Prevention of immune-mediated transfusion reactions

Abstract

Disclosed herein are methods of preventing or treating alloimmunization in a subject in need thereof, the method comprising administering an anti-B-cell antibody to the subject prior to the subject receiving a blood transfusion.

Description

PREVENTION OF IMMUNE-MEDIATED TRANSFUSION REACTIONSCLAIM OF PRIORITY|00011 This application claims the benefit of U.S. Provisional Patent Application Serial No. 63 / 671 ,955, filed on July 16, 2024, and U.S. Provisional Patent Application Serial No. 63 / 704,955, filed on October 8, 2024. The entire contents of the foregoing are hereby incorporated by reference in their entireties.STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT

[0002] This invention was made with government support under Grant Nos. HL149626 and HL 161239 awarded by the National Institutes of Health. The government has certain rights in the invention.BACKGROUND

[0003] Blood transfusion is a critical component of modem medical care, routinely employed in the management of anemia and hematologic disorders such as sickle cell disease and thalassemia. Despite its life-saving potential, transfusion therapy carries the risk of immunologic complications, including alloimmunization and other immune-mediated reactions. Alloimmunization occurs when a recipient’s immune system recognizes and mounts a response against non-self antigens present on transfused blood components, such as red blood cells, platelets, and plasma proteins. This immune response can complicate future transfusions, limit compatible donor availability, and lead to adverse clinical outcomes such as hemolytic transfusion reactions or platelet refractoriness. The incidence and severity of these complications are influenced by factors such as the recipient’s immune status, the degree of antigenic mismatch, and the frequency of transfusions. As such, there is a continued need for strategies that can mitigate the immunologic risks associated with transfusion therapy.SUMMARY

[0004] This disclosure relates to methods for preventing or treating alloimmunization and other immune-mediated transfusion reactions in subjects undergoing blood transfusion. Alloimmunization, a common complication of transfusion therapy, arises when the recipient's immune system mounts a response against foreign antigens present on transfused blood products or components. The disclosed methods involve the administration of anti-B-cellantibodies, such as anti-CD20, anti-CD19, or anti-BAFF-R antibodies, prior to transfusion. These antibodies selectively target B cells, prevent B cell activation and / or differentiation, thereby modulating the immune response and reducing the likelihood of the development of antibodies against transfused products to prevent immune-mediated transfusion reactions including, e.g., red blood cell (RBC) auto- and allo-immunization, platelet refractoriness, and plasma factor development.

[0005] In particular, the disclosure demonstrates that administration of e.g., an anti-BAFF- R antibody or an anti-CD19 antibody, significantly reduces antibody production against transfused red blood cells. Experimental data provided herein show that pre-treatment with these agents effectively suppresses the generation of antibodies against red blood cell antigens, thereby mitigating the risk of alloimmunization and other immune-mediated transfusion reactions.

[0006] Accordingly, in some aspects, provided herein are methods of preventing or treating alloimmunization in a subject in need thereof, the methods include administering an anti-B- cell antibody to the subject prior to the subject receiving a blood transfusion. In some embodiments, the subject receives blood transfusion episodically. In some embodiments, the subject receives blood transfusion chronically. In some embodiments, the subject has sickle cell disease, thalassemia, anemia, cancer, hemophilia, kidney disease, liver disease, severe infection, or thrombocytopenia. In some embodiments, the subject has sickle cell disease. In some embodiments, the subject has a hematologic cancer.

[0007] In some embodiments, the anti-B-cell antibody is an anti-CD20 antibody, an anti- CD19 antibody, or an anti-BAFF-R antibody. In some embodiments, the anti-B-cell antibody is an anti-CD20 antibody selected from rituximab, ocrelizumab, or ublituximab-xiiy. In some embodiments, the anti-B-cell antibody is an anti-CD19 antibody selected from tafasitamab, loncastuximab tesirine, or obexelimab. In some embodiments, the anti-B-cell antibody is obexelimab. In some embodiments, the anti-B-cell antibody is an anti-BAFF-R antibody selected from ianalumab or tabalumab. In some embodiments, the anti-B-cell antibody is ianalumab.

[0008] In some embodiments, the transfusion is of whole blood or a cellular blood component. In some embodiments, the transfused blood or blood product is ABO and / or Rh blood type matched. In some embodiments, the methods comprising administering the anti-B- cell antibody prior to each transfusion.

[0009] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Methods and materials are described herein for use in the present invention; other, suitable methods and materials known in the art can also be used. The materials, methods, and examples are illustrative only and not intended to be limiting. All publications, patent applications, patents, sequences, database entries, and other references mentioned herein are incorporated by reference in their entirety. In case of conflict, the present specification, including definitions, will control.

[0010] Other features and advantages of the invention will be apparent from the following detailed description and figures, and from the claims.BRIEF DESCRIPTION OF THE DRAWINGS

[0011] FIG. 1 shows levels of anti-rat RBC antibodies in mice repeatedly immunized with rat RBCs following treatment with ianalumab as compared to control.

