Dapiglutide for use in treating a sub-group of subjects

Abstract

The present invention relates to use of a GLP-1R / GLP-2R dual agonist, namely dapiglutide, for treatment of obesity, diabetes and / or related disorders and / or for reduction of body weight in a sub-group of subjects.

Description

[0001] DAPIGLUTIDE FOR USE IN TREATING A SUB-GROUP OF SUBJECTS

[0002] FIELD OF THE INVENTION

[0003] The present invention relates to use of a GLP-1 R / GLP-2R dual agonist, namely dapiglutide, for treatment of obesity, diabetes and / or related disorders and / or for reduction of body weight in a sub-group of subjects.

[0004] BACKGROUND TO THE INVENTION

[0005] Glucagon-like peptide-1 (GLP-1) is a peptide hormone secreted by intestinal cells in response to food intake. GLP-1 regulates energy homeostasis by stimulating secretion of insulin and inhibiting glucagon secretion to decrease blood glucose levels, and by inhibiting gastric motility and secretion.

[0006] The effects of GLP-1 are mediated by GLP-1 binding to the G protein-coupled receptor (GPCR) GLP-1 receptor (GLP-1 R). Binding of an agonist such as GLP-1 induces a conformational change in a GPCR to activate it. Activated receptors couple to heterotrimeric G proteins. Subsequently, the heterotrimeric G protein dissociate and G protein signalling mediates the generation of second messengers such as cyclic adenosine monophosphate (cAMP), inositol triphosphate (IP3) and Ca2+. Activated receptors are phosphorylated, primarily in the carboxyl terminus and intracellular loops, by GPCR kinases. Phosphorylated receptors recruit p-arrestins, which are multifunctional adaptor proteins that block further G protein / GPCR coupling (referred to as desensitization), potentially through a steric hindrance mechanism, p-arrestins also mediate clathrin-dependent endocytosis of activated GPCRs as well as independent signalling pathways downstream of GPCRs. p-arrestins scaffold mitogen- activated protein kinases, tyrosine kinases and E3 ubiquitin ligases.

[0007] Other peptides that agonise GLP-1 R are known. For example, exendin-4 is a homologue of GLP-1 found in the venom of the Gila monster. Oxyntomodulin is a peptide hormone that agonises both GLP-1 R and the glucagon receptor.

[0008] Moreover, agonism of GLP-1 R has potential for therapeutic effects such as reduction of blood glucose and reduction of food intake leading to body weight loss. Accordingly, various synthetic GLP-1 R agonists are commercially available for treatment of type 2 diabetes and obesity. Examples of such commercially available GLP-1 R agonists include semaglutide (Ozempic, Wegovy, Rybelsus), exenatide (Byetta, Bydureon), liraglutide (Victoza, Saxenda), lixisenatide (Lyxumia, Adlyxin), dulaglutide (Trulicity) and albiglutide (Eperzan, Tanzeum). Other synthetic GLP-1 R agonists include taspoglutide, tirzepatide (a dual agonist, which agonises both GLP-1 R and gastric inhibitory peptide receptor (GIPR)) and retatrutide (a triple agonist, of GLP-1 R, GIPR and the glucagon receptor).

[0009] Certain GLP-1 R agonists exhibit “biased signalling” (also referred to as “biased agonism”), whereby activation of GLP-1 R by the agonist stimulates signalling via the G protein- and cAMP-dependent pathway alongside reduced recruitment of p-arrestin. In other words, the signalling induced by certain GLP-1 R agonists is biased towards G protein-dependent signalling, and away from p-arrestin recruitment. Such compounds may be referred to as “biased GLP-1 R agonists”, whereas compounds which do not exhibit such biased signalling may be referred to as “balanced GLP-1 R agonists”.

[0010] Furthermore, biased GLP-1 R agonists appear to exhibit superior reduction of blood glucose and body weight relative to comparable balanced GLP-1 R agonists.

[0011] For example, the GLP-1 R agonist P5 promotes G-protein-dependent signalling comparable to GLP-1 and exendin-4, but exhibits reduced p-arrestin-dependent signalling. P5 was more effective than exendin-4 at controlling chronic hyperglycaemia in mice (Zhang et al. 2015 Nature Communications 6 8918).

[0012] Additionally, exendin-4 variants exhibiting G protein-biased signalling produce greater longterm insulin release and glycaemic benefits without increased signs of nausea relative to unmodified exendin-4 (Jones et al. 2018 Nature Communications 9 1602). An acylated exendin-4 variant exhibiting signalling biased towards G protein-dependent signalling reduced blood glucose, food intake and body weight more effectively than an acylated exendin-4 variant exhibiting signalling biased towards p-arrestin recruitment (Lucey et al. 2020 Molecular Metabolism 37 100991).

[0013] The GLP-1 R / GIPR dual agonist tirzepatide also exhibits G protein-biased signalling, though its absolute potency at the GLP-1 R is lower than the GLP-1 mono-agonist semaglutide, which does not exhibit G protein-biased signalling (Willard et al. 2020 JCI Insight 5 17).

[0014] G protein-biased GLP-1 R mono-agonists that produce superior blood glucose control and weight loss in mice relative to semaglutide have also been developed, e.g. SRB107 (Hinds et al. 2024 Diabetes Obes Metab. 26 65-77). Dapiglutide is a 33-amino acid acylated peptide molecule that agonises both GLP-1 R and the related receptor GLP-2R. (GLP-2R is agonised in normal human physiology by GLP-2, a peptide hormone related to, but different from, GLP-1 .) The peptide was disclosed for the first time by Zealand Pharma in WO 2018 / 104561 A1 (Compound 18 and SEQ ID NO 18 therein) and has the following peptide sequence: Hy-H[Aib]EGSFTSELATILD[K([17-carboxy-heptadecanoyl]isoGlu)]QAARDFIAWLIQHKITD- OH (SEQ ID NO 1).

[0015] Dapiglutide reduces blood glucose and increases small intestine weight in mice. Human subjects administered four once-weekly doses of dapiglutide exhibited a dose-dependent reduction in appetite and body weight in a Multiple Ascending Dose Trial Assessing Safety, Tolerability, Pharmacokinetics and Pharmacodynamics of dapiglutide (clinical trial No. NCT04612517) as described in Example 6 of WO 2023 / 031380 A9.

[0016] SUMMARY OF THE INVENTION

[0017] The present inventors have determined that dapiglutide is a biased GLP-1 R agonist. In particular, dapiglutide showed signalling bias at GLP-1 R, displaying full agonist activity in cAMP formation, whilst having a significantly blunted response to p-arrestin recruitment. Further in vitro characterization showed that dapiglutide-induced cAMP formation kinetics persisted for up to 12 hours unlike native GLP-1 , potentially reflecting signal bias, lack of receptor desensitization, and a promising efficacy profile in human weight loss trials.

[0018] Therefore, dapiglutide, a dual GLP-1 R / GLP-2R agonist, has a unique GLP-1 R biased agonism signalling profile that may translate into efficacious weight management and diabetes treatment.

[0019] In view of the findings of Zhang et al. 2015, Jones et al. 2018, Lucey et al. 2020, Hinds et al. 2023 and Willard et al. 2020 regarding biased GLP-1 R agonists, referred to herein, dapiglutide may provide a superior option for weight loss treatment and / or diabetes treatment relative to balanced GLP-1 R agonists.

[0020] The present invention leverages this feature of dapiglutide. Generally, the invention relates to treating with dapiglutide a subject who has received previous treatment with a balanced GLP- 1 R agonist. In other words, the invention concerns situations where a subject has been previously undergoing weight loss treatment or treatment of diabetes with a balanced GLP- 1 R agonist but then had to cease treatment, such as due to side-effects of the balanced GLP- 1 R agonist or because treatment with the balanced GLP-1 R agonist was ineffective e.g. did not lead to sufficient weight loss. Dapiglutide, as a biased GLP-1 R agonist, may provide a superior treatment option for such subjects.

[0021] Thus, the invention may be considered to relate generally to treatment of a sub-group of subjects (i.e., a patient sub-population), namely subjects for whom it is not desirable to continue treatment with a balanced GLP-1 R agonist. The invention may therefore be useful for a sub-group of subjects who are refractory or non-responsive to treatment with a balanced GLP-1 R agonist.

[0022] Put another way, in some embodiments, the present invention relates to dapiglutide for use in treating a specific sub-group of subjects (i.e., a patient sub-population). The present inventors have demonstrated in the instant application that dapiglutide can function as a biased GLP- 1 R agonist, thus providing a credible use of dapiglutide in treating a sub-population of subjects who are refractory or non-responsive to treatment with a balanced GLP-1 R agonist, or a subpopulation of subjects who have experienced adverse side-effects when treated with a balanced GLP-1 R agonist.

[0023] The invention relates generally to uses and methods for reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss. Accordingly, the invention concerns treatment or prevention of obesity, morbid obesity, obesity-linked gallbladder disease or obesity-induced sleep apnoea. The invention also concerns non- therapeutic (i.e., cosmetic) methods for reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss. The invention also concerns treatment or prevention of inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome.

[0024] Thus, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating obesity, morbid obesity, obesity-linked gallbladder disease, obesity- induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome, or of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist.

[0025] The invention also provides a non-therapeutic method of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, and wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist.

[0026] DESCRIPTION OF THE FIGURES

[0027] Figure 1 : cAMP formation at human GLP-1 R (A), p-arrestin2 recruitment at human GLP-1 R (B) and p-arrestin2 recruitment at rat GLP-1 R (C) upon stimulation with different concentrations of a GLP-1 R agonist (GLP-1 , exendin-4, liraglutide, semaglutide or dapiglutide) as a percentage of the maximum response (Emax) achieved by stimulation of the GLP-1 R with Exendin-4 at 1 nM (A), 1000 nM (B) or 316 nM (C).

[0028] Figure 2: Dapiglutide shows a prolonged cAMP response to increase its potency relative to GLP-1. (A) Monitoring intracellular cAMP levels over 12 hours shows persistent increases upon dapiglutide stimulation whereas GLP-1 induced cAMP levels gradually decrease. (B) Consequently, the potency of dapiglutide increases relative to GLP-1 when comparing total cAMP formed at 1- and 12-hours following stimulation. Data in (A) are representative kinetic curves performed in triplicate of which AUCs are calculated as mean ± SEM from 3-6 independent experiments and plotted as a function of the agonist concentration.

[0029] DESCRIPTION OF THE INVENTION

[0030] Dapiglutide

[0031] Dapiglutide is an acylated peptide molecule that agonises both GLP-1 R and GLP-2R. Dapiglutide is thus a GLP-1 R / GLP-2R dual agonist (sometimes denoted GLP-1 / GLP-2 receptor dual agonist or GLP-1 / GLP-2 dual agonist). Dapiglutide is Compound 18 (Cpd. 18) in the patent application published as WO 2018 / 104561 A1 , which is incorporated herein by reference.

[0032] The amino acid sequence of dapiglutide is as follows:

[0033] Hy-H[Aib]EGSFTSELATILD[K([17-carboxy-heptadecanoyl]-isoGlu)]QAARDFIAWLIQHKITD- OH (SEQ ID NO 1).

[0034] The amino acids of the peptide part of dapiglutide are represented in the above sequence (and in other sequences herein) using the conventional one-letter code for naturally occurring amino acids, i.e.: A (Ala), G (Gly), L (Leu), I (lie), V (Vai), F (Phe), W (Trp), S (Ser), T (Thr), Y (Tyr), N (Asn), Q (Gin), D (Asp), E (Glu), K (Lys), R (Arg), H (His), M (Met), C (Cys) and P (Pro). “[Alb]” refers to a-aminoisobutyric acid. The amino acid residues are of the L-configuration. The amino acid sequence is written left to right in amino (N-) to carboxy (C-) orientation, respectively.

