Methods, treatments, and systems for delaying conversion to advanced age-related macular degeneration (AMD)

Abstract

The present disclosure provides methods and systems for treating and delaying progression of age-related macular degeneration (AMD) in patients in need thereof.

Description

Attorney Docket No.: CUR-00225Methods, Treatments, and Systems for Delaying Conversion to Advanced Age-related Macular Degeneration (AMD)CROSS-REFERENCE TO RELATED APPLICATION

[0001] This application claims the benefit of priority to U.S. Provisional Application No.: 63 / 762,873, filed on February 25, 2025, the entire content of which is hereby incorporated by reference.GOVERNMENT SUPPORT

[0002] This invention was made with government support under R01EY032456 awarded by the National Eye Institute of the National Institutes of Health and also with government support under UL1 TR002535 awarded by NIH / NCATS to Colorado CTSA. The government has certain rights in the invention.BACKGROUND

[0003] Age-related macular degeneration (AMD), a chronic multifactorial progressive disease affecting the macula region of the retina and specifically the photoreceptor support system, is a leading cause of vision loss in the elderly. It is projected that AMD will impact 288 million people worldwide by 2040. A hallmark feature of AMD is the presence of extracellular deposits called drusen between the basal surface of the Retinal Pigment Epithelium (RPE) and Bruch’s membrane in the macula. AMD can be classified into early, intermediate, and advanced AMD. The early / intermediate stages are characterized by increasing drusen size and pigmentary changes in the macula. There are two forms of advanced AMD, neovascular (NVAMD), distinguished by abnormal growth of choroidal blood vessels and geographic atrophy (GA), characterized by areas of atrophy of the photoreceptors, RPE cells, and choriocapillaris. Epidemiological risk factors related to AMD include age and cigarette smoking. Besides age, genetic background is often a significant non-modifiable risk factor for all stages of AMD, while smoking often is the most significant modifiable risk factor.

[0004] However, to date there have been no identifiable methods or biomarkers to identify patients at stages where interventional therapies can stabilize or rescue their vision before progression of AMD to advanced disease. There is a large need in the field for such methods and interventions.SUMMARY

[0005] In an aspect, the present disclosure provides a method of diagnosing an intermediate age-related macular degeneration (iAMD) patient as having a high risk of progression from iAMD to 1FH13302894.9Attorney Docket No.: CUR-00225advanced AMD comprising (a) obtaining a first plasma sample from the iAMD patient at a first timepoint, (b) obtaining at least one successive plasma sample from the iAMD patient at a successive timepoint, (c) comparing the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the at least one successive plasma sample, and (d) determining that the iAMD patient has a high risk of progression from iAMD to advanced AMD if the level of any one of or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the at least one successive plasma sample is elevated compared to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample.

[0006] In some embodiments, each of the at least one successive plasma sample is obtained from the iAMD patient at a timepoint later than the first timepoint. In some embodiments, the at least one successive plasma sample comprises from 1 to 20 successive plasma samples. In some embodiments, the successive plasma samples are obtained at a regular interval after the first timepoint. In some embodiments, the regular interval is from 1 day to 5 years.

[0007] In some embodiments, the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the at least one successive plasma sample is associated with a shorter time of progression to advanced AMD using a hazard ratio for each of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0008] In some embodiments, the hazard ratio for C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 is greater than 1.

[0009] In an aspect, the present disclosure provides a method of treating age-related macular degeneration (AMD) comprising (a) obtaining a first plasma sample from an iAMD patient at a first timepoint and a second plasma sample from the iAMD patient at a second timepoint, (b) measuring the level of at least one systemic complement factor and / or at least one ratio of systemic complement factors in the first plasma sample and in the second plasma sample, (c) identifying the patient as having an elevated risk of progressing from iAMD to advanced AMD, and (d) administering at least one inhibitor of complement activation to the patient if the patient is identified as having an elevated risk of progressing from iAMD to advanced AMD, wherein the second timepoint is later than the first timepoint, and wherein the at least one systemic complement factor is selected from the list consisting of C4 and C4b and the at least one ratio of systemic complement factors is selected from the list consisting of C3a / C3, C5a / C5, and sC5b-9 / C5.

[0010] In some embodiments, the identifying comprises (a) comparing the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the second plasma sample,2FH13302894.9Attorney Docket No.: CUR-00225and (b) determining that the patient has an elevated risk of progressing from iAMD to advanced AMD if the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is elevated in the second plasma sample compared to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample.

[0011] In some embodiments, the administering delays progression from iAMD to advanced AMD in the iAMD patient. In some embodiments, the administering is systemic, ophthalmic, or a combination thereof. In some embodiments, the administering is systemic.

[0012] In some embodiments, the inhibitor of complement activation targets any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5. In some embodiments, the inhibitor of complement activation is Lampalizumab, Tesidolumab, CLG561, POT4 (AL-78898A), cemdisiran, Berinert, Cinryze, Ruconest, Enjaymo (Sutimlimab), Soliris (Eculizumab), Ultomiris (Ravulizumab), Zilbrysq (Zilucoplan), Veopoz (Pozelimab), Izervay (Avacincaptad Pegol), Tavneos (Avacopan), Fabhalta (Iptacopan), Voydeya (Danicopan), Pegcetacoplan (Empaveli, or Syfovre for injection), Crovalimab, Iptacopan (Fabhalta), Danicopan (Voydeya), Avacopan (Tavneos), Narsoplimab (OMS721), AMY-101, LNP023, or ANX005.

