Use of combination therapy of bmp-2 and denosumab in spinal fusion surgery

Abstract

The present invention relates to uses of a combination therapy of bone morphogenetic protein-2 and denosumab in spinal fusion surgery. When bone morphogenetic protein-2 and denosumab are used in combination during spinal fusion surgery as in the present invention, side effects frequently occurring due to spinal fusion surgery, such as osteolysis, inflammation, wound dehiscence, and bleeding, can be effectively prevented and treated.

Description

Use of BMP-2 and Denosumab in Combination Therapy in Bone Fusion

[0001] The present invention relates to the use of a combination therapy of a type II bone morphogenetic protein and denosumab in bone fusion surgery, and more specifically, to the use of a combination therapy of a type II bone morphogenetic protein and denosumab that can effectively treat complications such as osteolysis, inflammation, wound dehiscence, and hemorrhage occurring after bone fusion surgery.

[0002] Osteoporosis is a very common degenerative disease among the elderly that can result from a decrease in bone density and lead to chronic pain and disability. Spinal fusion is frequently used to treat spinal stenosis, spinal instability, and other conditions causing chronic low back pain; however, patients with osteoporosis face a higher risk of non-union and subsidence after spinal fusion, which can negatively affect the surgical outcome.

[0003] Bone morphogenetic protein type 2 (BMP-2) is a potent osteogenic agent applied topically to promote bone healing and increase the fusion rate after spinal fusion surgery. However, BMP-2 has been reported to be associated with various complications such as spinal osteolysis, edema, cyst formation, wound complications, and fever (Gautschi OP, Frey SP, Zellweger R. Bone morphogenetic proteins in clinical applications. ANZ J Surg 2007;77:626-31; Tannoury CA, An HS. Complications with the use of bone morphogenetic protein 2 (BMP-2) in spine surgery. Spine J 2014;14:552-9). Among these, osteolysis is a major complication of spinal fusion surgery that can lead to implant failure and often require reoperation. In addition, BMP-2 is known to influence early osteoclast activity and inflammatory responses; in this case, it can induce wound dehiscence along with a chain reaction of inflammation, which may lead to oozing events at the spinal fusion site.

[0004] Accordingly, the inventors have completed the present invention by making diligent efforts to develop a combination therapy capable of effectively suppressing complications such as osteolysis, inflammation, wound dehiscence, and bleeding that occur by the local application of BMP-2 to bone fusion surgery.

[0005] The present invention aims to provide a pharmaceutical composition for assisting in bone fusion treatment that can treat complications associated with bone fusion.

[0006] To achieve the above objective, the present invention provides a pharmaceutical composition for adjuvant treatment of bone fusion, comprising a type 2 bone morphogenetic protein (BMP-2) and denosumab as active ingredients.

[0007] In the present invention, the type 2 bone morphogenetic protein may be administered locally to the bone fusion site, and the denosumab may be administered systemically.

[0008] In the present invention, the type 2 bone-forming protein may be characterized by being mixed with hydroxyapatite and autogenous bone and locally implanted at the surgical site.

[0009] In the present invention, the denosumab may be characterized as being administered systemically by subcutaneous injection.

[0010] In the present invention, the composition may be characterized by preventing or treating complications associated with bone fusion surgery.

[0011] In the present invention, the composition is according to bone fusion surgery

[0012] (i) reduction in osteolysis; and / or

[0013] (ii) It may be characterized by reducing the occurrence and / or persistence of inflammation, wounds and / or bleeding.

[0014] In the present invention, the type 2 bone morphogenetic protein (BMP-2) may be characterized by being administered topically once at a dose of 0.5 mg to 6 mg.

[0015] In the present invention, the denosumab may be characterized by being initially administered at a dose of 60 mg within one week before or after bone fusion surgery, and subsequently administered additionally at intervals of 5 to 7 months.

[0016] In the present invention, the composition may be characterized by being administered to a patient receiving bone fusion treatment diagnosed with osteopenia or osteoporosis.

[0017] The present invention also aims to provide a composition for suppressing therapeutic side effects caused by bone morphogenetic protein type 2 (BMP-2), comprising denosumab as an active ingredient.

[0018] In the present invention, the treatment with the type 2 bone morphogenetic protein (BMP-2) may be characterized as a bone fusion procedure involving the transplantation of the type 2 bone morphogenetic protein.

[0019] As in the present invention, when type II bone morphogenetic protein and denosumab are used in combination during bone fusion, side effects such as osteolysis, inflammation, wound dehiscence, and bleeding that frequently occur due to bone fusion can be effectively prevented and treated.