[0012] FIG. 2 shows levels of anti -rat RBC antibodies in mice repeatedly immunized with rat RBCs following treatment with XENP8206 as compared to control.DETAILED DESCRIPTION

[0013] Immune-mediated transfusion reactions are those that trigger a response from the patient's immune system to the transfused blood products. Immune-mediated transfusion reactions include immediate reactions and delayed reactions. Immediate immune-mediated transfusion reactions include, but are not limited to, immediate hemolytic transfusion reaction (IHTR), febrile non-hemolytic transfusion reaction (FNHTR), anaphylactic and anaphylactoid reactions, allergic reactions, and noncardiogenic pulmonary reactions. Delayed immune- mediated transfusion reactions include, but are not limited to, delayed hemolytic transfusion reaction (DHTR), delayed serological transfusion reaction (DSTR), post-transfusion purpura (PTP), transfusion-associated graft-versus-host disease (TA-GVHD), alloimmunization, and immunosuppression.

[0014] Platelet refractoriness arising from HLA alloimmunization is a serious complication of transfusion therapy. Platelet transfusion refractoriness is a repeated suboptimal response to platelet transfusions with lower-than-expected posttransfusion platelet counts.

[0015] While transfusions are effective in preventing sickle cell morbidity, their use is complicated by a high incidence of RBC alloimmunization and transfusion-relatedcomplications. The risk of alloimmunization continues to increase with RBC exposure, such that 60% of chronically transfused adults have become alloimmunized. Furthermore, more than half of these patients have antibodies to more than 1 antigen, which makes it difficult to obtain compatible blood, and results in DHTR and occasional life-threatening events. Preliminary data indicate that alloimmunization also increases the rate of RBC autoantibody formation in sickle cell disease (SCD). The mechanism underlying the increased incidence of alloimmunization in these patients may be multifactorial, but the lack of phenotypic compatibility between donor and recipient blood is clearly a major factor.

[0016] Despite its benefits, RBC transfusion results in alloimmunization in approximately 20-50% of patients with SCD. Alloantibodies can cause delayed hemolytic transfusion reactions which in SCD patients can trigger hyperhemolysis, a life-threatening poorly understood phenomena in which the transfused and the patient's own RBCs are destroyed. In addition, finding compatible units for patients with alloantibodies can be difficult and identifying and characterizing the antibodies can be costly, time-consuming and laborious, causing transfusion delays. As such, alloimmunization is associated with morbidity and mortality in chronically transfused SCD patients. How ever for the indications described above, few additional / altemative therapeutic options besides transfusion exist. Differences in minor (non-ABO) blood group antigens between mostly Caucasian blood donors and transfusion recipients who are of African descent are mainly responsible for formation of alloantibodies. Even with provision of Rh-D, -C, and -E antigen-matched donor RBCs, patients continue to develop Rh antibodies, w hich may in part be due to genetic diversity of the RH locus in donors of African ancestry; many of these antibodies are considered clinically significant. This highlights the need for better characterization of triggers of alloimmunization, identification of risk factors, and possible use of prophylactic drugs, given just before a transfusion, to prevent alloimmunization in this highly vulnerable population. Genetic as well as acquired patient- related factors are likely to influence the process of alloimmunization. The inflammatory nature of sickle cell disease may contribute to higher alloimmunization rates in SCD Studies in experimental models indicate that the recipient inflammatory’ state increases the risk of alloimmunization. In retrospective studies, SCD patients transfused for acute, and therefore inflamed, complications had increased alloimmunization rales, and patients receiving episodic transfusions, likely for acute complications, were also at greater risk of DHTR / hyperhemolysis.

[0017] In chronically transfused patients with SCD, reduced peripheral regulatory T cell (Treg) suppressive function (in the absence of accessory cells) and altered Th responses withhigher circulating IFN-a (Thl cytokine) but lower IL-10 (anti-inflammatory) cytokine levels are seen in antibody responders as compared to non-responders (Bao et al. Am J Hematol 86: 1001-6, 2011). These data are consistent with a model in which a generalized immune dysregulation exists in SCD alloimmunized patients with an imbalance between the regulatory (Tregs) and effector (Th) cells, possibly due to an underlying inflammatory state (Platt, J Clin Invest 106:337-8, 2000). As a result, the model predicts that the likelihood of antibody production is increased since Tregs can suppress B cells either directly or indirectly through inhibition of activation / expansion of effector Th cells which in turn control IgG antibody responses.

[0018] Transfusion support is vital to the management of patients with hematologic disorders and malignancies. Many patients require blood transfusion during the course of their illness. It is well known that alloimmunization against RBC antigens resulting from the genetic dispanties between donor and recipient are one of the risks of blood transfusion. The risk depends on the recipient’s exposure to the foreign antigen and its immunogenicity. The number and frequency of the transfusions as well as the recipient’s sex, age, and underlying disease may also influence immunization. Clinically significant RBC alloantibodies develop in more than 30% of patients receiving multiple transfusions and can pose major problems in the case of long-term transfusion therapy. Several researchers found that RBC alloimmunization mainly occurs after the first few transfusions. Red blood cell antibodies, which can become undetectable over time, can cause delayed transfusion reactions after incompatible blood transfusions. The matching of donor and recipient RBC phenotypes to avoid sensitization in chronically transfusion dependent patient populations is recommended.