[0013] In some embodiments, the method comprises administering a second therapeutic agent. In some embodiments, the second timepoint is from 1 day to 5 years after the first timepoint.

[0014] In some embodiments, the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the second plasma sample is associated with a shorter time of progression to advanced AMD using a hazard ratio for each of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0015] In some embodiments, the hazard ratio for C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 is greater than 1.

[0016] In an aspect, the present disclosure provides a method of diagnosing an iAMD patient having a high risk of progression from iAMD to advanced AMD comprising (a) obtaining a plasma sample from the iAMD patient, (b) measuring the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the plasma sample, (c) comparing the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the plasma sample to a reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5, and (d) determining that the iAMD patient has a high risk of progression from iAMD to advanced AMD if the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the plasma sample is elevated compared to a reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0017] In some embodiments, the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is established from a cohort of reference AMD patients.3FH13302894.9Attorney Docket No.: CUR-00225

[0018] In some embodiments, the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 100% greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0019] In some embodiments, the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 50% greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0020] In some embodiments, the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 25% greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0021] In some embodiments, the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 10% greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0022] In an aspect, the present disclosure provides a kit for assessing risk of progression from iAMD to advanced AMD in a subject comprising: reagents and instructions for measuring the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in a first plasma sample and the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in a second plasma sample; and instructions providing criteria for classifying the subject as at risk for progressing from iAMD to advanced AMD.BRIEF DESCRIPTION OF THE DRAWINGS

[0023] For a better understanding of the invention, reference may be made to embodiments shown in the following drawings. The components in the drawings are not necessarily to scale and related elements may be omitted, or in some instances proportions may have been exaggerated, so as to emphasize and clearly illustrate the novel features described herein. In addition, system components can be variously arranged, as is known in the art.

[0024] FIG. 1 is a schematic showing the classic, lectin, and alternative complement pathways. These three pathways are activated differently but all connect at the central point C3. The three pathways are interrelated by the action of the alternative pathway as an amplification loop for the classical and lectin pathways. After C3, the complement system enters the terminal pathway, culminating in the membrane attached complex (also known as C5b-9). As activation flows through the cascade, the components are cleaved yielding activation fragments that are released into circulation. The complement factors measured as part of this study are underlined.4FH13302894.9Attorney Docket No.: CUR-00225

[0025] FIGs.2A-C are tables and graphs showing relationships between complement biomarkers and time to progression to advanced AMD. FIG.2A is a table showing hazard ratios of time to progression to any advanced AMD from joint models fit to each biomarker separately. FIG.2B are graphs showing estimated tdROC curves with corresponding tdAUC values for joint models incorporating three complement factor ratios separately, and a multivariable joint model incorporating C3a / C3 and sC5b-9 / C5 (Combined) factor ratios. FIG. 2C is a table showing the relationship between the complement factors with the described secondary outcomes, progression to specifically GA or NV AMD as competing phenotypes.

[0026] FIG. 3 shows the relationship of ratios C3a / C3 (fg / ng) and C5a / C5 (fg / ng) with time to progression to either GA or NV AMD.

[0027] FIG. 4 shows a forest plot of estimated hazard ratios and 95% credible intervals of the association between longitudinal complement factors or complement factor ratios and time to progression to any advanced age-related macular degeneration (AMD), and geographic atrophy (GA), or neovascular AMD (NV AMD) as competing phenotypes.DETAILED DESCRIPTION

[0028] Approximately 8 million Americans have an intermediate stage of AMD (characterized by the presence of large-sized drusen in the macula (center of the retina)), placing them at risk for developing advanced disease and vision loss. Advanced AMD is classified into two clinical forms: geographic atrophy (GA) or dry AMD and an exudative or wet form characterized by choroidal neovascularization (CNV) or neovascular AMD (NVAMD). GA refers to confluent areas of retinal pigment epithelial (RPE) cell death accompanied by overlying photoreceptor atrophy. GA has a substantial impact on visual acuity: approximately 40% of a subset of patients has been shown to lose at least 3 Snellen equivalent lines of vision over 2 years.

[0029] The present disclosure provides characterization of the role of systemic activation of the complement system and progression to advanced AMD. In particular, twenty-five systemic complement factors / complement factor ratios were analyzed and measured in a large cohort of patients for time to progression from a specific point to the development of any advanced AMD either GA, or NVAMD. This large iAMD cohort is unique in its longitudinal follow-up and additional phenotyping of AMD using multimodal imaging.

[0030] In one aspect, the present disclosure provides a method of diagnosing an intermediate age-related macular degeneration (iAMD) patient as having a high risk of progression from iAMD to 5FH13302894.9Attorney Docket No.: CUR-00225advanced AMD comprising (i) obtaining a first plasma sample from the iAMD patient at a first timepoint, (ii) obtaining at least one successive plasma sample from the iAMD patient at a successive timepoint, (iii) comparing the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in the first plasma sample to the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in the at least one successive plasma sample, and (iv) determining that the iAMD patient has a high risk of progression from iAMD to advanced AMD if the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in the at least one successive plasma sample is elevated compared to the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in the first plasma sample.

[0031] In one aspect, the present disclosure provides a method for identifying an iAMD patient at risk for progressing to advanced AMD comprising analyzing a plasma sample from the patient, wherein an elevated level of at least one complement factor, and / or at least one elevated ratio of complement factors, or any combination thereof, when compared with a one unit lower level, indicates that the iAMD patient is at risk of progressing to advanced AMD As described herein, patient specific biomarker trajectories have been assessed and modeled. This allows for associating the modeled (predicted) biomarker values at any time with the hazard of progression. The hazard ratio of progression is the instantaneous risk of progression for each unit biomarker increase.

