contains 300 μg to 450 μg of MMP. [Aspect B-19] The treating agent according to Aspect B-1, which is a unit dosage form.[Aspect B-20] A pharmaceutical composition for treating a disease caused by intervertebral disc degeneration, comprising an MMP as an active ingredient, wherein the dose of MMP per administration is 100 μg to 700 μg. [Aspect B-21] The pharmaceutical composition according to Aspect B-20, wherein the disease caused by intervertebral disc degeneration is selected from the group consisting of herniated disc, low back pain, discopathy, spinal deformity, and spondylosis deformans caused by intervertebral disc degeneration. [Aspect B-22] The pharmaceutical composition according to Aspect B-21, wherein the spinal deformity is kyphoscoliosis. [Aspect B-23] The pharmaceutical composition according to Aspect B-22, wherein the kyphoscoliosis is kyphoscoliosis. [Aspect B-24] The pharmaceutical composition according to Aspect B-20, wherein the disease caused by intervertebral disc degeneration is selected from the group consisting of herniated disc, discopathy, kyphoscoliosis, and spondylosis deformans caused by intervertebral disc degeneration. [Aspect B-25] The pharmaceutical composition according to Aspect B-20, wherein the MMP is administered in a single dose of 250 μg to 500 μg. [Aspect B-26] The pharmaceutical composition according to Aspect B-20, wherein the MMP is administered in a single dose of 300 μg to 450 μg. [Aspect B-27] The pharmaceutical composition according to Aspect B-20, wherein the MMP is a recombinant human MMP. [Aspect B-28] The pharmaceutical composition according to Aspect B-20, for administration directly to the site affected by the disease. [Aspect B-29] The pharmaceutical composition according to Aspect B-20, for administration once per day to a patient suffering from the disease. [Aspect B-30] The pharmaceutical composition according to Aspect B-20, for administration multiple times to a patient suffering from the disease. [Aspect B-31] The pharmaceutical composition according to Aspect B-20, for administration to a patient suffering from the disease who is not receiving conservative treatment for the disease. [Aspect B-32] The pharmaceutical composition according to Aspect B-20, for administration to a patient suffering from the disease immediately after a definitive diagnosis of the disease. [Aspect B-33] The pharmaceutical composition according to Aspect B-32, wherein the definitive diagnosis of the disease is performed using MRI. [Aspect B-34] The pharmaceutical composition according to Aspect B-20, which is an injection, the amount of which per dose is 2 cc or more. [Aspect B-35] The pharmaceutical composition according to Aspect B-20, wherein the amount of MMP contained is 100 μg to 700 μg.[Aspect B-36] The pharmaceutical composition according to Aspect B-20, wherein the MMP content is 250 μg to 500 μg. [Aspect B-37] The pharmaceutical composition according to Aspect B-20, wherein the MMP content is 300 μg to 450 μg. [Aspect B-38] The pharmaceutical composition according to Aspect B-20, which is a unit dosage form.

[0014] According to the present invention, even in the case of humans, diseases caused by intervertebral disc degeneration can be treated using MMP as an active ingredient, and more specifically, diseases caused by intervertebral disc degeneration selected from the group consisting of herniated disc, low back pain, discopathy, spinal deformity, and degenerative spondylosis can be treated.

[0015] As shown in the Examples below, where the presence or absence of anti-KTP-001 antibodies in serum was examined and the results were negative, the present MMP-7 (KTP-001) formulation surprisingly did not cause anaphylaxis, unlike the competing product condoliase (trade name: HERNICORE (registered trademark)). Therefore, in a more specific embodiment, the treatment agent of the present invention can be administered multiple times. Furthermore, while condoliase (trade name: HERNICORE (registered trademark)) is not a treatment target until 6 weeks or more after the start of conservative treatment, the treatment agent of the present invention in a more specific embodiment can be administered immediately after diagnosis is confirmed, which is useful.

[0016] Figure 1 shows the schedule of this clinical trial. Figure 2 shows the cohort schedule. Figure 3 shows an overview of the clinical trial procedures. Figure 4 shows the progression of leg pain (NRS: average pain over the past 24 hours) (FAS). The number of subjects at each time point (sham group, 150 μg group, 300 μg group, 600 μg group, and so forth) is as follows: Baseline: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 24 hours after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 1 week after administration: 3 subjects, 3 subjects, 10 subjects, 2 subjects; 2 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 4 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 6 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 13 weeks after administration: 3 subjects, 2 subjects, 11 subjects, 2 subjects; 24 weeks after administration / at time of discontinuation: 3 subjects, 3 subjects, 11 subjects, 2 subjects. Figure 5 shows the time course of lower limb pain (NRS: worst pain in the past 24 hours) (FAS). The number of subjects at each time point (Sham group, 150 μg group, 300 μg group, 600 μg group, and so on) is as follows: Baseline: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 24 hours after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 1 week after administration: 3 subjects, 3 subjects, 10 subjects, 2 subjects; 2 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 4 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 6 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 13 weeks after administration: 3 subjects, 2 subjects, 11 subjects, 2 subjects; 24 weeks after administration / at time of discontinuation: 3 subjects, 3 subjects, 11 subjects, 2 subjects. Figure 6 shows the time course of lower back pain (NRS: average pain over the past 24 hours) (FAS). The number of subjects at each time point (sham group, 150 μg group, 300 μg group, 600 μg group, and so on) is as follows: Baseline: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 24 hours after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 1 week after administration: 3 subjects, 3 subjects, 10 subjects, 2 subjects; 2 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 4 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 6 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 13 weeks after administration: 3 subjects, 2 subjects, 11 subjects, 2 subjects; 24 weeks after administration / at time of discontinuation: 3 subjects, 3 subjects, 11 subjects, 2 subjects. Figure 7 shows the time course of lower back pain (NRS: worst pain in the past 24 hours) (FAS).The numbers of subjects at each time point (Sham group, 150 μg group, 300 μg group, 600 μg group, and so forth) are as follows: Baseline: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 24 hours after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 1 week after administration: 3 subjects, 3 subjects, 10 subjects, 2 subjects; 2 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 4 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 6 weeks after administration: 3 subjects, 3 subjects, 11 subjects, 2 subjects; 13 weeks after administration: 3 subjects, 2 subjects, 11 subjects, 2 subjects; 24 weeks after administration / at time of discontinuation: 3 subjects, 3 subjects, 11 subjects, 2 subjects. Figure 8 shows the time to additional treatment (Kaplan-Meier plot) (FAS). Number of subjects at baseline: 3 in the sham group, 3 in the 150 μg group, 11 in the 300 μg group, 2 in the 600 μg group. Figure 9 shows the time course of serum keratan sulfate concentrations (PPS). The number of subjects at each time point (sham group, 150 μg group, 300 μg group, 600 μg group, etc.) is as follows: Baseline: 3, 3, 11, 2; 24 hours after administration: 3, 3, 11, 2; 1 week after administration: 3, 3, 10, 2; 2 weeks after administration: 3, 3, 11, 1; 6 weeks after administration: 3, 3, 10, 0.

[0017] The present invention provides a therapeutic agent for diseases caused by intervertebral disc degeneration, comprising an MMP as an active ingredient, wherein the MMP is administered at a single dose of 100 μg to 700 μg. The disease caused by intervertebral disc degeneration is, for example, selected from the group consisting of herniated disc, low back pain, discopathy, spinal deformity, and spondylosis degenerativeis, which are caused by intervertebral disc degeneration. Here, spinal deformity is, for example, kyphoscoliosis. Here, kyphoscoliosis is, for example, kyphoscoliosis. The disease caused by intervertebral disc degeneration is, for example, selected from the group consisting of herniated disc, discopathy, kyphoscoliosis, and spondylosis degenerativeis, which are caused by intervertebral disc degeneration.

[0018] The dose of MMP per administration may be, for example, 100 μg or more, 110 μg or more, 120 μg or more, 130 μg or more, 140 μg or more, 150 μg or more, 160 μg or more, 170 μg or more, 180 μg or more, 190 μg or more, 200 μg or more, 210 μg or more, 220 μg or more, 230 μg or more, 240 μg or more, 250 μg or more, 260 μg or more, 270 μg or more, 280 μg or more, 290 μg or more, 300 μg or more, 310 μg or more, 320 μg or more, 330 μg or more, 340 μg or more, 350 μg or more, 360 μg or more, 370 μg or more, 380 μg or more, 390 μg or more, 400 μg or more, 410 μg or more, 420 μg or more, 430 μg or more, 440 μg or more, 450 μg or more, 460 μg or more, 470 μg or more, 480 μg or more, 490 μg or more, 500 μg or more, 510 μg or more, 520 μg or more, 530 μg or more, 540 μg or more, 550 μg or more, 560 μg or more, 570 μg or more, 580 μg or more, 590 μg or more, 600 μg or more, 610 μg or more, 620 μg or more, 630 μg or more, 640 μg or more, 65 430 μg or more, 440 μg or more, 450 μg or more, 460 μg or more, 470 μg or more, 480 μg or more, 490 μg or more, 500 μg or more, 510 μg or more, 520 μg or more, 530 μg or more, 540 μg or more, 550 μg or more, 560 μg or more, 570 μg or more, 580 590 μg or more, 600 μg or more, 610 μg or more, 620 μg or more, 630 μg or more, 640 μg or more, 650 μg or more, 660 μg or more, 670 μg or more, 680 μg or more, or 690 μg or more.

[0019] The dosage of MMP used in a single application is as follows: 700 μg or less, 690 μg or less, 680 μg or less, 670 μg or less, 660 μg or less, 650 μg or less, 640 μg or less, 630 μg or less, 620 μg or less, 610 μg or less, 600 μg or less, 590 μg or less, 580 μg or less, 570 μg or less, 560 μg or less, 550 μg or less, 540 μg or less, 530 μg or less, 520 μg or less, 510 μg or less, 500 μg or less, 490 μg or less, 480 μg or less, 470 μg or less, 460 μg or less, 450 μg or less, 440 μg or less, 430 μg or less, 420 μg or less, 410 μg or less, 400 μg or less. Below μg, below 390 μg, below 380 μg, below 370 μg, below 360 μg, below 350 μg, below 340 μg, below 330 μg, below 320 μg, below 310 μg, below 300 μg, below 290 μg, below 280 μg, below 270 μg, below 260 μg, below 250 μg, below 240 μg, below 230 μg, below 220 μg, below 210 μg, below 200 μg, below 190 μg, below 180 μg, below 170 μg, below 160 μg, below 150 μg, below 140 μg, below 130 μg, below 120 μg, and below 110 μg.

[0020] MMPとしては, MMP-7のほか, MMP-3などがげられる.

[0021] The MMP is preferably a recombinant human MMP. The MMP-7 is preferably a recombinant human MMP-7. MMP-7 is an extracellular matrix degrading enzyme. MMP-7 is a matrix metalloproteinase (hereinafter sometimes referred to as "MMP") belonging to the zinc-type metalloproteinase family, which has a zinc molecule at its active site. MMPs are produced as precursors, and upon extracellular secretion, the signal sequence is processed, followed by the prosequence, resulting in their active form. While extracellularly secreted MMPs regulate extracellular matrix metabolism, MMP-7 is primarily secreted by cancer cells and has been reported to be involved in invasion and metastasis. MMP-7 lacks the hinge and hemopexin-like domains found in many other MMPs. It is the smallest molecular unit among MMPs and utilizes collagen and extracellular matrix components (fibronectin, vitronectin, laminin, and aggrecan) as substrates. MMP-7 is presumed to be involved in the spontaneous regression of herniated discs because it utilizes aggrecan, a major component of cartilage tissue, as a substrate; macrophages derived from surgical specimens of herniated discs express MMP-7; and studies using MMP-7-deficient mice have shown no activation of inflammatory cytokines involved in the regression of herniated discs. The MMP-7 contained as an active ingredient in the therapeutic agent of the present invention may be full-length MMP-7 or a portion of MMP-7. For example, a known full-length MMP-7 (SEQ ID NO: 2) can be used (https: / / www-ncbi-nlm-nih-gov.translate.goog / protein / NP_002414?_x_tr_sl=en&_x_tr_tl=ja&_x_tr_hl=ja&_x_tr_pto=sc), and the portion of MMP-7 can be that described in the Examples below (SEQ ID NO: 1), including equivalents thereof. The precursor of human matrix metalloproteinase-7 (MMP-7) has a molecular weight of approximately 29 kDa, and the active form of human matrix metalloproteinase-7 (MMP-7) has a molecular weight of approximately 19 kDa (173 amino acids). MMP-7 is activated (cleaved) from the approximately 29 kDa precursor to become the active form of approximately 19 kDa, which exhibits enzymatic activity.The MMP-7 is preferably an active form of MMP-7.

[0022] The therapeutic agent of the present invention is intended for administration, for example, by intrathecal administration, oral administration, intravenous administration, subcutaneous administration, transdermal administration, intramuscular administration, intraarticular administration, nasal administration, intraperitoneal administration, direct injection into target tissue, inhalation administration, enteral administration, enema administration, tube feeding, etc. However, the therapeutic agent of the present invention is preferably intended for administration directly to the affected area of ​​the disease. The affected area may, for example, be a herniated area. More specifically, the affected area may include the intervertebral disc portion, particularly the intervertebral disc portion near the herniation, and the nucleus pulposus portion, particularly the herniated portion of the nucleus pulposus.

[0023] The therapeutic agent of the present invention may be administered, for example, into an intervertebral disc, particularly into an intervertebral disc near a herniation and / or into the nucleus pulposus, particularly into the herniated portion of the nucleus pulposus. For example, during disc puncture, a puncture needle is advanced percutaneously under X-ray fluoroscopy to puncture the intervertebral disc. For example, an inner tube is advanced from there toward the herniated disc, selectively puncturing the herniated disc and injecting the therapeutic agent of the present invention. For example, the intervertebral level affected by the lumbar disc herniation is identified under X-ray fluoroscopy. Then, for example, the patient is positioned in a prone or semi-lateral position under X-ray fluoroscopy so that the target disc space does not overlap with adjacent endplates. Then, for example, the body surface from the lumbar region to the pelvis is disinfected, and a sterilized disc puncture needle is used under X-ray fluoroscopy to puncture the skin and the outer layer of the annulus fibrosus of the disc. During skin puncture, a local anesthetic may be administered subcutaneously. Thereafter, for example, X-ray fluoroscopy is performed from the front, lateral, and oblique positions as appropriate, and the tip of the intervertebral disc puncture needle is positioned centrally within the intervertebral disc. For example, to more accurately administer the therapeutic agent to the herniated disc mass, a device may be used in which the inner barrel of the intervertebral disc puncture needle can be bent toward the herniated orifice where the herniated disc bulges or prolapses. Preferably, the therapeutic agent of the present invention is then injected. Alternatively, to more accurately administer the therapeutic agent to the herniated disc mass, the intervertebral disc puncture needle may be inserted into the intervertebral disc under X-ray fluoroscopy via the intervertebral foramen or interlaminar space, and the therapeutic agent of the present invention may be administered. Alternatively, it is anticipated that insertion of the puncture needle into the intervertebral disc may be difficult due to the subject's anatomical characteristics. In such cases, the therapeutic agent of the present invention may be administered into the epidural space, for example, via the intervertebral foramen or interlaminar space.

[0024] The therapeutic agent of the present invention may be administered, for example, by epidural injection. In some cases, a method of administering the therapeutic agent directly to the herniated disc mass, rather than intradiscal administration, is preferable. For example, a spinal endoscope or surgical microscope is used to reach the vicinity of the herniated disc bulge or prolapse from the anterior part of the disc, the intervertebral foramen, or the intervertebral space, and the herniated disc is punctured using, for example, a disc puncture needle, and the therapeutic agent of the present invention is administered.

[0025] The treatment agent of the present invention may be administered using a device such as the puncture device described in Japanese Patent No. 4181599. The puncture device described in Japanese Patent No. 4181599 is characterized by comprising a lumen-shaped puncture body having a protrusion opening on its side, an acting body housed within the puncture body and having an acting part that acts inside the body, and a guide means for causing the acting part of the acting body to protrude laterally from the protrusion opening. Furthermore, the puncture device described in Japanese Patent No. 4181599 is more specifically a puncture device comprising a lumen-shaped puncture body having an opening on its side, an acting body housed within the puncture body and having an acting part that acts inside the body, and a guide means for causing the acting part of the acting body to protrude laterally from the opening, the guide means comprising a wire housed within the puncture body for guiding the acting body, and a moving means for freely moving the wire from the opening to the side of the puncture body, the tip of the wire being fixed to the puncture body, and the moving means moving the wire in the lengthwise direction relative to the puncture body, thereby bending the wire and causing a part of it to protrude from the opening, and causing the acting part to protrude laterally from the opening.

[0026] By administering the therapeutic agent of the present invention in this manner, the natural regression of hernia can be promoted.