[0020]

[0021] Figure 1 illustrates the process of filling a posterior lumbar intra-trunk cage with rhBMP-2 for spinal fusion. (A) Prepare rhBMP-2 powder contained in a vial by dissolving it in a provided solution and drawing it out with a syringe; (B) apply rhBMP-2 to hydroxyapatite (HA) granules (Novosis, CGBio Co., Ltd., Seoul, Korea); and (C) fill the intra-trunk cage with HA granules soaked in rhBMP-2 and autologous bone from a laminectomy. rhBMP-2: Recombinant human bone morphogenetic protein type II.

[0022] Figure 2 shows a flowchart of the patient inclusion and propensity score matching (PSM) strategy. A total of 251 patients with reduced bone density underwent PLIF (posterior lumbar interbody fusion), of which 100 patients were selected by PSM and 50 were included in each treatment group.

[0023] Figure 3 shows radiological examples of complications that occurred after intra-trunk cage insertion using rhBMP-2. (A) Osteolysis (white arrow). (B) Subsidence (yellow arrow). (C) Osteolysis and subsidence occurring 1 year after surgery.

[0024] Figure 4 shows the results of comparing bone metabolic status after rhBMP-2 and denosumab treatment. Both groups demonstrated successful vertebral fusion (A), and there was no statistically significant difference in terms of subsidence (B). However, a statistically significant difference was observed in the occurrence of osteolysis (C). *p < 0.05

[0025] Figure 5 shows the cumulative incidence of postoperative bleeding in combination with denosumab and rhBMP-2 versus rhBMP-2 alone. In the survival analysis, the two groups showed a statistically significant difference in the incidence of postoperative bleeding. That is, the group treated with denosumab and rhBMP-2 showed a significant association with reduced postoperative bleeding compared to the group treated with rhBMP-2 alone.

[0026]

[0027] Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by a skilled expert in the art to which this invention pertains. In general, the nomenclature used herein is well known and commonly used in the art.

[0028]

[0029] In the numerical ranges described in this specification, “to” is used to mean including both threshold ranges (greater than or equal to and less than), and when not including both threshold ranges, the numerical range is described as “greater than” and “less than.” In this specification, the term “about” used for numerical values ​​is used to mean a range that is expected to produce an effect substantially equivalent to the stated numerical value by a person skilled in the art; for example, it may be ±20%, ±10%, ±5%, etc. of the stated numerical value, but is not limited thereto.

[0030]

[0031] In this invention, it was confirmed that combination therapy with rhBMP-2 and denosumab can significantly reduce the risk of complications induced by rhBMP-2 in osteoporotic patients who have undergone posterior lumbar interbody fusion (PLIF). Specifically, although there was no significant difference in PLIF fusion rates between patients administered rhBMP-2 and denosumab in combination and those administered only rhBMP-2, it was confirmed that during the PLIF process, the incidence of osteolysis was significantly reduced in patients administered rhBMP-2 and denosumab in combination compared to those administered only rhBMP-2, and that inflammatory cascades, wound dehiscence, and oozing events could be effectively managed.

[0032]

[0033] Accordingly, in one aspect, the present invention relates to a composition comprising type 2 bone morphogenetic protein (BMP-2) and denosumab as active ingredients.

[0034] In the present invention, the composition may be a pharmaceutical composition for bone fusion, and preferably, may be a pharmaceutical composition for assisting in bone fusion treatment or a pharmaceutical composition for preventing or treating side effects or complications associated with bone fusion treatment.

[0035] The composition of the present invention can be applied to individuals requiring arthrodesis treatment. Arthrodesis refers to a surgical procedure in which two or more bones or joints are intentionally fixed and fused into one. It is primarily performed to reduce severe pain caused by arthritis or trauma, and to provide stability in cases where functional recovery of the joint is difficult due to fractures or other conditions. Arthrodesis can be applied to improve fractures or instability in the spine, wrists, ankles, fingers, etc., but is not limited thereto.

[0036] In one embodiment, the composition of the present invention may be used when a fracture occurs in a specific part of the body, and may be applied, for example, to the treatment of fusion for vertebral fractures. Vertebral fractures include, but are not limited to, vertebral fractures caused by various factors such as traumatic vertebral fractures or compression fractures due to osteoporosis.

[0037] In another embodiment, the composition of the present invention may be used in cases where bone fusion is required due to instability in a body part or specific part of the body that requires long-term support and fusion, for example, in cases where bone fusion is required due to spinal instability. Spinal instability may be caused by degenerative changes, weakening of ligaments or muscles, etc., but is not limited thereto.