[0032] In another aspect, the present disclosure provides a method of stratifying iAMD patients using prognostic complement factors as biomarkers to identify patients who may respond to treatment and delay or prevent progression to advanced AMD.

[0033] In certain embodiments, provided herein is a method for identifying a patient at risk for AMD progression who may be suitable for an intervention comprising administering an effective amount of at least one inhibitor of complement activation to the patient when the patient exhibits elevation in a plasma sample of complement factor / ratio.

[0034] In another embodiment, provided herein is a method for delaying progression of AMD in a patient with iAMD comprising administering an effective amount of at least one inhibitor of complement activation to the patient when the patient exhibits elevation in a plasma sample of at least one complement factor / ratio, and / or at least one elevated ratio of complement factors, when compared with a one unit lower level.

[0035] In certain embodiments, the elevated complement factor is C4, C4b and / or at least one ratio of C3a / C3, C5a / C5, sC5b-9 / C5, or any combination thereof.

[0036] In certain embodiments, the at least one inhibitor of complement activation is Lampalizumab, Tesidolumab, CLG561, POT4 (AL-78898A), cemdisiran, Berinert, Cinryze, Ruconest, Enjaymo (Sutimlimab), Soliris (Eculizumab), Ultomiris (Ravulizumab), Zilbrysq (Zilucoplan), Veopoz6FH13302894.9Attorney Docket No.: CUR-00225(Pozelimab), Izervay (Avacincaptad Pegol), Tavneos (Avacopan), Fabhalta (Iptacopan), Voydeya (Danicopan), Pegcetacoplan (Empaveli, or Syfovre for injection), Crovalimab, Iptacopan (Fabhalta), Danicopan (Voydeya), Avacopan (Tavneos), Narsoplimab (OMS721), AMY-101, LNP023, ANX005,or any combination thereof.

[0037] In another aspect, the present disclosure provides a method of treating age-related macular degeneration (AMD) comprising (i) obtaining a first plasma sample from an iAMD patient at a first timepoint and a second plasma sample from the iAMD patient at a second timepoint, (ii) measuring the level of at least one systemic complement factor and / or at least one ratio of systemic complement factors in the first plasma sample and in the second plasma sample, (iii) identifying the patient as having an elevated risk of progressing from iAMD to advanced AMD, and administering at least one inhibitor of complement activation to the patient if the patient is identified as having an elevated risk of progressing from iAMD to advanced AMD, wherein the second timepoint is later than the first timepoint, and wherein the at least one systemic complement factor is selected from the list consisting of C4 and C4b and the at least one ratio of systemic complement factors is selected from the list consisting of C3a / C3, C5a / C5, and sC5b-9 / C5.Definitions and Abbreviations

[0038] “Age-related Macular Degeneration”, also referred to herein as “AMD”, as used herein is a disease of the eye caused by degeneration of the cells of the macula which is the part of the retina that is responsible for central vision. AMD can be either (1) wet (exudative) which is characterized by the abnormal growth of blood vessels underneath the retina which leads to leaking of fluid or blood which ultimately damages the photoreceptors or (2) dry (non-exudative) which is characterized by the accumulation of cellular debris called drusen between the retina and the choroid.

[0039] “Geographic Atrophy”, also referred to herein as “GA”, as used herein is a disease involving degeneration of the retinal pigment epithelium (RPE), associated with loss of photoreceptors. GA is the advanced form of dry AMD.

[0040] “GA Area”, as used herein refers to a discrete area representing loss of retinal anatomy (e.g., photoreceptors and retinal pigment epithelium (RPE). GA area is measured by standard imaging techniques such as fundus autofluorescence (FAF) and digital color fundus photography (CFP),

[0041] “Early AMD”, as used herein is a disease characterized by multiple small (<63 pm) or >1 intermediate drusen (>63 pm and <125 pm).7FH13302894.9Attorney Docket No.: CUR-00225

[0042] “Intermediate AMD”, as used herein is a disease characterized by many intermediate or >1 large drusen (>125 pm) often accompanied by hyper or hypopigmentation of the retinal pigment epithelium.

[0043] “Advanced AMD”, as used herein is a disease characterized by geographic atrophy (GA) or neo vascular (wet) AMD).

[0044] Clinical Features for AMD ClassificationDefinition(Lesions assessed within 2 disc Classification of AMD diameters of fovea in either eye)No apparent aging changes No drusen andNo AMD pigmentary abnormalities*Normal aging changes Only drupelets (small drusen <63 pm) andNo AMD pigmentary abnormalities*Early AMD Medium drusen > 63 pm and < 125pm andNo AMD pigmentary abnormalities*Intermediate AMD Large drusen > 125 pm and / orAny AMD pigmentary abnormalities*Late AMD Neovascular AMD and / orAny geographic atrophyAMD = age related macular degeneration* AMD pigmentary abnormalities = any definite hyper-or hypopigmentary abnormalities associated with medium or large drusen but not associated with known disease entities.

[0045] The term “complement-associated eye condition” is used in the broadest sense and includes all eye conditions the pathology of which involves some or all complement pathways. Complement-associated eye conditions include, without limitation, macular degenerative diseases, such as all stages of age-related macular degeneration (AMD), including dry and wet (non-exudative and exudative) forms, choroidal neovascularization (CNV), geographic atrophy (GA), uveitis, diabetic and other ischemia-related retinopathies, and other intraocular neovascular diseases, such as diabetic macular edema, pathological myopia, von Hippel-Lindau disease, histoplasmosis of the eye, Central Retinal Vein Occlusion (CRVO), comeal neovascularization, and retinal neovascularization. In one example, complement-associated eye conditions include age-related macular degeneration (AMD), including non-exudative (dry or atrophic) and exudative (wet) AMD, choroidal neovascularization (CNV), diabetic retinopathy (DR), geographic atrophy (GA) and endophthalmitis.