[0019] As used herein, the term ‘'chronically transfused” refers to subjects who have received multiple transfusions of whole blood or cellular blood components. The terms “chronically transfused” and “repeated transfusion” are considered equivalent for purposes of the present disclosure.

[0020] AS used herein, the term “episodically transfused” refers to subjects who receive transfusions of whole blood or cellular blood components. The terms “episodically transfused” and “acute transfusion” are considered equivalent for purposes of the present disclosure.

[0021] As used herein, the term “blood transfusion” includes transfusion of whole blood or a blood product. The term “blood products” typically refers to red blood cells or platelets.

[0022] Blood and blood products for transfusion are tested for blood type to administer blood of the same blood type to the recipient. In some embodiments, the transfusion is matched for ABO blood types. In some embodiments, the blood is further matched for Rh t pe. In some embodiments, the blood is further matched for additional blood types.

[0023] Disclosed herein is the use of pharmaceutical agents which target and inactivate key immune cells (e.g., B cells) involved in the development of antibodies against transfused products to prevent immune-mediated transfusion reactions including red blood cell (RBC) auto- and allo-immunization, platelet refractoriness, and plasma factor development.

[0024] By removing key immune cells involved in the initiation of antibody development using B cell depleting pharmaceutical agents (e.g.. anti-B-cell antibodies), transfusion recipients will not be able to mount an immune response against transfused products including RBCs, platelets, and plasma factors. This treatment will prevent immune-mediated destruction of transfused cells and development of antibodies against plasma products, thereby improving transfusion efficacy.

[0025] Pharmaceutical agents useful in the methods disclosed herein include, but are not limited to, anti-B-cell antibodies. In some embodiments, the anti-B-cell antibodies are B celldepleting antibodies. Exemplary anti-B-cell antibodies include, but are not limited to, anti- CD20 antibodies, anti-CD19 antibodies, and anti-B-cell activating factor receptor (BAFF-R) antibodies.

[0026] Exemplary7anti-CD20 antibodies include, but are not limited to, rituximab (RITUXAN®, Genentech), ocrelizumab (OCREVUS®, Hoffman-La Roche, Genentech), ofatumumab (KESIMPTA®, Novartis), and ublituximab-xiiy (BRIUMVI®, TG Therapeutics).

[0027] Exemplary anti-CD19 antibodies include, but are not limited to, tafasitamab (MONJUVI®, Incyte), loncastuximab tesirine (ZYNLONTA®, ADC Therapeutics), and obexelimab (Xencor, Inc.; see. E.g., Mol Immunol. 2008 Sep;45(15):3926-33).

[0028] Exemplary anti-BAFF-R antibodies include, but are not limited to, ianalumab (VAY736, Novartis) and tabalumab (LY 2127399, Eli Lilly and Company). Other BAFF- targeting treatments include, but are not limited to, blisibimod and atacicept.

[0029] In some embodiments, the anti-B cell antibody is ianalumab. Ianalumab has a novel dual mechanism of action comprising blockade of BAFF-R-mediated signaling and depletion of B cells mediated by antibody-dependent cellular cytotoxicity. Ianalumab has shownfavorable safety and efficacy in Sjogren's Syndrome (SjS), Systemic Lupus Erythematosus (SLE), Chronic Lymphocytic Leukemia (CLL), Immune Thrombocytopenia (ITP). and Warm Autoimmune Hemolytic Anemia (wAIHA).|0030| In some embodiments, the anti-B-cell antibody is a B-cell depleting antibody. In some embodiments, the B-cell depleting antibody is an anti-CD20 antibody, an anti-CD19 antibody, or an anti-BAFF-R antibody. In some embodiments, the B-cell depleting antibody is ianalumab.

[0031] In some embodiments, the anti-B-cell antibody is obexelimab. Obexelimab is a bifunctional, non-cytolytic, humanised monoclonal antibody that binds CD19 and Fc gamma receptor lib to inhibit B cells, plasmablasts, and CD19-expressing plasma cells.Methods of Treatment

[0032] The methods described herein include methods for the prevention or treatment of disorders associated with alloimmunization in subjects in need thereof. In some embodiments, the subjects in need thereof are those that have or will receive blood transfusions. In some embodiments, the subjects in need thereof are episodically or chronically transfused subjects. In some embodiments, the subjects have sickle cell disease, thalassemia, anemia, cancer, hemophilia, kidney disease, liver disease, severe infection, or thrombocytopenia. For example, subjects in need thereof can include sickle cell disease patients that receive chronic transfusion. The subjects in need thereof also include those that have leukemia or other blood cancers, as well as cancer patients that receive chemotherapy and require transfusion support during treatment, for example, when platelet or red cell counts drop. In some embodiments, the subjects in need thereof are those that will be receiving transfusions (e.g., episodically or chronically).