[0038] In another aspect, the present invention may be used in cases where neuropathic pain occurs due to spinal stenosis, for example, when pain is induced by nerve compression caused by stenosis of the intervertebral foramen. In such cases, posterior spinal decompression may be necessary to alleviate pain, and additional measures to ensure nerve decompression and stability, such as intervertebral foramen expansion or pedicle screw fixation, may be required depending on the circumstances. In such situations, stabilization of the spine through intervertebral fusion is essential, and the application of the composition of the present invention in such fusion surgery is desirable.

[0039] Indications for bone fusion surgery include any condition in which the structure of bones or joints is damaged, weakened, or unstable, such as, for example, spinal degenerative disease, scoliosis, spinal deformity, fractures caused by trauma, arthritis, joint instability, structural damage to bones or joints due to infectious diseases, or structural damage to bones or joints due to tumors, but are not limited thereto.

[0040] As a specific embodiment, the bone fusion may preferably be spinal fusion, e.g., posterior lumbar interbody fusion (PLIF), but is not limited thereto.

[0041] In the present invention, the Bone Morphogenetic Protein-2 (BMP-2) is a protein belonging to the Transforming Growth Factor-Beta (TGF-β) family that promotes the formation and regeneration of bone and cartilage. BMP-2 is known to play a significant role primarily in the process of bone and cartilage formation. BMP-2 provides osteoinductive signals to induce stem cells to differentiate into osteoblasts, thereby promoting bone regeneration and bone fusion. BMP-2 is mainly used as a bone graft substitute or in orthopedic surgeries such as spinal fusion, and Infuse® is a commercially available pharmaceutical product. However, when BMP-2 is used in bone fusion surgery, side effects such as inflammation and bleeding may occur.

[0042] In the present invention, the type 2 bone-forming protein can be implanted in orthopedic fields such as osteofusion through various biomaterial carriers (metals, ceramics, polymers, composites) and delivery systems (hydrogels, microspheres, nanoparticles, fibers).

[0043] In the present invention, the type 2 bone-forming protein can be used to promote bone formation and enhance recovery in lumbar intervertebral fusion or open fractures (e.g., tibial fractures).

[0044] In one embodiment, the type 2 bone morphogenetic protein may be a recombinant type 2 bone morphogenetic protein (rBMP-2), and preferably a recombinant type 2 bone morphogenetic protein (rhBMP-2) derived from a human.

[0045] In the present invention, denosumab is a monoclonal antibody that targets RANKL and blocks the binding of RANKL to RANK (a receptor on the surface of osteoclasts) to prevent the activation of osteoclasts. Denosumab is mainly sold as a treatment for osteoporosis under the trade names Prolia® and Xgeva®, and side effects such as hypocalcemia, skin disorders, gastrointestinal disorders, bone pain, bleeding, delayed wound healing, and inflammation have been reported.

[0046] In the present invention, the type 2 bone-forming protein may be administered locally to the bone fusion site, and the denosumab may be administered systemically.

[0047] In a preferred embodiment, the type 2 bone morphogenetic protein may be mixed with hydroxyapatite and autogenous bone and locally implanted at the surgical site, but the method of application of the type 2 bone morphogenetic protein is not limited thereto.

[0048] In a preferred embodiment, the denosumab may be administered systemically, for example, by subcutaneous injection. The denosumab may be administered once within one week before or after bone fusion, or administered once within one week before or after bone fusion and then repeated 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10 times at intervals of 5 to 7 months.

[0049] The above-mentioned type 2 bone morphogenetic protein and the above-mentioned denosumab may be administered simultaneously, separately, or sequentially. The above-mentioned type 2 bone morphogenetic protein and the above-mentioned denosumab may be manufactured as separate drugs and may also be provided in the form of a kit containing all of them. In this case, the kit may enclose instructions explaining the dosage and method of administration for each drug.

[0050] The above pharmaceutical composition is administered in a pharmaceutically effective amount. The term "pharmaceutically effective amount" means an amount sufficient to treat a disease with a reasonable benefit / risk ratio applicable to medical treatment, and the effective dose level may be determined based on factors including the type and severity of the patient's disease, drug activity, sensitivity to the drug, time of administration, route of administration and elimination rate, duration of treatment, concurrently used drugs, and other factors well known in the medical field.

[0051] Specifically, type 2 bone morphogenetic protein (BMP-2) may be administered topically once in any range of about 0.5 mg to about 6 mg, for example, in a dose of about 0.5 mg to about 5.5 mg, about 0.5 mg to about 5 mg, about 0.5 mg to about 4.5 mg, about 0.5 mg to about 4.0 mg, about 0.5 mg to about 3.5 mg, about 0.5 mg to about 3.0 mg, about 0.5 mg to about 2.5 mg, about 0.5 mg to about 2.0 mg, about 0.5 mg to about 1.5 mg, or about 0.5 mg to about 1.0 mg.