[0027] The therapeutic agent of the present invention may be administered to a patient with the disease once a day, for example, once, twice, three times, four times, five times, six times, seven times, eight times, nine times, or ten times a day.

[0028] The therapeutic agent of the present invention may be administered multiple times to a patient with the disease, for example. The number of times administered to a patient with the disease may be, for example, 1 time, 2 times, 3 times, 4 times, 5 times, 6 times, 7 times, 8 times, 9 times, 10 times, 11 times, 12 times, 13 times, 14 times, 15 times, 16 times, 17 times, 18 times, 19 times, 20 times, 21 times, 22 times, 23 times, 24 times, 25 times, 26 times, 27 times, 28 times, 29 times, 30 times, 31 times, 32 times, 33 times, 34 times, 35 times, 36 times, 37 times, 38 times, 39 times, 40 times, 41 times, 42 times, 43 times, 44 times, 45 times, 46 times, 47 times, 48 ​​times, 49 ... 0, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, or 100 times.

[0029] The treatment agent of the present invention may be, for example, one intended to be administered to a patient with the above-mentioned disease who is not receiving conservative treatment for the disease.

[0030] The therapeutic agent of the present invention may be administered to a patient suffering from the above-mentioned disease immediately after a definitive diagnosis of the disease. Here, the definitive diagnosis may be performed using, for example, MRI. Examples of definitive diagnosis include confirming the presence of neurological symptoms such as radiculopathy, cauda equina, or myelopathy, and then using magnetic resonance imaging (MRI) to confirm the state of nerve compression and intervertebral disc degeneration, e.g., the location and extent of herniation. Furthermore, the definitive diagnosis may involve using a discography to image the herniated mass at the site to be treated and accurately determine the location and extent of the herniated disc. Therefore, the therapeutic agent of the present invention may be administered directly to the herniated area of ​​a patient suspected of having disc degeneration (e.g., herniation) after MRI and discography are performed. If disc degeneration (e.g., herniation) is detected in the patient, the therapeutic agent of the present invention may be administered according to the pathological condition. Administration of the therapeutic agent of the present invention in this manner can promote the natural regression of herniated tissue. Examples of the drug to be administered to a patient with the disease immediately after a definitive diagnosis of the disease include a drug to be administered to a patient after a definitive diagnosis of the disease who has not received conservative treatment for the disease, and a drug to be administered to a patient within a predetermined time after a definitive diagnosis of the disease. Here, examples of within a predetermined time include within 1 minute, within 2 minutes, within 3 minutes, within 4 minutes, within 5 minutes, within 6 minutes, within 7 minutes, within 8 minutes, within 9 minutes, within 10 minutes, within 20 minutes, within 30 minutes, within 40 minutes, within 50 minutes, within 1 hour, within 2 hours, within 3 hours, within 4 hours, within 5 hours, within 6 hours, within 7 hours, within 8 hours, within 9 hours, within 10 hours, within 20 hours, within 30 hours, within 40 hours, within 50 hours, within 60 hours, within 70 hours, within 80 hours, within 90 hours, within 100 hours, within 200 hours, within 300 hours, within 400 hours, within 500 hours, within 600 hours, within 700 hours, within 800 hours, within 900 hours, and the like.

[0031] The therapeutic agent of the present invention may be formulated into oral dosage forms such as tablets, capsules, elixirs, and microcapsules, or parenteral dosage forms such as injections, ointments, and patches. That is, the therapeutic agent of the present invention may be, for example, an injection, with a single dose of 2 cc or more. The single dose of the therapeutic agent of the present invention in the form of an injection may be, for example, 2 cc or more, 3 cc or more, 4 cc or more, 5 cc or more, 6 cc or more, 7 cc or more, 8 cc or more, or 9 cc or more. The single dose of the therapeutic agent of the present invention in the form of an injection may be, for example, 10 cc or less, 9 cc or less, 8 cc or less, 7 cc or less, 6 cc or less, 5 cc or less, 4 cc or less, or 3 cc or less. Note that a solution volume of 1 cc was used in the US clinical trial described below. However, in discography, administering 1 cc of contrast agent into the intervertebral disc did not allow complete imaging from the center of the disc to the herniated disc. It is preferable to administer at least 2 cc to 3 cc of contrast agent to visualize the herniated disc mass. Therefore, from the viewpoint of ensuring sufficient distribution of the active ingredient to the affected area, the single dose of the treatment agent of the present invention is preferably 2 cc or more. Another treatment agent for herniated discs, Hernicore (registered trademark), is administered in a dose of 1 cc, but its effectiveness in treating only lumbar disc herniation of subligamentous extrusion type according to the Macnab classification has been confirmed, and pharmaceutical approval has only been obtained for this type of lumbar disc herniation.In contrast, the present inventors have found that the therapeutic agent of the present invention, administered in an amount of 2 cc or more, is expected to reach the affected area based on findings from intervertebral discography, and is therefore expected to be effective in treating not only subligamentous extrusion, but also protrusion, transligamentous extrusion, and sequestration, preferably subligamentous extrusion, protrusion, and transligamentous extrusion, and more preferably subligamentous extrusion and transligamentous extrusion. In particular, non-clinical studies have confirmed that KTP-001 did not cause any pathological or physiological abnormalities when administered epidurally or intrathecally, and MMP-7-positive cells have been confirmed in the tissues of surgical specimens with herniated discs, suggesting that it can be safely administered to subligamentous extrusion and transligamentous extrusion. Therefore, from the perspective of achieving a broad therapeutic effect for disc herniation, not limited to subligamentous extrusion, the dosage of the treatment agent of the present invention per administration is preferably 2 cc or more.

[0032] The content of MMP contained in this disclosure is 100 μg or more, 110 μg or more, 120 μg or more, 130 μg or more, 140 μg or more, 150 μg or more, 160 μg or more, 170 μg or more, 180 μg or more, 190 μg or more, 200 μg or more, 210 μg or more, 220 μg or more, 230 μg or more, 240 μg or more, 250 μg or more, 260 μg or more, 270 μg or more, 280 μg or more, 290 μg or more, 300 μg or more, 310 μg or more, 320 μg or more, 330 μg or more, 340 μg or more, 350 μg or more, 360 μg or more, 370 μg or more, 380 μg or more, 390 μg or more, 400 μg or more, 410 μg or more, 420 μg or more, 430 μg or more, 440 μg or more, 450 μg or more, 460 μg or more, 470 μg or more, 480 μg or more, 490 μg or more, 500 μg or more, 510 μg or more, 520 μg or more, 530 μg or more, 540 μg or more, 550 μg or more, 560 μg or more, 570 μg or more, 580 μg or more, 590 μg or more, 600 μg or more, 610 μg or more, 620 μg or more, 630 μg or more, 640 μg or more, 650 μg or more, 660 μg or more, 670 μg or more, 680 μg or more, and also 690 μg or more.

[0033] The therapeutic agent of the present invention has an MMP content of, for example, 700 μg or less, 690 μg or less, 680 μg or less, 670 μg or less, 660 μg or less, 650 μg or less, 640 μg or less, 630 μg or less, 620 μg or less, 610 μg or less, 600 μg or less, 590 μg or less, 580 μg or less, 570 μg or less, 560 550 µg or less, 540 µg or less, 530 µg or less, 520 µg or less, 510 µg or less, 500 µg or less, 490 µg or less, 480 µg or less, 470 µg or less, 460 µg or less, 450 µg or less, 440 µg or less, 430 µg or less, 420 µg or less, 410 µg or less, 400 μg or less, 390 μg or less, 380 μg or less, 370 less than μg, less than 360 μg, less than 350 μg, less than 340 μg, less than 330 μg, less than 320 μg, less than 310 μg, less than 300 μg, less than 290 μg, less than 280 μg, less than 270 μg, less than 260 μg, less than 250 μg, less than 240 μg, less than 230 μg, less than 220 μg, 210 less than μg, less than 200 μg, less than 190 μg, less than 180 μg, less than 170 μg, less than 160 μg, less than 150 μg, less than 140 μg, less than 130 μg, less than 120 μg, or less than 110 μg.

[0034] The therapeutic agent of the present invention may be, for example, a unit preparation. A unit preparation is, for example, a preparation corresponding to a single administration. Examples of unit preparations include tablets, capsules, and preparations enclosed in ampoules or syringes.

[0035] As shown in the examples below, by administering the therapeutic agent of the present invention to a subject, a disease caused by intervertebral disc degeneration in the subject can be treated. The disease caused by intervertebral disc degeneration is, for example, selected from the group consisting of herniated disc, low back pain, discopathy, spinal deformity, and spondylosis deformans, which are caused by intervertebral disc degeneration. Here, the spinal deformity is, for example, kyphoscoliosis. Here, the kyphoscoliosis is, for example, kyphoscoliosis. The disease caused by intervertebral disc degeneration is, for example, selected from the group consisting of herniated disc, discopathy, kyphoscoliosis, and spondylosis deformans, which are caused by intervertebral disc degeneration. Here, examples of intervertebral disc herniation include, for example, protrusion, subligamentous extrusion, transligamentous extrusion, and sequestrated disc or sequestration, based on the Macnab classification. The treatment agent of the present invention can treat any of these types of intervertebral disc herniation. However, the treatment agent of the present invention is preferably capable of treating protrusion, subligamentous extrusion, and transligamentous extrusion, and more preferably subligamentous extrusion and transligamentous extrusion. Note that the term "sequestrated disc" refers to a disc that has migrated from a high disc position to the cranial or caudal side. Disease treatment includes not only treatment but also prevention. Disease treatment includes complete cure, amelioration of symptoms, and alleviation of symptoms.

[0036] The subject may be, for example, a vertebrate. The vertebrate may be, for example, a mammal such as a mouse, a rat, a rabbit, a pig, a cow, a monkey, or a human. The mammal is preferably a human. The subject may be of any age, including an infant, a juvenile, an adolescent, an adult, or an elderly person.

[0037] The therapeutic agent of the present invention may consist of an MMP, or may be formulated as a pharmaceutical composition in which it is mixed with a pharmaceutically acceptable carrier.

[0038] Examples of pharmaceutically acceptable carriers include solvents such as sterilized water and physiological saline; binders such as gelatin, corn starch, tragacanth gum, and gum arabic; excipients such as crystalline cellulose; and leavening agents such as corn starch, gelatin, and alginic acid.

[0039] Pharmaceutically acceptable carriers include additives such as lubricants such as magnesium stearate, sweeteners such as sucrose, lactose, and saccharin, flavorings such as peppermint and rhododendron oil, stabilizers such as benzyl alcohol and phenol, buffers such as phosphates and sodium acetate, solubilizers such as benzyl benzoate and benzyl alcohol, antioxidants, preservatives, surfactants, and emulsifiers.

[0040] Pharmaceutical compositions can be formulated, for example, by combining the above-mentioned carriers appropriately and mixing them in unit dosage forms required for generally accepted pharmaceutical practice.

[0041] When the pharmaceutical composition is an injection, examples of the solvent for the injection include isotonic solutions containing adjuvants such as physiological saline, glucose, D-sorbitol, D-mannose, D-mannitol, sodium chloride, etc. The solvent for the injection may contain alcohol such as ethanol, polyalcohol such as propylene glycol, polyethylene glycol, nonionic surfactants such as Polysorbate 80 (trademark), HCO-50, etc.

[0042] The treatment agent of the present invention may be accompanied by an instruction manual. The instruction manual may include, for example, information about the active ingredient contained, the single dose of the active ingredient MMP, the number of doses per day, the administration method, the total number of doses, and the amount per dose. The attachment of the instruction manual does not necessarily require a physical written document, and may be provided via an electronic communication line such as the Internet.

[0043] The present invention provides a method for treating a disease caused by intervertebral disc degeneration in a subject, comprising administering an MMP to the subject, wherein the amount of MMP administered to the subject per dose is 100 μg to 700 μg. Examples of MMPs include MMP-7 and MMP-3. The disease caused by intervertebral disc degeneration is, for example, selected from the group consisting of herniated disc, low back pain, discopathy, spinal deformity, and spondylosis degenerativeis, which are caused by intervertebral disc degeneration. Here, the spinal deformity is, for example, kyphoscoliosis. Here, the kyphoscoliosis is, for example, kyphoscoliosis. The disease caused by intervertebral disc degeneration is, for example, selected from the group consisting of herniated disc, discopathy, kyphoscoliosis, and spondylosis degenerativeis, which are caused by intervertebral disc degeneration.

[0044] The present invention provides a pharmaceutical composition for use in treating diseases caused by intervertebral disc degeneration, comprising an MMP as an active ingredient, wherein the MMP is administered at a dose of 100 μg to 700 μg per administration. Examples of MMPs include MMP-7 and MMP-3. Diseases caused by intervertebral disc degeneration include, for example, herniated discs, low back pain, discopathy, spinal deformity, and spondylosis degenerativeis, which are caused by intervertebral disc degeneration. Examples of spinal deformity include kyphoscoliosis. Examples of kyphoscoliosis include kyphoscoliosis. Diseases caused by intervertebral disc degeneration include, for example, herniated discs, discopathy, kyphoscoliosis, and spondylosis degenerativeis, which are caused by intervertebral disc degeneration.

[0045] The present invention provides the use of an MMP in the manufacture of a pharmaceutical composition for use in treating a disease caused by intervertebral disc degeneration, wherein the MMP is used at a single dose of 100 μg to 700 μg. Examples of MMPs include MMP-7 and MMP-3. The disease caused by intervertebral disc degeneration is, for example, selected from the group consisting of herniated disc, low back pain, discopathy, spinal deformity, and spondylosis degenerativeis, which are caused by intervertebral disc degeneration. Here, the spinal deformity is, for example, kyphoscoliosis. Here, the kyphoscoliosis is, for example, kyphoscoliosis. The disease caused by intervertebral disc degeneration is, for example, selected from the group consisting of herniated disc, discopathy, kyphoscoliosis, and spondylosis degenerativeis, which are caused by intervertebral disc degeneration.

[0046] List of abbreviations

[0047] Introduction: Nonclinical studies have shown that rhMMP-7 has the ability to degrade human herniated disc specimens and beagle dog intervertebral discs, without affecting neural tissue, ligaments, or epidural tissue. Furthermore, rhMMP-7 has high degrading activity for aggrecan but very low degrading activity for type I and II collagen, suggesting strong tissue or degradation specificity (Non-Patent Document 4). In toxicity studies using single and two-week intravenous administration in rats and dogs, hemorrhagic and inflammatory changes were observed at doses significantly higher than the exposure levels expected in humans if all intradiscally administered KTP-001 had been transferred to the bloodstream. These hemorrhagic and inflammatory changes are thought to be due to the enzymatic effects of excessive intravenously administered KTP-001 on blood vessels. Reproductive and developmental toxicity studies in rats and rabbits showed no effects on female reproductive function, early embryonic development, or embryo-fetal development. No evidence of fetal teratogenicity was found.

[0048] In the United States, a Phase I / II clinical trial began in 2013 with the primary objective of confirming the safety and tolerability of a single intradiscal injection of KTP-001 in patients with lumbar disc herniation. Six patients were administered doses of 5 μg, 15 μg, 50 μg, and 150 μg. No serious complications were observed in any of the patients, and blood KTP-001 concentrations and antibodies were not detected. Administration of doses up to 150 μg in patients with disc herniation was reported to be safe. The most common adverse events were injection site pain, bronchitis, procedural pain, back pain, pain in extremities, musculoskeletal pain, muscle spasms, and disc bulge. The distribution of adverse events was similar across all doses, and no deaths occurred during the trial. Four patients experienced serious adverse events (appendicitis, diverticulitis, urinary tract infection, and menorrhagia), but none of these adverse events were determined to be causally related to the study drug. Furthermore, no significant changes were observed in serum keratan sulfate concentrations, except in the 150 μg group. In the 150 μg group, mean serum keratan sulfate concentrations increased 24 hours after administration, peaked 1 week after administration, and gradually decreased until 4 weeks after administration. In conclusion, KTP-001 was safe and well-tolerated at the dose studied. All serum KTP-001 concentrations were below the limit of quantification, and anti-KTP-001 antibodies were negative in all patients. Regarding efficacy, leg pain (worst pain and average pain over the past 24 hours) assessed using the Numeric Rating Scale (NRS) showed a significant decrease from baseline in the 15 μg and 50 μg groups compared with the 5 μg group. Furthermore, in both treatment groups, leg elevation test results changed from positive at baseline to negative at Week 6 and Week 13 in more than half of the subjects. The femoral nerve extension test changed from positive at baseline to negative at Week 6 in one patient and from positive at baseline to negative at Week 13 in three patients.