[0046] The term “administering” as used herein is used in the broadest sense and inter alia encompasses enteral, topical administration and “parenteral administration”. “Parenteral8FH13302894.9Attorney Docket No.: CUR-00225administration” 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, intrastemal injection, infusion, ocular, intraocular, intravitreal, juxtascleral, subtenon and superchoroidal. “IVT when used herein refers to intravitreal.

[0047] As used herein, the term "blood" encompasses whole blood or any fraction of blood, such as serum and plasma as conventionally defined. Blood plasma refers to the fraction of whole blood resulting from centrifugation of blood treated with anticoagulants. Blood serum refers to the watery portion of fluid remaining after a blood sample has coagulated. Fluid or tissue samples are often collected in accordance with standard protocols hospitals or clinics generally follow.

[0048] The term “assessing AMD” is used to indicate that the method according to the present invention will aid a medical professional including, e.g., a physician to assess whether an individual is at risk of developing intermediate or advanced AMD or prognosing to intermediate or advanced AMD. The presence of elevated or altered levels of any one or combination of C4, C4b, and / or the ratios C3a / C3, C5a / C5, and sC5b-9 / C5, in a plasma sample of an iAMD patient indicates that the patient is at risk of progressing from iAMD to advanced AMD as further described herein.

[0049] As used herein, the term “one-unit lower level” serves as a baseline or reference for the complement or ratio levels obtained from patient biologic samples. Part of the analysis of these patient samples utilizes a hazard ratio (HR), which is used to compare the risk of an event happening in one group to another group over time. Patients determined to have elevated complement levels or ratios (e.g., the hazard ratio) compared to “one-unit lower level” are more likely to progress to more serious or advanced AMD and are thus suitable for treatment to slow this progression and preserve sight.

[0050] In some embodiments, the presence of elevated levels of any one or combination of C4, C4b, and / or the ratios C3a / C3, C5a / C5, and sC5b-9 / C5, in a plasma sample of an iAMD patient indicates that the patient is more likely to respond to treatment with an effective amount of at least one inhibitor of complement activation.

[0051] Results from prognostic tests may be combined with other test results to diagnose progression to more advanced AMD. In some embodiments, the results from predisposition analyses may be combined with other test results, epidemiologic or genetic in nature, indicative of progression to more advanced AMD. In these embodiments, the combination of the prognostic test results with9FH13302894.9Attorney Docket No.: CUR-00225other test results can be probative or progression to more advanced AMD, and the combination can be utilized as an AMD diagnostic.

[0052] The term “progression” as used herein refers to the worsening of a disease over time. The “progression rate” or “rate of progression” of a disease refers to how fast or slow a disease develops over time in a patient diagnosed with the disease. The disease is often chronic, and the time frame can be weeks, months or years. The progression rate of a disease can be represented by measurable changes over time of particular characteristics of the disease. For example, the progression rate of a patient with GA can be represented by the growth rate of GA lesion area from baseline to month 18 as measured by a standard imaging method such as fundus autofluorescence (FAF) or color fundus photography (CFP). A patient carrying particular genetic trait is said to have, or more likely to have, “increased progression rate” if her disease state progresses faster than those patients without such genetic trait. On the other hand, a patient responding to a therapy is said to have, or more likely to have, “decreased progression rate” if her disease progression slows down after the therapy, when compared to her disease state prior to the treatment or to other patients without the treatment.

[0053] ‘ ‘More likely to respond” as used herein refers to patients that are most likely to demonstrate a slowing down or prevention of progression of AMD. With regard to GA, “more likely to respond” refers to patients that are most likely to demonstrate a reduction in loss of GA area by FAF or CFP with treatment. With regard to intermediate AMD, “more likely to respond” refers to patients that are more likely to demonstrate a slowing of progression to advanced AMD.Diagnosing an intermediate age-related macular degeneration (iAMD) patient at risk of progression to advanced AMD

[0054] In one aspect, the present disclosure provides methods for diagnosing an intermediate age-related macular degeneration (iAMD) patient as having a high risk of progression from iAMD to advanced AMD comprising (i) obtaining a first plasma sample from the iAMD patient at a first timepoint, (ii) obtaining at least one successive plasma sample from the iAMD patient at a successive timepoint, (iii) comparing the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the at least one successive plasma sample, and (iv) determining that the iAMD patient has a high risk of progression from iAMD to advanced AMD if the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the at least one successive plasma sample is elevated compared to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample.10FH13302894.9Attorney Docket No.: CUR-00225

[0055] In some embodiments, the level of C4 in the first plasma sample is compared to the level of C4 in the second plasma sample. In some embodiments, the level of C4b in the first plasma sample is compared to the level of C4b in the second plasma sample. In some embodiments, the level of C3a / C3 in the first plasma sample is compared to the level of C3a / C3 in the second plasma sample. In some embodiments, the level of C5a / C5 in the first plasma sample is compared to the level of C5a / C5 in the second plasma sample. In some embodiments, the level of sC5b-9 / C5 in the first plasma sample is compared to the level of sC5b-9 / C5 in the second plasma sample.