[0035] “Hy-” at the N-terminus of the dapiglutide peptide sequence indicates a free primary amine group (-NH2) at the N-terminus. “-OH” at the C-terminus of the dapiglutide peptide sequence indicates a carboxyl group (-COOH) at the C-terminus.

[0036] “[K([17-carboxy-heptadecanoyl]-isoGlu)]” indicates a 17-carboxy-heptadecanoyl group linked via an iso-glutamate (isoGlu) residue to the side-chain of a lysine residue in the dapiglutide peptide sequence. [17-carboxy-heptadecanoyl]-isoGlu (i.e., a 17-carboxy-heptadecanoyl group linked to an isoGlu residue) has the following structure: wherein the dotted line indicates the covalent bind linking to the nitrogen atom in the sidechain of the lysine in the dapiglutide peptide.

[0037] Dapiglutide as used in the invention may be in the form of a pharmaceutically acceptable salt. Thus, any reference herein to dapiglutide encompasses pharmaceutically acceptable salts thereof. As used herein, the term “pharmaceutically acceptable salt” is intended to indicate a salt which is not harmful to a subject to which the salt in question is administered.

[0038] Suitable salts formed with bases include metal salts, such as alkali metal or alkaline earth metal salts, for example sodium, potassium or magnesium salts; ammonia salts and organic amine salts, such as those formed with morpholine, thiomorpholine, piperidine, pyrrolidine, a lower mono-, di- or tri-alkylamine (e.g., ethyl-tert-butyl-, diethyl-, diisopropyl-, triethyl-, tributyl- or dimethylpropylamine), or a lower mono-, di- or tri-(hydroxyalkyl)amine (e.g., mono-, di- or triethanolamine). Internal salts may also be formed. Similarly, salts can be formed using organic or inorganic acids. For example, salts can be formed from the following acids: formic, acetic, propionic, butyric, valeric, caproic, oxalic, lactic, citric, tartaric, succinic, fumaric, maleic, malonic, mandelic, malic, phthalic, hydrochloric, hydrobromic, phosphoric, nitric, sulphuric, benzoic, carbonic, uric, methanesulphonic, naphthalenesulphonic, benzenesulphonic, toluenesulphonic, p-toluenesulphonic (i.e. 4-methylbenzene-sulphonic), camphorsulphonic, 2- aminoethanesulphonic, aminomethylphosphonic and trifluoromethanesulphonic acid (the latter also being denoted triflic acid), as well as other known pharmaceutically acceptable acids. Amino acid addition salts can also be formed with amino acids, such as lysine, glycine, or phenylalanine.

[0039] Dapiglutide may be synthesised using techniques known in the art, such as by solid-phase or liquid-phase peptide synthesis methodology. In this context, reference may also be made to WO 98 / 11125 and, among many others, Fields, G.B. et al., 2002, “Principles and practice of solid-phase peptide synthesis”. In: Synthetic Peptides (2nd Edition). Synthesis of dapiglutide is described in Example 1 of WO 2018 / 104561 A1.

[0040] Balanced GLP-1R agonist

[0041] A “GLP-1 R agonist” is any compound which agonises (i.e., activates or stimulates) GLP-1 R. A GLP-1 R agonist may also be referred to herein as a “GLP-1 agonist”, “GLP-1 analogue” or “GLP-1 derivative”.

[0042] A “balanced GLP-1 R agonist” is a GLP-1 R agonist that exhibits balanced signalling from GLP- 1 R. In other words, when a balanced GLP-1 R agonist binds GLP-1 R, it stimulates downstream signalling in the same manner as native GLP-1 ; that is, the balanced GLP-1 R agonist stimulates both downstream signalling via the G-protein- and cAMP-dependent pathway, and also stimulates recruitment of p-arrestin.

[0043] A balanced GLP1-R agonist contrasts with a “biased GLP-1 R agonist”. A biased GLP-1 R agonist stimulates signalling via the G-protein- and cAMP-dependent pathway with a similar profile to GLP-1 , but exhibits reduced or non-existent p-arrestin recruitment relative to GLP-1 . A balanced GLP-1 R agonist is not a biased GLP-1 R agonist. A balanced GLP-1 R agonist may also be referred to as an “unbiased GLP-1 R agonist”.

[0044] Whether a given GLP-1 R agonist is a balanced GLP-1 R agonist or a biased GLP-1 R agonist may be determined using assays known in the art, such as those described in the Examples herein. In general, such assays involve stimulating GLP-1 R in vitro with different GLP-1 R agonists and measuring cAMP-dependent signalling (i.e., cAMP formation) and p-arrestin recruitment, then comparing the results for a given GLP1-R agonist to the results for GLP-1. The results for the GLP-1 R agonist being tested can also be compared to the results for other known balanced GLP-1 R agonists, such as exendin-4. Therefore, whether a GLP-1 R agonist is a balanced GLP-1 R agonist may be determined by comparing cAMP formation and p-arrestin recruitment stimulated by the GLP-1 R agonist to cAMP formation and p-arrestin recruitment stimulated by GLP-1 or exendin-4. In some embodiments, cAMP formation and p-arrestin recruitment stimulated by the GLP-1 R agonist is compared to cAMP formation and p-arrestin recruitment stimulated by GLP-1.

[0045] Preferably, cAMP formation and p-arrestin recruitment stimulated by the GLP-1 R agonist is compared to cAMP formation and p-arrestin recruitment stimulated by exendin-4. Exendin-4 has been shown to have the same GLP-1 R signalling profile as native GLP-1 (i.e., exendin-4 stimulates both cAMP formation and p-arrestin recruitment to the same degree as native GLP- 1).

[0046] The terms “stimulation”, “induction” and “activation” as used herein in reference to cAMP formation and p-arrestin recruitment are interchangeable. cAMP signalling and p-arrestin recruitment induced by a given GLP-1 R agonist may each be expressed as potency of the GLP-1 R agonist using EC50 (half maximal effective concentration), which is the concentration of the GLP-1 R agonist which achieves half maximum effect (i.e., half maximum cAMP formation or p-arrestin recruitment, depending upon which is being measured). cAMP signalling and p-arrestin recruitment induced by a given GLP-1 R agonist may also each be expressed as efficacy of the GLP-1 R agonist using Emax, which is the maximum effect (i.e., maximum cAMP formation or p-arrestin recruitment, depending upon which is being measured) which the GLP-1 R agonist can be expected to achieve. Once this maximum magnitude of effect has been achieved, a higher dose will not achieve a greater magnitude of effect.

[0047] To compare to a known balanced GLP-1 R agonist, cAMP formation and p-arrestin recruitment for a GLP-1 R agonist may each be expressed as a percentage (%) of the Emax of cAMP formation or Emax of p-arrestin recruitment respectively by a known GLP-1 R agonist, as measured in the same assay. In preferred embodiments, cAMP formation stimulated by the GLP-1 R agonist is expressed as a percentage of the Emax of cAMP formation stimulated by exendin-4, and p-arrestin recruitment stimulated by the GLP-1 R agonist is expressed as a percentage of the Emax of p-arrestin recruitment stimulated by exendin-4. Thus, for example, a given GLP-1 R agonist may exhibit 100% Emax cAMP formation relative to exendin-4 (i.e., the GLP-1 R agonist stimulates cAMP formation to the same degree as exendin-4) but exhibit only 5% Emax p-arrestin recruitment relative to exendin-4 (i.e., the GLP- 1 R agonist recruits p-arrestin to a much lesser degree than exendin-4). Such a GLP-1 R agonist would be considered a biased GLP-1 R agonist, as it signals via cAMP to a similar degree to, but recruits p-arrestin to a much lesser degree than, the balanced GLP-1 R agonist exendin-4.

[0048] The percentage of Emax of cAMP formation relative to exendin-4 for a given GLP-1 R agonist is referred to herein as “% Emax cAMP (exendin-4)”. The percentage of Emax of p-arrestin recruitment relative to exendin-4 for a given GLP-1 R agonist is referred to herein as “% Emax P-arrestin (exendin-4)”.

[0049] In some embodiments, a balanced GLP-1 R agonist exhibits at least about 100% Emax cAMP (exendin-4) and at least about 100% Emax p-arrestin (exendin-4). In some embodiments, a balanced GLP-1 R agonist exhibits at least about 90% Emax cAMP (exendin-4) and at least about 90% Emax p-arrestin (exendin-4). In some embodiments, a balanced GLP-1 R agonist exhibits at least about 80% Emax cAMP (exendin-4) and at least about 80% Emax p-arrestin (exendin-4). In some embodiments, a balanced GLP-1 R agonist exhibits at least about 70% Emax cAMP (exendin-4) and at least about 70% Emax p-arrestin (exendin-4).

[0050] It is the ratio of potency or efficacy of cAMP formation and p-arrestin recruitment that determines whether a given GLP-1 R agonist is a balanced GLP-1 R agonist, rather than its absolute potency or efficacy in cAMP formation and p-arrestin recruitment. Thus, a GLP-1 R agonist with lower potency or efficacy of cAMP formation than a known balanced GLP-1 R agonist would nonetheless be considered a balanced GLP-1 R agonist if it also exhibits correspondingly lower potency or efficacy of p-arrestin recruitment.

[0051] The balanced GLP-1 R agonist may be a dual agonist or a triple agonist. In other words, the balanced GLP-1 R agonist may agonise GLP-1 R and also agonise other receptors. Thus, a dual agonist or triple agonist remains a “GLP-1 R agonist” (in addition to being an agonist of the other receptors). For example, retatrutide is a GLP-1 R agonist which is a triple agonist of GLP-1 R, GIPR and the glucagon receptor.

[0052] Exendin-4, semaglutide and liraglutide are known balanced GLP-1 R agonists. In some embodiments, the balanced GLP-1 R agonist is semaglutide, GLP-1 , exendin-4 or liraglutide. All references herein to GLP-1 R agonists include pharmaceutically acceptable salts thereof. In preferred embodiments, the balanced GLP-1 R agonist is semaglutide. Semaglutide is a derivative of GLP-1 described in Example 4 of WO 2006 / 097537 and has the formula: Hy- HXEGTFTSDVSSYLEGQAAKEFIAWLVRGRG-OH (SEQ ID NO 2), wherein X at position 2 is 2-aminoisobutyric acid (Aib) and the side-chain amino group of the lysine at position 20 is linked to the lipohilic moiety [2-(2-[2-(2-[2-(2-[4-(17-Carboxyheptadecanoylamino)-4(S)- carboxybutyrylamino]ethoxy)ethoxy]acetylamino)ethoxy]ethoxy)acetyl].

[0053] In some embodiments, the balanced GLP-1 R agonist is GLP-1 (i.e., native GLP-1). The term “native GLP-1” as used herein to refers to GLP-1 as produced by the human body (i.e., endogenous GLP-1), and is intended to differentiate from synthetic GLP-1 analogues. GLP-1 is a peptide hormone secreted by intestinal cells in response to food intake.

[0054] GLP-1 can be produced as a 30-amino acid peptide amidated at the C-terminus. This form of GLP-1 is referred to as “GLP-1 (7-36)amide” and has the following sequence: Hy-HAEGTFTSDVSSYLEGQAAKEFIAWLVKGR-NH2(SEQ ID NO 3).

[0055] GLP-1 can alternatively be produced as a 31 -amino acid peptide, which is referred to as “GLP- 1 (7-37)” and has the following sequence: Hy-HAEGTFTSDVSSYLEGQAAKEFIAWLVKGRG-OH (SEQ ID NO 6).

[0056] Both GLP-1 (7-36)amide and GLP-1 (7-37) are commercially available. The term “GLP-1” as used herein encompasses all forms of GLP-1 , including GLP-1 (7-36)amide and GLP-1 (7-37).