[0049] The primary objective of this investigator-initiated clinical trial is to confirm the safety and tolerability of a single intradiscal injection of KTP-001 in patients with lumbar disc herniation. A secondary objective is to confirm efficacy in patients with subposterior longitudinal ligament prolapse, which is less susceptible to early spontaneous regression. In a Phase I / II clinical trial conducted in the United States, elevated serum keratan sulfate levels were observed only after the KTP-001 dose was gradually increased to 150 μg. Because elevated serum keratan sulfate levels are a marker of the resolution of prolapsed disc nucleus pulposus, increasing the KTP-001 dose to 150 μg or higher is expected to enhance the efficacy of this agent in resolving herniated discs. Therefore, in this clinical trial, patients with lumbar disc herniation were administered KTP-001 at doses ranging from 150 μg to 600 μg, and the tolerability, safety, and secondary efficacy were evaluated at each dose.

[0050] The purpose of the clinical trial was to confirm the safety and tolerability of a single intradiscal administration of this drug in patients with lumbar disc herniation. Based on the results of this clinical trial, we will also consider the recommended dose for the next phase and the optimal endpoints for efficacy evaluation. Furthermore, we will examine the transfer of KTP-001 and keratan sulfate from the intervertebral disc to serum over time, and investigate the presence of anti-KTP-001 antibodies in serum.

[0051] 1. Clinical trial planning

[0052] 1.1 Overall design and planning of the clinical trial

[0053] 1.1.1 Type of Clinical Trial Phase I / IIa Clinical Trial

[0054] 1.1.2 Study Design Multicenter, single-blind, dose-escalation, single-dose study

[0055] 1.1.3 Treatments studied The following doses of the investigational drug were administered to each cohort: * Cohort 1: KTP-001 150 μg or sham * Cohort 2: KTP-001 300 μg * Cohort 3: KTP-001 600 μg

[0056] 1.1.4 Patient population studied and planned number of cases Target number of cases: 18 cases + additional cases (maximum of 5 cases) For the KTP-001 groups, the following numbers of cases were set as subjects eligible for safety evaluation up to 6 weeks after administration of the investigational drug. * Cohort 1: 3 cases in the sham group, 3 cases in the KTP-001 150 μg group * Cohort 2: 6 cases in the KTP-001 300 μg group * Cohort 3: 6 cases in the KTP-001 600 μg group If any of the 3 cases in the 150 μg group in Cohort 1 discontinued treatment within 6 weeks and safety could not be evaluated up to 6 weeks, additional cases would be added as appropriate. In addition, additional cases (maximum of 5 cases) would be added to cohorts of doses where safety could be confirmed and efficacy in secondary endpoints was suggested.

[0057] 1.1.5 Level and method of blinding This clinical study was conducted as a single-blind study. In all cohorts, subjects were not informed of which cohort they were in, nor whether they were in the KTP-001 or sham group.

[0058] 1.1.6 Type of control and study configuration This clinical trial consisted of three cohorts, with subjects enrolled starting with Cohort 1, followed by Cohort 2 and Cohort 3. Cohort 1 had a sham group. * Cohort 1: KTP-001 150 μg group or sham group * Cohort 2: KTP-001 300 μg group * Cohort 3: KTP-001 600 μg group

[0059] 1.1.7 Allocation Method for Clinical Trials The principal investigator (subinvestigator) or clinical trial collaborator allocated registered subjects using the electronic data capture system (EDC). Cohort 1 was randomly allocated to three subjects in the sham group and three subjects in the 150 μg group. Cohorts 2, 3, and additional cases were not allocated.

[0060] 1.1.8 Sequence and Length of the Clinical Trial Period This clinical trial consisted of a single administration in all cohorts. The administration schedule is shown in Figure 1. For each cohort, 150 μg or sham, 300 μg, or 600 μg of KTP-001 was injected intradiscally. The investigator (subinvestigator) was allowed to use local anesthetics. All cohorts were single-blind, and subjects were not informed of which cohort they were participating in. Details of the procedures performed at each visit are described in "1.5.1.2 Observation and Test Items and Their Timing."

[0061] 1.1.9 Various Committees Established and Their Roles An efficacy and safety evaluation committee was established for this clinical trial. It reviewed and evaluated the occurrence of serious adverse events of concern and provided advice and recommendations to the coordinating investigator regarding the addition of cases to the highest dose cohort that were deemed safe. This was specified in the procedure manual for the efficacy and safety evaluation committee, which will be provided separately.

[0062] 1.1.10 Interim Analysis No interim analysis was performed in this study.

[0063] 1.2 Clinical Trial Design Considerations, Including the Selection of the Control Group This clinical trial was a multicenter, single-blind, dose-escalation, single-dose study consisting of three cohorts. Cohort 1 received a single dose of KTP-001, either 150 μg or sham, Cohort 2 received a single dose of KTP-001, and Cohort 3 received a single dose of KTP-001, either 300 μg or 600 μg (puncture only in the sham group). The study aimed to confirm the tolerability, safety, and secondary efficacy of each dose. In a Phase I / II clinical trial conducted in the United States, six patients were administered the 5, 15, 50, and 150 μg groups. No adverse events were reported, and serum levels of KTP-001 and anti-KTP-001 antibodies were not detected. Furthermore, administration of up to 150 μg was not associated with safety issues in patients with disc herniation. Therefore, the purpose of this clinical trial was to confirm the safety of doses of 300 μg and 600 μg, which are two and four times the dose of 150 μg.

[0064] 1.3 Selection of the study population

[0065] 1.3.1 Inclusion criteria

[0066] 1.3.1.1 Target disease: Lumbar disc herniation under the posterior longitudinal ligament

[0067] 1.3.1.2 Inclusion criteria Patients who met all of the following criteria were included. Diagnosis and evaluation were in accordance with the diagnostic criteria proposed by the Committee for the Development of Guidelines for the Treatment of Lumbar Disc Herniation (Non-patent Document 1). 1) Patients diagnosed with lumbar disc herniation of the type below the posterior longitudinal ligament at the level of L3-L4, L4-L5, or L5-S1 based on clinical symptoms, neurological findings, and MRI (patients diagnosed with lumbar disc herniation of the type below the posterior longitudinal ligament at the level of L3-L4 or L4-S1 in the case of sacralization, or L4-L5, L5-L6, or L6-S1 in the case of lumbar vertebralization). 2) Patients with a positive leg elevation test or femoral nerve extension test, neurologically consistent with a disc level of lumbar disc herniation. 3) Patients with an average leg pain score / day of 4 or higher for at least 3 of the 5 days immediately prior to administration and an average leg pain score / day of 2 or higher for all 5 days immediately prior to administration (using an 11-point NRS ranging from "0: no pain" to "10: worst pain [the most severe pain ever experienced]"). 4) Patients immediately prior to administration (Day 1) Patients with a lower limb pain score of 4 or higher. 5) Adult males or females aged 20 to 60 years (at the time of consent). 6) Body mass index (BMI) of 18 to 35 kg / m. 27) Patients whose medical history, electrocardiogram, and physical examination findings have been confirmed by the principal investigator (subinvestigator) to be clinically unaffected. 8) Oswestry Disability Index (ODI) of 30% or greater. 9) Patients whose preoperative X-ray findings confirmed that their vertebral endplates were closed and that no growth plates were present. 10) Patients who received a thorough explanation using an information sheet, understood the contents, and voluntarily provided written consent to participate in the clinical trial. [Rationale for inclusion criteria] The main criteria are listed below. The type of lumbar disc herniation targeted was prolapse of the posterior longitudinal ligament, which is thought to allow for appropriate evaluation of drug efficacy with little influence from spontaneous regression. The lower age limit for the target age group was set at 20 years, taking into account the common age of lumbar disc herniation (20-40 years). While the vertebral endplates are generally considered closed in adults, patients whose pre-administration X-rays confirmed that their vertebral endplates were closed and that no growth plates were present were included in the study. The upper age limit was set at 60 years, taking into account the involvement of spinal canal stenosis.

[0068] 1.3.1.3 Exclusion criteria Patients who met the following criteria were excluded. If any of the following exclusion criteria were met during the clinical trial period, the clinical trial would be discontinued at the discretion of the principal investigator (subinvestigator). 1) Patients diagnosed with bulging disc herniation (protrusion), posterior longitudinal ligament perforation disc herniation (transligamentous extrusion), sequestration lumbar disc herniation, or intradural herniation based on clinical symptoms, neurological findings, and MRI. 2) Patients diagnosed with intraforaminal or extraforaminal herniation by MRI. 3) Patients with significant disc herniation in two or more locations on MRI, and in whom the intervertebral space involved in the clinical symptoms cannot be identified based on clinical symptoms and physical findings, or in whom it is determined that herniation at multiple intervertebral spaces may be involved. 4) Patients who have previously undergone intradiscal intervention* or back surgery for the herniated disc that is the target of this clinical trial. *Interventional treatment: This refers to the treatments listed in "Exclusion Criterion 5" (chemonucleolysis, or clinical trials using drugs targeting the intervertebral disc). 5) Patients who have previously undergone chemonucleolysis or participated in clinical trials using drugs targeting the intervertebral disc, regardless of the height of the disc. 6) Patients with the following lumbar diseases or deformities other than lumbar disc herniation: i) Lumbar spondylolisthesis, lumbar spondylolysis, scoliosis, lumbar spinal stenosis not caused by lumbar disc herniation as the primary disease ii) Lumbar vertebral body fracture, ankylosing spondylitis, inflammatory bone disease, inflammatory disc disease, primary or metastatic malignant tumor, other diseases related to the vertebral body 7) Patients with cauda equina syndrome or progressive motor paralysis of the lower limbs 8) Patients who wish to become pregnant. Pregnant, breastfeeding, or female patients who may be pregnant as determined by a pregnancy test 9) Patients whose vital signs and clinical test values ​​at screening correspond to Grade 2 or higher according to the Japanese translation of the Common Terminology Criteria for Adverse Events (CTCAE) ver. 5.0 10) Patients who are deemed inappropriate for participation in the clinical trial in accordance with the clinical trial protocol [Rationale for setting exclusion criteria] 1) to 4), 10): To target eligible subjects for this clinical trial. 5) to 7), 9): Due to consideration of the safety of the subjects and the possibility of affecting the evaluation of the safety and efficacy of the investigational drug.8) The effects on pregnancy and the fetus cannot be completely ruled out.

[0069] 1.3.2 Discontinuation of Patient Treatment or Evaluation In this clinical trial, subjects who met the discontinuation criteria were considered to have been discontinued from the trial. In addition, the trial was considered to have been completed when the prescribed observations and tests at 24 weeks after administration as specified in the clinical trial protocol were completed.

[0070] 1.3.2.1 Criteria for discontinuation before administration of investigational drug If any of the following conditions apply to a subject, the subject will not be administered the investigational drug. 1) Ineligible at screening: If the subject does not meet the inclusion criteria or if it is found that the subject violates the exclusion criteria. 2) Subject's request: If the subject refuses or withdraws consent. 3) Investigator's (subinvestigator's) judgment: If the physician determines that it is difficult to administer the investigational drug.

[0071] 1.3.2.2 Discontinuation Criteria After Investigational Drug Administration If any of the following conditions apply after administration of the investigational drug, the clinical trial for that subject will be discontinued. 1) Adverse event: If the physician determines that the subject is unable to continue the trial due to the occurrence of an adverse event, if the subject requests discontinuation due to the occurrence of an adverse event, or if the subject dies as a result of an adverse event and the trial cannot be continued 2) Insufficient effect: If the effect of the investigational drug is insufficient and it is necessary to switch to another treatment 3) Unable to follow-up: If the subject does not attend the hospital, and prescribed visits, examinations, and observations (including follow-up by telephone, etc.) cannot be made 4) Serious deviations from the protocol: If serious deviations from the clinical trial protocol are observed (GCP violations, deviations from inclusion or exclusion criteria, registration violations, duplicate registration, etc.) 5) Ineligibility after administration of the investigational drug: If it is found that the subject does not meet the inclusion criteria after administration of the investigational drug, or if it is found that the subject meets the exclusion criteria. However, if it is found that an exclusion criterion 8) has been violated after the administration of the investigational drug, or if it is judged that tests other than X-ray images can be continued, the trial may be continued after ensuring the safety of the subject. 6) Subject's request: When the subject refuses or withdraws consent 7) Implementation of restricted concomitant drugs, restricted concomitant therapies, and prohibited concomitant therapies: When a restricted concomitant drug or restricted concomitant therapy is newly administered, or when a prohibited concomitant therapy is administered. However, tests and observations will continue even after discontinuation. 8) Judgment of the principal investigator (sub-investigator): When the doctor judges that it is difficult to continue the clinical trial for any other reason.

[0072] 1.3.2.3 Handling of Subjects Upon Discontinuation or Withdrawal The investigator (subinvestigator) was to discontinue the trial if the subject declined to participate in the trial or withdrew consent, or if the investigator determined that the trial could not be continued for any reason. In such cases, the date and time of discontinuation / withdrawal, the reason for discontinuation / withdrawal, and the progress of the trial were to be recorded in the patient's medical record and electronic case report form (eCRF). At the time of discontinuation / withdrawal, necessary tests were performed and a safety evaluation was to be conducted. If the trial was discontinued due to an adverse event, appropriate measures and treatment were to be implemented immediately, and the patient was to be followed up as appropriate until the adverse event returned to its pre-event state or was alleviated, or until the investigator (subinvestigator) determined that further investigation was unnecessary. The response after discontinuation was recorded in the patient's medical record and other source documents. If consent was withdrawn after the start of study drug administration, whether it was due to an adverse event or other incident (e.g., relocation) was clarified as much as possible and recorded in the patient's medical record and eCRF to serve as a reference for determining whether the patient should be included in the safety evaluation.

[0073] 1.4 Treatment

[0074] 1.4.1 Treatment

[0075] 1.4.1.1 Dosage and Administration A single dose of the investigational drug was administered to each cohort at the following doses: * Cohort 1: KTP-001 150 μg or sham * Cohort 2: KTP-001 300 μg * Cohort 3: KTP-001 600 μg KTP-001 administration group: The injection site was visualized under X-ray fluoroscopy, and 2.0 mL of the KTP-001 injection prepared to the administered dose was injected into the intervertebral disc. Sham group: As with the drug administration group, the needle was punctured from a posterior oblique position toward the relevant intervertebral disc, reaching the muscles anterior to the disc, but only the puncture was performed and no injection was administered.

[0076] 1.4.1.2 Transition to the next cohort

[0077] 1.4.1.2.1 Procedures for transitioning to the next cohort and decision on adding cases The cohort schedule is shown in Figure 2. [Transition from Cohort 1 to Cohort 2] Randomized enrollment began in Cohort 1 (150 μg group, Sham group), and the decision on whether to transition to Cohort 2 was made based on safety data obtained up to 6 weeks after administration in that cohort. * If no events corresponding to "1.4.1.2.2 Safety Assessment, 1) 2)" were observed in any of the three cases in the 150 μg group, the coordinating investigator consulted with the principal investigator and clinical trial advisor via email or web conference, etc., and if they unanimously decided that there were no safety issues according to the criteria in "1.4.1.2.2 Safety Assessment," the patient would be transitioned to Cohort 2. * If any of the three patients in the 150 μg group experienced an event corresponding to "1.4.1.2.2 Safety Assessment, 1) 2"), the coordinating investigator was to consult the Efficacy and Safety Evaluation Committee regarding whether to continue the clinical trial. * If the Efficacy and Safety Evaluation Committee determined that there were no problems with continuing the clinical trial, the patient could move on to Cohort 2. * If the Efficacy and Safety Evaluation Committee determined that there were safety issues that would prevent the trial from continuing, the coordinating investigator was to decide whether to discontinue the trial in accordance with the recommendation of the Efficacy and Safety Evaluation Committee. Furthermore, if any of the three patients in the 150 μg group in Cohort 1 were discontinued within 6 weeks and safety could not be evaluated up to 6 weeks, additional patients were to be added as appropriate.

[0078] [Transition from Cohort 2 to Cohort 3, decision on adding cases] * If no events corresponding to "1.4.1.2.2 Safety Assessment, 1) 2)" were observed in any of the six patients in the 300 μg group, the coordinating investigator would consult with the principal investigator and clinical trial advisor via email or web conference, and if they unanimously determined that there were no safety issues in accordance with the criteria in "1.4.1.2.2 Safety Assessment," the patient would be transferred to Cohort 3. * If any of the six patients in the 300 μg group experienced an event corresponding to "1.4.1.2.2 Safety Assessment, 1) 2)," the coordinating investigator would consult with the Efficacy and Safety Assessment Committee regarding whether or not to continue the clinical trial, in accordance with the procedures in "1.4.1.2.2 Safety Assessment." * If the Efficacy and Safety Assessment Committee determined that there were no issues with continuing the clinical trial, the patient would be able to transition to Cohort 3. *If the Efficacy and Safety Evaluation Committee determines that there are safety issues, the committee will advise and recommend to the coordinating investigator regarding the addition of 150 μg dose cases to Cohort 1. The coordinating investigator will follow the advice and recommendation of the Efficacy and Safety Evaluation Committee and add cases to the highest dose cohort (150 μg group) that is determined to have no safety issues, to further examine the safety and efficacy of this drug (the number of additional cases will be limited to a maximum of five, and will be added to the extent feasible within the clinical trial period).