[0033] Generally, the methods include administering a therapeutically effective amount of one or more anti-B cell antibodies disclosed herein to a subject prior to blood transfusion. As used in this context, to “treat” means to ameliorate at least one symptom of the disorder associated with alloimmunization. Symptoms associated with alloimmunization can include immediate hemolytic transfusion reaction (IHTR), febrile non-hemolytic transfusion reaction (FNHTR), anaphylactic and anaphylactoid reactions, allergic reactions, and noncardiogenic pulmonary reactions, delayed hemolytic transfusion reaction (DHTR), delayed serological transfusion reaction (DSTR), post-transfusion purpura (PTP), transfusion-associated graft- versus-host disease (TA-GVHD), and immunosuppression. Thus, the methods provided hereincan result in a reduction in alloimmunization, hemolytic transfusion reaction (IHTR), febrile non-hemolytic transfusion reaction (FNHTR), anaphylactic and anaphylactoid reactions, allergic reactions, and noncardiogenic pulmonary reactions, delayed hemolytic transfusion reaction (DHTR), delayed serological transfusion reaction (DSTR), post-transfusion purpura (PTP), transfusion-associated graft-versus-host disease (TA-GVHD), platelet refractoriness, or immunosuppression. The methods provided herein can result in a reduction of alloantibody production against transfused blood or blood products, including, e.g.. red blood cells, platelets and plasma factors, by the subject. The provided methods can also result in reduced formation of red blood cell autoantibodies. In some embodiments, the methods provided herein improves transfusion efficiency by reducing alloantibody production. For example, the methods provided herein can increase post-transfusion platelet counts.

[0034] The anti-B-cell antibodies described herein can be administered prior to a transfusion in an episodically or chronically transfused subject. Subjects who receive chronic transfusions may receive transfusion on a repeated basis over the course of months or years. The frequence of chronic transfusion can be on a daily, weekly, bi-weekly, once-every -threeweekly, monthly, bi-monthly, once-every -three-month basis, or on a more infrequent basis. For subjects who receive transfusions chronically, the frequency of administration may be adjusted throughout the course of treatment. For example, the subjects may receive transfusions at a first frequency followed by a second frequency, wherein the first frequence is higher or lower than the second frequency. Subjects who receive episodic transfusions may receive one or multiple transfusions.

[0035] In some embodiments, the anti-B-cell antibodies are administered prior to each transfusion to a subject who receives chronic or episodic transfusions. In some embodiments, the anti-B-cell antibodies are administered prior to a subset of the transfusions received by the subject. The transfusion can be whole blood transfusion or transfusion of a cellular blood component. In some embodiments, the transfused blood is ABO and / or Rh blood type matched.

[0036] In some embodiments, the methods provided herein include administering an anti- CD20 antibody (e.g.. any of the anti-CD20 antibodies described herein or known in the art), an anti-CD19 antibody (e.g., any of the anti-CD19 antibodies described herein or known in the art), or an anti-BAFF-R antibody (e.g., any of the anti- BAFF-R antibodies described herein or known in the art) to a subject in need thereof prior to a transfusion.

[0037] In some embodiments, the provided methods include administering ianalumab to a subject in need thereof (e.g., an episodically or chronically transfused subject). Ianalumab can be administered via any suitable routes, including intravenously and subcutaneously. In some embodiments, ianalumab is administered prior to a transfusion. In some embodiments, ianalumab is administered every 1, 2, 3, 4, 5, 6, 7, or 8 weeks. In some embodiments, ianalumab is administered monthly. Ianalumab can be administered at a dose of about 5 to about 50 mg / kg (e.g.. about 5 to about 15, about 8 to about 10. about 9, about 15 to about 25, about 25 to about 35, or about 35 to about 50 mg / kg). Ianalumab can also be administered at a fixed dosage of about 50 mg to about 500 mg (e.g., about 50 to about 100, about 100 to about 150, about 150 to about 200. about 200 to about 250, about 250 to about 300, about 300 to about 350, about 350 to about 400, about 400 to about 450, or about 450 to about 500 mg).

[0038] In some embodiments, the provided methods include administering obexelimab to a subject in need thereof (e.g.. an episodically or chronically transfused subject). Obexelimab can be administered via any suitable routes, including intravenously and subcutaneously. In some embodiments, obexelimab is administered prior to a transfusion. In some embodiments, obexelimab is administered every 1, 2, 3, 4, 5, 6, 7, or 8 weeks. Obexelimab can be administered at a dose of about 0.5 to about 20 mg / kg (e.g., about 1 to 10, about 2 to 8, about 4 to 6, about 10 to 15, or about 15 to 20 mg / kg).Pharmaceutical Compositions

[0039] The anti B-cell antibodies described herein can be formulated as a pharmaceutical composition for administration to a subject, e.g., to treat a disease or condition described herein. Typically, a pharmaceutical composition includes a pharmaceutically acceptable carrier. As used herein, “pharmaceutically acceptable carrier” includes any and all solvents, dispersion media, coatings, antibacterial and antifungal agents, isotonic and absorption delaying agents, and the like that are physiologically compatible. The composition can include a pharmaceutically acceptable salt, e.g., an acid addition salt or a base addition salt (see e.g., Berge, S.M., et al. (1977) J. Pharm. Sci. 66: 1-19).