[0056] In some embodiments, the level of C4 and C4b in the first plasma sample is compared to the level of C4 and C4b in the second plasma sample. In some embodiments, the level of C4, C4b, and C3a / C3, in the first plasma sample is compared to the level of C4, C4b, and C3a / C3, in the second plasma sample. In some embodiments, the level of C4, C4b, C3a / C3, and C5a / C5 in the first plasma sample is compared to the level of C4, C4b, C3a / C3, and C5a / C5 in the second plasma sample. In some embodiments, the level of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample is compared to the level of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the second plasma sample.

[0057] In some embodiments, each of the at least one successive plasma sample is obtained from the iAMD patient at a timepoint later than the first timepoint. In some embodiments, the at least one successive plasma sample comprises from 1 to 20 (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20) plasma samples.

[0058] In some embodiments, the successive plasma samples are obtained at a regular interval after the first timepoint. In some embodiments, when the successive plasma samples are obtained at a regular interval, the regular interval is from 1 day to 5 years (e.g., every day, every 2 days, every 3 days, every 4 days, every 5 days, every 6 days, every 7 days, every 8 days, every 9 days, every 10 days, every 11 days, every 12 days, every 13 days, every 14 days, every 15 days, every 16 days, every 17 days, every 18 days, every 19 days, every 20 days, every 21 days, every 22 days, every 23 days, every 24 days, every 25 days, every 26 days, every 27 days, every 28 days, every 29 days, every 30 days, every week, every 2 weeks, every 3 weeks, every 4 weeks, every 5 weeks, every 6 weeks, every 7 weeks, every 8 weeks, every 9 weeks, every 10 weeks, every 11 weeks, every 12 weeks, every month, every 2 months, every 3 months, every 4 months, every 5 months, every 6 months, every 7 months, every 8 months, every 9 months, every 10 months, every 11 months, every 12 months, every 16 months, every 24 months, every 3 years, every 4 years, or every 5 years).

[0059] In some embodiments, the successive plasma samples are obtained at irregular intervals after the first timepoint. In some embodiments, the successive plasma samples are obtained at a regular11FH13302894.9Attorney Docket No.: CUR-00225interval except for at least one successive plasma sample. In some embodiments, at least one plasma sample is not obtained (e.g., a missed plasma sample for a given interval).

[0060] In some embodiments, the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the at least one successive plasma sample is associated with a shorter time of progression to advanced AMD using a hazard ratio for each of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5. In some embodiments, the hazard ratio for any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is greater than 1. In some embodiments, a hazard ratio greater than 1 indicates a positive association for C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 and a shorter time to progression from iAMD to advanced AMD.

[0061] In one aspect the present disclosure provides a method of diagnosing an iAMD patient having a high risk of progression from iAMD to advanced AMD comprising (a) obtaining a plasma sample from the iAMD patient, (b) measuring the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the plasma sample, (c) comparing the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the plasma sample to a reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5, and (d) determining that the iAMD patient has a high risk of progression from iAMD to advanced AMD if the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the plasma sample is elevated compared to a reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0062] In some embodiments, the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is established from a cohort of AMD patients, to establish for example a baseline.

[0063] In some embodiments, the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 100% (e.g., 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, 50%, 51%, 52%, 53%, 54%, 55%, 56%, 57%, 58%, 59%, 60%, 61%, 62%, 63%, 64%, 65%, 66%, 67%, 68%, 69%, 70%, 71%, 72%, 73%, 74%, 75%, 76%, 77%, 78%, 79%, 80%, 81%, 82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98%, 99%, or 100%) greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0064] In some embodiments, the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 50% (e.g., 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%,12FH13302894.9Attorney Docket No.: CUR-002259%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, 25%, 26%, 27%, 28%, 29%, 30%, 31%, 32%, 33%, 34%, 35%, 36%, 37%, 38%, 39%, 40%, 41%, 42%, 43%, 44%, 45%, 46%, 47%, 48%, 49%, or 50%) greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0065] In some embodiments, the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 25% (e.g., 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 11%, 12%, 13%, 14%, 15%, 16%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%, or 25%) greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

[0066] In some embodiments, the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 10% (e.g., 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, or 10%) greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.Identifying an intermediate age-related macular degeneration (iAMD) patient at risk for converting to advanced AMD

[0067] In one aspect, the present disclosure provides a method for identifying an intermediate age-related macular degeneration (iAMD) patient at risk for converting to advanced AMD comprising analyzing a plasma sample from the patient, wherein an elevated level of at least one complement factor, and / or at least one elevated ratio of complement factors, or any combination thereof, when compared with one unit lower level indicates that the iAMD patient will is at a higher risk of progressing to advanced AMD.

[0068] The complement system has an important role in defending the host against infections, acting as a bridge between innate and adaptive immunity, and facilitating disposal of immune complexes, the products of inflammation or trauma, and apoptotic cells. The complement cascade (Fig. 1), consisting of over 50 circulating or cell surface-based proteins, can be activated by different immune-based triggers through three initiating pathways, the lectin (LP), classical (CP) and alternative pathways (AP). Early events occurring in these pathways lead to the formation of the C3 convertase which cleaves C3, the first factor which is located at the intersection of the 3 pathways, into C3a (anaphylatoxin) and C3b (opsonin). C3b is important to the functions of the amplification loop as it engages the AP proteins to greatly increase pathway activation. C3b also opsonizes targets and facilitates the clearance of apoptotic or damaged / stressed cells. On surfaces, additional C3b molecules clustered with the CP / LP and the AP C3 convertases generate the C5 convertase. Cleavage 13FH13302894.9Attorney Docket No.: CUR-00225of C5 by the C5 convertase occurs as part of the terminal pathway (TP) leading to the production of C5a (anaphylatoxin) and C5b, a component of the Membrane Attack Complex (MAC). C5b, together with complement factors C6–C9, form the MAC which lyses and destroys target cells as well as engages pre-inflammatory pathways in nucleated cells. To prevent uncontrolled complement activation, soluble and cell-associated regulators, such as Factor H and Factor I, provide downregulation at several points of complement activation.