[0079] [Decision on adding cases to Cohort 3] * If no events corresponding to "1.4.1.2.2 Safety Assessment, 1) 2)" were observed among the six cases in the 600 μg group, the coordinating investigator decided to consult the Efficacy and Safety Evaluation Committee on safety data obtained up to six weeks after administration in Cohort 1 (3 cases), Cohort 2 (6 cases), and Cohort 3 (6 cases). The Efficacy and Safety Evaluation Committee will review and evaluate the obtained data to determine whether to continue the clinical trial and will provide advice and recommendations to the coordinating investigator regarding the addition of cases. In accordance with the advice and recommendations of the Efficacy and Safety Evaluation Committee, the coordinating investigator decided to add cases to the highest dose cohort that was determined to have no safety issues, and to further investigate the safety and efficacy of the drug (the number of additional cases was limited to a maximum of five, and as many as possible within the clinical trial period). * If any of the six patients in the 600 μg group experienced an event corresponding to "1.4.1.2.2 Safety Assessment, 1) 2"), the coordinating investigator would consult the Efficacy and Safety Assessment Committee regarding whether to continue the clinical trial, following the procedures in "1.4.1.2.2 Safety Assessment." * If the Efficacy and Safety Assessment Committee determined that there were no problems with continuing the clinical trial, additional patients would be added to the highest dose cohort determined to be safe, and the safety and efficacy of the drug would be further investigated. * If the Efficacy and Safety Assessment Committee determined that there were safety problems, the Efficacy and Safety Assessment Committee would advise and recommend to the coordinating investigator regarding the addition of additional patients to the 300 μg cohort in Cohort 2. The coordinating investigator, following the advice and recommendation of the Efficacy and Safety Assessment Committee, decided to add additional patients to the highest dose cohort determined to be safe (here, the 300 μg group) and further investigate the safety and efficacy of the drug (the number of additional patients was limited to a maximum of five, and as many as feasible within the clinical trial period).

[0080] 1.4.1.2.2 Safety Assessment If any of the following adverse events are observed during the clinical trial, the principal investigator (subinvestigator) is to report the event to the coordinating investigator (clinical trial coordinating office) and the investigators at other medical institutions cooperating with the clinical trial within 24 hours of becoming aware of the event. The coordinating investigator is then to consult with the Efficacy and Safety Assessment Committee. If the Efficacy and Safety Assessment Committee determines that the reported event poses a risk to continuing the clinical trial, it is to make a recommendation to the coordinating investigator. The coordinating investigator is to make a final decision on whether there are any tolerability issues, taking into account the recommendation of the Efficacy and Safety Assessment Committee. Furthermore, new subject enrollment is to be suspended until the Efficacy and Safety Assessment Committee has evaluated the adverse event and made a recommendation regarding continuation or dose escalation of the clinical trial. 1) If a serious adverse event (see "1.5.1.2.18.1.1 Definition of a Serious Adverse Event") is observed, it is to be reported using the format in the clinical trial protocol. 2) If any of the following events i) to v) indicating a worsening of the primary disease were observed, they were to be reported using the format of the clinical trial protocol. i) Neurological disorder equivalent to cauda equina ii) New worsening of radicular symptoms associated with bilateral or unilateral lower limb motor impairment observed after administration of the study drug iii) Changes in MRI brightness equivalent to significant endplate edema or sclerosis compared to before administration of the study drug iv) A decrease of 30% or more in intervertebral disc height (assessed by X-ray: average of anterior and posterior height) compared to before administration v) The following lumbar instability confirmed by X-ray at the treatment site * An anterior movement of 3 mm or more between the posterior edge of the upper vertebral body and the posterior edge of the lower vertebral body compared to the baseline * An increase in intervertebral range of motion of 5 degrees or more compared to the range of motion measured in images of maximum flexion and extension before administration * Changes in endplate destruction confirmed by X-ray after administration Details such as the evaluation method by the Efficacy and Safety Evaluation Committee are specified in the Procedures for the Efficacy and Safety Evaluation Committee.

[0081] 1.4.2 Identification of the investigational drug The investigator provided the investigational drug manager with a procedure manual for the investigational drug and its management. Details of packaging, labeling, and management of the investigational drug, as well as procedures for maintaining blinding, were in accordance with the procedure manual for the management of the investigational drug.

[0082] 1.4.2.1 Investigational Medicinal Product KTP-001 is rhMMP-7, and each 2.0 mL vial contains 1.0 mg of KTP-001. Drug Substance Description: KTP-001 is a recombinant human MMP-7 protein that degrades proteoglycans. No animal-derived raw materials are used in the manufacture of the drug substance used in clinical trials. International Nonproprietary Name: At the current development stage, there is no nonproprietary name for KTP-001. Code Name: KTP-001 Structural Formula: The amino acid sequence (SEQ ID NO: 1) of the protein expressed by the gene sequence encoding KTP-001 is shown below. Molecular formula: C 860 H 1299 N 239 O 251 S4 Molecular weight: 19130.23 (theoretical value) Formulation: Lyophilized powder for injection. KTP-001 formulation was dissolved in 0.5 mL of sterile water for injection and then diluted with KTP-001 diluent to the appropriate dose. KTP-001 consists of 173 amino acids, has no disulfide bonds, and forms a complex with two zinc ions. Its molecular weight is approximately 19 kDa. Histidines at positions 69, 84, and 97 and aspartic acid at position 71 are involved in structural zinc ion binding. Histidines at positions 120, 124, and 130 are involved in catalytic zinc ion binding. [Physical, Chemical, and Biological Properties of KTP-001] Appearance: Clear, colorless liquid UV spectrum: Absorption maximum at approximately 280 nm with a shoulder at approximately 290 nm. Biological properties: Digestes both the synthetic substrate of matrix metalloprotease (MOCAc-Pro-Leu-Gly-Leu-A2pr (Dnp)-Ala-Arg-NH2) and the natural substrate aggrecan.

[0083] 1.4.2.2 Packaging and Labeling Each individual box is labeled with the content, storage method, serial number, expiration date, and the name, affiliation, job title, and address of the coordinating investigator, and is labeled as being for clinical trial use. The affiliation and job title of the coordinating investigator displayed on the individual box are those at the start of the clinical trial, and the labeling on the individual box will not be changed even if these change during the clinical trial.

[0084] 1.4.2.3 Serial Number and Expiration Date The serial numbers and expiration dates of the investigational drugs used in this study are shown in Table 3 (Serial Number and Expiration Date of Investigational Drug).

[0085] 1.4.2.4 Management of investigational drugs Delivery and collection of investigational drugs 1) The investigational drug provider delivered the investigational drug to the medical institution conducting the study. 2) After the administration of the investigational drug was completed or discontinued, the principal investigator or a designated investigational drug manager collected the investigational drug in accordance with the investigational drug management procedure manual. Investigational drug management procedures 1) The investigational drug manager managed the investigational drug in accordance with the investigational drug management procedure manual and recorded the receipt and disbursement status in the investigational drug management table. 2) The principal investigator and investigational drug manager checked the consistency of the information entered on the investigational drug management table, remaining medication, and eCRF, and if any inconsistencies were found, they immediately investigated the cause and kept a record of the findings.

[0086] 1.4.3 Method of patient allocation to treatment groups This is described in “1.1.7 Method of patient allocation to clinical trials.”

[0087] 1.4.4 Dose Selection in Clinical Trials The selection of the investigational drug dose is described in "1.4.1 Treatment Methods." The rationale for setting the dose is described in "1.2 Considerations for Clinical Trial Design, Including Selection of Control Group."

[0088] 1.4.5 Dose Selection and Administration Timing for Each Patient The dose selection and administration timing for each patient are described in "1.4.1 Treatment Method." The rationale for setting the dose is described in "1.2 Considerations for Clinical Trial Design Including Selection of Control Group."

[0089] 1.4.6 Blinding Described in "1.1.5 Level and method of blinding."

[0090] 1.4.7 Concomitant medications and therapies

[0091] 1.4.7.1 Concomitant medications If pain persists after administration of the investigational drug, the following adjunctive medications (analgesics) may be used. However, the use of adjunctive medications (analgesics) was prohibited for 6 hours before pain assessment. * Nonsteroidal anti-inflammatory drugs (loxoprofen sodium, celecoxib, etc.) * Acetaminophen * Tramadol hydrochloride

[0092] 1.4.7.2 Restricted Concomitant Medications and Restricted Therapies For the restricted concomitant medications and therapies listed below, if the medication or treatment was being continued prior to obtaining consent, it was possible to continue during the clinical trial period, but changes to the treatment (increased medication dose or increased frequency of medication or treatment) were not permitted after consent was obtained. Reductions in medication dose and frequency of medication or treatment were permitted. [Restricted concomitant medications] * Medications for peripheral neuropathic pain (pregabalin, mirogabalin) * Antiepileptic drugs (gabapentin, etc.) * Antidepressants (duloxetine, amitriptyline) * N-methyl-D-aspartate receptor antagonists (ketamine hydrochloride, etc.) * Corticosteroids (excluding topical medications, eye drops, and inhalants) * Muscle relaxants, Chinese herbal medicines, extract of inflamed skin from vaccinia virus-inoculated rabbits [Restricted concomitant therapies] Trigger point block, heat therapy, bracing therapy, traction therapy, acupuncture and moxibustion therapy, chiropractic, etc.

[0093] 1.4.7.3 Prohibited concomitant therapies From the time of obtaining consent until the end of observation 24 weeks after administration, nerve block therapies such as nerve root block and epidural block, and surgical treatment (including nucleolysis with condoliase) were prohibited.

[0094] 1.4.8 Compliance with treatment The compliance with treatment was monitored through the subject's medical records, etc. For observation and testing methods, see "1.5.1 Efficacy and safety evaluation items and flowchart."

[0095] 1.5 Efficacy and Safety

[0096] 1.5.1 Efficacy and Safety Endpoints and Flowchart

[0097] 1.5.1.1 Overview of Clinical Trial Procedures An overview of the clinical trial procedures is shown in Figure 3. In accordance with the provisions for obtaining consent and the method of obtaining consent, the principal investigator (sub-investigator) explained the purpose and content of the clinical trial to the patient in an explanatory document and obtained consent. The principal investigator (sub-investigator) registered the subject in the EDC and assigned a subject identification code. The principal investigator (sub-investigator) confirmed that the subject met "1.3.1.1 Target Disease" and "1.3.1.2 Inclusion Criteria" and did not fall under "1.3.1.3 Exclusion Criteria." Before the start of administration, the principal investigator (sub-investigator) conducted observations and tests specified in the clinical trial protocol. After final confirmation based on the pre-administration tests that the subject met the inclusion criteria and did not violate any exclusion criteria, the principal investigator (sub-investigator) enrolled the subject in this clinical trial. The principal investigator (sub-investigator) or clinical trial collaborator assigned the subject to the EDC. The principal investigator (subinvestigator) initiated administration or treatment of the KTP-001 group or sham group (Cohort 1 only) according to the subject's assigned group. Observations and tests specified in the clinical trial protocol were conducted until 24 weeks after administration. However, if any of the criteria in "1.3.2.2 Discontinuation Criteria after Study Drug Administration" were met, the trial was discontinued. If the adverse event had not resolved or improved at 24 weeks after administration or at the time of discontinuation, follow-up was to be conducted as appropriate until the adverse event had resolved or improved to the state before the adverse event occurred, or until the principal investigator (subinvestigator) determined that further investigation was unnecessary. Even if the subject was absent from the follow-up investigation, follow-up was to be conducted by appropriate means, such as telephone.

[0098] 1.5.1.2 Observation and inspection items and their implementation timing The observation and inspection schedule is shown in Tables 4 and 5 (Observation and inspection schedule). a Subjects were hospitalized for 24 hours after intradiscal injection. Subjects were discharged if safety concerns were not identified based on test data up to 24 hours. Hospitalizations solely for testing purposes or prolonged hospitalization due to social reasons were not considered adverse events (see "1.5.1.2.18.1 Definition of Adverse Events"). b MRI scans were performed using the same method throughout the study, and the same model was used at each study center and at its designated testing facility whenever possible. Screening MRI scans were performed within 14 days prior to study drug administration. c If any significant abnormalities were detected in electrocardiograms after study drug administration, additional tests were performed, and the clinical significance and diagnosis were recorded. d Hematology, blood chemistry, coagulation, and urinalysis were performed. e Pregnancy tests were performed only in female subjects and were not required for male subjects. The results of the urine pregnancy test at 0 hours before administration were obtained before study drug administration. If a subject's regular menstrual cycle did not occur during the study period (if pregnancy was suspected) and at the end of the study, a urine pregnancy test was performed to confirm that the subject was not pregnant during the study. f The study drug was administered by intradiscal injection under fluoroscopic guidance. g If X-ray images taken within 14 days prior to obtaining consent were available, these images were used with the subject's consent. h Tests were conducted only at the time of visit.

[0099] 1.5.1.2.1 Clinical Trial Schedule 1) Screening Screening was conducted on subjects who provided written consent. The screening period from obtaining consent to administering the investigational drug (Day 1) was a maximum of 28 days. If X-ray images taken within 14 days prior to obtaining consent were available, they could be used with the subject's consent. The principal investigator (subinvestigator) made a comprehensive assessment of the subject's eligibility based on the subject inclusion and exclusion criteria and selected the subjects. In this clinical trial, patients who dropped out during the screening period and were not enrolled were allowed to re-enroll. In the case of re-enrollment, new consent was to be obtained from the patient in consultation with the coordinating investigator.

[0100] 2) Study drug administration (Day 1) Subjects were hospitalized for 24 hours after the intradiscal injection of the study drug and were discharged once all procedures were completed and the investigator determined that the subject was safe to be discharged. Note that hospitalizations solely for the purpose of testing or prolonged hospitalization due to social reasons were not considered adverse events (see "1.5.1.2.18.1 Definition of Adverse Events").

[0101] 3) Observation and testing at discontinuation For subjects who were discontinued in accordance with "1.3.2.2 Discontinuation Criteria after Study Drug Administration," the observation and testing items stipulated in Tables 4 and 5 (Observation and Test Schedules) at 24 weeks after administration were promptly conducted after discontinuation. Among the examples of restricted concomitant drugs and restricted concomitant therapies shown in "1.4.7.2 Restricted Concomitant Drugs and Restricted Concomitant Therapies," cases in which changes to treatment (increased dosage, increased frequency of medication / treatment) were made after consent was obtained, and examples of prohibited concomitant therapies shown in "1.4.7.3 Prohibited Concomitant Therapies" were considered discontinued cases, but observation and testing were continued even after discontinuation. When continuing observation after discontinuation, evaluation items, etc. were specified at the visit after discontinuation. Analysis of safety and MRI image evaluation after discontinuation was to be conducted.

[0102] 1.5.1.2.2 Obtaining consent Prior to the implementation of this clinical trial, the principal investigator (sub-investigator) provided a thorough explanation to the patient using an IRB-approved informed consent form, and then obtained written consent from the patient to voluntarily participate in the clinical trial.

[0103] 1.5.1.2.3 Subject Background The following data on the subject's clinical characteristics were collected at screening: Age, sex, race*, medical history, complications, concomitant medications / previous medications, and disc herniation level (L3-L4, L4-L5, L5-S1; L3-L4, L4-S1 if sacralized; L4-L5, L5-L6, L6-S1 if lumbarized). *If racial information was not recorded in source documents such as medical records, the principal investigator (sub-investigator) or clinical trial collaborator would collect this information from the subject themselves at screening.

[0104] 1.5.1.2.4 Physical Examination A physical examination, including height and weight, was performed at screening. A physical examination, including weight, was performed pre-dose. A physical examination was performed again 2 hours post-dose to confirm there were no abnormal findings. A physical examination, including weight, was performed 24 hours post-dose and at scheduled visits throughout the study (weeks 1, 2, 4, 6, 13, and 24 post-dose).

[0105] 1.5.1.2.5 MRI Images MRI images were taken at screening, and 6 and 13 weeks after the intradiscal injection of the investigational drug. The MRI images taken at screening were taken within 14 days prior to the administration of the investigational drug. The morphology and brightness changes of the endplate adjacent to the administered disc, as well as the size of the disc herniation, were evaluated by two members of an image evaluation committee consisting of third-party radiologists. Images were taken using the same method throughout the clinical trial, and the same model was used as much as possible at each participating medical institution and at the testing facilities designated by each participating medical institution.

[0106] 1.5.1.2.6 X-ray images X-rays were taken at screening and at 6, 13, and 24 weeks after administration to evaluate the disc height (average of anterior and posterior disc height) and lumbar instability (vertebral body slippage, intervertebral range of motion, endplate changes) of the administered disc. Regarding X-ray images taken at screening, if any had been taken within 14 days prior to obtaining consent, those images could be used with the subject's consent. At the time of administration, the puncture needle was inserted into the center of the intervertebral disc under X-ray fluoroscopy, and the injection site was photographed.