[0040] Pharmaceutical formulation is a well-established art, and is further described, e.g., in Gennaro (ed.), Remington: The Science and Practice of Pharmacy , 20th ed., Lippincott, Williams & Wilkins (2000) (ISBN: 0683306472); Ansel et al., Pharmaceutical Dosage Forms and Drug Delivery Systems. 7th Ed.. Lippincott Williams & Wilkins Publishers (1999) (ISBN:0683305727); and Kibbe (ed.), Handbook of Pharmaceutical Excipients American Pharmaceutical Association. 3rd ed. (2000) (ISBN: 091733096X).

[0041] The pharmaceutical compositions may be in a variety of forms. These include, for example, liquid, semi-solid and solid dosage forms, such as liquid solutions (e.g., injectable and infusible solutions), dispersions or suspensions, tablets, pills, powders, liposomes and suppositories. The preferred form can depend on the intended mode of administration and therapeutic application. Typically compositions for the agents described herein are in the form of injectable or infusible solutions.

[0042] Such compositions can be administered by a parenteral mode (e.g., intravenous, subcutaneous, intraperitoneal, or intramuscular injection). In one embodiment, the antibody composition is administered intravenously. In another embodiment, the antibody composition is administered subcutaneously. The phrases “parenteral administration” and “administered parenterally” as used herein mean modes of administration other than enteral and topical administration, usually by injection, and include, without limitation, intravenous, intramuscular, intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, intraperitoneal, transtracheal, subcutaneous, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal, epidural and intrastemal injection and infusion.

[0043] The composition can be formulated as a solution, microemulsion, dispersion, liposome, or other ordered structure suitable for stable storage at high concentration. Sterile injectable solutions can be prepared by incorporating an agent described herein in the required amount in an appropriate solvent with one or a combination of ingredients enumerated above, as required, followed by filtered sterilization. Generally, dispersions are prepared by incorporating an agent described herein into a sterile vehicle that contains a basic dispersion medium and the required other ingredients from those enumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and freeze drying that yield a powder of an agent described herein plus any additional desired ingredient from a previously sterile-filtered solution thereof.Administration

[0044] The anti-B-cell antibodies or pharmaceutical compositions comprising the same described herein can be administered to a subject, e.g., a human subject in need thereof, for example, by a variety of methods. For many applications, the route of administration is one of: intravenous injection or infusion (IV). subcutaneous injection (SC), intraperitoneally (IP),or intramuscular injection. It is also possible to use intra-articular delivery'. Other modes of parenteral administration can also be used. Examples of such modes include: intraarterial, intrathecal, intracapsular, intraorbital, intracardiac, intradermal, transtracheal, subcuticular, intraarticular, subcapsular, subarachnoid, intraspinal, and epidural and intrastemal injection. In some cases, administration can be oral. The route and / or mode of administration can also be tailored for the individual case, e.g., by monitoring the subject.

[0045] If a subject is at risk for developing a disease or condition described herein, the antibodies or pharmaceutical compositions described herein can be administered before the full onset of the disease or condition, e.g., as a preventative measure. The duration of such preventative treatment can be a single dosage of the antibody or the treatment may continue (e.g., multiple dosages).

[0046] A pharmaceutical composition may include a ‘'therapeutically effective amount” of an agent described herein. Such effective amounts can be determined based on the effect of the administered agent, or the combinatorial effect of agents if more than one agent is used. A therapeutically effective amount of an agent may also vary according to factors such as the disease state, age, sex, and weight of the individual, and the ability of the compound to elicit a desired response in the individual, e.g., amelioration of at least one disease or condition parameter or amelioration of at least one symptom of the disease or condition. A therapeutically effective amount is also one in which any toxic or detrimental effects of the composition are outweighed by the therapeutically beneficial effects.Devices and Kits for Therapy

[0047] Pharmaceutical compositions that include the antibodies described herein can be administered with a medical device. The device can be designed with features such as portability, room temperature storage, and ease of use so that it can be used in emergency situations, e.g., by an untrained subject or by emergency personnel in the field, removed from medical facilities and other medical equipment. The device can include, e.g., one or more housings for storing pharmaceutical preparations that include the antibody, and can be configured to deliver one or more unit doses of the antibody. The device can be further configured to administer a second agent either as a single pharmaceutical composition that also includes the antibody described herein or as two separate pharmaceutical compositions.

[0048] The pharmaceutical composition may be administered with a syringe. The pharmaceutical composition can also be administered with a needleless hypodermic injectiondevice, such as the devices disclosed in US 5,399,163; 5,383,851; 5,312,335; 5,064,413; 4,941,880; 4.790,824; or 4,596,556. Examples of well-known implants and modules include: US 4,487,603, which discloses an implantable micro-infusion pump for dispensing medication at a controlled rate; US 4,486,194, which discloses a therapeutic device for administering medicaments through the skin; US 4,447,233, which discloses a medication infusion pump for delivering medication at a precise infusion rate; US 4,447,224, which discloses a variable flow implantable infusion apparatus for continuous drug delivery; US 4,439.196. which discloses an osmotic drug delivery system having multi-chamber compartments; and US 4,475,196, which discloses an osmotic drug delivery system. Many other devices, implants, delivery systems, and modules are also known.