[0057] In some embodiments, the balanced GLP-1 R agonist is exendin-4. Exendin-4 is a 39-amino acid homologue of GLP-1 found in the venom of the Gila monster, and has the following sequence:

[0058] Hy-HGEGTFTSDLSKQMEEEAVRLFIEWLKNGGPSSGAPPPS-NH2(SEQ ID NO 4).

[0059] The synthetic version of exendin-4 is called exenatide. The terms “exendin-4” and “exenatide” are used interchangeably herein.

[0060] “-NH2” at the C-terminus of a peptide sequence indicates an amide group (-CONH2) at the C- terminus.

[0061] In some embodiments, the balanced GLP-1 R agonist is liraglutide. Liraglutide is a derivative of GLP-1 described in Example 37 of US patent no. 6,268,343 and has the sequence: Hy- HAEGTFTSDVSSYLEGQAAKEFIAWLVRGRG-OH (SEQ ID NO 5), wherein the side-chain amino group of the lysine at position 20 is linked to the lipohilic moiety hexadecanoyl (i.e. palmitoyl) via a y-Glu linker.

[0062] In some embodiments, the balanced GLP-1 R agonist is not oxyntomodullin, tirzepatide, SRB107 or P5.

[0063] Treatment with a balanced GLP-1R agonist

[0064] According to the invention, the subject has received previous treatment with a balanced GLP- 1 R agonist.

[0065] The term “treatment” in this context refers to a course of administration of the balanced GLP- 1 R agonist, such as treatment of type 2 diabetes or treatment intended to induce weight loss (i.e., reduce body weight) in the subject. Thus, the term “treatment” in this context means “course of treatment” (with the balanced GLP-1 R agonist) or “course of administration” (of the balanced GLP-1 R agonist). A course of treatment is receipt of one or more doses of the balanced GLP-1 R agonist by the subject.

[0066] “T reatment” with the balanced GLP-1 R agonist does not imply or require that any physiological effect, such as weight loss or reduction of symptoms of disease, was achieved in the subject by treatment with the balanced GLP-1 R reduction (though it is also not excluded that a physiological effect, such as weight loss, was achieved). Treatment of the subject with the GLP-1 R agonist may not have had any effect. Treatment of the subject with the GLP-1 R agonist may not have had any effect satisfactory to the subject and / or their physician.

[0067] Furthermore, “treatment” with the balanced GLP-1 R agonist does not imply or require that the subject was suffering from a disease, the symptoms of which required alleviating. For example, the subject may have been treated with the balanced GLP-1 R agonist for non- therapeutic purposes, such as to reduce body weight for cosmetic reasons.

[0068] The term “received previous treatment with a balanced GLP-1 R agonist” expresses that the subject, prior to the point in time at which dapiglutide is administered to the subject in accordance with the invention, had received a course of treatment with the balanced GLP-1 R agonist (i.e., the subject had taken one or more doses of the balanced GLP-1 R agonist).

[0069] In preferred embodiments, the previous treatment with a balanced GLP-1 R agonist refers to treatment of the same disease or disorder as the intended treatment with dapiglutide. Ceased treatment

[0070] In some embodiments, the subject has ceased treatment with the balanced GLP-1 R agonist.

[0071] The term “has ceased treatment with the balanced GLP-1 R agonist” means that the subject is no longer receiving (i.e., the subject has stopped taking) the balanced GLP-1 R agonist. In other words, the balanced GLP-1 R agonist has ceased to be administered to the subject. There may be no intent that the subject will take future doses of the balanced GLP-1 R agonist.

[0072] The subject may have ceased treatment with the balanced GLP-1 R agonist for any reason, such as due to advice from their physician.

[0073] In some embodiments, the subject has ceased treatment with the balanced GLP-1 R agonist due to side effects of the balanced GLP-1 R agonist. In some embodiments, the subject has ceased treatment with the balanced GLP-1 R agonist due to failure of the balanced GLP-1 R agonist to treat diabetes or obesity or failure to reduce body weight of the subject (i.e., due to a lack of weight loss in the subject).

[0074] In some embodiments, the subject has ceased treatment with the balanced GLP-1 R agonist due to failure of the balanced GLP-1 R agonist to treat one or more disease or disorder selected from obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, prediabetes and metabolic syndrome, in the subject.

[0075] In some embodiments, the subject has ceased treatment with the balanced GLP-1 R agonist due to failure of the balanced GLP-1 R agonist to reduce body weight, inhibit weight gain, reduce food intake, reduce appetite or promote weight loss in the subject.

[0076] In some embodiments, dapiglutide or a pharmaceutically acceptable salt thereof is for use in a method of treating obesity in a subject, wherein the subject has received previous treatment with a balanced GLP-1 R agonist, wherein the subject has ceased treatment with the balanced GLP-1 R agonist due to failure of the balanced GLP-1 R agonist to treat obesity in the subject.

[0077] In some embodiments, dapiglutide or a pharmaceutically acceptable salt thereof is for use in a method of treating obesity in a subject, wherein the subject has received previous treatment with a balanced GLP-1 R agonist, wherein the subject has ceased treatment with the balanced GLP-1 R agonist due to failure of the balanced GLP-1 R agonist to treat obesity or morbid obesity in the subject. In some embodiments, dapiglutide or a pharmaceutically acceptable salt thereof is for use in a method of treating type-2 diabetes in a subject, wherein the subject has received previous treatment with a balanced GLP-1 R agonist, wherein the subject has ceased treatment with the balanced GLP-1 R agonist due to failure of the balanced GLP-1 R agonist to treat type-2 diabetes in the subject.

[0078] The subject may have ceased treatment with the balanced GLP-1 R agonist at any previous point in their life, such as in the recent past or in the distant past. In some embodiments, the subject ceased treatment with the balanced GLP-1 R agonist about one week or more ago, about one month or more ago, about six months or more ago, or about one year or more ago.

[0079] The subject may have previously ceased treatment with the balanced GLP-1 R agonist and then restarted treatment with the balanced GLP-1 R agonist, only to then again cease treatment with the balanced GLP-1 R agonist. This may have occurred any number of times in the past life of the subject.

[0080] Thus, the present invention may be useful as a second-line therapy wherein previous treatment with a balanced GLP-1 R agonist has been ceased due to non-responsiveness or unwanted side-effects, particularly given the present application provides the first evidence that dapiglutide functions as a biased GLP-1 R agonist. Thus, the present invention may be particularly useful as a second-line therapy due to differences in the mechanism of action, which may result in an improved response or reduction in side effects, in view of the findings of Zhang et al. 2015, Jones et al. 2018, Lucey et al. 2020, Hinds et al. 2023 and Willard et al. 2020.

[0081] Medical use

[0082] The invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating obesity, morbid obesity, obesity-linked gallbladder disease, obesity- induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome, or of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject having the characteristics described herein (i.e. , wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist and the subject has ceased treatment with the balanced GLP-1 R agonist). The term “treatment” (as well as “treating” and other grammatical variants thereof) as employed in the context of using dapiglutide to treat any of the diseases described herein (i.e., obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, prediabetes and / or metabolic syndrome) refers to an approach for obtaining beneficial or desired clinical results. For the purposes of the present invention, beneficial or desired clinical results include, but are not limited to, alleviation of symptoms, diminishment of extent of disease, stabilization of (i.e. not worsening of) state of disease, delay or slowing of disease progression, amelioration or palliation of disease state, and remission (whether partial or total), whether detectable or undetectable. "Treatment", in the context of treating disease using dapiglutide, may also refer to prolongation of survival compared to expected survival in the absence of treatment. "Treatment" is an intervention performed with the intention of preventing the development of, or altering the pathology of, a disorder. Accordingly, "treatment" refers to therapeutic treatment and may in some instances also refer to prophylactic measures. “Treatment”, in the context of treating disease using dapiglutide, also means inhibition or reduction of an increase in pathology or symptoms (e.g. weight gain) compared to the absence of treatment, and is not necessarily meant to imply complete cessation or cure of the relevant condition.

[0083] In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome.

[0084] In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating obesity, morbid obesity, obesity-linked gallbladder disease or obesity-induced sleep apnoea, in a subject having the characteristics described herein.

[0085] In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating obesity and morbid obesity in a subject having the characteristics described herein.

[0086] In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating obesity in a subject having the characteristics described herein. In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject having the characteristics described herein.

[0087] In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating one or more disease or disorder selected from obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes and metabolic syndrome, in a subject having the characteristics described herein.

[0088] In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating one or more disease or disorder selected from obesity, morbid obesity, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes and metabolic syndrome, in a subject having the characteristics described herein.

[0089] Gallbladder disease, which includes inflammation, infection and presence of gallstones has been mechanistically linked to, for example, insulin resistance, obesity and type 2 diabetes (Di Ciaula et al. 2021. Curr Opin Gastroenterol. 34(2):71— 80). Suitably, it will be understood that, in some embodiments, the present invention is capable of treating obesity-linked gallbladder disease.

[0090] Sleep apnoea, such as obstructive sleep apnoea, may be directly induced by obesity via mechanical means (e.g., airway compression and narrowing) and other physiological means, such as inflammation (Dempsey et al. 2010. Physiol Rev. 90(1):47— 112). Suitably, it will be understood that, in some embodiments, the present invention is capable of treating obesity- induced sleep apnoea.

[0091] Prevention

[0092] The invention also provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating or preventing one or more disease or disorder selected from obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes and metabolic syndrome, or of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

[0093] The invention also provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of preventing one or more disease or disorder selected from obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes and metabolic syndrome, or of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

[0094] In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of preventing one or more disease or disorder selected from obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes and metabolic syndrome, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

[0095] In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of preventing one or more disease or disorder selected from obesity, morbid obesity, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes and metabolic syndrome, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

[0096] In some embodiments, the invention provides dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of preventing obesity or morbid obesity, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

[0097] The terms "prevention" and grammatical variants thereof (e.g., “prevented”, “preventing”, “prevent”) as employed in the present context refer to an approach for hindering or preventing the development of, or altering the pathology of, a condition, disease or disorder. Accordingly, "prevention" may refer to prophylactic or preventive measures. For the purposes of this invention, beneficial or desired clinical results include, but are not limited to, prevention or slowing of symptoms, progression or development of a disease, whether detectable or undetectable. A subject (e.g. a human) in need of “prevention” may thus be a subject not yet afflicted with the disease or disorder in question. The term “prevention” thus includes inhibiting or slowing the onset of disease relative to the absence of treatment, and is not necessarily meant to imply permanent prevention of the relevant disease, disorder or condition. In some embodiments, “prevention” or “prophylaxis” in the context of the present invention may mean prevention of weight gain (i.e. inhibiting weight gain). In some embodiments, “prevention” or “prophylaxis” may mean prevention of gain of body fat.

[0098] Methods of treatment and use in manufacture of a medicament

[0099] The present invention is expressed herein as dapiglutide or a pharmaceutically acceptable salt thereof for use in the methods described herein.

[0100] The invention may be alternatively expressed as a method of treatment comprising administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof.

[0101] Thus, the invention provides a method of treating obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome, or of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, wherein the subject has received previous treatment with a balanced GLP-1 R agonist, and the subject has ceased treatment with the balanced GLP-1 R agonist).

[0102] In some embodiments, the invention provides a method of treating obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, wherein the subject has received previous treatment with a balanced GLP-1 R agonist, and the subject has ceased treatment with the balanced GLP-1 R agonist.

[0103] In some embodiments, the invention provides a method of treating obesity, morbid obesity, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, wherein the subject has received previous treatment with a balanced GLP-1 R agonist, and the subject has ceased treatment with the balanced GLP-1 R agonist.

[0104] In some embodiments, the invention provides a method of treating inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome.