[0052] Meanwhile, the effective dose of hydroxyapatite and autogenous bone administered mixed with the above-mentioned type 2 bone morphogenetic protein can be easily determined by a clinician according to the manufacturer's (supplier's) guidelines to suit the patient's application site.

[0053] Meanwhile, denosumab may be initially administered within one week before or after bone fusion surgery in any range of about 60 mg to about 120 mg, and subsequently administered at intervals of 5 to 7 months.

[0054] For example, denosumab may be administered in a single dose of about 60 mg to about 110 mg, about 60 mg to about 100 mg, about 60 mg to about 90 mg, about 60 mg to about 80 mg, or about 60 mg to about 70 mg, and preferably in a single dose of about 60 mg.

[0055] Denosumab is initially administered within approximately one week before or after the day of bone fusion surgery, and may be additionally administered at intervals of approximately 5 to 7 months, for example, about 6 months. However, if the date of administration of denosumab is postponed, it may be additionally administered at intervals of approximately 5 to 7 months, for example, about 6 months, based on the date of the final administration.

[0056] In a specific embodiment, the pharmaceutical composition of the present invention may be applied in a manner in which a type 2 bone morphogenetic protein (e.g., rhBMP-2) is applied topically using a cage to an individual undergoing bone fusion treatment, and denosumab is administered subcutaneously systemically.

[0057] The cage used for bone fusion in the present invention is made of a biocompatible material such as titanium or PEEK (polyetheretherketone) and can be inserted into the spine in an anterior or posterior insertion manner.

[0058] The cages available for use in the present invention include TLIF (Transforaminal Lumbar Interbody Fusion) cages, PLIF (Posterior Lumbar Interbody Fusion) cages, and ALIF (Anterior Lumbar Interbody Fusion) cages, but are not limited thereto.

[0059] The composition according to the present invention may be characterized by preventing or treating complications associated with bone fusion surgery, and

[0060] For example, following bone fusion

[0061] (i) reduction in osteolysis and / or

[0062] (ii) It may be characterized by reducing the occurrence and / or persistence of inflammation, wounds and / or bleeding.

[0063] Although not limited thereto, the above composition may be characterized by being administered to a patient diagnosed with osteoporosis who is undergoing osteofusion treatment.

[0064] In one embodiment, the above composition is preferably administered to a patient diagnosed with a bone mineral density (BMD) of about -1.0 or less, preferably -2.5 or less. Patients diagnosed with a BMD between -1.0 and -2.5 are classified as having osteopenia according to World Health Organization (WHO) standards, and in particular, a BMD of -2.5 or less indicates osteoporosis, and a BMD of -3.0 or less indicates severe osteoporosis, which tends to increase the risk of complications such as osteolysis and nonunion after bone fusion surgery.

[0065] Therefore, the target of application of this composition may be patients with osteopenia with a BMD of -1.0 or lower, and the effect may be more pronounced when applied to patients with osteoporosis with a BMD of -2.5 or lower or -3.0 or lower.

[0066] In the present invention, "pharmaceutical composition" means that it is prepared for the purpose of preventing or treating a disease, and can be used by being formulated into various forms according to conventional methods. For example, it can be formulated into oral formulations such as powders, granules, tablets, capsules, suspensions, emulsions, and syrups, and can be used by being formulated into external preparations, suppositories, and sterile injectable solutions.

[0067] The term "prevention" as used in the present invention may refer to any act of suppressing or delaying the onset of a disease, condition, or symptom of an individual by administering a pharmaceutical composition according to one embodiment.

[0068] The term "treatment" may refer to any act in which symptoms of an individual's disease or condition are improved or beneficially altered by the administration of a pharmaceutical composition according to one embodiment.

[0069] The above pharmaceutical composition may be provided as a pharmaceutical composition comprising an active ingredient alone, or comprising one or more pharmaceutically acceptable carriers, excipients, or diluents.

[0070] Specifically, the carrier may be, for example, a colloidal suspension, powder, saline solution, lipid, liposome, microsphere, or nano-spherical particle. These may form a complex with or be associated with a transport means and may be transported in vivo using a transport system known in the art, such as lipids, liposomes, microparticles, gold, nanoparticles, polymers, condensation agents, polysaccharides, polyamino acids, dendrimers, saponins, adsorption-enhancing substances, or fatty acids.