[0049] An antibody described herein can be provided in a kit. In one embodiment, the kit includes (a) a container that contains a composition that includes an antibody described herein, and optionally (b) informational material. The informational material can be descriptive, instructional, marketing or other material that relates to the methods described herein and / or the use of the agents for therapeutic benefit.

[0050] In an embodiment, the kit also includes a second agent for treating a disease or condition described herein. For example, the kit includes a first container that contains a composition that includes the antibody described herein, and a second container that includes the second agent.

[0051] The informational material of the kits is not limited in its form. In one embodiment, the informational material can include information about production of the compound, molecular weight of the compound, concentration, date of expiration, batch or production site information, and so forth. In one embodiment, the informational material relates to methods of administering the antibody described herein, e.g.. in a suitable mode of administration (e.g., a mode of administration described herein), to treat a subject who has had or who is at risk for a disease or condition described herein. The information can be provided in a variety of formats, include printed text, computer readable material, video recording, or audio recording, or information that provides a link or address to substantive material, e.g., on the internet.

[0052] In addition to the antibody, the composition in the kit can include other ingredients, such as a solvent or buffer, a stabilizer, or a preservative. The antibody can be provided in any form, e.g., liquid, dried or lyophilized form, preferably substantially pure and / or sterile. When the agents are provided in a liquid solution, the liquid solution preferably is an aqueoussolution. When the agents are provided as a dried form, reconstitution generally is by the addition of a suitable solvent. The solvent, e.g., sterile water or buffer, can optionally be provided in the kit.|0053| The kit can include one or more containers for the composition or compositions containing the agents. Tn some embodiments, the kit contains separate containers, dividers or compartments for the composition and informational material. For example, the composition can be contained in a bottle, vial, or syringe, and the informational material can be contained in a plastic sleeve or packet. In other embodiments, the separate elements of the kit are contained within a single, undivided container. For example, the composition is contained in a bottle, vial or syringe that has attached thereto the informational material in the form of a label. In some embodiments, the kit includes a plurality (e.g., a pack) of individual containers, each containing one or more unit dosage forms (e.g.. a dosage form described herein) of the agents. The containers can include a combination unit dosage, e.g., a unit that includes both the antibody described herein and the second agent, e.g., in a desired ratio. For example, the kit includes a plurality of syringes, ampules, foil packets, blister packs, or medical devices, e.g., each containing a single combination unit dose. The containers of the kits can be air tight, waterproof (e.g., impermeable to changes in moisture or evaporation), and / or light-tight. The kit optionally includes a device suitable for administration of the composition, e.g., a syringe or other suitable delivery device. The device can be provided pre-loaded with one or both of the agents or can be empty, but suitable for loading.EXAMPLESExample 1. Efficacy of VAY736 on inhibition of alloimmunization

[0054] Using allogenic (glycophorin A) expressing red blood cells (RBCs), we will screen by flow-based assays the development of RBC alloantibodies and will perform an in-depth analysis of splenic B and T cell compartments, to determine the effectiveness of VAY736 (ianalumab) treatment in preventing B cell activation / differentiation. In Study 1, prevention of alloimmunization by VAY736 in wildtype mice (C57 / BL6) will be tested. In Study 2, prevention of alloimmunization by VAY736 in sickle cell Townes mice will be tested. In Study 3, the efficacy of VAY736 in thalassemia (TH3 / +) mice will be studied.

[0055] Mice will be pre-treated i.p. with VAY736, isotype or PBS control followed by transfusion of leuko-reduced lOOpl (equivalent to 1-2 units) RBCs from transgenic miceexpressing human glycoprotein A (huGPA) on a weekly basis for 4 weeks in the following groups of mice:(1) HuGPA mouse RBCs + VAY736, n=10(2) HuGPA mouse RBCs +isotype control, n=10(3) HuGPA mouse RBCs +PBS, n=l 0(4) No treatment, n=6(5) HuGPA mouse RBCs +rituximab, n=10

[0056] In mice having a B6 background, roughly 2 / 3 of transfused mice are expected to develop RBC alloAbs.

[0057] The Experimental Protocol is as follows:10 days prior to VAY736 / isotvpe / transfusions:• Bleed mice (80pl) : o CBC (by Advia 120) o Plasma alloanti-RBC measurement (by flow-based indirect antiglobulin test)Week 0- inject VAY736 / isotype (IQOmg / Kg / mouse) or PBS and then transfuse with huGPA RBCs plus CpGWeek 1- inject VAY736 / isotype (IQOmg / Kg / mouse) or PBS and then transfuse with huGPARBCs aloneJust before injection of VAY736 / isotype:• Bleed mice (80pl) : o CBC (Advia 120- to check lymphocyte depletion) o Plasma alloantibody measurement (by flow-based indirect antiglobulin test)Week 2- inject VAY736 / isotvpe (100mg / K.g / mouse) or PBS and then transfuse with huGPARBCs aloneJust before injection of VAY736 / isotype:• Bleed mice (50pl) : o Plasma alloantibody measurement (by flow-based indirect antiglobulin test)Week 3- inject VAY736 / isotype (IQOmg / Kg / mouse) or PBS and then transfuse with huGPA RBCs aloneJust before injection of VAY736 / isotype:• Bleed mice (80pl) : o CBC (Advia 120- to check lymphocyte depletion) o Plasma alloantibody test (by flow-based indirect antiglobulin test) oWeek 4- inject VAY736 / isotype (IQOmg / Kg / mouse) or PBS and then transfuse with huGPA RBCs aloneJust before injection of VAY736 / isotype:• Bleed mice (50pl) : o Plasma alloantibody measurement (by flow-based indirect antiglobulin test)Week 5- sacrifice mice• Bleed mice: o CBC (by Advia 120) o Plasma alloantibody measurement (by flow-based indirect antiglobulin test)• Mouse blood immunophenotyping• Mouse spleen B cell, T helper / Treg• Mouse bone marrow B cell profiling