[0107] 1.5.1.2.7 Neurological Examinations Examinations were conducted at screening, before administration, 2 and 24 hours after administration, and on the scheduled visit day. The neurological examination consisted of pain provocation tests such as the leg elevation test and femoral nerve extension test, and neurological findings such as manual muscle testing of both lower limb muscles, sensory (tactile) testing, and lower limb deep tendon reflexes. The results of the neurological examinations were recorded individually on the eCRF. Each neurological finding was recorded, and at the same time, an overall assessment (worsening, no change, improvement, normalization) compared to baseline was recorded.

[0108] 1) Pain induction test a) Leg raising test In the leg raising test, subjects were placed in a supine position and their legs were raised at three different angles (0-30 degrees, 30-70 degrees, and over 70 degrees), and pain was assessed. The angle at which pain appeared (0-30 degrees, 30-70 degrees, and over 70 degrees) was recorded on the eCRF. b) Femoral nerve extension test In the femoral nerve extension test, subjects were placed in a prone position and their knee joints were flexed and their hip joints extended, and pain was assessed. The evaluation result was recorded on the eCRF as either "negative" or "positive."

[0109] 2) Neurological findings a) Manual muscle testing The investigator (sub-investigator) or clinical trial collaborator evaluated the degree of force exerted by the subject's lower limb muscles (iliopsoas, quadriceps, hamstrings, tibialis anterior, gastrocnemius, toe flexors, and toe extensors) on a 6-point scale from 0 (no muscle contraction observed) to 5 (the subject can move across the entire range of motion even with strong resistance). b) Sensory testing The evaluation was conducted by touch. The subject's lower limbs were lightly touched with a soft brush or cotton wool. The investigator (sub-investigator) scored abnormal areas on the doll diagram on the questionnaire. c) Deep tendon reflexes The investigator (sub-investigator) or clinical trial collaborator evaluated whether the reflexes were functioning normally in the subject's areas (patellar tendon, Achilles tendon).

[0110] 1.5.1.2.8 Vital signs were measured at screening, before administration, and 2, 4, 6, and 24 hours after administration, and on scheduled visits. Heart rate, systolic and diastolic blood pressure, respiratory rate, and body temperature were measured.

[0111] 1.5.1.2.9 12-lead ECG: Performed at screening and 24 hours after administration. If any significant ECG abnormalities were detected after study drug administration, additional tests were to be performed and the clinical significance and diagnosis recorded.

[0112] 1.5.1.2.10 Clinical Tests, Pregnancy Tests, and Viral Infection Tests 1) Clinical Tests Hematological tests, blood biochemistry tests, coagulation tests, and urinalysis were performed (see Table 6 (Clinical Test Items) for details). Tests were performed at screening, 24 hours after administration, and at visits 1, 2, and 6 weeks after administration (see Tables 4 and 5 (Observation and Test Schedules)). Clinical tests were measured in the laboratories of each clinical trial site or at clinical testing institutions contracted by each site. The sample collection date was recorded on the eCRF. Subjects were in a sitting or recumbent position to have blood drawn. Blood collection for clinical tests followed the procedures of the clinical testing institution. Screening clinical test results were defined as the final measurement values ​​before administration of the study drug. Clinical test reference values ​​were used for clinical evaluation. The amount of blood collected in this clinical trial is shown in Table 7 (Amount of blood collected in this clinical trial).

[0113] 2) Pregnancy Testing Pregnancy testing was only performed on female subjects and was not required for male subjects. Serum human chorionic gonadotropin beta subunit (βHCG) tests were performed at screening and at the 13-week post-treatment visit. Urinary βHCG tests were performed at least 0 hours before administration and at the 24-week post-treatment visit, or at the time of study discontinuation if the study was discontinued midway. Urine pregnancy tests were performed at appropriate times, also referring to note e in Tables 4 and 5 (observation and testing schedule). If pregnancy was discovered after administration of the study drug, the trial could be continued after ensuring the subject's safety. However, if the trial was continued, X-ray imaging was not permitted. Furthermore, efforts were made to collect information in accordance with the "Pregnancy during the Clinical Trial Period" section of the clinical trial protocol.

[0114] 3) Viral infection testing During screening, the presence or absence of hepatitis B virus surface antigen (HBs) antigen, anti-hepatitis C virus (HCV) antibody, and anti-human immunodeficiency virus (HIV) antibody was confirmed.

[0115] 1.5.1.2.11 Anti-KTP-001 Antibody Measurement Blood samples for serum anti-KTP-001 antibody measurement were collected before administration and at the visit 13 weeks after administration.

[0116] 1.5.1.2.12 Pharmacokinetic (PK) Measurements Serum KTP-001 concentrations were measured before administration and 2, 4, 6, and 24 hours after administration. The following PK parameters were measured using serum KTP-001 concentration data: * Maximum serum concentration (C max ) (unit: μg / mL) *Time to reach maximum serum concentration (T max ) (unit: h) * Area under the serum concentration-time curve from 0 hour to 24 hours after administration (AUC 0-24h ) (unit: h*μg / mL)

[0117] 1.5.1.2.13 Pharmacodynamic (PD) Measurements Blood samples for keratan sulfate concentrations were collected pre-dose, 24 hours post-dose, and at 1, 2, and 6 weeks post-dose. Serum keratan sulfate concentrations were measured using an enzyme-linked immunosorbent assay.

[0118] 1.5.1.2.14 Pain Assessment 1) Low Back Pain and Leg Pain (NRS) Assessments were conducted at screening, before administration, 2, 4, 6, and 24 hours after administration, and on designated visit days. The subjects' low back pain and leg pain (worst pain and average pain "over the past 24 hours," and "current pain" 2, 4, and 6 hours after administration) were assessed using an 11-point numerical rating scale on the NRS.

[0119] 2) Use of auxiliary medications (analgesics) This was confirmed at screening, before administration, 24 hours after administration, and on the scheduled visit date.

[0120] 3) Pain Detect: This was conducted at screening, before administration, 24 hours after administration, and on the designated visit day. Subjects rated their own pain using the Japanese version of the Pain Detect. Nine questions were scored (0 to 38 points).

[0121] 1.5.1.2.15 Physical Function Assessment. This was conducted at screening, pre-dose, 24 hours post-dose, and on the scheduled visit. The degree to which low back or leg pain interfered with the subject's ability to manage daily tasks was measured using the ODI (Version 2.0). Improvement, no change, or worsening of functional level was assessed based on the change in score from baseline. The ODI measures nine domains of daily function: pain intensity, self-care, lifting, walking, sitting, standing, sleep, social activities, and transportation. Questions about sex life were omitted from this study. Items were scored from 0 to 5, with 0 representing the best functional level and 5 representing the worst functional level. A percentage was then calculated from these responses (subject score / maximum total score: 45 points x 100) and recorded as the ODI for that day. Scores were then categorized into disability levels, as shown in Table 8 below.

[0122] 1.5.1.2.16 Quality of Life (QOL) Assessments were conducted at screening, pre-dose, 24 hours post-dose, and on scheduled visits. Subjects assessed their health status using the EuroQol 5 Dimensions 5 Level (EQ-5D-5L) developed by the EuroQol Group. Five overall health utility scales (mobility, personal care, usual activities, pain / discomfort, and anxiety / depression) were each rated on a 5-point scale. The QOL score developed by Ikeda et al. (Non-Patent Document 5) was also used.

[0123] 1.5.1.2.17 Provision, collection, and confirmation of patient diary At the time of screening, the principal investigator (sub-investigator) or clinical trial collaborator handed the patient diary to the subject and instructed them to fill out "i) lower back pain and leg pain (NRS)" and "ii) use of adjunctive medications (analgesics)" under "12) Pain assessment." The principal investigator (sub-investigator) collected and checked the patient diary according to the specified schedule, and then recorded the information in the eCRF.

[0124] 1.5.1.2.18 Adverse Events

[0125] 1.5.1.2.18.1 Definition of Adverse Events In this clinical trial, an adverse event is any undesirable or unintended sign (including abnormal laboratory test values), symptom, or disease that occurs in a subject after administration of the investigational product or a procedure for the administration of the investigational product, but before the end of the clinical trial, regardless of whether there is a causal relationship to the investigational product or clinical trial procedure. The following events are not considered adverse events: * Procedures for diagnostic purposes only (endoscopy, etc.) * Fluctuations in a disease or condition that were present before the start of the clinical trial that are within the expected daily range of fluctuation or have not worsened * When no undesirable medical events have occurred (social hospitalization, visits / hospitalization for tests / medication, etc.)

[0126] 1.5.1.2.18.1.1 Definition of Serious Adverse Events Serious adverse events are defined in "1.5.1.2.18.1 Definition of Adverse Events" as follows: 1) Death 2) Those that may lead to death 3) Those that require hospitalization or prolonged hospitalization for treatment 4) Disability 5) Those that may lead to disability 6) Those that are as serious as the cases listed in 1) to 5) 7) Congenital diseases or abnormalities in future generations

[0127] 1.5.1.2.18.1.2 Adverse Reactions If the investigator (sub-investigator) cannot rule out a causal relationship between an adverse event that occurred after administration of the investigational drug and the investigational drug, the adverse event will be defined as an adverse reaction.

[0128] 1.5.1.2.18.2 Evaluation of Adverse Events

[0129] 1.5.1.2.18.2.1 Assessment of the severity of adverse events The severity was assessed using the CTCAE ver. 5.0 on a 5-point scale (Grades 1 to 5). Adverse events not defined in CTCAE ver. 5.0 were assessed according to the severity levels shown in Table 9 below.

[0130] 1.5.1.2.18.2.2 Assessment of Causal Relationship of Adverse Events Causal relationship to the study drug was determined according to one of the categories shown in Table 10 below. The causal relationship with the administration of the investigational drug was determined by the investigator (subinvestigator) taking into consideration the subject's general condition, complications, concomitant medications and therapies, and the temporal relationship.

[0131] 1.5.1.2.18.2.3 Outcome of Adverse Events The outcome of an adverse event should be one of the categories shown in Table 11 below.

[0132] 1.5.1.2.18.3 Adverse Events of Concern The following adverse events were considered to be adverse events of concern and were to be reported to the coordinating investigator (clinical trial coordinating office) and the investigators of other medical institutions jointly conducting the clinical trial within 24 hours of the principal investigator (sub-investigator) becoming aware of the occurrence of the event: 1) When MRI or X-ray findings show the appearance of modic changes, a decrease in intervertebral disc height of 30% or more compared to before administration, or the appearance of intervertebral instability 2) When worsening of lower limb pain is observed. In other words, when the average daily lower limb pain score on the NRS increases by 2 points or more compared to before administration and this condition persists for 3 or more consecutive days 3) When objective changes are observed in neurological tests (progression of muscle weakness, worsening sensory impairment, changes in deep tendon reflexes) regardless of changes in pain 4) When emergency MRI, epidural steroid injection, selective nerve root block, or surgical intervention is performed at the discretion of the principal investigator (sub-investigator)

[0133] 1.5.1.2.18.4 Expected adverse events Adverse events that the investigator (subinvestigator) judged to be "expected" were defined as "expected adverse events."

[0134] 1.5.1.2.18.5 Pregnancy during the Clinical Trial If the investigator (sub-investigator) finds out that a female subject is pregnant after administration of the investigational drug, he / she will immediately consider discontinuing some tests, such as X-rays, and will monitor the patient's progress while reporting this to the coordinating investigator. Furthermore, if the investigator (sub-investigator) finds out that a male subject's partner is pregnant, he / she will endeavor to obtain information on the patient's progress with the subject's or partner's consent. If the pregnancy of the subject or the male subject's partner results in a serious adverse event (e.g., postpartum complications, spontaneous abortion, stillbirth, neonatal death, congenital anomaly, etc.), the investigator (sub-investigator) will promptly report this in accordance with "1.5.1.2.18.1 Definition of Adverse Events."

[0135] 1.5.1.3 Evaluation Contents

[0136] 1.5.1.3.1 Primary endpoints (safety) * Adverse events * Vital signs * 12-lead electrocardiogram * Clinical tests * MRI images * X-ray images * Anti-KTP-001 antibody

[0137] 1.5.1.3.2 Secondary endpoints 1) Pain assessment (pain intensity) * NRS* assessment of leg pain * NRS* assessment of low back pain * Worst pain and average pain over the past 24 hours 2) Neurological examination * Leg elevation test * Femoral nerve extension test 3) PK and PD * PK: Serum KTP-001 concentration, PK parameters (C max , T max , AUC 0-24h *PD: serum keratan sulfate concentration

[0138] 1.5.1.3.3 Exploratory endpoints 1) Pain assessment i) Pain intensity * ODI * Use of adjunctive medications (analgesics) ii) Type of pain * Pain Detect 2) Physical function assessment * EQ-5D-5L 3) Neurological examination * Global assessment of neurological findings 4) Presence or absence of restricted concomitant medications, their contents (including reduction in dosage and frequency of administration), and duration 5) Presence or absence of additional treatment*, their contents, and duration until initiation * Additional treatment: Use of new restricted concomitant medications, permitted concomitant medications, or prohibited concomitant therapies, or addition of restricted concomitant medications or restricted concomitant therapies, or changes in treatment contents during the clinical trial period 6) MRI images (changes in the size of herniated disc)

[0139] 1.5.2 Appropriateness of Measurements

[0140] 1.5.2.1 Primary Safety Endpoints The safety endpoints selected for this study were typical for the patient population with herniated discs and were widely used both domestically and internationally.

[0141] 1.5.2.2 Secondary and Exploratory Efficacy Endpoints The efficacy endpoints selected in this study were those previously selected in domestic and international patient populations with herniated discs. The NRS is considered a robust and reliable method for measuring pain in patients with chronic pain (NPL 6).

[0142] 1.5.3 Primary Safety Endpoints The primary safety endpoints and the rationale for their establishment are described in "1.5.1.3.1 Primary Endpoints (Safety)" and "1.5.2 Appropriateness of Measurement Items."

[0143] 1.5.4 Measurement of drug concentration Serum KTP-001 concentration and its PK parameters (C max , T max , AUC 0-24h ) were set as other secondary endpoints.

[0144] 1.6 Data Quality Assurance

[0145] 1.6.1 Quality Control and Quality Assurance of the Clinical Trial The coordinating investigator set quality goals, prepared a quality management plan outlining the plan for achieving the quality goals, and disseminated it to all personnel involved in the clinical trial. No risks anticipated in the quality management plan were observed in this clinical trial, and no new risks were identified during the conduct of the clinical trial. To ensure the appropriate implementation of the following quality control and quality assurance activities, the principal investigator and head of the medical institution will allow monitors, auditors, and regulatory authorities to directly access source documents, and will attend and respond to monitoring, audits, and inspections as necessary.

[0146] 1.6.2 Quality Control The accuracy, consistency, completeness, and reliability of the data in this clinical trial were ensured as follows: 1) A monitor appointed by the coordinating investigator monitored and confirmed that the clinical trial was being conducted appropriately in compliance with the clinical trial protocol and GCP, etc. 2) A monitor appointed by the coordinating investigator directly inspected the source documents and confirmed that the eCRF was accurate. 3) The principal investigator ensured that the clinical trial was being appropriately monitored by having a monitor appointed by the coordinating investigator visit the medical institution and other facilities involved in the conduct of the clinical trial and directly inspect the source documents, etc.

[0147] 1.6.3 Quality Assurance 1) The auditors evaluated whether the clinical trial systems at the medical institution and other facilities involved in the conduct of the clinical trial were properly established and functioning appropriately. 2) The auditors conducted on-site audits at the medical institution as necessary and confirmed that the clinical trial was being conducted appropriately and that the reliability of the data was sufficiently maintained by directly inspecting source documents, etc. 3) The coordinating investigator prepared a procedure manual for conducting audits of this clinical trial and ensured that the audits were conducted in accordance with said procedure manual and the audit plan based on said procedure manual. Furthermore, standardization and quality assurance were carried out between facilities for clinical testing.

[0148] 1.7 Determining the Statistical Methods and Sample Size Planned in the Clinical Trial Protocol

[0149] 1.7.1 Statistics and Analysis Plan The statistician prepared a statistical analysis plan before the first subject enrolled in this clinical trial. After data fixation, the statistician performed the analysis in accordance with the statistical analysis plan. Furthermore, if the analysis plan was changed, the statistician revised the statistical analysis plan in accordance with standard operating procedures, and recorded the timing, content, reason, and person responsible for the revision. The main analysis items and analysis methods were as follows: 1) Treatment of subjects found to be non-compliant with GCP Subjects found to be non-compliant with GCP were excluded from all analysis populations. 2) Significance and confidence levels When conducting tests, the significance level was set at 5% on both sides. Two-sided confidence intervals with a 95% confidence level were used. Confidence intervals were calculated using the Clopper-Pearson method for the analysis of adverse events and side effects, and the Kaplan-Meier method for the analysis of the time to additional treatment. 3) Summary Statistics Quantitative characteristics were summarized using the number of subjects, mean, standard deviation, minimum, median, and maximum. Qualitative characteristics were summarized using the number of cases and percentages in each category. 4) Baseline values ​​The most recent measurement value obtained between -24 hr and 0 hr on Day 1 (or at screening for items not measured between -24 hr and 0 hr on Day 1) before administration of the investigational drug was used as the baseline value. 5) Handling of missing and rejected data Missing and rejected data were not imputed.