[0071] When the above pharmaceutical composition is formulated, it may be prepared using diluents or excipients such as commonly used lubricants, sweeteners, flavorings, emulsifiers, suspending agents, preservatives, fillers, volume expanders, binders, wetting agents, disintegrants, and surfactants. Solid dosage forms for oral administration may include tablets, pills, powders, granules, capsules, etc., and these solid dosage forms may be prepared by mixing at least one excipient, for example, starch, calcium carbonate, sucrose or lactose, gelatin, etc., with the above composition. In addition, lubricants such as magnesium stearate and talc may also be used in addition to simple excipients. Liquid formulations for oral administration include suspensions, oral liquids, emulsions, syrups, etc., and may contain various excipients, such as humectants, sweeteners, flavorings, and preservatives, in addition to commonly used simple diluents like water and liquid paraffin. Formulations for parenteral administration may include sterile aqueous solutions, non-aqueous solvents, suspensions, emulsions, lyophilized formulations, and suppositories. Propylene glycol, polyethylene glycol, vegetable oils such as olive oil, and injectable esters such as ethyl oleate may be used as non-aqueous solvents and suspensions. Witepsol, macrogol, Tween 61, cacao oil, laurin oil, glycerogelatin, etc. may be used as bases for suppositories, and known diluents or excipients may be used when manufactured in the form of ophthalmic preparations.

[0072] The term "administration" refers to the introduction of a specific substance into an individual by an appropriate method, and "individual" refers to all living organisms capable of bone fusion surgery, including humans, rats, mice, livestock (cattle, sheep, horses, pigs), dogs, and cats. Specific examples may include mammals, including humans.

[0073] In one embodiment, the route of administration of the pharmaceutical composition is not limited to but includes external application to the skin, oral, intravenous, intramuscular, thoracic, intra-arterial, intramedullary, intradural, intracardiac, transdermal, subcutaneous, intraperitoneal, intranasal, intestinal, local, sublingual, or rectal.

[0074] In another aspect, the present invention relates to the combination use of the type 2 bone morphogenetic protein (BMP-2) and denosumab.

[0075] In another aspect, the present invention relates to the use of the combination of the type 2 bone morphogenetic protein (BMP-2) and denosumab, specifically, use in the treatment of bone fusion, preferably use in the treatment of indications where bone fusion is applied, more preferably use in assisting the treatment of bone fusion, or use in preventing or treating side effects or complications associated with bone fusion.

[0076] In another aspect, the present invention relates to a method for treating bone fusion, comprising the step of administering the type 2 bone morphogenetic protein (BMP-2) and denosumab to an individual in need thereof, preferably a method for treating an indication to which bone fusion is applied, more preferably a method for assisting in the treatment of bone fusion, or a method for preventing or treating side effects or complications associated with bone fusion.

[0077] In another aspect, the present invention relates to the use of the type 2 bone morphogenetic protein (BMP-2) and denosumab in the manufacture of a drug for the treatment of bone fusion, preferably for the treatment of indications to which bone fusion is applied, more preferably for the treatment of bone fusion, or for the prevention or treatment of side effects or complications associated with bone fusion.

[0078] The above-mentioned type 2 bone morphogenetic protein (BMP-2) and denosumab can be manufactured as separate drugs.

[0079]

[0080] In this invention, it was confirmed that the combined use of type 2 bone morphogenetic protein and denosumab can reduce bone-related complications and positively promote healing effects in osteoporotic patients undergoing PLIF. In particular, this invention can help reduce the risk of nonunion and promote a healthier healing process in patients with low bone mineral density (BMD), such as those with osteoporosis.

[0081]

[0082] The present invention offers the additional advantage of reducing the incidence of osteolysis by using denosumab in combination with type II osteomorphic protein. Osteolysis is a major complication of spinal fusion surgery that can lead to implant failure and require reoperation; this is a well-known side effect of type II osteomorphic protein, and the present invention confirms that it can be effectively managed by using it in combination with denosumab.

[0083] Interestingly, while inflammatory reactions and bleeding are known to be infrequent side effects of denosumab, it has been confirmed that inflammation, wound dehiscence, and bleeding reactions can be effectively managed when denosumab is administered in combination with type 2 osteomorphic protein during bone fusion surgery.

[0084] Consequently, the use of denosumab in combination with type 2 bone morphogenetic protein can improve the outcome of bone fusion surgery and minimize the need for reoperation.

[0085] For reference, the expected synergistic effects were not observed when existing drugs, such as teriparatide, bisphosphonates, or selective estrogen receptor modulators, were applied to spinal fusion in combination with type II osteomorphic protein. Specifically, while teriparatide and bisphosphonates are known to increase bone density, their combined use with spinal fusion did not clearly demonstrate an effect in suppressing complications during the bone fusion process. For instance, although teriparatide promotes bone formation, it does not inhibit osteoclast activation, which limits its ability to reduce osteolysis caused by the side effects of type II osteomorphic protein; similarly, bisphosphonates did not demonstrate sufficient efficacy in the progression of bone fusion.