[0069] The relationship between systemic overactivation of the complement system with time to progression to advanced AMD has been analyzed as described herein in a longitudinal cohort of patients with intermediate AMD (iAMD). As the data provided herein illustrate, higher levels of several systemic complement factors and ratios, in particular, C3a / C3, C5a / C5, and sC5b-9 / C5 were significantly associated with time to conversion to any advanced AMD in iAMD patients. Two ratios C3a / C3 and C5a / C5 were significantly associated with time to conversion to geographic atrophy (GA). Thus, overactivation of systemic complement pathways increases the risk of conversion to advanced AMD in patients with intermediate AMD and provides a therapeutic and diagnostic basis for treating patients at a stage when their vision can be stabilized.

[0070] In certain embodiments, the elevated level of at least one complement factor and / or at least one elevated ratio of complement factors is C4, C4b, and / or the ratios C3a / C3, C5a / C5, and sC5b-9 / C5, or any combination thereof, indicates that the iAMD patient is at a higher risk of progressing to advanced AMD.

[0071] Exemplary ranges of the diagnostic complement factors, which can be present in any one or combination in a patient with iAMD who is likely to progress to advanced AMD include the following:Imaging

[0072] In certain embodiments, AMD patients were further examined using ophthalmic imaging. In certain embodiments, the ophthalmic imaging was multimodal imaging (MMI), which can use any of or combination of ophthalmic imaging methods, such as optical coherence tomography (OCT), fluorescein angiography (FA), and fundus autofluorescence (FAF).

[0073] In certain embodiments, the method further comprises ophthalmic imaging of the patient’s eyes, wherein the ophthalmic imaging provides phenotypic classification of AMD. MMI imaging can provide additional phenotypic classification of disease utilizing color fundus photo, fundus autofluorescence, and spectral domain optical coherence tomography of the macula to further14FH13302894.9Attorney Docket No.: CUR-00225determine AMD phenotype. Such ophthalmic follow up is typically conducted at 6-month intervals for AMD patients.Methods of Treating iAMD patients at Risk for Advancing to Advanced AMD

[0074] An aspect of the present disclosure provides for methods for treating age-related macular degeneration (AMD) in a patient with intermediate AMD (iAMD) comprising administering an effective amount of at least one inhibitor of complement activation to the patient when the patient exhibits elevation in a plasma sample of at least one complement factor / ratio, and / or at least one elevated ratio of complement factors, when compared with one unit lower level

[0075] Additional aspects provide for a method for delaying progression of AMD in a patient with iAMD comprising administering an effective amount of at least one inhibitor of complement activation to the patient when the patient exhibits elevation in a plasma sample of at least one complement factor, and / or at least one elevated ratio of complement factors, when compared with a one unit lower level.

[0076] In an aspect the present disclosure provides methods of treating AMD comprising (i) obtaining a first plasma sample from an iAMD patient at a first timepoint and a second plasma sample from the iAMD patient at a second timepoint, (ii) measuring the level of at least one systemic complement factor and / or at least one ratio of systemic complement factors in the first plasma sample and in the second plasma sample, (iii) identifying the patient as having an elevated risk of progressing from iAMD to advanced AMD, and (iv) administering at least one inhibitor of complement activation to the patient if the patient is identified as having an elevated risk of progressing from iAMD to advanced AMD, wherein the second timepoint is later than the first timepoint, and wherein the at least one systemic complement factor is selected from the list consisting of C4 and C4b and the at least one ratio of systemic complement factors is selected from the list consisting of C3a / C3, C5a / C5, and sC5b-9 / C5.

[0077] In some embodiments, the identifying comprises (i) comparing the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the second plasma sample, and (ii) determining that the patient has an elevated risk of progressing from iAMD to advanced AMD if the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is elevated in the second plasma sample compared to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample.15FH13302894.9Attorney Docket No.: CUR-00225

[0078] In some embodiments, the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the second plasma sample is associated with a shorter time of progression to advanced AMD using a hazard ratio for each of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5. In some embodiments, the hazard ratio for C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 is greater than 1.

[0079] In some embodiments, the second timepoint is from 1 day to 5 year (e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, 21 days, 22 days, 23 days, 24 days, 25 days, 26 days, 27 days, 28 days, 29 days, 30 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 16 months, 24 months, 3 years, 4 years, or 5 years) after the first timepoint.

[0080] In some embodiments, administering delays progression from iAMD to advanced AMD in the iAMD patient. In some embodiments administering delays progression from iAMD to advanced AMD in the iAMD patient by at least 1 day (e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days, 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, 21 days, 22 days, 23 days, 24 days, 25 days, 26 days, 27 days, 28 days, 29 days, 30 days, 1 week, 2 weeks, 3 weeks, 4 weeks, 5 weeks, 6 weeks, 7 weeks, 8 weeks, 9 weeks, 10 weeks, 11 weeks, 12 weeks, 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 12 months, 2 years, 3 years, 4 years, 5 years, 6 years, 7, years, 8 years, 9 years, or 10 years).