[0150] 1.7.1.1 Statistical Analysis Plan

[0151] 1.7.1.1.1 Analysis Sets 1) Full Analysis Set (FAS): This was the population enrolled in the clinical study and administered the investigational drug at least once. 2) Per Protocol Analysis Set (PPS): This was the population of FAS that met the inclusion criteria and excluded subjects who were judged to have an impact on efficacy evaluation, such as: i) Subjects who violated the exclusion criteria ii) Subjects who violated restricted concomitant medications, restricted concomitant therapies, or prohibited concomitant therapies iii) Subjects who met the discontinuation criteria for the study but did not discontinue iv) Subjects who violated the dosage, administration, and administration period 3) Safety Analysis Set (SAF): This was the population of subjects who received the investigational drug at least once and whose progress was monitored.

[0152] 1.7.1.1.2 Demographics and Other Baseline Characteristics Summary statistics were calculated for demographics and other baseline characteristics by group.

[0153] 1.7.1.1.3 Safety Analysis

[0154] 1.7.1.1.3.1 Analyzed Indicators The following indicators were analyzed for each group. 1) Adverse events The number of incidents, number of cases, incidence rate, and 95% confidence intervals were calculated for adverse events and side effects. The Clopper-Pearson method was used to calculate confidence intervals. A similar analysis was performed by severity and seriousness. 2) Clinical test values, vital signs, 12-lead electrocardiogram, MRI, X-ray, anti-KTP-001 antibody Summary statistics of measured values ​​were calculated by time of measurement. Summary statistics of changes from baseline were also calculated by time after the start of administration.

[0155] 1.7.1.1.3.2 Handling of adverse events and side effects

[0156] 1.7.1.1.3.2.1 Adverse events and side effects Adverse events and side effects that occurred from the start of administration of the study drug to the end of the post-administration observation period (24 weeks / discontinuation) were included.

[0157] 1.7.1.1.3.2.2 Number of Events If multiple adverse events (adverse reactions in adverse reaction counts, SOCs in system organ class (SOC) counts, and PTs in preferred term (PT) counts) occurred in the same subject, each was counted as one event and not combined.

[0158] 1.7.1.1.3.2.3 Number of Cases If the same subject experienced multiple adverse events (adverse reactions in the adverse reaction count, SOCs in the SOC count, or PTs in the PT count), these were counted as one case and summarized. In addition, if the same subject experienced multiple adverse events with the same SOC (PTs in the PT count) but different severity / severity, the event with the worst severity / severity was counted as one case.

[0159] 1.7.1.1.4 Efficacy Analysis The following statistics were calculated for each efficacy endpoint by group.

[0160] 1.7.1.1.4.1 Secondary Endpoints 1) Pain Assessment (Pain Intensity) * NRS* assessment of leg pain, NRS* assessment of lower back pain Summary statistics were calculated for each time point observed from baseline to 24 weeks after administration. Summary statistics of the change from baseline were also calculated for each time point. * Worst pain and average pain over the past 24 hours 2) Neurological Examination * Leg Raising Test For each measurement period from baseline to 24 weeks after administration, the number and percentage of subjects with each diagnostic result (0 to less than 30 degrees, 30 to less than 70 degrees, 70 degrees or more) were calculated. In addition, a shift table was created for each measurement time point relative to the baseline results. * Femoral Nerve Extension Test For each measurement period from baseline to 24 weeks after administration, the number and percentage of subjects with each diagnostic result (negative, positive) were calculated. In addition, a shift table was created for each measurement time point relative to the baseline results.

[0161] 1.7.1.1.4.2 Exploratory Endpoints 1) Pain Assessment (Pain Intensity) * ODI Summary statistics were calculated for each time point for results observed from baseline to 24 weeks after administration. Summary statistics were also calculated for the change from baseline at each time point. * Use of Adjunctive Medications (Analgesics) The number and percentage of subjects who used adjunctive medications (analgesics) were calculated for each measurement period from Day 1 0 hours to 24 weeks after administration and for the entire period. 2) Pain Assessment (Type of Pain) * Pain Detect Summary statistics were calculated for the score consisting of 9 questions for each time point for results observed from baseline to 24 weeks after administration. Summary statistics were also calculated for the change from baseline at each time point. 3) Physical Function Assessment * EQ-5D-5L: Summary statistics of QOL scores and their changes were calculated for each assessment period from baseline to 24 weeks after treatment. 4) Neurological Examination * Neurological Findings: Evaluations of manual muscle testing, sensory testing, and deep tendon reflexes were comprehensively assessed, and the neurological findings from baseline to 24 weeks after treatment were compared with baseline to calculate the number and percentage of patients with each diagnostic outcome (0: worsening, 1: no change, 2: improvement, 3: normalization). 5) Presence, content, and time to initiation of additional treatment: The occurrence of additional treatment was referred to as an "event," and the number of days until the event was compared between groups using the log-rank test. The Kaplan-Meier method was used to calculate the event rate and its 95% confidence interval for each group, and a Kaplan-Meier plot of the event rate was also plotted. If subjects who were lost to follow-up discontinued due to adverse events, these were treated as competing risks, and supplementary analysis was performed to calculate the time-point event rate and its 95% confidence interval using the Cumulative Incidence Function method. 6) MRI images (changes in the size of disc herniation) MRI evaluators evaluated the MRI images in the following order (a) to (c). (a) For each case number (Y-001, etc.), a table listing the following was prepared and submitted to the secretariat.* The presence and extent of changes in the endplate (e.g., modic change) and intervertebral discs on MRI (whether there was any inconsistency with the natural course of herniation, etc.). * The volume of herniated discs on MRI was evaluated for each case using two methods: whether there was a tendency for shrinkage or not. (b) The secretariat then disclosed to the MRI evaluator which group the case number belonged to (allocation list). (c) After the evaluation, the above flow of obtaining group information was used to ensure blinding, and changes in each case were observed. Finally, the MRI evaluators conferred and compared each group qualitatively with the other groups.

[0162] 1.7.1.1.5 Pharmacokinetic analysis Summary statistics (number of subjects, mean, standard deviation, minimum, median, maximum, and coefficient of variation) were calculated for serum KTP-001 concentrations at each blood sampling time point. PK parameters (C max , T max , AUC 0-24h ) summary statistics were to be calculated. If PK parameters other than these were to be calculated, they were to be described in the analysis plan. PK parameters were to be calculated from serum KTP-001 concentration data and actual sample collection times by non-compartmental analysis using Phoenix WinNonlin (Certara LP, Princeton, NJ, USA version 8.0 or higher). AUC 0-24h The linear trapezoidal method was used to calculate the lower limit of quantification. The lower limit of quantification was set at 0.1 (μg / mL), and any values ​​observed below the lower limit of quantification were treated as 0 (μg / mL) and used in the analysis.

[0163] 1.7.1.1.6 Pharmacodynamic Analysis Summary statistics (number of subjects, mean, standard deviation, minimum, median, maximum) were calculated for serum keratan sulfate concentrations and changes from baseline at each blood sampling time point.

[0164] 1.7.2 Determination of Case Number Target case number: 18 cases + additional cases (maximum 5 cases) For the KTP-001 administration groups, the following number of cases was set as subjects eligible for safety evaluation up to 6 weeks after administration of the investigational drug. * Cohort 1: 3 cases in the sham group, 3 cases in the KTP-001 150 μg group * Cohort 2: 6 cases in the KTP-001 300 μg group * Cohort 3: 6 cases in the KTP-001 600 μg group Note: If any of the 3 cases in the 150 μg group in Cohort 1 discontinued treatment within 6 weeks and safety could not be evaluated up to 6 weeks, additional cases would be added as appropriate. In addition, additional cases (maximum 5 cases) would be added to cohorts of doses where safety could be confirmed and efficacy in secondary endpoints was suggested.

[0165] <Rationale for Cohort Case Size Setting> The dose used in Cohort 1 has been confirmed to be safe and tolerable in a US study. While no specific adverse events are anticipated, three subjects are required to observe at least one adverse event with an incidence rate of 70% or higher with 90% power. Because this clinical trial will be conducted at two centers with careful consideration for safety, the target number of subjects for Cohort 1 was set at three, taking feasibility into account. Similarly, six subjects are required for Cohort 2 and Cohort 3 to observe at least one adverse event with an incidence rate of 40% or higher with 90% power. Because this clinical trial will be conducted at two centers with careful consideration for safety, the target number of subjects for Cohort 2 and Cohort 3 was set at six, taking feasibility into account. For cohorts with doses where safety was confirmed and efficacy in the secondary endpoints was suggested, up to five additional subjects were added to confirm safety in those cohorts and explore efficacy. By adding five more cases to the cohort, bringing the total to 11, it became possible to secure the number of cases necessary to observe at least one case of an adverse event with an incidence rate of 20% or higher with 90% detection power.

[0166] 2. Clinical trial subjects: Subjects enrolled in Cohort 1 received a single intradiscal injection of 150 μg or sham-administered acetaminophen, subjects enrolled in Cohort 2 received 300 μg, and subjects enrolled in Cohort 3 received 600 μg (puncture only in the sham group).

[0167] 2.1 Breakdown of subjects The breakdown of subjects in consented cases is shown in Table 12 (Breakdown of subjects (consented cases)), and a summary of reasons for discontinuation is shown in Table 13 (Summary of reasons for discontinuation (consented cases)). A list of discontinued cases is attached in Appendix 16.2.1. Of the 24 patients who obtained consent, 19 received the study drug, and 5 discontinued the study before administration. Of the 19 patients who received the study drug, 5 discontinued the study after administration. Reasons for discontinuation before administration of the study drug included ineligibility at screening in 3 patients, subject request (refusal or withdrawal of consent) and investigator's decision in 1 patient each. Reasons for discontinuation after administration of the study drug included restricted concomitant medications and restricted concomitant therapy in 4 patients, and insufficient efficacy in 1 patient.

[0168] 2.2 Protocol Deviations The breakdown of protocol deviations in consented cases is shown in Table 14 (Protocol Deviations (Consented Cases)). Of the 24 consented cases, no significant deviations from the clinical trial protocol were observed, but non-significant deviations were observed in 8 cases. The breakdown of non-significant deviations was as follows: "MRI imaging was performed using the wrong imaging procedure manual" in 6 cases, "due to an EDC error, the treatment group was assigned the day before administration," "administration of restricted concomitant medications," and "missing future visits and tests on the scheduled visit date due to COVID-19 infection" in 1 case each. There were no deviations from the clinical trial protocol that could have affected the study results.

[0169] 3. Evaluation of efficacy

[0170] 3.1 Analyzed Datasets The analyzed datasets in this clinical study are shown in Table 15 (Analyzed Datasets). Of the 24 subjects who provided consent, 3 subjects were ineligible at screening, 1 subject requested treatment, and 1 subject was deemed by the investigator (sub-investigator) to be difficult to administer the investigational drug. This left 19 subjects for the SAF, FAS, and PPS. The number of subjects employed in the FAS and PPS was the same, but the analysis period differed depending on the subject.

[0171] 3.2 Demographic and other baseline characteristics

[0172] 3.2.1 Subject demographics The subject demographics of the SAF are shown in Tables 16 and 17 (Subject demographics (SAF)). The demographic and other baseline characteristics of SAF are summarized below. Males accounted for 33.3% (1 / 3) of the sham group, 100% (3 / 3) of the 150 μg group, 81.8% (9 / 11) of the 300 μg group, and 100.0% (2 / 2) of the 600 μg group. Age (mean ± standard deviation [minimum, maximum]) was 46.3 ± 15.9 years (28, 57 years) in the sham group, 49.7 ± 7.4 years (44, 58 years) in the 150 μg group, 37.5 ± 7.4 years (27, 51 years) in the 300 μg group, and 33.0 ± 7.1 years (28, 38 years) in the 600 μg group. The main locations of herniated discs were L4-L5 in 66.7% (2 / 3 cases) in the sham group, 33.3% (1 / 3 cases) in the 150 μg group, 54.5% (6 / 11 cases) in the 300 μg group, and 0% (0 / 2 cases) in the 600 μg group, and L5-S1 in 33.3% (1 / 3 cases) in the sham group, 66.7% (2 / 3 cases) in the 150 μg group, 36.4% (4 / 11 cases) in the 300 μg group, and 100.0% (2 / 2 cases) in the 600 μg group.

[0173] 3.2.2 Medical History and Complications The proportion of subjects with a medical history was 66.7% (2 / 3 subjects) in the sham group, 100% (3 / 3 subjects) in the 150 μg group, 36.4% (4 / 11 subjects) in the 300 μg group, and 0% (0 / 2 subjects) in the 600 μg group (Tables 16 and 17). The only medical history occurring in two or more subjects in each group was appendicitis (3 subjects in the 150 μg group), with each other medical history occurring in one subject each. The proportion of subjects with complications was 66.7% (2 / 3 subjects) in the sham group, 66.7% (2 / 3 subjects) in the 150 μg group, 54.5% (6 / 11 subjects) in the 300 μg group, and 100.0% (2 / 2 subjects) in the 600 μg group. The only complication occurring in two or more subjects in each group was seasonal allergy (2 subjects in the 300 μg group), with each other complication occurring in one subject each.

[0174] 3.3 Measurement of Treatment Adherence The status of study drug administration in the FAS is shown in Table 18 (Study Drug Administration Status (FAS)). The mean total dose of the investigational drug was 150 μg in the 150 μg group, 300 μg in the 300 μg group, and 600 μg in the 600 μg group, and was administered as planned in all groups. All patients in the FAS (3 patients in the sham group, 3 patients in the 150 μg group, 11 patients in the 300 μg group, and 2 patients in the 600 μg group) received a single intradiscal injection of the investigational drug (only puncture in the sham group).

[0175] 3.4 Efficacy Results and Individual Patient Data Tables

[0176] 3.4.1 Efficacy Analysis

[0177] 3.4.1.1 Secondary endpoints

[0178] 3.4.1.1.1 Pain assessment (pain intensity)

[0179] 3.4.1.1.1.1 Evaluation of leg pain Figure 4 (average pain over the past 24 hours) and Figure 5 (worst pain over the past 24 hours) show the progression of leg pain in the FAS. The mean values ​​of leg pain (average pain over the past 24 hours and worst pain over the past 24 hours) in the FAS decreased over time from baseline in all groups. A similar trend was observed in the PPS.

[0180] 3.4.1.1.1.2 Evaluation of lumbar back pain Figure 6 (average pain over the past 24 hours) and Figure 7 (worst pain over the past 24 hours) show the progression of lumbar back pain in the FAS. The mean values ​​of lumbar back pain (average pain over the past 24 hours and worst pain over the past 24 hours) in the FAS decreased over time from baseline in all groups. A similar trend was observed in the PPS.

[0181] 3.4.1.1.2 Neurological examination

[0182] 3.4.1.1.2.1 Leg Raising Test The shift tables for the leg raising test in PPS are shown in Tables 19 and 20 (Leg Raising Test Shift Tables (PPS)). In the PPS, the sham group showed an improvement of over 90% in the leg raising test after 24 weeks of administration or at the time of discontinuation, while the 150 μg group showed an improvement of over 90% as early as 6 weeks after administration, and the 300 μg group showed an improvement of over 90% as early as 4 weeks after administration. Furthermore, a tendency for improvement was observed in the groups administered this drug 2 hours after administration. In particular, the 300 μg group showed a significant improvement compared to baseline 2 hours after administration, with an 80% improvement 1 week after administration. Similar results were observed in the FAS. *Improvement rate: The percentage of cases in which the baseline temperature was "0 to less than 30 degrees" and then improved to "30 to less than 70 degrees" or "70 degrees or more," or cases in which the baseline temperature was "30 to less than 70 degrees" and then improved to "70 degrees or more."

[0183] 3.4.1.1.2.2 Femoral Nerve Extension Test The shift table for the femoral nerve extension test in FAS is shown in Table 21 (Shift Table for Femoral Nerve Extension Test (FAS)). The results of the femoral nerve extension test at baseline in the FAS were "negative" in all subjects. In the 150 μg group, one subject changed from "negative" to "positive" 24 hours after administration and one subject at one week after administration, but no subjects changed to "positive" after two weeks after administration. In the 300 μg group, one subject changed from "negative" to "positive" 2 hours after administration, but no subjects changed to "positive" after 24 hours after administration. In the sham group and the 600 μg group, no subjects changed from "negative" to "positive". Similar results were observed in the PPS.