[0058] Methods

[0059] Plasma alloantibody measurement: To 1 pl of diluted leukoreduced RBCs from huGPA mouse RBCs (5xl06 / ul), add 50pl of 1 : 10 D-PBS (D-PBS - no calcium chloride: no magnesium chloride) diluted plasma from experimental mice; as a control use naive B6 mice RBCs. Incubate at 37°C for 1 hr; wash x3 with D-PBS at room temp followed by 50pl of 1 :50 diluted FITC-conjugated anti-mouse IgG incubate at 4°C for 15min; wash x2 with D-PBS at room temp and run on BD Fortessa4 and analysis by FloJo.

[0060] Complete Blood Counts. To 50pl of whole blood, add 150pl of PBS and run on Advia 120 Hematology’ analyzer. Absolute blood counts (including white blood cell counts etc) are then corrected by multiplying by 4.Example 2: lanalumab reduces incompatible anti-RBC antibody production

[0061] lanalumab (VAY736), is a glycoengineered (afucosylated), fully human IgGl monoclonal antibody directed against B-cell activating factor receptor (BAFF-R), causing blockade of the signaling pathway BAFF-R as well as direct lysis and depletion of BAFF-R- expressing B-cells. To test the efficacy of ianalumab (anti-BAFFR) in preventing antibody formation against incompatible red blood cells (RBCs), 8-10-week-old C57BL / 6 mice (n=15) were injected with leukoreduced rat RBCs (2 x 10 per mouse) intraperitoneally (i.p.) on a weekly basis for 11 weeks and dosed with ianalumab (100 mg / kg; i.p.; weekly) 5 days prior to immunization. Control groups included rat RBC immunized mice treated with PBS i.p. weekly (n=14 mice), and ianalumab only (100 mg / kg) (n=5 mice) or PBS (n=5 mice i.p., weekly). Mice were then sacrificed, and 50ul of 1 : 1000 diluted plasma collected from the terminal bleeds added to lul of diluted leukoreduced rat RBCs (5xl06 / ul), incubated at 37C for 1 hr; and after several washes, the cells were stained with FITC-conjugated anti-mouse IgG (Vector Labs, cat #FI-2000-1.5); and ran on BD Fortessa4. Data was analyzed using FloJo and relative levels of antibodies bound to rat RBCs represented as mean fluorescence intensity (MFI).

[0062] A significant reduction in anti-rat RBC antibodies were detected at terminal bleed on week 11 in ianalumab-treated immunized mice compared to PBS-treated immunized mice (FIG. 1). These results demonstrate that lanalumab can effectively reduce anti-RBC antibody production against transfused RBCs.Example 3: XENP8206 reduces incompatible anti-RBC antibody production

[0063] Obexelimab is a non-depleting anti-human CD 19 mAb with an Fc region engineered to have high affinity for human FcyRIIb, thereby co-engaging BCR and FcyRIIb. XENP8206 is a mAb which bears the same Fc / RIIb-enhanced human Fc domain as does obexelimab but which recognizes murine CD19 rather than human CD19. The effect of XENP8206 on anti-RBC antibody production was tested.

[0064] Human FcgRIIb transgenic B6 mice were injected with leukoreduced rat RBCs (2 x 10 per mouse) intraperitoneally (IP) on a weekly basis for 11 weeks. XENP8206 was administered twice weekly IP from week -1 through week 11 at a dose of 10 mg / kg (n=16 mice). Control groups included rat RBC immunized mice treated with PBS i.p. twice weekly (n=16 mice), and XENP8206 alone (twice weekly IP at a dose of lOmg / kg, n=3 mice) or PBS alone (twice weekly IP, n=3 mice). Mice were then sacrificed, and 50pL of 1 : 1000 diluted plasma collected from the terminal bleeds added to IpL of diluted leukoreduced rat RBCs (5xl06 / pL), incubated at 37C for 1 hr; and after several washes, the cells were stained withFITC-conjugated anti-mouse IgG (Vector Labs, cat #FI-2000-1.5); and ran on BD Fortessa4. Data was analyzed using FloJo and relative levels of antibodies bound to rat RBCs represented as mean fluorescence intensity (MFI).|0065| A significant reduction in anti-rat RBC antibodies were detected at terminal bleed on week 11 in XENP8206 -treated immunized mice compared to PBS-treated immunized mice (FIG. 2). These results demonstrated that XENP8206 can effectively reduce anti-RBC antibody production against transfused RBCs.