[0081] In some embodiments, the administering is systemic, ophthalmic, or a combination thereof. In some embodiments, the administering is systemic. In some embodiments, the administering is ophthalmic. In some embodiments, the administering comprises systemic and ophthalmic administration.

[0082] In some embodiments, the inhibitor of complement activation targets any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5. In some embodiments, the inhibitor of complement activation is Lampalizumab, Tesidolumab, CLG561, POT4 (AL-78898A), cemdisiran, Berinert, Cinryze, Ruconest, Enjaymo (Sutimlimab), Soliris (Eculizumab), Ultomiris (Ravulizumab), Zilbrysq (Zilucoplan), Veopoz (Pozelimab), Izervay (Avacincaptad Pegol), Tavneos (Avacopan), Fabhalta (Iptacopan), Voydeya (Danicopan), Pegcetacoplan (Empaveli, or Syfovre for injection), Crovalimab, Iptacopan (Fabhalta), Danicopan (Voydeya), Avacopan (Tavneos), Narsoplimab (OMS721), AMY-101, LNP023, or ANX005. In some embodiments, the method further comprises administering a second therapeutic agent as herein disclosed.16FH13302894.9Attorney Docket No.: CUR-00225Inhibitors of Complement Factors and Complement Activation

[0083] The complement system is a group of plasma proteins that, when activated, cause target cell lysis and facilitate phagocytosis through opsonization. Complement is activated through a series of proteolytic steps by three main pathways: the classical pathway, which is usually activated by immune complexes, the alternative pathway that can be induced by unprotected cell surfaces, and the mannose-binding lectin pathway. All three pathways of the complement cascade converge on the proteolytic cleavage of the complement component 5 (C5) protein. Cleavage of complement component 5 (C5) results in the production of the C5a and C5b fragments, a critical process during complement cascade activation. C5a can generate pleiotropic physiological responses by binding to its receptors. C5a is a potent proinflammatory mediator that induces chemotactic migration, enhances cell adhesion, stimulates oxidative burst, and induces the release of various inflammatory mediators such as histamine or cytokines. C5b mediates the formation of the membrane attack complex (MAC, or C5b-9) that leads to cell lysis in the late stages of complement-dependent cytotoxicity (CDC). Furthermore, in nucleated cells resistant to cytolysis by C5b-9, sublytic amounts of C5b-9 can trigger cellular activation leading to cell proliferation, generation of proinflammatory mediators, and production of extracellular matrix.

[0084] Antibodies or compounds that block any of the upstream complement factors are suitable for methods of treating iAMD patients at risk for advancing to advanced AMD, as described herein.

[0085] Examples of suitable inhibitor antibodies include monoclonal antibodies against C5, a number of are known in the art and have been described, for example, in U. S. Publication or Patent Nos. 10,633, 434; 11,479,602; 11,492,392; 9206251; 9107861; 9079949; 9051365; 8999340;8883158; 8241628; 7999081; 7432356; 7361339; 7279158; 6534058; 6355245; 6074642;20160299305; 20160051673; 20160031975; 20150158936; 20140056888; 20130022615; and 20120308559; and in documents WO2015198243, WO2015134894, W02015120130, EP2563813B1, EP2328616B1 and EP2061810B1. EP2328616B1 relates to antibodies directed against complement protein C5 and compositions and methods of use thereof. Wong et al., Transl Res. 2015, 165(2):306-320 relates to anti-complement C5 therapy with eculizumab for the treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome.

[0086] In some embodiments, the presence of elevated levels of any one or combination of C4, C4b, and / or the ratios C3a / C3, C5a / C5, and sC5b-9 / C5, in a plasma sample of an iAMD patient indicates that the patient is more likely to respond to treatment with an effective amount of at least one inhibitor of complement activation.17FH13302894.9Attorney Docket No.: CUR-00225

[0087] In certain embodiments, iAMD patients identified as at-risk for progression to advanced AMD are treated with an effective amount of any one or combination of inhibitors of complement activation: Lampalizumab, Tesidolumab, CLG561, POT4 (AL-78898A), cemdisiran, Berinert, Cinryze, Ruconest, Enjaymo (Sutimlimab), Soliris (Eculizumab), Ultomiris (Ravulizumab), Zilbrysq (Zilucoplan), Veopoz (Pozelimab), Izervay (Avacincaptad Pegol), Tavneos (Avacopan), Fabhalta (Iptacopan), Voydeya (Danicopan), Pegcetacoplan (Empaveli, or Syfovre for injection), Crovalimab, Iptacopan (Fabhalta), Danicopan (Voydeya), Avacopan (Tavneos), Narsoplimab (OMS721), AMY-101, LNP023, or ANX005.Additional Treatments and Combinations

[0088] Any of the inhibitors of complement activation may be used in combination with one or more additional therapeutic agents including, but not limited to, an anti-coagulant (e.g., warfarin, aspirin, heparin, phenindione, fondaparinux, idraparinux, and thrombin inhibitors such as argatroban, lepirudin, bivalirudin, or dabigatran) an anti-inflammatory drug (e.g., corticosteroids, and nonsteroidal anti-inflammatory drugs), an antihypertensive (e.g., an angiotensin-converting enzyme inhibitor), an immunosuppressive agent (e.g., vincristine, cyclosporine A, or methotrexate), a fibrinolytic agent (e.g., ancrod, e-aminocaproic acid, antiplasmin-a.sub.l, prostacyclin, and defibrotide), a lipid-lowering agent such as an inhibitor of hydroxymethylglutaryl CoA reductase, an anti-CD20 agent such as rituximab, an anti-TNF agent such as infliximab, an anti-seizure agent (e.g., magnesium sulfate), a C3 inhibitor, or an anti-thrombotic agent.