[0105] In some embodiments, the invention provides a method of treating obesity, morbid obesity, obesity-linked gallbladder disease or obesity-induced sleep apnoea in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, wherein the subject has received previous treatment with a balanced GLP-1 R agonist.

[0106] In some embodiments, the invention provides a method of treating obesity and morbid obesity in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, wherein the subject has received previous treatment with a balanced GLP-1 R agonist, and the subject has ceased treatment with the balanced GLP-1 R agonist.

[0107] In some embodiments, the invention provides a method of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, wherein the subject has received previous treatment with a balanced GLP-1 R agonist.

[0108] The present invention may alternatively be expressed as use of dapiglutide or a pharmaceutically acceptable salt thereof in the manufacture of a medicament for the purposes and methods described herein.

[0109] Thus, the invention also provides use of dapiglutide or a pharmaceutically acceptable salt thereof in manufacture of a medicament for treating obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome, or for reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist. In some embodiments, the invention provides use of dapiglutide or a pharmaceutically acceptable salt thereof in manufacture of a medicament for treating inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome.

[0110] In some embodiments, the invention provides use of dapiglutide or a pharmaceutically acceptable salt thereof in manufacture of a medicament for treating obesity, morbid obesity, obesity-linked gallbladder disease or obesity-induced sleep apnoea in a subject having the characteristics described herein.

[0111] In some embodiments, the invention provides use of dapiglutide or a pharmaceutically acceptable salt thereof in manufacture of a medicament for reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject having the characteristics described herein.

[0112] All embodiments of the invention described herein are embodiments of the medical uses, the methods of treatment and the uses in the manufacture of a medicament of the invention.

[0113] Non-therapeutic methods

[0114] Dapiglutide may be used for non-therapeutic purposes. In this respect, it may be desirable for a subject to reduce food intake to lose weight (or inhibit weight gain) despite the subject not being obese or morbidly obese, such as for cosmetic reasons. Administration of dapiglutide may achieve these desired effects (reduced body weight, reduced food intake, weight loss and / or inhibited weight gain). In such embodiments, administration of dapiglutide to the subject would not be therapeutic as no disease or disorder would be treated by dapiglutide.

[0115] The invention thus provides a non-therapeutic method of reducing body weight, inhibiting weight gain, reducing gastric emptying or intestinal transit, reducing food intake, reducing appetite, or promoting weight loss in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

[0116] A subject may be treated with dapiglutide for cosmetic purposes, i.e. , to achieve an improved appearance, or so that they perceive that they have an improved appearance, due to weight loss. The non-therapeutic methods of the invention may thus be termed “cosmetic” methods. The invention thus provides a cosmetic method of method of reducing body weight, inhibiting weight gain, reducing gastric emptying or intestinal transit, reducing food intake, reducing appetite, or promoting weight loss in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

[0117] Considerations regarding a subject that has received previous treatment with the balanced GLP-1 R agonist as described herein apply equally when dapiglutide is used for therapeutic and non-therapeutic purposes.

[0118] The invention also provides a non-therapeutic method of preventing obesity in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

[0119] Reduced body weight

[0120] In some embodiments, the subject has reduced body weight following administration of dapiglutide. In some embodiments, following administration of dapiglutide the body weight of the subject is reduced by at least 5%, at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35% or at least 40%.

[0121] In some embodiments, the subject has reduced body mass index (BMI) following administration of dapiglutide. In some embodiments, following administration of dapiglutide the BMI of the subject is reduced by at least 5%, at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35% or at least 40%. BMI is calculated for human subjects by dividing the weight of the subject in kilograms by the square of the height of the subject in metres.

[0122] Reduced appetite

[0123] In some embodiments, the subject has decreased appetite following administration of dapiglutide.

[0124] The term “appetite” refers to a subject’s desire to consume food. The appetite of the subject may be determined by measuring how much food the subject consumes using techniques known in the art, such as the mixed meal test or standard meal test described in Example 6 of WO 2023 / 031380. Thus, in some embodiments, appetite is measured using the mixed meal test. In some embodiments, appetite is measured using the standard meal test. In some embodiments, following administration of dapiglutide the appetite of the subject is reduced by at least 5%. In some embodiments, following administration of dapiglutide the appetite of the subject is reduced by at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, at least 50%, at least 55% or at least 60%.

[0125] In a preferred embodiment, the subject has reduced food consumption following administration of dapiglutide. “Food consumption” is synonymous with “food intake”. Thus, in a preferred embodiment, the subject has reduced food intake following administration of dapiglutide. The term “food consumption” refers to the amount of food the subject consumes in a given setting or period, such as a single meal, over multiple meals or over a particular period. Food consumption of the subject may be measured by techniques known in the art, such as the mixed meal test or standard meal test described in Example 6 of WO 2023 / 031380. Thus, in some embodiments, food consumption is measured using the mixed meal test. In some embodiments, food consumption is measured using the standard meal test. In some embodiments, following administration of dapiglutide the food consumption of the subject is reduced by at least 5%. In some embodiments, following administration of dapiglutide the food consumption of the subject is reduced by at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45% or at least 50%. In some embodiments, following administration of dapiglutide the amount of food consumed by the subject is reduced to 95% or less of the amount of food consumed by the subject prior to administration of dapiglutide. In some embodiments, following administration of dapiglutide the amount of food consumed by the subject is reduced to 90% or less, 85% or less, 80% or less, 75% or less, 70% or less, 65% or less, 60% or less, 55% or less, or 50% or less of the amount of food consumed by the subject prior to administration of dapiglutide. In a preferred embodiment, following administration of dapiglutide the amount of food consumed by the subject is reduced to 65% or less of the amount of food consumed by the subject prior to administration of dapiglutide.

[0126] Subject

[0127] As described herein, the invention relates more particularly to dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes or metabolic syndrome, or of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject, wherein the subject has received previous treatment with a balanced GLP-1 R agonist.

[0128] The terms “patient”, “subject” and “individual” may be used interchangeably and refer to either a human or a non-human animal. These terms include mammals such as humans, primates, livestock animals (e.g., bovines and porcines), companion animals (e.g., canines and felines) and rodents (e.g., mice and rats). In a preferred embodiment, the subject is a human subject.

[0129] The body weight of a subject may be referred to using Body Mass Index (BMI), which is calculated for human subjects by dividing the weight of the subject in kilograms by the square of the height of the subject in metres.

[0130] In some embodiments, the subject is obese. In some embodiments, the subject has a BMI of 30.0 to 39.9 kg / m2corresponding to obese.

[0131] In some embodiments, the subject is morbidly obese. In some embodiments, the subject has a BMI of 40.0 kg / m2or higher corresponding to morbidly obese.

[0132] The invention also provides non-therapeutic methods of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof. Such non-therapeutic methods aim to reduce body weight of subjects that are not obese or morbidly obese.

[0133] In some embodiments of the non-therapeutic methods of the invention, the subject is of a healthy weight. In other words, in some embodiments, the subject is not overweight, not obese and not morbidly obese. In some embodiments, the subject has a BMI of 18.5 to 24.9 kg / m2corresponding to healthy weight.

[0134] In some embodiments of the non-therapeutic methods of the invention, the subject is overweight. In other words, in some embodiments, the subject is not of a healthy weight, but is not obese and not morbidly obese. In some embodiments, the subject has a BMI of 25.0 to 29.9 kg / m2corresponding to overweight.

[0135] Side effects

[0136] GLP-1 R agonists may have side effects. In context of the invention, the term “side effects” refers to physiological effects of the GLP-1 R agonist other than reduced body weight or appetite reduction. Side effects are typically unpleasant for the subject. For example, GLP-1 R agonists are known to induce nausea and vomiting in subjects.

[0137] In some embodiments, the previous treatment with the balanced GLP-1 R agonist was altered due to side effects of the balanced GLP-1 R agonist. In other words, in some embodiments, the previous course of treatment with the balanced GLP-1 R agonist was changed in some way in response to side effects. For example, the subject may have ceased previous treatment with the balanced GLP-1 R agonist to avoid suffering from the side effects.

[0138] In some embodiments, the subject has ceased treatment with the balanced GLP-1 R agonist due to side effects of the balanced GLP-1 R agonist.

[0139] In some embodiments, the side effects comprised or consisted of nausea or vomiting. In some embodiments, the side effects comprised nausea. In some embodiments, the side effects consisted of nausea. In some embodiments, the side effects comprised vomiting. In some embodiments, the side effects consisted of vomiting. In some embodiments, the side effects comprised nausea and vomiting. In some embodiments, the side effects consisted of nausea and vomiting.

[0140] In preferred embodiments, the subject does not experience side effects of nausea and / or vomiting following administration of dapiglutide. In some preferred embodiments, the subject does not experience nausea following administration of dapiglutide. In some preferred embodiments, the subject does not experience vomiting following administration of dapiglutide.

[0141] In some embodiments, the subject experiences less severe side effects following administration of dapiglutide than they experienced during previous treatment with the balanced GLP-1 R agonist. The term “less severe” encompasses experiencing side effects less frequently and experiencing side effects of lower magnitude.

[0142] In some embodiments, the subject experiences nausea less severely following administration of dapiglutide than they experienced during previous treatment with the balanced GLP-1 R agonist. In some embodiments, the subject experiences vomiting less severely following administration of dapiglutide than they experienced during previous treatment with the balanced GLP-1 R agonist. In some embodiments, the subject experiences nausea less often following administration of dapiglutide than they experienced during previous treatment with the balanced GLP-1 R agonist. In some embodiments, the subject experiences vomiting less often following administration of dapiglutide than they experienced during previous treatment with the balanced GLP-1 R agonist.

[0143] Dosage regime

[0144] According to the invention, dapiglutide or a pharmaceutically acceptable salt thereof is administered to the subject following any appropriate dosage regime, such as any dosage regime described herein.

[0145] The term “dosage regime” (or “dosage regimen”, “dosage protocol” or “treatment protocol”, all of which are used interchangeably herein) refers to the manner in which dapiglutide is administered to the subject, encompassing the dose of dapiglutide administered to the subject at each administration event, the timing of individual administration events (i.e., the interval between administration events) and the mode of administration of dapiglutide to the subject (i.e., the means by which dapiglutide is introduced into the body of the subject). The term “administration event” refers to the introduction of dapiglutide into the body of the subject at a given point in time. For example, an injection of a composition of dapiglutide would be an administration event.

[0146] The dosage regime most appropriate for subject treatment will vary with the disease or condition to be treated, and according to the subject’s weight and other parameters. It is expected that doses, in the g / kg range, and shorter or longer duration or frequency of treatment may produce therapeutically or non-therapeutically useful results, such as a statistically significant reduction of body weight. In some instances, the dosing regimen may include the administration of maintenance doses appropriate for preventing increase in body weight that occurs following cessation of initial treatment. The dosage sizes and dosing regimen most appropriate for human use may be guided by the results obtained by the present invention, and may be confirmed in properly designed clinical trials.

[0147] An effective dosage and treatment protocol may be determined by conventional means, starting with a low dose in laboratory animals and then increasing the dosage while monitoring the effects, and systematically varying the dosage regimen as well. Numerous factors may be taken into consideration by a clinician when determining an optimal dosage for a given subject. Such considerations are known to the skilled person. The dosage regime may involve administering more than one dose of dapiglutide. Thus, in some embodiments, dapiglutide is administered to the subject one or more times. In some embodiments, dapiglutide is administered to the subject 1 , 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 , or 12 times. In some embodiments, dapiglutide is administered to the subject 1 or more, 2 or more, 3 or more, 4 or more, 5 or more, 6 or more, 7 or more, 8 or more, 9 or more, 10 or more, 11 or more, 12 or more, or 13 or more times.