[0086] On the other hand, the combined administration of the type II bone morphogenetic protein and denosumab, which is the composition of the present invention, reduced osteolysis by effectively inhibiting osteoclast activity through RANKL inhibition, while maintaining the potent osteogenic effect of the type II bone morphogenetic protein during the spinal fusion process. In addition, this combination was found to have the additional benefit of managing complications such as inflammatory responses and hemorrhage. These research results indicate that the combination of type II bone morphogenetic protein and denosumab can produce synergistic effects that cannot be achieved with combinations of existing drugs.

[0087] Accordingly, in another aspect, the present invention relates to a pharmaceutical composition for suppressing side effects caused by type 2 bone morphogenetic protein therapy comprising denosumab as an active ingredient.

[0088] In the present invention, denosumab can treat, alleviate, and / or prevent side effects (e.g., (i) osteolysis and / or (ii) the occurrence and / or persistence of inflammation, wounds, and / or bleeding) that occur during orthopedic treatment using type 2 bone morphogenetic protein.

[0089] In another aspect, the present invention relates to the use of denosumab for suppressing side effects caused by treatment using a type 2 bone morphogenetic protein.

[0090] In another aspect, the present invention relates to a method for suppressing side effects caused by treatment using a type 2 bone morphogenetic protein, comprising the step of administering denosumab to an individual in need thereof.

[0091] In another aspect, the present invention relates to the use of denosumab for the manufacture of a drug for suppressing side effects caused by treatment using type 2 bone morphogenetic protein.

[0092] In the present invention, the treatment using the Type II bone morphogenetic protein may be, but is not limited to, a treatment for an indication for which the use of the Type II bone morphogenetic protein is clinically approved, and such indications are obvious to a person skilled in the art. Unless otherwise defined, technical and scientific terms used in the present invention have the meaning generally understood by a person of ordinary knowledge in the technical field to which this invention belongs. Furthermore, repetitive descriptions of technical configurations and functions identical to those of the prior art are to be omitted.

[0093] Furthermore, the present invention provides a method for treating a disease characterized by administering a pharmaceutical composition according to the present invention to a subject requiring treatment, and additionally provides a use of the pharmaceutical composition according to the present invention for manufacturing a drug for treating a disease. In the present invention, the detailed description of the therapeutic use, the treatment method, and the use for manufacturing a drug is the same as the detailed description of the composition, unless they are mutually contradictory.

[0094]

[0095] Examples

[0096]

[0097] The present invention will be described in more detail below through examples. These examples are intended solely to illustrate the present invention, and it will be obvious to those skilled in the art that the scope of the present invention is not to be interpreted as being limited by these examples.

[0098]

[0099] 1. Patient

[0100] This study was conducted on patients who received PLIF to treat spinal conditions, such as spinal stenosis and spinal instability, from 2017 to 2021. This study was approved by the Institutional Review Board (IRB) of Yonsei University College of Medicine (IRB No.: 1-2022-0032), and the submission of written informed consent was waived due to the retrospective nature of the study. During PLIF, 0.5 mg of recombinant human bone morphogenetic protein type II rhBMP-2 (INFUSE®Graft / or NOVOSIS, Medtronic / or CGBio Co. Ltd) was soaked in a dose of hydroxyapatite (Novosis®CGBio Co., Ltd.) appropriate for the surgical site and mixed with the necessary amount of autologous bone harvested from the patient's laminectomy site. The mixture was then placed into an interbody cage (CAPSTONE®Spinal System / or Lumfix, Medtronic / or CGbio), and the cage was inserted into the intervertebral space, thereby ensuring a single local administration of rhBMP-2 to the surgical site (Fig. 1). Denosumab was initiated during the postoperative hospitalization prior to discharge and administered every six months during the follow-up period. Denosumab (Prolia ®Pre-filled syringe (AMGEN) was administered as a 1-syringe (60 mg) by subcutaneous injection into the upper arm, upper thigh, or abdomen every 6 months after the onset of surgery. If the regular dose was missed, it was administered as soon as possible, and thereafter, subcutaneous injections were given every 6 months starting from the last dose date.

[0101] Inclusion criteria were patients who had undergone PLIF and possessed clinical and radiological data capable of evaluating observable union status (sinking, nonunion, osteolysis). This data was measured using CT scans and X-ray images at one year post-surgery. Patients with a history of previous spinal surgery or re-surgery, or those with major comorbidities that could affect bone healing, such as rheumatoid arthritis, tumors, or severe trauma, were excluded from the study.