[0184] 3.4.1.2 Exploratory Endpoints

[0185] 3.4.1.2.1 Pain assessment

[0186] 3.4.1.2.1.1 Pain intensity

[0187] 3.4.1.2.1.1.1 Oswestry Disability Index (ODI) The ODI over time for the FAS is shown in Tables 22A-22B (ODI over time (FAS)), and the ODI over time for the PPS is shown in Tables 23A-23B (ODI over time (PPS)). In the FAS, the mean ODI value in the sham group decreased over time starting 24 hours after skin puncture. On the other hand, in the 150-600 μg group, the mean ODI value was maintained from 1 to 4 weeks after administration and then decreased. 24 hours after administration, the 300 μg group showed a significant improvement compared to baseline. Similar results were observed in the PPS.

[0188] 3.4.1.2.1.1.2 Use of adjunctive medications (analgesics) The use of adjunctive medications (analgesics) in the FAS is shown in Table 24 (Use of adjunctive medications (analgesics) (FAS)). In the FAS, the proportion of subjects who used adjunctive medications (analgesics) in the 300 μg group was 54.5% (6 / 11 cases) at baseline, and 90.0% (9 / 10 cases) and 81.8% (9 / 11 cases) at 1 and 2 weeks after administration, respectively, indicating an increase compared to baseline, but subsequently remained at a similar level to baseline. The number of cases in the sham group and the 150 and 600 μg groups was small, and no consistent trend was observed in the use of adjunctive medications (analgesics). Similar results were observed in the PPS.

[0189] 3.4.1.2.1.2 Type of Pain (Pain Detect) A summary of Pain Detect in the FAS is shown in Tables 25 and 26 (Summary of Pain Detect (FAS)). The mean Pain Detect scores in the FAS decreased over time from baseline in all groups, and similar results were observed in the PPS.

[0190] 3.4.1.2.2 Physical Function Assessment (EQ-5D-5L) The trends in EQ-5D-5L scores in the FAS are shown in Tables 27 and 28 (Changes in EQ-5D-5L scores (FAS)). The mean EQ-5D-5L scores in the FAS increased over time from baseline in all groups except the 600 μg group, in which the scores decreased from baseline until one week after administration and then increased over time. Similar results were observed in the PPS.

[0191] 3.4.1.2.3 Neurological Examination The change in the global assessment of neurological findings compared to baseline in the FAS is shown in Tables 29A and 29B (Change in the global assessment of neurological findings compared to baseline (FAS)), and the change in the global assessment of neurological findings compared to baseline in the PPS is shown in Table 29C (Change in the global assessment of neurological findings compared to baseline (PPS)). In the sham group of the FAS, improvement in neurological findings was observed as early as two weeks after administration, whereas in the 150-600 μg group, improvement in neurological findings was observed as early as two hours after administration. Significant improvement in neurological findings was observed 24 hours after administration in the 300 μg group compared to the sham group. Similar results were observed in the PPS.

[0192] 3.4.1.2.4 Presence, content (including dose reduction and reduced administration frequency), and duration of restricted concomitant medications Seventeen of the 19 patients who received the investigational drug used restricted concomitant medications during the clinical trial period. The breakdown of the purpose of use was "primary disease" in 15 patients and "adverse events" in 4 patients (some overlapping). Of the 15 patients who used the drug for "primary disease," 10 patients discontinued administration of the restricted concomitant medication after receiving this drug (two of whom discontinued administration after reducing the dose), and five patients continued administration of the restricted concomitant medications. The four patients who used the drug for "adverse events" experienced hypoesthesia, hypoesthesia and pain in the extremities, joint pain and pain in the extremities, and intervertebral disc protrusion, respectively, and therefore used restricted concomitant medications. However, all events recovered or improved, and the use of restricted concomitant medications was discontinued.

[0193] 3.4.1.2.5 Presence, content, and time until initiation of additional treatment Figure 8 shows a Kaplan-Meier plot of the time until additional treatment occurred in the FAS. The time until additional treatment occurred in 50% of subjects in the FAS was approximately 14 weeks in the sham group (3 subjects), approximately 2 weeks in the 150 μg group (3 subjects), approximately 6 weeks in the 300 μg group (11 subjects), and approximately 1.5 weeks in the 600 μg group (2 subjects). The sham group had a longer time until additional treatment occurred than the other groups. Due to the small number of subjects, no particular trend was observed between the time until additional treatment occurred and each group. Similar results were observed in the PPS.

[0194] 3.4.1.2.6 MRI images (changes in size of herniated disc)

[0195] 3.4.1.2.6.1 Presence and Severity of Changes in the Intervertebral Disc and Endplate The presence and severity of changes in the intervertebral disc and endplate were evaluated in the FAS and PPS. MRI of one patient in the 300 μg group (subject number: Y-010) revealed Type 1 Modic changes that progressed both 6 and 13 weeks after administration, a finding consistent with those occurring in the natural course of herniation. Three patients in the 300 μg group (subject numbers: Y-018, K-004, K-006) showed Type 3 Modic changes from the initial MRI, but no tendency for these to increase or decrease during follow-up was observed. Based on the above, no changes in the intervertebral disc and endplate were observed that were strongly suspected to be caused by administration of this drug.

[0196] 3.4.1.2.6.2 Evaluation of disc herniation volume The results of evaluation of disc herniation volume by MRI are shown in Table 30 (Evaluation results of disc herniation volume). In this clinical trial, some cases in the sham group showed a decrease in disc size over time (33.3% at 6 weeks and 66.7% at 13 weeks after administration), but this was considered appropriate as a natural decrease in herniation size. Also noteworthy is that although this clinical trial was not designed to test for significance and therefore does not demonstrate a significant difference, at 13 weeks after administration, there was a tendency for the disc to decrease by 81.8% in the 300 μg group and 100% in the 600 μg group, which may represent a certain level of efficacy of this drug. *Three pairwise comparisons were performed between the Sham group and the other three groups using Fisher's exact test, and no significant differences were found.

[0197] 3.4.2 Pharmacodynamics

[0198] 3.4.2.1 Serum Keratan Sulfate Concentration Figure 9 shows the time course of serum keratan sulfate concentrations in PPS. Serum keratan sulfate concentrations increased dose-dependently at each time point. No clear time-dependent changes were observed in serum keratan sulfate concentrations in the sham group or the 150 μg group. In the 300 μg group, serum keratan sulfate concentrations began to increase 24 hours after administration, peaked at 1 week after administration (mean change from baseline in serum keratan sulfate concentrations: 265,300 ng / mL), and then decreased. In the 600 μg group, serum keratan sulfate concentrations began to increase 24 hours after administration, peaking at 2 weeks after administration (mean change from baseline in serum keratan sulfate concentrations: 710,000 ng / mL).

[0199] 3.4.3 Statistical and analytical issues Details of the statistical methods used for analysis in this clinical study were summarized in the Statistical Analysis Plan (Version 3.0).

[0200] 3.4.3.1 Adjustment for covariates No adjustment for covariates was performed in this study.

[0201] 3.4.3.2 Handling of dropouts or missing values ​​Imputation of missing data was not performed in this clinical study.

[0202] 3.4.3.3 Interim analysis and data monitoring No interim analysis was performed in this clinical trial. Regarding data monitoring, an Efficacy and Safety Assessment Committee was established to review and evaluate the occurrence of serious adverse events of concern and to provide advice and recommendations to the coordinating investigator regarding the addition of cases to the highest dose cohort that was determined to pose no safety issues, and the clinical trial was conducted based on its deliberations.

[0203] 3.4.3.4 Multicenter Study Although this was a multicenter study, no analysis by center was performed.

[0204] 3.4.3.5 Multiple comparisons and multiplicity The primary analysis item in this study was the safety of the investigational drug in the analysis population. Other analysis items were treated as secondary, so no adjustment for multiplicity was performed.

[0205] 3.4.3.6 Use of Patient "Efficacy Subpopulations" Not Applicable

[0206] 3.4.3.7 Active Control Studies Intended to Show Equivalence Not Applicable

[0207] 3.4.3.8 Subgroup Considerations Not Applicable

[0208] 3.4.4 Tabulation of Individual Response Data Individual efficacy response data were generated for each subject.

[0209] 3.4.5 Drug dose, drug concentration, and their relationship to response These were not planned or performed in this clinical study.

[0210] 3.4.6 Drug-drug and drug-disease interactions These were not planned or performed in this study.

[0211] 3.4.7 Display by patient A table was created for each data point by subject.

[0212] 3.4.8 Efficacy and Pharmacodynamic Conclusions * Mean values ​​for leg pain and lumbar back pain (average pain over the past 24 hours and worst pain) decreased over time from baseline in all groups. * In the leg raising test, PPS showed a 90% or greater improvement in the sham group after 24 weeks of treatment or at discontinuation, while the 150 μg group showed a 90% or greater improvement as early as 6 weeks after treatment and the 300 μg group showed a 90% or greater improvement as early as 4 weeks after treatment. In the leg raising test, a trend toward improvement was observed 2 hours after administration. In particular, the 300 μg group showed a significant improvement compared to baseline 2 hours after treatment, with an 80% improvement at 1 week after treatment. * In the ODI, the 300 μg group showed a significant improvement compared to baseline 24 hours after treatment. * In neurological findings, in the FAS, improvement was observed in cases in the sham group starting two weeks after administration, while improvement was observed in cases in the 150-600 μg groups as early as two hours after administration. In neurological findings, significant improvement was observed 24 hours after administration in the 300 μg group compared to the sham group. * Serum keratan sulfate concentrations increased dose-dependently at each time point. No clear changes over time were observed in serum keratan sulfate concentrations in the sham group and the 150 μg group. In the 300 μg and 600 μg groups, serum keratan sulfate concentrations began to increase 24 hours after administration, reaching their peaks at one and two weeks after administration, respectively.

[0213] 4. Safety Assessment

[0214] 4.1 Number of cases administered the investigational drug, period, and dose Of the 19 subjects, a single intradiscal administration was administered to 3 cases in the sham group, 3 cases in the 150 μg group, 11 cases in the 300 μg group, and 2 cases in the 600 μg group (puncture only in the sham group).

[0215] 4.2 Adverse Events To compile adverse events in this clinical trial, the names of symptoms and events listed on the eCRF were translated using the ICH International Medical Dictionary, Japanese version (MedDRA / J) Ver. 26.1.

[0216] 4.2.1 Brief Summary of Adverse Events A summary of adverse events is provided in Table 31 (Summary of Adverse Events (SAF)). Seven adverse events occurred in 2 of 3 patients (66.7%) in the sham group, one in 1 of 3 patients (33.3%) in the 150 μg group, 18 in 7 of 11 patients (63.6%) in the 300 μg group, and eight in 2 of 2 patients (100.0%) in the 600 μg group. Three adverse events occurred in 3 of 11 patients (27.3%) in the 300 μg group and four in 2 of 2 patients (100.0%) in the 600 μg group, with none occurring in the sham or 150 μg groups. One serious adverse event occurred in 1 of 11 patients (9.1%) in the 300 μg group and none in the other groups. No adverse events resulted in death or discontinuation of treatment. Two adverse events of interest and two adverse reactions of interest were observed in two of two patients (100.0%) in the 600 μg group, and none were observed in the other groups. Four expected adverse events were observed in three of 11 patients (27.3%) in the 300 μg group and four in two of two patients (100.0%) in the 600 μg group, and none were observed in the other groups. The occurrence of expected adverse events was the same as the occurrence of adverse reactions.

[0217] 4.2.2 Presentation of Adverse Events The occurrence of adverse events by symptom is shown in Tables 32 and 33 (Occurrence of Adverse Events by Symptom (SAF)). The SOC classification for adverse events occurring in three or more patients in either group was "musculoskeletal and connective tissue disorders" (7 cases in 5 of 11 patients (45.5%) in the 300 μg group), "infections and infestations" (4 cases in 4 of 11 patients (36.4%) in the 300 μg group), and "nervous system disorders" (3 cases in 3 of 11 patients (27.3%) in the 300 μg group). Adverse events occurring in two or more patients in either group (by PT) were pain in extremity (4 cases in 3 of 11 patients (27.3%) in the 300 μg group), back pain (3 cases in 3 of 11 patients (27.3%) in the 300 μg group), nasopharyngitis, COVID-19, and hypoesthesia (2 cases each in 2 of 11 patients (18.2%) in the 300 μg group). All other adverse events occurred in only one patient.

[0218] 4.2.3 Analysis of adverse events

[0219] 4.2.3.1 Incidence of adverse reactions The adverse reactions observed in SAF were as follows: Arthralgia: 1 event in 1 / 2 patients (50.0%) in the 600 μg group Back pain: 2 events in 2 / 11 patients (18.2%) in the 300 μg group, 1 event in 1 / 2 patients (50.0%) in the 600 μg group Pain in extremity: 1 event in 1 / 11 patients (9.1%) in the 300 μg group, 1 event in 1 / 2 patients (50.0%) in the 600 μg group Intervertebral disc protrusion: 1 event in 1 / 2 patients (50.0%) in the 600 μg group

[0220] 4.2.3.2 Occurrence of adverse events by severity No adverse events of CTCAE Grade 3 or higher were observed.

[0221] 4.2.4 Listing of adverse events by patient A listing of adverse events by patient was created.

[0222] 4.3 Deaths, other serious adverse events, and other significant adverse events

[0223] 4.3.1 Listing of deaths, other serious adverse events, and other significant adverse events A list of adverse events leading to death and adverse events leading to discontinuation of study drug administration was prepared.

[0224] 4.3.1.1 Deaths No deaths occurred in this study.

[0225] 4.3.1.2 Other serious adverse events In this study, hypoesthesia was observed as a serious adverse event in 1 of 11 patients (9.1%) in the 300 μg group. Details of this case are described in Section 4.3.2.

[0226] 4.3.1.3 Other significant adverse events In this clinical trial, "other significant adverse events" were examined, including "adverse events leading to discontinuation of the clinical trial," "adverse events of interest," and "anticipated adverse events."

[0227] 4.3.1.3.1 Adverse events leading to discontinuation of the study No adverse events leading to discontinuation of the study drug were observed in this study.

[0228] 4.3.1.3.2 Adverse events of interest Adverse events of interest were back pain and disc protrusion, which were observed in 1 of 2 patients (50.0%) in the 600 μg group, and a causal relationship to the administration of the investigational drug could not be ruled out for both events.

[0229] 4.3.1.3.3 Expected adverse events The expected adverse events observed in the SAF were as follows: Arthralgia: 1 event in 1 of 2 patients (50.0%) in the 600 μg group Back pain: 2 events in 2 of 11 patients (18.2%) in the 300 μg group, 1 event in 1 of 2 patients (50.0%) in the 600 μg group Pain in extremity: 2 events in 1 of 11 patients (9.1%) in the 300 μg group, 1 event in 1 of 2 patients (50.0%) in the 600 μg group Intervertebral disc protrusion: 1 event in 1 of 2 patients (50.0%) in the 600 μg group The occurrence of expected adverse reactions was the same as that of adverse reactions (see section 4.2.3.1).

[0230] 4.3.2 Description of Deaths, Other Serious Adverse Events, and Several Other Significant Adverse Events Hypoesthesia (Subject ID: Y-007) The subject was a male, 30 years old at the time of consent, with the level of the herniated disc at L4-L5. His medical history included surgery for a deviated nasal septum and bilateral maxillary and mandibular wisdom tooth extractions, as well as complications such as contact dermatitis and tinea pedis. Twelve days after administration of 300 μg of this drug, the subject developed severe hypoesthesia and non-severe back pain. Both events were Grade 2 in severity and resolved 79 days after onset. After thorough examination using MRI, computed tomography (CT), X-rays, etc., no test findings were found that could be determined to be clearly due to the administration of KTP-001 into the intervertebral disc (changes in brightness on MRI of the administered disc and adjacent endplates, morphological changes such as narrowing of the disc space on CT or X-ray).It was determined that the main impact was due to COVID-19 infection that developed six days after administration of the drug, and a causal relationship with the administration of the investigational drug was ruled out.

[0231] 4.3.3 Analysis and Discussion of Deaths, Other Serious Adverse Events, and Other Significant Adverse Events No deaths occurred in this clinical study. One serious adverse event, hypoesthesia (CTCAE Grade 2), occurred in 1 of 11 patients (9.1%) in the 300 μg group, but the event resolved and a causal relationship to the study drug was ruled out. The severity of all adverse events observed in this study was Grade 2 or less, and none of the events resulted in serious outcomes. Overall, the study was considered to be well tolerated.

[0232] 4.4 Laboratory evaluation

[0233] 4.4.1 Listing of individual laboratory values ​​for each patient A listing of individual laboratory values ​​was created.

[0234] 4.4.2 Evaluation of each clinical test item

[0235] 4.4.2.1 Clinical laboratory values ​​throughout the trial The trends in clinical laboratory values ​​(hematology, blood chemistry, and coagulation tests) were investigated, as were the trends in urine test results.