[0148] Treatment with dapiglutide may continue for as long as is necessary to reduce body weight or maintain reduced body weight. In some embodiments, dapiglutide is administered to the subject over a period of weeks or months, or for 1 year or more than 1 year. Dapiglutide may be administered to the subject for a period of, for example, one month to twenty years, for example for a period of one month, two months, three months, four months, five months, six months, seven months, eight months, nine months, ten months, eleven months, one year, two years, three years, four years, five years, six years, seven years, eight years, nine years, ten years, eleven years, twelve years, thirteen years, fourteen years, fifteen years, sixteen years, seventeen years, eighteen years, nineteen years or twenty years. In some embodiments, dapiglutide is administered to the subject for the remaining lifetime of the subject.

[0149] Dose

[0150] In some embodiments, dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject in a therapeutically effective amount.

[0151] As will be apparent to one skilled in the medical art, a “therapeutically effective amount” will vary depending upon, inter alia, the age, weight and / or gender of the subject (patient) to be treated. Other factors that may be of relevance include the physical characteristics of the specific subject (patient) under consideration, the subject’s diet, the nature of any concurrent medication, the particular compound(s) employed, the particular mode of administration, the desired pharmacological effect(s) and the particular therapeutic indication. Because these factors and their relationship in determining this amount are well known in the medical arts, the determination of therapeutically effective dosage levels for treatment of the medical indications disclosed herein, will be within the ambit of the skilled person.

[0152] As used herein, the term “a therapeutically effective amount” refers to an amount which reduces symptoms of a given condition or pathology, and preferably which normalizes physiological responses in an individual with that condition or pathology. Reduction of symptoms or normalization of physiological responses can be determined using methods routine in the art and may vary with a given condition or pathology. In one embodiment of the invention, administration of dapiglutide commenced at lower dosage levels, with dosage levels being increased until the desired effect of preventing / treating the relevant medical indication is achieved. This would define a therapeutically effective amount.

[0153] Dapiglutide may be administered to the subject at any dose suitable to achieve treatment of one or more diseases and disorders selected from inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes, metabolic syndrome, obesity, morbid obesity, obesity-linked gallbladder disease or obesity-induced sleep apnoea, and / or to achieve reduction of body weight, inhibition of weight gain, reduction of food intake, reduction of appetite and / or or promotion of weight loss. Dapiglutide may be administered to the subject at any dose suitable to achieve treatment of obesity or reduction of body weight.

[0154] The term “dose” refers to the amount of dapiglutide or pharmaceutically acceptable salt thereof administered to a subject at a given administration event (e.g., a “dose” of 1.0 mg dapiglutide). Depending on the context, the term “dose” may also refer to the administration event per se (i.e., a single dose formulation) (e.g., the subject being given a “dose” of dapiglutide).

[0155] In some embodiments, dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject at a dose of about 1.0 mg to about 30.0 mg. In other words, in some embodiments, each single dosage formulation administered to the subject comprises about 1.0 mg to about 30.0 mg of dapiglutide or the pharmaceutically acceptable salt thereof.

[0156] In some embodiments, dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject at a dose of about 1.0 mg to about 30.0 mg, about 5.0 mg to about 30.0 mg, about 10.0 mg to about 30.0 mg, about 15.0 mg to about 30.0 mg, about 20.0 mg to about 30.0 mg, about 25.0 mg to about 30.0 mg, about 1.0 mg to about 25.0 mg, about 5.0 mg to about 25.0 mg, about 10.0 mg to about 25.0 mg, about 15.0 mg to about 25.0 mg, about 20.0 mg to about 25.0 mg, about 1 .0 mg to about 20.0 mg, about 5.0 mg to about 20.0 mg, about 10.0 mg to about 20.0 mg, about 15.0 mg to about 20.0 mg, about 1.0 mg to about 15.0 mg, about 5.0 mg to about 15.0 mg, about 10.0 mg to about 15.0 mg, about 1.0 mg to about 10.0 mg, or about 5.0 mg to about 10.0 mg.

[0157] In some embodiments, dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject at a dose of about 1 .0 mg, about 1 .5 mg, about 2.0 mg, about 2.5 mg, about 3.0 mg, about 3.5 mg, about 4.0 mg, about 4.5 mg, about 5.0 mg, about 5.5 mg, about 6.0 mg, about 6.5 mg, about 7.0 mg, about 7.5 mg, about 8.0 mg, about 9.0 mg, about 10.0 mg, about 11.0 mg, about 12.0 mg, about 13.0 mg, about 14.0 mg, about 15.0 mg, about

[0158] 16.0 mg, about 17.0 mg, about 18.0 mg, about 19.0 mg, about 20.0 mg, about 21.0 mg, about

[0159] 22.0 mg, about 23.0 mg, about 24.0 mg, about 25.0 mg, about 26.0 mg, about 27.0 mg, about

[0160] 28.0 mg, about 29.0 mg, or about 30.0 mg.

[0161] In some embodiments, dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject at a dose of at least about 1 .0 mg, at least about 2.0 mg, at least about 2.25 mg, at least about 3.0 mg, at least about 4.0 mg, at least about 5.0 mg, at least about 6.0 mg, at least about 7.0 mg, at least about 8.0 mg, at least about 9.0 mg, or at least about 10.0 mg.

[0162] In some embodiments, dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject at a dose of up to about 10.0 mg, up to about 15.0 mg, up to about 20.0 mg, up to about 25.0 mg, or up to about 30.0 mg.

[0163] In some embodiments, the dose of dapiglutide is the same, or substantially the same, at each administration. In other words, in some embodiments, dapiglutide is administered at the same dose each time. In other embodiments, the dose of dapiglutide may differ at each administration. Typically, dapiglutide is administered at the same dose at each administration but this is not a requirement.

[0164] Titration

[0165] In some embodiments, dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject following a titration protocol.

[0166] The term “titration protocol” means that dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject in a series of ascending doses (i.e. , starting from a low dose and increasing to progressively higher doses) until a final treatment dose is reached, after which the subject continues with treatment at the treatment dose.

[0167] A first purpose of following a titration protocol may be to determine an appropriate dose of dapiglutide for the subject. The increasing dose of dapiglutide allows a physician to observe side effects at different doses and thereby determine an appropriate dose for treatment.

[0168] A second purpose of following a titration protocol may be to acclimatise the subject to any side effects of dapiglutide. Initial administration of dapiglutide may produce side effects which decrease in severity after further administrations as the subject adapts. Administering dapiglutide at a lower dose according to the titration protocol may curtail the initial severity of these side effects.

[0169] Thus, in some embodiments, dapiglutide is administered to the subject in ascending doses. In some embodiments, dapiglutide is administered to the subject following an ascending dose protocol. In some embodiments, dapiglutide is administered to the subject following an up- titration protocol. An “up-titration protocol” refers to administering dapiglutide in progressively increasing doses, as described herein, and contrasts with “down-titration”, wherein the dose is progressively decreased.

[0170] The dose of dapiglutide or the pharmaceutically acceptable salt thereof administered to the subject according to the titration protocol may be any dose described herein. Likewise, the treatment dose of dapiglutide or the pharmaceutically acceptable salt thereof (i.e., the dose administered to the subject for a prolonged period following up-titration, to achieve reduced body weight) may be any dose described herein.

[0171] Timing of administration

[0172] Dapiglutide may be administered to the subject at any interval suitable to achieve treatment of a disease or disorder selected from inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes, metabolic syndrome, obesity, morbid obesity, obesity-linked gallbladder disease or obesity-induced sleep apnoea, or to achieve reduction of body weight, inhibition of weight gain, reduction of food intake, reduction of appetite or promotion of weight loss.

[0173] In preferred embodiments, dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject about once weekly.

[0174] The term “week” means approximately 7 days, such as approximately 5, 5.5, 6. 6.5, 7, 7.5, 8, 8.5 or 9 days with each “day” being counted as approximately a 24 hour period. In some embodiments, “week” means 7 days ±2 days. That is to say, the administration may take place either up to and including two days before, or up to and including two days after the stated day. As such, the administration may take place 2 or 1 days before, or 1 or 2 days after, the stated day. In preferred embodiments, administration takes place once every 7thday.

[0175] Mode of administration

[0176] Dapiglutide or a pharmaceutically acceptable salt thereof may be administered to the subject by any mode of administration common or standard in the art. The term “mode of administration” refers to the means or route by which dapiglutide is administered to the subject.

[0177] Thus, in some embodiments, dapiglutide or the pharmaceutically acceptable salt is administered to the subject by injection, such as subcutaneous injection, intravenous injection or intramuscular injection. In some embodiments, dapiglutide or the pharmaceutically acceptable salt is administered to the subject by the, oral, sublingual, intranasal or rectal route.

[0178] In preferred embodiments, dapiglutide or the pharmaceutically acceptable salt is administered to the subject by subcutaneous injection.

[0179] Composition

[0180] Dapiglutide or the pharmaceutically acceptable salt thereof may be formulated as a composition, in particular a pharmaceutical composition for storage or administration.

[0181] Thus, in some embodiments, dapiglutide or the pharmaceutically acceptable salt thereof is in the form of a composition comprising dapiglutide or the pharmaceutically acceptable salt thereof in admixture with a carrier.

[0182] In some embodiments, the composition is a pharmaceutical composition, and the carrier is a pharmaceutically acceptable carrier, preferably a pharmaceutically acceptable carrier, excipient or vehicle.

[0183] In some embodiments, the pharmaceutical composition is a solution for injection. In some embodiments, the pharmaceutical composition is a liquid for injection. In some embodiments, the pharmaceutical composition is a liquid for infusion.

[0184] In some embodiments, the pharmaceutical composition is formulated for injection.

[0185] Preferably, the pharmaceutical composition is formulated for subcutaneous injection. An exemplary pharmaceutical composition with dapiglutide for subcutaneous injection is shown in WO 2023 / 031380.

[0186] Definitions

[0187] Unless otherwise defined herein, scientific and technical terms used in this application shall have the meanings that are commonly understood by those of ordinary skill in the art. Generally, nomenclature used in connection with, and techniques of, chemistry, molecular biology, cell and cancer biology, immunology, microbiology, pharmacology, and protein and nucleic acid chemistry, described herein, are those well-known and commonly used in the art.

[0188] All patents, published patent applications and non-patent publications referred to in this application are specifically incorporated by reference herein. In case of conflict, the present specification, including its specific definitions, will control.

[0189] The singular forms “a”, “an”, and “the” as used herein include the plurals unless the context clearly dictates otherwise.

[0190] The terms “comprising”, “comprises” and “comprised of” as used herein are synonymous with “including”, “includes” or “containing”, “contains”, and are inclusive or open-ended and do not exclude additional, non-recited features. The terms “comprising”, “comprises” and “comprised of” also include the term “consisting of”. The term “including” is used to mean “including but not limited to”. “Including” and “including but not limited to” may be used interchangeably.

[0191] Each embodiment of the invention described herein may be taken alone or in combination with one or more other embodiments of the invention.

[0192] The invention will now be further described by way of Examples, which are meant to serve to assist one of ordinary skill in the art in carrying out the invention and are not intended in any way to limit the scope of the invention.