[0102]

[0103] 2. Data Collection

[0104] Clinical and radiological data were collected from electronic medical records and radiology reports. Information on each patient's age, sex, body mass index (BMI), baseline BMD, and postoperative clinical outcomes (lumbar flexion-extension range of motion, settlement, etc.) was collected. Settlement was defined as a disc height loss of 2 mm or more at the fusion level, and non-fusion was defined as a slip angle of 4 degrees or more at the surgical site on dynamic flexion-extension lateral radiographs. Regarding surgery and the administration of rhBMP-2 or denosumab, all patients underwent a Level 1 PLIF procedure involving the insertion of a lumbar cage containing local rhBMP-2. Additionally, some patients received systemic denosumab treatment. The decision to administer denosumab was at the discretion of the attending surgeon and was not included in the standardized protocol. Propensity score matching (PSM) analysis was performed to account for potential confounding effects due to baseline differences in age, sex, and BMD. The propensity score for each patient was determined using a logistic regression model with age, sex, and BMD as predictors. Patients who received rhBMP-2 and denosumab were matched with patients who received only rhBMP-2 using a 1:1 nearest neighbor matching algorithm and a caliper width of 0.1. In the present invention, 50 patients (denosumab, n=50; non-denosumab, n=50) were matched and analyzed (Fig. 2).

[0105] The primary outcome measure was union status, evaluated via radiographic analysis of lumbar flexion-extension range of motion and settlement. Secondary outcome measures included clinical outcomes such as postoperative osteolysis and pain. Complications such as osteolysis were defined as the unexpected pathological loss or dissolution of bone tissue adjacent to the trunk cage in relation to rhBMP-2 administration (Fig. 3), and wound effusion was defined as the need for dressing changes more than twice a day prior to discharge. This commonly occurs when there is inflammation beneath the wound site.

[0106]

[0107] 3. Statistical Analysis

[0108] Continuous variables were expressed as means and standard deviations, while categorical variables were expressed as frequencies and percentages. When data did not follow a normal distribution or variances were unequal between groups, the Mann-Whitney U test was used to compare the medians of the two independent groups. Differences in baseline characteristics between groups were analyzed for categorical variables using the chi-square test. Union rate, settlement, and osteolysis rate were compared using the chi-square test. A Cox proportional hazards regression model was used to identify risk factors for complications. The primary outcome of interest was event-free survival, defined as the time to effusion after surgery. For patients without complications, the follow-up period was calculated at the time of the last outpatient visit. The proportional hazards assumption of the model was verified by examining Kaplan-Meier survival curves. All statistical analyses were performed using IBM SPSS Statistics version 23.0 (IBM Co., Armonk, NY, USA), and statistical significance was set at p<0.05.

[0109]

[0110] 4. Effects of combination therapy

[0111] The baseline demographic characteristics of the two groups are shown in Table 1. The mean age of patients in the rhBMP-2 monotherapy group was 65.6 ± 6.9 years, while in the rhBMP-2 + denosumab group it was 68.6 ± 8.7 years. The age difference between the two groups was not statistically significant (p = 0.272). There was no significant difference in the gender distribution, and the majority of patients were female. The follow-up period was an average of 16.6 ± 3.3 months for patients treated with rhBMP-2 and 16.2 ± 3.4 months for patients treated with rhBMP-2 + denosumab, with no significant difference between the two groups (p = 0.419). There were also no significant differences in BMI and BMD T-scores.

[0112]

[0113]

[0114]

[0115] Spinal mobility was evaluated through flexion and extension measurements. There were no significant differences in flexion or extension between the two groups (p = 0.808 and p = 0.846, respectively). There were also no significant differences in spinal mobility between the two groups (p = 0.357). The fusion status was similar between the two groups, and the number of patients who achieved successful fusion was similar (Fig. 4A). Although the incidence of subsidence was lower in the rhBMP-2 monotherapy group than in the rhBMP-2 + denosumab group (Fig. 4B), this difference was not statistically significant (p = 0.100). However, the incidence of osteolysis was significantly lower in the rhBMP-2 + denosumab group than in the rhBMP-2 monotherapy group (p = 0.013) (Fig. 4C).

[0116]

[0117] Postoperative leg visual analog scale (VAS) scores were similar between the two groups. At 1 year postoperatively, the mean VAS for patients treated with rhBMP-2 was 2.1 ± 1.2, and for patients treated with rhBMP-2 + denosumab was 1.7 ± 1.8 (p = 0.323). At 2 years postoperatively, the mean VAS for the rhBMP-2 group was 2.8 ± 1.6, and for the rhBMP-2 + denosumab group was 2.3 ± 1.5 (p = 0.537) (Table 2).