[0066] Unless otherwise indicated, all numbers expressing quantities of ingredients, properties such as molecular weight, reaction conditions, and so forth used in the specification and claims are to be understood as being modified in all instances by the term "‘about / ’ As used herein the terms "about" and “approximately” means within 10 to 15%, preferably within 5 to 10%. Accordingly, unless indicated to the contrary, the numerical parameters set forth in the specification and attached claims are approximations that may vary depending upon the desired properties sought to be obtained by the present invention. At the very least, and not as an attempt to limit the application of the doctrine of equivalents to the scope of the claims, each numerical parameter should at least be construed in light of the number of reported significant digits and by applying ordinary rounding techniques. Notwithstanding that the numerical ranges and parameters setting forth the broad scope of the invention are approximations, the numerical values set forth in the specific examples are reported as precisely as possible. Any numerical value, however, inherently contains certain errors necessarily resulting from the standard deviation found in their respective testing measurements.

[0067] The terms “a,” “an,” “the” and similar referents used in the context of describing the invention (especially in the context of the following claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. Recitation of ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range. Unless otherwise indicated herein, each individual value is incorporated into the specification as if it were individually recited herein. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e g., “such as”) provided herein is intended merely to better illuminate the invention and does not pose a limitation on the scope of the invention otherwise claimed. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the invention.

[0068] Groupings of alternative elements or embodiments of the invention disclosed herein are not to be construed as limitations. Each group member may be referred to and claimed individually or in any combination with other members of the group or other elements found herein. It is anticipated that one or more members of a group may be included in, or deleted from, a group for reasons of convenience and / or patentability. When any such inclusion or deletion occurs, the specification is deemed to contain the group as modified thus fulfilling the written description of all Markush groups used in the appended claims.

[0069] Certain embodiments of this invention are described herein, including the best mode known to the inventors for carrying out the invention. Of course, variations on these described embodiments will become apparent to those of ordinary skill in the art upon reading the foregoing description. The inventor expects skilled artisans to employ such variations as appropriate, and the inventors intend for the invention to be practiced otherwise than specifically described herein. Accordingly, this invention includes all modifications and equivalents of the subject matter recited in the claims appended hereto as permitted by applicable law7. Moreover, any combination of the above-described elements in all possible variations thereof is encompassed by the invention unless otherwise indicated herein or otherwise clearly contradicted by context.

[0070] Specific embodiments disclosed herein may be further limited in the claims using consisting of or consisting essentially of language. When used in the claims, whether as filed or added per amendment, the transition term “consisting of’ excludes any element, step, or ingredient not specified in the claims. The transition term “consisting essentially of’ limits the scope of a claim to the specified materials or steps and those that do not materially affect the basic and novel characteristic(s). Embodiments of the invention so claimed are inherently or expressly described and enabled herein.

[0071] Furthermore, numerous references have been made to patents and printed publications throughout this specification. Each of the above-cited references and printed publications are individually incorporated herein by reference in their entirety7.

[0072] In closing, it is to be understood that the embodiments of the invention disclosed herein are illustrative of the principles of the present invention. Other modifications that maybe employed are within the scope of the invention. Thus, by way of example, but not of limitation, alternative configurations of the present invention may be utilized in accordancewith the teachings herein. Accordingly, the present invention is not limited to that precisely as shown and described.

Claims

What is claimed is:

1. A method of preventing or treating alloimmunization in a subject in need thereof, the method comprising administering an anti-B-cell antibody to the subject prior to the subject receiving a blood transfusion.

2. The method of claim 1, wherein the subject receives blood transfusion episodically.

3. The method of claim 1, wherein the subject receives blood transfusion chronically.

4. The method of any one of claims 1-3, wherein the subject has sickle cell disease, thalassemia, anemia, cancer, hemophilia, kidney disease, liver disease, severe infection, or thrombocytopenia.

5. The method of claim 4, wherein the subject has sickle cell disease.

6. The method of claim 4, wherein the subject has a hematologic cancer.

7. The method of any one of the above claims, wherein the anti-B-cell antibody is an anti- CD20 antibody, an anti-CD19 antibody, or an anti-BAFF-R antibody.

8. The method of claim 7, wherein the anti-B-cell antibody is an anti-CD20 antibody selected from rituximab, ocrelizumab, or ublituximab-xiiy.

9. The method of claim 7, wherein the anti-B-cell antibody is an anti-CD19 antibody selected from tafasitamab, loncastuximab tesirine, or obexelimab.

10. The method of claim 9, wherein the anti-B-cell antibody is obexelimab.

10. The method of claim 7, wherein the anti-B-cell antibody is an anti-BAFF-R antibody selected from ianalumab or tabalumab.

11. The method of claim 10. wherein the anti-B-cell antibody is ianalumab.

12. The method of any one of the above claims, wherein the transfusion is of whole blood or a cellular blood component.

13. The method of any one of the above claims, wherein the transfused blood or blood product is ABO and / or Rh blood type matched.

14. The method of claims 2 or 3, wherein the methods comprising administering the anti-B- cell antibody prior to each transfusion.

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