[0193] EXAMPLES

[0194] Materials and Methods cAMP assay

[0195] Generation of a cell line expressing the human GLP-1 receptor for determination of compound ability to induce GLP-1R-mediated formation of the intracellular second messenger cAMP The cDNA encoding the human glucagon-like peptide 1 receptor (GLP-1 R) (primary accession number P43220) was obtained from an cDNA IMAGE clone (MGC: 138331 IMAGE:8327594) corresponding to the mRNA sequence reported under NCBI GenBank accession number BC112126. The DNA encoding the GLP-1 R was amplified by PCR using primers adding terminal restriction sites for sub-cloning. The 5’-end primer additionally encoded a near Kozak consensus sequence to ensure efficient translation. The PCR products encoding the GLP-1 R were then sub-cloned into a mammalian expression vector containing a neomycin (G418) resistance marker. The fidelity of the part of the expression vector DNA encoding the GLP-1 R was confirmed by DNA sequencing. The mammalian expression vector encoding the GLP-1 R was then transfected into HEK293 cells (ATCC # CRL-1573) by a standard calcium phosphate transfection method. The cell line was grown in culture medium consisting of DM EM, GlutaMAX (Gibco # 61965), 10% (v / v) Foetal Bovine Serum (FBS), 100 units / ml Penicillin, 100 pg / ml Streptomycin, 1 mM Sodium Pyruvate, and 1x MEM non-essential amino acids (Gibco # 11140). 48 hours post-transfection, cells were seeded for limited dilution cloning and selected with 1 mg / ml G418 in the culture medium. Following 3 weeks in G418 selection, clones were picked and tested in the assay for determination of compound ability to induce GLP-1 R-mediated formation of the intracellular second messenger cAMP as described below. One clone was selected for use in compound profiling.

[0196] Assay for determination of compound ability to induce GLP-1 R-mediated formation of the intracellular second messenger cAMP

[0197] The day before performing the assay, cells expressing the GLP-1 R were seeded in pre-coated BD BioCoat™ Poly-L-Lysine 96-well tissue culture plates at a density of 40.000 cells / well in a volume of 200 pL culture medium.

[0198] On the day of assaying, culture medium was removed, and the cells were washed once with 37°C preheated 150 pl Assay Buffer (Tyrodes buffer prepared from tyrodes salts w / o bicarbonate [Sigma T2145] supplemented with 0.05% v / v Alkali-treated Casein [Sigma C4765] and 100 pM IBMX [Sigma I5879]). Then 100 pl of test compounds diluted to different concentrations in Assay buffer were added to each of the wells and incubated for 15 min at 37°C. Assay buffer without compound (vehicle) and Exendin-4 were used as controls for normalization at data analysis. The incubation was stopped by decanting and replacing test compounds and controls with 80 pl Lysis buffer (0.1 % w / v BSA [Sigma A9430], 5 mM HEPES [Invitrogen 15630], 0.3 % v / v Tween-20 [Sigma P7949] in deionized water and pH adjusted to pH 7.4). Following cell lysis for 10 min on a plate shaker to release intracellular cAMP, a 10 pl aliquot of the cell lysate was transferred to a 384-well plate and the cAMP levels determined using the AlphaScreen® cAMP Assay Kit (Perkin Elmer 6760635M) according to the manufacturers instructions on an Envision plate reader.

[0199] For data analysis, the determined cAMP levels induced by test compounds were normalized relative to the positive control (1 nM Exendin-4 is 100%) and negative control (vehicle is 0%) to calculate the EC50 from the compound concentration response curve using the 3-parameter logistic (3PL) nonlinear concentration response model based on the formula Y=Bottom + (Top-Bottom) / (1+10A(LogEC50-X)), where Y is percent activation, X is compound concentrations and Top, Bottom, and EC50 are the parameters fitted.

[0200] The EC50 value in this assay is the concentration of stimulatory / agonistic compound required to achieve the half-maximal response of the compound’s ability to form the second messenger cAMP upon activation of the hGLP-1 R under the given assay conditions. The Top-value corresponds to the maximal response (Emax) that can be obtained by the compound at a saturating concentration in this assay relative to the maximal response induced by the reference stimulatory compound Exendin-4 at 1 nM.

[0201] A compound which has a lower EC50 value in this assay is considered to be more potent in activating the signalling pathway leading to intracellular cAMP formation pathway in comparison to a compound with a higher EC50 value. A compound, such as Exendin-4, which has an Emax corresponding to that of the endogenous agonist GLP-1 for the GLP-1 R is considered a full agonist and capable of fully activating the signalling pathway leading to intracellular cAMP formation in this particular assay format. A compound with a lower Emax than the endogenous agonist is considered a partial agonist and capable of partially activating the signalling pathway leading to intracellular cAMP formation in this particular assay format. A compound not giving a response is considered not to be a stimulatory compound the signalling pathway leading to intracellular cAMP formation in this particular assay format.

[0202] P-arrestin recruitment assay

[0203] Generation of a cell line expressing a human GLP-1 receptor construct for determining compound ability to recruit beta-arrestin2 to the human GLP-1 receptor

[0204] The assay for determining a compound’s ability to recruit beta-arrestin2 to the GLP-1 receptor uses the PathHunter p-Arrestin Principle for GPCR Applications developed by the company DiscoveRx, now Eurofins-DiscoveRx. In brief, DNA encoding the GLP-1 R is fused in frame with a small p-galactosidase (p-gal) enzyme fragment (called ProLink™) and co-expressed in HEK293 cells stably expressing a fusion protein of p-arrestin2 with a larger, N-terminal deletion mutant of p-gal (called EA). Activation of the GLP-1 R by an agonist typically resulting in recruitment and binding of p-Arrestins to the GLP-1 R, now recruits the p-arrestin2-EA fusion protein to the ProLink™-tagged GLP-1 R, thereby forcing complementation of the two enzyme fragments, resulting in the formation of an active p-gal enzyme. This interaction leads to an increase in enzyme activity and can be measured by chemiluminescence using a substrate that emits light upon conversion by the p-gal enzyme. The cDNA encoding the human glucagon-like peptide 1 receptor (GLP-1 R) (primary accession number P43220) was obtained from an cDNA IMAGE clone (MGC:138331 IMAGE:8327594) corresponding to the mRNA sequence reported under NCBI GenBank accession number BC112126. The DNA encoding the GLP-1 R without the stop codon was amplified by PCR using primers adding terminal restriction sites for subcloning. The 5’-end primer additionally encoded a near Kozak consensus sequence to ensure efficient translation. The 3’-end primer included a restriction site to allow subcloning of the GLP-1 R DNA in-frame with the ProLink™ tag present in the pCMV-ProLink™1 vector (DiscoveRx 93-0167). The PCR products were then subcloned into the pCMV-ProLink™1 vector (DiscoveRx 93-0167) to generate a mammalian expression vector encoding a GLP-1 R-ProLink™ fusion protein and a neomycin (G418) resistance marker. The fidelity of the part of the expression vector DNA encoding the GLP-1 R-ProLink™ fusion protein was confirmed by DNA sequencing.

[0205] The mammalian expression vector encoding the GLP-1 R-ProLink™ fusion protein was then transfected into the PathHunterTM HEK 293 p-Arrestin Parental Cell Line (DiscoveRx 93- 0165) using FuGENE® 6 Transfection Reagent (Promega E2691) according to the manufactrures instructions. The PathHunterTM HEK 293 p-Arrestin Parental Cell Line is a HEK293 based cell line which expresses the EA-tagged p-Arrestin2 fusion protein and was maintained with 300 pg / ml hygromycin as selection antibiotic in culture medium consisting of DMEM, GlutaMAX (Gibco # 61965), 10% (v / v) Foetal Bovine Serum (FBS), 100 units / ml Penicillin, 100 pg / ml Streptomycin, 1 mM Sodium Pyruvate, and 1x MEM non-essential amino acids (Gibco # 11140). 48 hours post-transfection, cells were seeded for limited dilution cloning and selected with 300 pg / ml hygromycin 0.5 mg / ml G418 in the culture medium. Following 3 weeks under hygromycin and G418 selection, clones were picked and tested in the assay for determining compound ability to recruit beta-arrestin2 to the human GLP-1 receptor as described below. One clone was selected for use in compound profiling.

[0206] Generation of a cell line expressing a rat GLP-1 receptor construct for determining compound ability to recruit beta-arrestin2 to the rat GLP-1 receptor

[0207] The procedure for generation of a cell line expressing a rat GLP-1 receptor construct for determining compound ability to recruit beta-arrestin2 to the rat GLP-1 receptor was essentially the same as described above for generation of a cell line expressing a human GLP- 1 receptor construct for determining compound ability to recruit beta-arrestin2 to the human GLP-1 receptor, with the following exception: The cDNA encoding the rat glucagon-like peptide 1 receptor (GLP-1 R) (primary accession number P32301) was obtained by genesynthesis (GeneArt) and corresponded to the revers transcript of the mRNA sequence reported under NCBI GenBank accession number NM_012728.2.

[0208] The day before performing the assay, cells expressing the p-arrestin2-EA and human GLP- 1 R- ProLink™ fusion proteins (human receptor assay) or the p-arrestin2-EA and rat GLP-1 R- ProLink™ fusion proteins (rat receptor assay) fusion proteins were seeded in black pre-coated BD BioCoat™ Poly-L-Lysine 96-well tissue culture plates at a density of 40.000 cells / well in a volume of 200 pL culture medium.

[0209] On the day of assaying, culture medium was removed, and the cells were washed once with 37°C preheated 150 pl Assay Buffer (Hank’s Balanced Salt Solution (HBSS) (1X), without calcium, without magnesium [Invitrogen 14175], 0.05 % VA / Casein Alkali-treated Casein [Sigma C4765], 1 mM CaCI2, 1 mM MgCI2, and 20 mM HEPES [Invitrogen 15630], adjusted to pH 7.4). Then 50 pl of test compounds serially diluted to different concentrations in Assay buffer were added to each of the wells and incubated for 90 min at 37°C. Assay buffer without compound (vehicle) and Exendin-4 (1000 nM for human receptor assay, 316 nM for rat receptor assay) were used as controls for normalization at data analysis. The assay was stopped by adding 12 pl of chemiluminescent detection reagent substrate prepared according to the manufacturer’s instructions (PathHunter® Detection Kit, DiscoverRx 93-0001). Following incubation in the dark for 60 min at room temperature, the chemiluminescent signal was measured on an Envision plate reader according to the manufacturer’s instructions. The chemiluminescent signal correlates to the degree of p-arrestin2 recruitment to the human or rat GLP-1 R.

[0210] For data analysis, the chemiluminescent signal induced by test compounds were normalized relative to the positive (1000 nM Exendin-4 for human receptor assay, 316 nM Exendin-4 for rat receptor assay is 100%) and negative control (vehicle is 0%) to calculate the EC50 from the compound concentration response curve using the 3-parameter logistic (3PL) nonlinear concentration response model based on the formula Y=Bottom + (Top- Bottom) / (1+10A(LogEC50-X)), where Y is percent activation, X is compound concentrations and Top, Bottom, and EC50 are the parameters fitted.

[0211] The EC50 value is the concentration of stimulatory / agonistic compound required to achieve the half-maximal response of the compound in the particular assay tested, here the compound’s ability to induce recruitment of p-arrestin2 to the human or rat GLP-1 R upon activation of the hGLP-1 R or rGLP-1 R under the given assay conditions. The Top-value corresponds to the maximal response (Emax) that can be obtained by the compound at a saturating concentration in the assay relative to the maximal response induced by the reference stimulatory compound Exendin-4 at 1000 nM Exendin-4 for the human receptor assay or 316 nM Exendin-4 for the rat receptor assay.

[0212] A compound which has a lower EC50 value for inducing recruitment of p-arrestin2 to the human or rat GLP-1 R upon receptor activation is considered to be more potent in recruiting p- arrestin2 to the receptor in comparison to a compound with a higher EC50 value. A compound, such as Exendin-4, which has an Emax corresponding to that of the endogenous agonist GLP- 1 for the GLP-1 R is considered as a full agonist and capable of fully recruiting p-arrestin2 to the receptor to the extent of the endogenous agonist GLP-1 under the given assay conditions. A compound with a lower Emax than the endogenous agonist is considered a partial agonist and capable of partially recruiting p-arrestin2 to the receptor under the given assay conditions. A compound not giving a response in the p-arrestin2 recruitment assay is considered not to be a stimulatory compound in terms of recruiting p-arrestin2 to the receptor under the given assay conditions.