[0118]

[0119]

[0120]

[0121] Survival analysis revealed a significant difference in the incidence and duration of postoperative bleeding between the rhBMP-2 monotherapy group and the group treated with the combination of rhBMP-2 and denosumab (p = 0.014). The combination of rhBMP-2 and denosumab effectively reduced the incidence and duration of postoperative bleeding. The duration of denosumab use and the degree of bleeding and osteolysis were not statistically significant (Fig. 5).

[0122]

[0123] Foregoing, specific parts of the present invention have been described in detail. It will be apparent to those skilled in the art that such specific descriptions are merely preferred embodiments and do not limit the scope of the invention. Accordingly, the actual scope of the invention is defined by the appended claims and their equivalents.

[0124]

[0125] National R&D project that supported this invention

[0126] [Project ID] 2800000003

[0127] [Project No.] 00233632 (RS-2023-00233632)

[0128] [Ministry Name] Ministry of Science and ICT

[0129] [Name of Project Management (Specialized) Agency] National Research Foundation of Korea

[0130] [Research Project Name] Foundation for International Cooperation (R&D)

[0131] [Research Project Title] Artificial Intelligence Algorithm for Assisting Central Nervous System Endoscopic Surgery in Neurosurgery

[0132] development

[0133] [Name of Project Performing Organization] Eulji University Industry-Academic Cooperation Foundation

[0134] [Research Period] 2023.10.01 ~ 2026.09.30

[0135] National R&D project that supported this invention

[0136] [Project ID] 2710001826

[0137] [Project No.] 00225555 (RS-2023-00225555)

[0138] [Ministry Name] Ministry of Science and ICT

[0139] [Name of Project Management (Specialized) Agency] National Research Foundation of Korea

[0140] [Research Project Name] Bio-Medical Technology Development (R&D)

[0141] [Research Project Title] Regeneration of intractable spinal ligament diseases through regulation of intrinsic stem cell differentiation

[0142] Development of bio-based technologies

[0143] [Name of Project Performing Organization] Ulsan National Institute of Science and Technology

[0144] [Research Period] April 1, 2023 ~ December 31, 2027

Claims

1. A pharmaceutical composition for adjuvant treatment of bone fusion, comprising type 2 bone morphogenetic protein (BMP-2) and denosumab as active ingredients.

2. A pharmaceutical composition for adjuvant treatment of bone fusion according to claim 1, characterized in that the type 2 bone morphogenetic protein is administered locally to the bone fusion site and the denosumab is administered systemically.

3. In Paragraph 2, A pharmaceutical composition for adjuvant treatment of bone fusion, characterized in that the above-mentioned type 2 bone morphogenetic protein is mixed with hydroxyapatite and autogenous bone and locally implanted at the surgical site.

4. A pharmaceutical composition for adjuvant treatment of bone fusion surgery, characterized in that, in paragraph 2, the denosumab is administered systemically by subcutaneous injection.

5. A pharmaceutical composition for assisting in the treatment of bone fusion, wherein, in claim 1, the composition prevents or treats complications associated with bone fusion.

6. In paragraph 5, the above composition is according to bone fusion surgery (i) reduction in osteolysis; and / or (ii) A pharmaceutical composition for adjuvant treatment of bone fusion, characterized by reducing the occurrence and / or persistence of inflammation, wound and / or bleeding.

7. A pharmaceutical composition for adjuvant treatment of bone fusion, characterized in that, in claim 1, the type 2 bone morphogenetic protein (BMP-2) is administered topically once at a dose of 0.5 mg to 6 mg.

8. A pharmaceutical composition for adjuvant treatment of bone fusion according to claim 1, wherein the denosumab is initially administered at a dose of 60 mg within one week before or after bone fusion, and subsequently administered additionally at intervals of 5 to 7 months.

9. A pharmaceutical composition for adjuvant bone fusion treatment according to claim 1, characterized in that the composition is administered to a patient undergoing bone fusion treatment diagnosed with osteopenia or osteoporosis.

10. A composition for suppressing therapeutic side effects caused by bone morphogenetic protein type 2 (BMP-2), comprising denosumab as an active ingredient.

11. A composition for suppressing side effects of treatment by type 2 bone morphogenetic protein (BMP-2), characterized in that, in claim 10, the treatment by the type 2 bone morphogenetic protein (BMP-2) is a bone fusion surgery involving the transplantation of the type 2 bone morphogenetic protein.

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