[0236] 4.4.2.1.1 Hematology No clear or clinically significant differences were observed in the mean and median values ​​of hematology parameters between groups. Furthermore, no clinically significant changes were observed in the mean and median values ​​of any parameter over time.

[0237] 4.4.2.1.2 Blood chemistry tests

[0238] 4.4.2.1.2.1 Aspartate aminotransferase Baseline aspartate aminotransferase (AST) (mean ± standard deviation) was 18.7 ± 9.8 U / L in the sham group, 32.7 ± 1.5 U / L in the 150 μg group, 20.8 ± 7.7 U / L in the 300 μg group, and 31.5 ± 13.4 U / L in the 600 μg group, with small numbers of subjects resulting in variation between groups. AST (mean ± standard deviation) at 6 weeks post-treatment was 23.0 ± 19.9 U / L in the sham group, 31.3 ± 5.8 U / L in the 150 μg group, 22.1 ± 3.4 U / L in the 300 μg group, and 49.5 ± 21.9 U / L in the 600 μg group, with the mean value in the 600 μg group being higher than in the other groups. There were only two patients in the 600 μg group, and in one of these patients, the AST value exceeded the upper limit of normal two weeks after administration of the drug, which was thought to have affected the overall values ​​in the 600 μg group (see section 4.4.2.3).

[0239] 4.4.2.1.2.2 Alanine Aminotransferase Baseline alanine aminotransferase (ALT) (mean ± standard deviation) was 22.3 ± 23.3 U / L in the sham group, 53.0 ± 6.6 U / L in the 150 μg group, 28.0 ± 26.3 U / L in the 300 μg group, and 37.5 ± 19.1 U / L in the 600 μg group, with small numbers of subjects resulting in variation between groups. ALT (mean ± standard deviation) at 6 weeks post-treatment was 28.3 ± 37.0 U / L in the sham group, 44.3 ± 14.7 U / L in the 150 μg group, 28.9 ± 13.0 U / L in the 300 μg group, and 95.5 ± 78.5 U / L in the 600 μg group, with the mean value being higher in the 600 μg group than in the other groups. There were only two patients in the 600 μg group, and in one of these patients, the ALT level exceeded the upper limit of normal two weeks after administration of the drug, which was thought to have affected the overall values ​​in the 600 μg group (see section 4.4.2.3).

[0240] 4.4.2.1.3 Coagulation Tests No clear or clinically significant differences were observed in the mean and median values ​​of coagulation test items (prothrombin time, activated partial thromboplastin time) between groups. Furthermore, no clinically significant changes were observed in the mean and median values ​​of any test items over time.

[0241] 4.4.2.1.4 Urinalysis No clear or clinically meaningful differences were observed between groups in the shift tables for urine test items: urine glucose, urine protein, ketone bodies, and occult blood. Furthermore, no clinically significant changes were observed over time for these items. Regarding pH and specific gravity, no clear or clinically significant differences were observed between groups in the mean and median values. Furthermore, no clinically significant changes were observed over time in the mean and median values ​​for either test item.

[0242] 4.4.2.2 Individual Patient Changes Individual laboratory values ​​were tabulated.

[0243] 4.4.2.3 Individual Clinically Significant Abnormalities Blood biochemistry tests revealed abnormal changes corresponding to increased ALT, increased AST, and increased gamma-glutamyltransferase (gamma-GTP) in one patient in the 600 μg group (all Grade 1 in severity), but all of these events improved after appropriate examination by a gastroenterologist. Both events were considered to be due to the effects of concomitant medications, and a causal relationship to the administration of the investigational drug was ruled out.

[0244] 4.5 Vital Signs, Physical Observations, and Other Safety-Related Observations

[0245] 4.5.1 Vital Signs No clinically significant changes were observed in the mean and median values ​​of systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, and body temperature throughout the study period in any group.

[0246] 4.5.2 12-lead ECG A list of 12-lead ECGs and a tabulation of positive and negative 12-lead ECGs were prepared. Results of 12-lead ECGs 24 hours after administration showed no clinically significant findings in any group. Results of tabulation of positive and negative 12-lead ECGs 24 hours after administration showed no clinically significant changes from baseline in any group.

[0247] 4.5.3 MRI Imaging A trend in MRI imaging results was created. MRI imaging results at baseline were "no findings" (100.0%) in all groups. MRI imaging results at 6 weeks after administration were "no findings" (100.0%) in the sham group, the 150 μg group, and the 600 μg group. In the 300 μg group, "no abnormal findings" were observed in 10 / 11 subjects (90.9%), and "abnormal findings (type of abnormal findings: other) but not clinically significant" were observed in 1 / 11 subjects (9.1%). MRI imaging results at 13 weeks after administration were "no findings" (100.0%) in all groups. MRI imaging results at both 6 and 13 weeks after administration were "no findings" in most subjects.

[0248] 4.5.4 X-ray images The time course of X-ray image examination results was compiled. No clinically significant X-ray findings were observed in any group throughout the trial period.

[0249] 4.5.5 Anti-KTP-001 antibody and serum KTP-001 concentrations, PK parameters (C max , T max , AUC 0-24h ) (PK analysis) The shift table of the results for the anti-KTP-001 antibody is shown in Table 34. Anti-KTP-001 antibodies were negative in all treatment groups at baseline and 13 weeks after administration. Serum KTP-001 concentrations were below the lower limit of quantitation in all subjects throughout the study. Because serum KTP-001 concentrations were below the lower limit of quantitation in all subjects, PK parameters for serum KTP-001 concentrations, a secondary endpoint, were not calculated.

[0250] 4.6 Safety Conclusions* Overall, the safety and tolerability of a single intradiscal injection of up to 600 μg of this drug in patients with lumbar disc herniation was good.* Seven adverse events occurred in 2 of 3 patients (66.7%) in the sham group, one event in 1 of 3 patients (33.3%) in the 150 μg group, 18 events in 7 of 11 patients (63.6%) in the 300 μg group, and eight events in 2 of 2 patients (100.0%) in the 600 μg group. Adverse events occurring in two or more patients in either group included pain in extremity (4 cases in 3 of 11 patients (27.3%) in the 300 μg group), back pain (3 cases in 3 of 11 patients (27.3%) in the 300 μg group), and nasopharyngitis, COVID-19, and hypoesthesia (2 cases each in 2 of 11 patients (18.2%) in the 300 μg group). * No adverse events resulted in death or discontinuation of treatment. One serious adverse event, hypoesthesia, occurred in 1 of 11 patients (9.1%) in the 300 μg group. No serious adverse events or adverse events leading to discontinuation of the study were observed. Adverse events of interest included back pain and disc protrusion (1 case each in 1 of 2 patients (50.0%) in the 600 μg group, and a causal relationship to the study drug could not be ruled out for both. * Hematological, coagulation, and urinalysis tests showed no significant, clinically meaningful, or clinically significant intergroup differences in mean and median values ​​or shift tables. Blood biochemistry tests showed higher mean AST and ALT values ​​at 6 weeks post-administration in the 600 μg group compared with other groups. Only two subjects were in the 600 μg group, and one of these subjects had AST and ALT values ​​exceeding the upper limit of normal starting two weeks after administration, which was thought to have affected the overall values ​​in the 600 μg group. This subject showed abnormal changes corresponding to increased ALT, increased AST, and increased γ-GTP (all Grade 1 in severity). * Vital signs, 12-lead electrocardiograms, and X-ray images showed no clinically significant changes throughout the study period. * Anti-KTP-001 antibody tests were negative in all subjects throughout the study period, and serum KTP-001 concentrations were below the lower limit of quantitation.

[0251] 5. Discussion and general conclusions

[0252] 5.1 Discussion This clinical trial was a multicenter, single-blind, dose-escalation, single-dose study designed to confirm the safety and tolerability of a single intradiscal injection of KTP-001 in patients with lumbar disc herniation. Of the 24 patients who provided consent, 19 were enrolled in the SAF, FAS, and PPS. Of the 19 subjects, a single intradiscal injection was administered to three patients in the sham group, three in the 150 μg group, 11 in the 300 μg group, and two in the 600 μg group (the sham group received only puncture). Adverse events occurred in 2 of 3 patients (66.7%) in the sham group (7 events), 1 in 1 of 3 patients (33.3%) in the 150 μg group (18 events) in 7 of 11 patients (63.6%) in the 300 μg group (18 events), and 2 of 2 patients (100.0%) in the 600 μg group (8 events). Adverse events occurring in two or more patients in any group included pain in extremity (4 events) in 3 of 11 patients (27.3%) in the 300 μg group, back pain (3 events) in 3 of 11 patients (27.3%) in the 300 μg group, and nasopharyngitis, COVID-19, and hypoesthesia (2 events each) in 2 of 11 patients (18.2%) in the 300 μg group. No adverse events led to death or discontinuation of treatment. One serious adverse event, hypoesthesia, occurred in 1 of 11 patients (9.1%) in the 300 μg group. No serious adverse events led to study discontinuation. Adverse events of interest, including back pain and disc protrusion, occurred in 1 of 2 patients (50.0%) in the 600 μg group, and a causal relationship to the study drug could not be ruled out for either. Hematology, coagulation, and urinalysis revealed no clear, clinically meaningful, or clinically significant intergroup differences in mean and median values ​​or shift tables. Blood chemistry tests revealed higher mean AST and ALT levels in the 600 μg group compared with the other groups at 6 weeks post-treatment. There were only two cases in the 600 μg group, and in one of these, AST and ALT values ​​exceeded the upper limit of normal two weeks after administration of the drug, which is thought to have affected the values ​​for the entire 600 μg group. In this case, abnormal fluctuations corresponding to increased ALT, increased AST, and increased γ-GTP were observed (all with a severity of Grade 1), but after appropriate examination by a gastroenterologist, all symptoms improved.No clinically significant changes were observed in vital signs, 12-lead electrocardiograms, magnetic resonance imaging (MRI), or radiographic images throughout the study period. Anti-KTP-001 antibodies were negative in all subjects throughout the study period, and serum KTP-001 concentrations were below the lower limit of quantification. Overall, the safety and tolerability of a single intradiscal administration of up to 600 μg of this agent in patients with lumbar disc herniation were favorable. Mean leg pain and low back pain (average pain over the past 24 hours and worst pain) decreased over time from baseline in all groups. In the leg elevation test, a 90% or greater improvement was observed as early as 6 weeks after administration in the 150 μg group and 4 weeks after administration in the 300 μg group compared with the sham group. A trend toward improvement was observed in the leg elevation test 2 hours after administration. In particular, the 300 μg group showed significant improvement compared to baseline 2 hours after administration, with an 80% improvement at 1 week after administration. The ODI showed significant improvement compared to baseline 24 hours after administration in the 300 μg group. Neurological findings showed improvement as early as 2 hours after administration in the 150-600 μg groups compared to the sham group. Neurological findings showed significant improvement 24 hours after administration in the 300 μg group compared to the sham group. Evaluation of herniated disc volume using MRI images showed a trend toward reduction of 81.8% in the 300 μg group and 100% in the 600 μg group at 13 weeks after administration, a result that may represent a certain level of efficacy of this drug. Serum keratan sulfate concentrations increased dose-dependently at each time point. No clear changes over time were observed in serum keratan sulfate concentrations in the sham group or the 150 μg group. In the 300 μg and 600 μg groups, serum keratan sulfate concentrations increased from 24 hours after administration and reached a peak at 1 and 2 weeks, respectively. Because serum KTP-001 concentrations were below the lower limit of quantitation in all subjects, PK parameters for serum KTP-001 concentrations, a secondary endpoint, were not calculated. Based on these findings, this clinical trial demonstrated a certain level of safety and efficacy in patients with lumbar disc herniation (subposterior longitudinal ligament prolapse) treated with a single intradiscal administration of up to 600 μg of KTP-001. Serum keratan sulfate concentrations, a marker indicating the resolution of prolapsed disc nucleus pulposus, increased over time in the 300 and 600 μg groups.Based on the serum keratan sulfate concentration results, the recommended dose for the next phase is 150-600 μg, more preferably 300-600 μg, and even more preferably 300-450 μg. Herniated discs are caused by degeneration of the intervertebral disc (normally, the disc has a dual structure consisting of an inner nucleus pulposus and an outer annulus fibrosus, but this structure breaks down due to age-related degeneration). Similarly, disc degeneration can lead to lumbar spondylosis, discopathy, and spinal deformity, which can also cause low back pain. This clinical trial of herniated discs revealed that administration of MMP-7 (KTP-001) into degenerated discs initially degrades the degenerated disc, followed by regeneration of new disc (cartilage tissue) matrix. Furthermore, MRI scans one year after administration revealed improvement in disc degeneration compared to before administration. For this reason, the above clinical trial is considered to be broadly applicable to diseases caused by intervertebral disc degeneration, including herniated discs, lower back pain, disc disease, spinal deformities (including kyphoscoliosis), and spondylosis deformans, which are caused by intervertebral disc degeneration.

[0253] Chemolysis of lumbar discs using MMP-3 (Storomelysin): Intradiscal injection therapy using MMPs for lumbar disc herniation was first initiated using MMP-3 (Storomelysin). As reported in a paper (Spine (Phila Pa 1976). 1997 May 15;22(10):1098-104), in vitro culture of surgical specimens from patients with lumbar disc herniation showed a significant decrease in wet weight after 24 hours in the MMP-3-treated group compared with the control group, and Safranin O staining of the cultured tissue revealed a decrease in proteoglycan staining. Furthermore, in an experimental system in which nucleus pulposus tissue from rat caudal discs was excised and transplanted into abdominal subcutaneous tissue, a significant decrease in the size of nucleus pulposus tissue was confirmed in the MMP-3-treated group compared with the control group. Furthermore, MMP-3-positive cells were confirmed in the surgical specimens. Therefore, MMP-3 is expressed in herniated disc tissue and is involved in the mechanism of spontaneous regression. Furthermore, it has been shown that MMP-3 promotes the degradation of herniated disc tissue or tissue containing excised nucleus pulposus subcutaneously transplanted. Therefore, it has become clear that administration of human recombinant MMP-3 to herniated lumbar disc tissue promotes spontaneous regression and is highly likely to degrade herniated disc tissue. Furthermore, based on another paper (Yamanashi Medical Journal 27(4), 117-124, 2013), it is believed that MMP-3 exerts the desired therapeutic effect at the same dose as MMP-7. Therefore, the findings of this example are considered to be applicable to MMPs in general, including MMP-3, not just MMP-7.

[0254] 5.2 Overall Conclusions KTP-001 was safe and well tolerated when administered intradiscally up to 600 μg in patients with lumbar disc herniation. Serum KTP-001 concentrations were below the lower limit of quantification in all subjects throughout the study, and anti-KTP-001 antibodies were negative. Efficacy evaluation revealed a reduction in lower limb pain and low back pain from baseline in all groups. Early improvement was observed in the leg raising test and neurological findings in the KTP-001 group. Serum keratan sulfate concentrations increased dose-dependently. These findings demonstrate that KTP-001 has a favorable safety and tolerability profile, improves neurological findings associated with disc herniation early after administration, and reduces low back pain and leg pain over time.

Claims

1. A treatment for a disease caused by intervertebral disc degeneration, which contains MMP as an active ingredient, and the dose of MMP per administration is 300 μg to 600 μg.

2. The therapeutic agent according to claim 1, wherein the disease caused by intervertebral disc degeneration is selected from the group consisting of herniated disc, low back pain, discopathy, spinal deformity, and degenerative spondylosis caused by intervertebral disc degeneration.

3. The treatment according to claim 2, wherein the spinal deformity is kyphoscoliosis.

4. The treatment according to claim 3, wherein the kyphoscoliosis is kyphoscoliosis.

5. The therapeutic agent according to claim 1, wherein the disease caused by intervertebral disc degeneration is selected from the group consisting of herniated disc, discopathy, kyphoscoliosis, and degenerative spondylosis caused by intervertebral disc degeneration.

6. The treatment agent according to claim 1, wherein the MMP is a recombinant human MMP.

7. The treatment agent according to claim 1, which is to be administered directly to the affected area of ​​the disease.

8. The treatment agent according to claim 1, for multiple administration to a patient with the disease.

9. The treatment agent according to claim 1, for administration to a patient with the disease who is not receiving conservative treatment for the disease.

10. The treatment agent according to claim 1, for administration to a patient with the disease immediately after a diagnosis that confirms the disease.

11. The treatment agent according to claim 10, wherein the diagnosis to confirm the disease is performed using MRI.

12. The treatment agent according to claim 1, which is an injection having a single dose of 2 cc or more.

13. The treatment agent according to claim 1, wherein the content of MMP is 300 μg to 600 μg.

14. The treatment agent according to claim 1, which is a unit dosage form.

15. The treatment agent according to claim 1, to be administered once a day to a patient with the disease.

Images