[0213] Generation of a HEK293 cell line stably co-expressing human GLP-1 R and a cAMP FRET biosensor

[0214] A HEK293 cell line stably co-expressing the human GLP-1 R and a cAMP FRET biosensor was generated by transfecting an expression vector encoding the GLP-1 R into a cell line already expressing the cAMP FRET biosensor.

[0215] The cAMP FRET biosensor cell line was generated in the HEK293 cellular background as a stable clone as described previously (Mathiesen J.M., Vedel L., Brauner-Osborne H. cAMP biosensors applied in molecular pharmacological studies of G protein-coupled receptors, Methods Enzymol. 2013;522:191-207). In brief, a cDNA construct corresponding to the amino acids 149-881 of the cAMP binding protein Rap guanine nucleotide exchange factor 3 (gene name RAPGEF3 / EPAC1 ; NCBI GenBank accession number AF103905.1 , CDS 445-2643) was flanked by the cyan fluorescent protein variant monomeric Cerulean (mCer; NCBI GenBank accession number: MH325112.1 , CDS 1519-2235) and the yellow fluorescent protein variant monomeric Citrine (mCit; NCBI GenBank accession number: MW987532.2, CDS 5634-6353) by sequential subcloning as described previously (Mathiesen J.M., Vedel L., Brauner-Osborne H. cAMP biosensors applied in molecular pharmacological studies of G protein-coupled receptors, Methods Enzymol. 2013;522:191-207) and subcloned into the pcDNA3.1 (+)zeo mammalian expression vector containing a zeocin resistance marker. The vector encoding the cAMP FRET biosensor insert (mCer-EPAC1(149-881 )-mCit) was sequence verified and then transfected into HEK293 cells by the calcium phosphate method. 48 hours post-transfection, cells were seeded for limited dilution cloning and selected with 50 pg / mL zeocin in culture medium. After 2 weeks, surviving single colonies exhibiting high fluorescence in a fluorescence microscope due to expression of the cAMP FRET biosensor were picked and propagated. A clone giving a clear FRET response to forskolin-induced intracellular cAMP formation in the FRET-based cAMP assay described below was selected as the HEK293 cAMP FRET biosensor cell line.

[0216] The cDNA encoding the human glucagon-like peptide 1 receptor (hGLP-1 R) (primary accession number P43220) was obtained from an cDNA IMAGE clone (MGC:138331 IMAGE:8327594) corresponding to the mRNA sequence reported under NCBI GenBank accession number BC112126. The DNA encoding the GLP-1 R was amplified by PCR using primers adding terminal restriction sites for subcloning. The 5’-end primer additionally encoded a near Kozak consensus sequence to ensure efficient translation. The PCR products encoding the hGLP-1 R were then subcloned into a mammalian expression vector containing a neomycin (G418) resistance marker. The fidelity of the part of the expression vector DNA encoding the hGLP-1 R was confirmed by DNA sequencing.

[0217] To generate a stable co-expressing cell line, the mammalian expression vector with the hGLP- 1 R insert was then transfected into the HEK293 cAMP FRET biosensor cell line by the FuGENE6® transfection method as described by the manufacturer. 24 hours posttransfection, cells were seeded for limited dilution cloning and selected with 500 pg / mL G418 and 50 pg / mL zeocin in the culture medium. After 3 weeks, surviving colonies were picked, propagated, and tested in the cAMP FRET activity assay as described below and one agonist responding clone selected for compound profiling.

[0218] Human GLP-1R cAMP FRET activity assay hGLP-1 R cAMP FRET activity was measured in the hGLP-1 R and cAMP FRET biosensor coexpressing HEK293 by quantitation of the hGLP-1 R-dependent formation of cAMP using the FRET technology. In brief, binding of cAMP to EPAC1 (149-881) results in a conformational change within EPAC1(149-881) part of the mCer-EPAC1 (149-881)-mCit biosensor construct by which the distance between the two adjacent fluorescent proteins (mCitrine and mCerulean) in increases and leads to a decrease in FRET (Mathiesen J.M., Vedel L., Brauner- Osborne H. cAMP biosensors applied in molecular pharmacological studies of G protein- coupled receptors, Methods Enzymol. 2013;522:191-207). Thus, GLP-1 R-dependent cAMP formation results in an increase in FRET signal. For assaying, the cell line was grown in DMEM, GlutaMAX (Gibco # 61965), 10% (v / v) Foetal Bovine Serum (FBS), 500 pg / mL G418 and 50 pg / mL zeocin, 100 units / ml Penicillin, 100 pg / ml Streptomycin, 1 mM Sodium Pyruvate, and 1x MEM non-essential amino acids (Gibco # 11140), and seeded at 40.000 cells / well in black poly-L-lysine-coated 96 well plates (Greiner Bio-One #655946) the day prior to assay.

[0219] On the day of analysis, growth medium was removed, and the cells were washed once with 100 pl Assay Buffer (0.05% (v / v) alkali-treated Casein (Sigma # C4765) and 20 mM HEPES in Hank’s Balanced Salt Solution (HBSS), pH 7.4) prior to compound stimuli by addition of increasing 3X final test concentrations of test compound (50 pl) diluted in Assay Buffer using the FLIPR® Tetra High Throughput Screening System (Molecular Devices, Inc.).

[0220] The FRET signal between mCer and mCit was recorded over time. The FRET ratio reflecting the amount of cAMP present in the cells as a given time point was plotted against time. For each curve of the different concentrations of GLP-1 and dapiglutide, the area under the curve (AUC) was calculated after a 1 hr (60 min) and a 12 hr (720 min) timepoint. The calculated AUC levels induced by test compounds were normalized relative to the maximal response induced by GLP-1 (100%) and the response to buffer alone (0%) at the given timepoint (1 or 12 hr). To determine the potency of the compounds following incubation for 1 or 12 hr, the EC50 value for each compound was estimated following plotting of the % of GLP-1 Emax max (% AUC) against the compound concentration using the 3-parameter logistic (3PL) nonlinear concentration response model based on the formula Y=Bottom + (Top- Bottom) / (1+10A(LogEC50-X)), where Y is percent activation, X is compound concentrations and Top, Bottom, and EC50 are the parameters fitted.

[0221] Example 1 - Measurement of GLP-1 R signalling induced by different GLP-1 R agonists

[0222] The ability of each of the GLP-1 R agonists GLP-1 , exendin-4, liraglutide, semaglutide and dapiglutide to induce cAMP signalling and p-arrestin recruitment via GLP-1 R was assessed using the assays described in the Materials and Methods herein. The results are shown in Table 1 below.

[0223] ECso is the concentration of the compound required to achieve the half-maximal response of the compound’s ability to (a) form the second messenger cAMP or (b) recruit p-arrestin2, upon activation of GLP-1 R. Emax is the maximal response that can be obtained by the compound at a saturating concentration expressed as a percentage (%) of the maximal response induced by Exendin- 4 at 1 nM (cAMP assay), 1000 nM (human GLP1-R p-arrestin2 assay) or 316 nM (rat GLP1- R p-arrestin2 assay).

[0224] Table 1 - cAMP and B-arrestin2 recruitment induced by GLP-1R agonists (95% confidence limits are shown in square brackets)

[0225] The data show that semaglutide and liraglutide are balanced GLP-1 R agonists, with an Emax for cAMP formation at human GLP-1 R of about 100% relative to 1 nM Exendin-4, an Emax for P-arrestin2 recruitment at human GLP-1 R of about 100% relative to 1000 nM Exendin-4, and an Emax for p-arrestin2 recruitment at rat GLP-1 R of over 100% relative to 316 nM Exendin- 4.

[0226] In contrast, the data also show that dapiglutide is a biased GLP-1 R agonist, with an Emax for cAMP formation at human GLP-1 R of about 100% relative to 1 nM Exendin-4, but a negligible (2% at 10 pM) Emax for p-arrestin2 recruitment at human GLP-1 R relative to 1000 nM Exendin-4, and a low (about 10% at 10 pM) Emax for p-arrestin2 recruitment at rat GLP-1 R relative to 316 nM Exendin-4. Figure 1A shows the magnitude of the cAMP formation response to stimulation of human GLP-1 R with each GLP-1 R agonist (GLP-1 , exendin-4, liraglutide, semaglutide or dapiglutide) at different concentrations, expressed as a percentage of Emax achieved by stimulation with Exendin-4 at 1 nM.

[0227] Figure 1 B shows the magnitude of the p-arrestin2 recruitment response to stimulation of human GLP-1 R with each GLP-1 R agonist (GLP-1 , exendin-4, liraglutide, semaglutide or dapiglutide) at different concentrations, expressed as a percentage of Emax achieved by stimulation with Exendin-4 at 1000 nM.

[0228] Figure 1C shows the magnitude of the p-arrestin2 recruitment response to stimulation of rat GLP-1 R with each GLP-1 R agonist (GLP-1 , exendin-4, liraglutide, semaglutide or dapiglutide) at different concentrations, expressed as a percentage of Emax achieved by stimulation with Exendin-4 at 316 nM.

[0229] Accordingly, the highest response for each compound shown in each of Figures 1A-C corresponds to the Emax (%) value presented in Table 1.

[0230] Example 2 - Dapiglutide induces a prolonged cAMP response cAMP levels induced by GLP-1 or dapiglutide were monitored over 12 hours. Persistent increases of cAMP levels are seen upon dapiglutide stimulation, whereas GLP-1 induced cAMP levels gradually decrease (Figure 2A). Consequently, the potency of dapiglutide increases relative to GLP-1 when comparing total cAMP formed at 1- and 12-hours following stimulation (Figure 2B). Data in (A) are representative kinetic curves performed in triplicate of which AUCs are calculated as mean ± SEM from 3-6 independent experiments and plotted as a function of the agonist concentration.

[0231] Example Summary - Dapiglutide is a dual agonist on human GLP-1- and GLP-2- receptors with a biased and prolonged cAMP signalling profile at the GLP-1 R

[0232] Introduction & Objective

[0233] Dapiglutide, a potential first-in-class therapy targeting obesity, is a dual agonist peptide designed for activating both the GLP-1 and GLP-2 receptors. In a multiple ascending dose cohort trial, healthy participants (mean BMI 24.6 kg / m2) receiving once-weekly s.c. injections of dapiglutide up to 6 mg for 4 weeks, showed dose-dependent body weight loss up to a mean 4.3%, along with dose-dependent reductions on plasma glucose and insulin. At the cellular level, GLP-1 R activation by native GLP-1 induces formation of its major second messenger cAMP and recruitment of p-arrestin, the latter involved in receptor desensitization. Recent studies hypothesized that biased agonists displaying lack of p-arrestin recruitment at the GLP- 1 R are beneficial in controlling blood glucose and body weight loss in DIO rats. Here we investigated the in vitro profile of dapiglutide, emphasising on GLP-1 R signalling bias and functional consequences.

[0234] Methods

[0235] The human GLP-1 R in vitro signalling profile was investigated in a kinetic cAMP formation assay and for recruitment of p-arrestin in HEK293 cells.

[0236] Results

[0237] At the GLP-1 R, dapiglutide showed signalling bias, displaying full agonist activity in cAMP formation, whilst having significantly blunted response to p-arrestin recruitment.

[0238] Further in vitro characterization showed that dapiglutide-induced cAMP formation kinetics persisted for up to 12 hours unlike native GLP-1 , potentially reflecting signal bias, lack of receptor desensitization, and a promising efficacy profile in the multiple ascending dose trial.

[0239] Conclusion

[0240] Dapiglutide, a dual GLP-1 / GLP-2 agonist, has a unique GLP-1 R biased agonism signalling profile that may translate into an efficacious weight management therapy in individuals with obesity.

[0241] All publications mentioned in the above specification are herein incorporated by reference. Various modifications and variations of the described methods and system of the invention will be apparent to those skilled in the art without departing from the scope and spirit of the invention. Although the invention has been described in connection with specific preferred embodiments, it should be understood that the invention as claimed should not be unduly limited to such specific embodiments. Indeed, various modifications of the described modes for carrying out the invention which are obvious to those skilled in biochemistry, molecular biology or related fields are intended to be within the scope of the following claims. CLAUSES

[0242] The invention is defined in the following numbered clauses:

[0243] 1. Dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating one or more disease or disorder selected from obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes and metabolic syndrome, or of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist.

[0244] 2. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to clause 1 , wherein the method is a method of treating one or more disease or disorder selected from obesity, morbid obesity, obesity-linked gallbladder disease and obesity-induced sleep apnoea.

[0245] 3. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to clause 1 , wherein the method is a method of treating one or more disease or disorder selected from obesity and morbid obesity.

[0246] 4. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to clause 1 , wherein the method is a method of treating one or more disease or disorder selected from inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes and metabolic syndrome.

[0247] 5. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to clause 1 , wherein the method is a method of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss.

[0248] 6. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 5, wherein the subject has a body mass index (BMI) of 30.0 to 39.9 kg / m2corresponding to obese, or a BMI of 40.0 kg / m2or higher corresponding to morbidly obese.

[0249] 7. A non-therapeutic method of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, and wherein the subject has received previous treatment with a balanced glucagon- like peptide-1 receptor (GLP-1 R) agonist.

[0250] 8. The method according to clause 7, wherein the subject has a body mass index (BMI) of 18.5 to 24.9 kg / m2corresponding to healthy weight, or a BMI of 25.0 to 29.9 kg / m2corresponding to overweight.

[0251] 9. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6, or the method according to clause 7 or clause 8, wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

[0252] 10. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or clause 9, or the method according to any one of clauses 7 to 9, wherein the balanced GLP-1 R agonist is semaglutide, glucagon-like peptide-1 (GLP-1), exendin-4 or liraglutide, preferably wherein the balanced GLP-1 R agonist is semaglutide.

[0253] 11 . Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6, 9 or 10, or the method according to any one of clauses 7 to 10, wherein the previous treatment with the balanced GLP-1 R agonist was altered due to side effects of the balanced GLP-1 R agonist, preferably wherein the side effects comprised or consisted of nausea and / or vomiting.

[0254] 12. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or 9 to 11 , or the method according to any one of clauses 7 to 11 , wherein the previous treatment with the balanced GLP-1 R agonist was altered due to failure of the balanced GLP-1 R agonist to treat one or more of the diseases or disorders of clauses 1 to 4.

[0255] 13. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or 9 to 12, or the method according to any one of clauses 7 to 12, wherein the previous treatment with the balanced GLP-1 R agonist was altered due to failure to reduce body weight of the subject.

[0256] 14. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or 9 to 13, or the method according to any one of clauses 7 to 13, wherein the subject does not experience side effects following administration of dapiglutide, preferably wherein the side effects comprise or consist of nausea and / or vomiting. 15. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or 9 to 14, or the method according to any one of clauses 7 to 14, wherein dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject at a dose of about 1.0 mg to about 30.0 mg, about 5.0 mg to about 30.0 mg, about 10.0 mg to about 30.0 mg, about 15.0 mg to about 30.0 mg, about 20.0 mg to about 30.0 mg, about 25.0 mg to about 30.0 mg, about 1.0 mg to about 25.0 mg, about 5.0 mg to about 25.0 mg, about 10.0 mg to about 25.0 mg, about 15.0 mg to about 25.0 mg, about 20.0 mg to about 25.0 mg, about 1.0 mg to about 20.0 mg, about 5.0 mg to about 20.0 mg, about 10.0 mg to about 20.0 mg, about 15.0 mg to about 20.0 mg, about 1.0 mg to about 15.0 mg, about 5.0 mg to about 15.0 mg, about 10.0 mg to about 15.0 mg, about 1.0 mg to about 10.0 mg, or about 5.0 mg to about 10.0 mg.

[0257] 16. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or 9 to 15, or the method according to any one of clauses 7 to 15, wherein dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject at a dose of about 1.0 mg, about 1.5 mg, about 2.0 mg, about 2.5 mg, about 3.0 mg, about 3.5 mg, about 4.0 mg, about 4.5 mg, about 5.0 mg, about 5.5 mg, about 6.0 mg, about 6.5 mg, about 7.0 mg, about 7.5 mg, about 8.0 mg, about 9.0 mg, about 10.0 mg, about 11 .0 mg, about 12.0 mg, about 13.0 mg, about 14.0 mg, about 15.0 mg, about 16.0 mg, about 17.0 mg, about 18.0 mg, about 19.0 mg, about 20.0 mg, about 21.0 mg, about 22.0 mg, about 23.0 mg, about 24.0 mg, about 25.0 mg, about 26.0 mg, about 27.0 mg, about 28.0 mg, about 29.0 mg, or about 30.0 mg.

[0258] 17. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or 9 to 16, or the method according to any one of clauses 7 to 16, wherein dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject following a titration protocol.

[0259] 18. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or 9 to 17, or the method according to any one of clauses 7 to 17, wherein dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject about once weekly.

[0260] 19. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or 9 to 18, or the method according to any one of clauses 7 to , wherein dapiglutide or the pharmaceutically acceptable salt is administered to the subject by subcutaneous injection, intravenous injection or intramuscular injection, or by oral, sublingual, intranasal or rectal route, preferably wherein dapiglutide or the pharmaceutically acceptable salt is administered to the subject by subcutaneous injection.

[0261] 20. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of clauses 1 to 6 or 9 to 19, or the method according to any one of clauses 7 to 19, wherein dapiglutide or the pharmaceutically acceptable salt thereof is in the form of a composition comprising dapiglutide or the pharmaceutically acceptable salt thereof in admixture with a carrier, preferably wherein the composition is a pharmaceutical composition and the carrier is a pharmaceutically acceptable carrier.

[0262] 21 . Dapiglutide or a pharmaceutically acceptable salt thereof for use according to clause 20, or the method according to clause 20, wherein the pharmaceutical composition is formulated for injection, preferably subcutaneous injection.

Claims

CLAIMS1. Dapiglutide or a pharmaceutically acceptable salt thereof for use in a method of treating one or more disease or disorder selected from obesity, morbid obesity, obesity-linked gallbladder disease, obesity-induced sleep apnoea, inadequate glucose control, glucose tolerance, dyslipidaemia, type 2 diabetes, pre-diabetes and metabolic syndrome, or of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss, in a subject, wherein the subject has received previous treatment with a balanced glucagon-like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

2. A non-therapeutic method of reducing body weight, inhibiting weight gain, reducing food intake, reducing appetite or promoting weight loss in a subject, wherein the method comprises administering to the subject dapiglutide or a pharmaceutically acceptable salt thereof, and wherein the subject has received previous treatment with a balanced glucagon- like peptide-1 receptor (GLP-1 R) agonist, and wherein the subject has ceased treatment with the balanced GLP-1 R agonist.

3. The method according to claim 2, wherein the subject has a body mass index (BMI) of 18.5 to 24.9 kg / m2corresponding to healthy weight, or a BMI of 25.0 to 29.9 kg / m2corresponding to overweight.

4. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to claim 1 , or the method according to claim 2 or 3, wherein the balanced GLP-1 R agonist is semaglutide, glucagon-like peptide-1 (GLP-1), exendin-4 or liraglutide, preferably wherein the balanced GLP-1 R agonist is semaglutide.

5. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to claim 1 or 4, or the method according to any one of claims 2 to 4, wherein the previous treatment with the balanced GLP-1 R agonist was altered due to side effects of the balanced GLP-1 R agonist, preferably wherein the side effects comprised or consisted of nausea and / or vomiting.

6. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of claims 1 or 4 to 5, or the method according to any one of claims 2 to 5, wherein the previous treatment with the balanced GLP-1 R agonist was altered due to failure of the balanced GLP- 1 R agonist to treat one or more of the diseases or disorders of claim 1 .

7. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of claims 1 or 4 to 6, or the method according to any one of claims 2 to 6, wherein the previous treatment with the balanced GLP-1 R agonist was altered due to failure to reduce body weight of the subject.

8. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of claims 1 or 4 to 7, or the method according to any one of claims 2 to 7, wherein the subject does not experience side effects following administration of dapiglutide, preferably wherein the side effects comprise or consist of nausea and / or vomiting.

9. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of claims 1 or 4 to 8, or the method according to any one of claims 2 to 8, wherein dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject at a dose of about 1 .0 mg to about 30.0 mg, about 5.0 mg to about 30.0 mg, about 10.0 mg to about 30.0 mg, about 15.0 mg to about 30.0 mg, about 20.0 mg to about 30.0 mg, about 25.0 mg to about 30.0 mg, about 1.0 mg to about 25.0 mg, about 5.0 mg to about 25.0 mg, about 10.0 mg to about 25.0 mg, about 15.0 mg to about 25.0 mg, about 20.0 mg to about 25.0 mg, about 1 .0 mg to about 20.0 mg, about 5.0 mg to about 20.0 mg, about 10.0 mg to about 20.0 mg, about 15.0 mg to about 20.0 mg, about 1.0 mg to about 15.0 mg, about 5.0 mg to about 15.0 mg, about 10.0 mg to about 15.0 mg, about 1.0 mg to about 10.0 mg, or about 5.0 mg to about 10.0 mg.

10. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of claims 1 or 4 to 9, or the method according to any one of claims 2 to 9, wherein dapiglutide or the pharmaceutically acceptable salt thereof is administered to the subject at a dose of about 1 .0 mg, about 1 .5 mg, about 2.0 mg, about 2.5 mg, about 3.0 mg, about 3.5 mg, about 4.0 mg, about 4.5 mg, about 5.0 mg, about 5.5 mg, about 6.0 mg, about 6.5 mg, about 7.0 mg, about 7.5 mg, about 8.0 mg, about 9.0 mg, about 10.0 mg, about 11.0 mg, about 12.0 mg, about 13.0 mg, about 14.0 mg, about 15.0 mg, about 16.0 mg, about 17.0 mg, about 18.0 mg, about 19.0 mg, about 20.0 mg, about 21.0 mg, about 22.0 mg, about 23.0 mg, about 24.0 mg, about 25.0 mg, about 26.0 mg, about 27.0 mg, about 28.0 mg, about 29.0 mg, or about 30.0 mg.11 . Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of claims 1 or 4 to 10, or the method according to any one of claims 2 to 10, wherein dapiglutideor the pharmaceutically acceptable salt thereof is administered to the subject about once weekly.

12. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of claims 1 or 4 to 11 , or the method according to any one of claims 2 to 11 , wherein dapiglutide or the pharmaceutically acceptable salt is administered to the subject by subcutaneous injection, intravenous injection or intramuscular injection, or by oral, sublingual, intranasal or rectal route, preferably wherein dapiglutide or the pharmaceutically acceptable salt is administered to the subject by subcutaneous injection.

13. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to any one of claims 1 to or 4 to 12, or the method according to any one of claims 2 to 12, wherein dapiglutide or the pharmaceutically acceptable salt thereof is in the form of a composition comprising dapiglutide or the pharmaceutically acceptable salt thereof in admixture with a carrier, preferably wherein the composition is a pharmaceutical composition and the carrier is a pharmaceutically acceptable carrier.

14. Dapiglutide or a pharmaceutically acceptable salt thereof for use according to claim 13, or the method according to claim 13, wherein the pharmaceutical composition is formulated for injection, preferably subcutaneous injection.

Images