[0089] The pharmaceutical compositions can be administered alone or in combination with other molecules known to have a beneficial effect on retinal attachment or damaged retinal tissue, including molecules capable of tissue repair and regeneration and / or inhibiting inflammation.Examples of useful, cofactors include complement inhibitors (such as inhibitors of Factor D, C5a receptor and antibody or Fabs against C5, C3, properidin, factor H, and the like), anti-VEGF agents (such as an antibody or FAB against VEGF, e.g., Eucentis or Avastin), basic fibroblast growth factor (bFGF), ciliary neurotrophic factor (CNTF), axokine (a mutein of CNTF), leukemia inhibitory factor (EIF), neutrotrophin 3 (NT-3), neurotrophin-4 (NT-4), nerve growth factor (NGF), insulin-like growth factor II, prostaglandin E2, 30 kD survival factor, taurine, and vitamin A.

[0090] Additional embodiments include further administering an anti- vascular endothelial growth factor (anti-VEGF) medication. Non-limiting examples of anti-VEGF medications include antibody derivatives such as ranibizumab (EUCENTIS); monoclonal antibodies such as bevacizumab (AVASTIN); small molecules that inhibit the tyrosine kinases stimulated by VEGF such as lapatinib 18FH13302894.9Attorney Docket No.: CUR-00225(TYKERB), sunitinib (SUTENT), sorafenib (NEXAVAR), axitinib, and pazopanib; and VEGF inhibitors such as THC, Cannabidiol and thiazolidinediones.

[0091] In certain embodiments, the second therapeutic agent is another inhibitor of complement activation protein. In certain embodiments, it is contemplated to use a combination (“cocktail”) of antibodies with broad neutralization or inhibitory activity against C5, or another complement factor. In some embodiments, non-competing antibodies may be combined and administered to a subject in need thereof. In some embodiments, the antibodies comprising the combination bind to distinct nonoverlapping epitopes on the protein. Exemplary antibodies comprising the combination may block the C5 binding to C5 convertase and / or may prevent / inhibit cleavage of C5 into C5a and C5b. In certain embodiments, the second antibody may possess longer half-life in human serum.

[0092] As used herein, the term “in combination with” means that an additional therapeutically active agent may be administered prior to, concurrent with, or after the administration of the inhibitor of complement activation. The term “in combination with” also includes sequential or concomitant administration of an inhibitor of complement activation and a second therapeutic agent.

[0093] The additional therapeutically active component(s) may be administered to a subject prior to administration of an inhibitor of complement activation. For example, a first component may be deemed to be administered “prior to” a second component if the first component is administered 1 week before, 72 hours before, 60 hours before, 48 hours before, 36 hours before, 24 hours before, 12 hours before, 6 hours before, 5 hours before, 4 hours before, 3 hours before, 2 hours before, 1 hour before, 30 minutes before, 15 minutes before, 10 minutes before, 5 minutes before, or less than 1 minute before administration of the second component. In other embodiments, the additional therapeutically active component(s) may be administered to a subject after administration of an anti-C5 antibody of the present invention. For example, a first component may be deemed to be administered “after” a second component if the first component is administered 1 minute after, 5 minutes after, 10 minutes after, 15 minutes after, 30 minutes after, 1 hour after, 2 hours after, 3 hours after, 4 hours after, 5 hours after, 6 hours after, 12 hours after, 24 hours after, 36 hours after, 48 hours after, 60 hours after, 72 hours after administration of the second component. In yet other embodiments, the additional therapeutically active component(s) may be administered to a subject concurrent with administration of an inhibitor of complement activation. “Concurrent” administration also includes, e.g., administration of an inhibitor of complement activation and an additional therapeutically active component to a subject in a single dosage form, or in separate dosage forms administered to the subject within about 30 minutes or less of each other. If administered in separate dosage forms, each dosage form may be administered via the same route 19FH13302894.9Attorney Docket No.: CUR-00225(e.g., both the inhibitor of complement activation and the additional therapeutically active component may be administered intravenously, etc.); alternatively, each dosage form may be administered via a different route (e.g., the inhibitor of complement activation may be administered intravenously, and the additional therapeutically active component may be administered orally). In any event, administering the components in a single dosage from, in separate dosage forms by the same route, or in separate dosage forms by different routes are all considered “concurrent administration,” for purposes of the present disclosure.

[0094] The present disclosure includes pharmaceutical compositions in which an inhibitor of complement activation, such as for example, anti-C5 antibody, is co-formulated with one or more of the additional therapeutically active component(s) as described elsewhere herein.Administration Regimens

[0095] According to certain embodiments, a single dose of an inhibitor of complement activation (or a pharmaceutical composition comprising a combination of an inhibitor of complement activation and any of the additional therapeutically active agents mentioned herein) may be administered to a subject in need thereof. According to certain embodiments, multiple doses of an inhibitor of complement activation (or a pharmaceutical composition comprising a combination of an inhibitor of complement activation and any of the additional therapeutically active agents mentioned herein) may be administered to a subject over a defined time course. The methods according to this aspect of the invention comprise sequentially administering to a subject multiple doses of an inhibitor of complement activation. As used herein, “sequentially administering” means that each dose of inhibitor of complement activation is administered to the subject at a different point in time, e.g., on different days separated by a predetermined interval (e.g., hours, days, weeks or months). Additional embodiments include methods which comprise sequentially administering to the patient a single initial dose of an inhibitor of complement activation, followed by one or more secondary doses of the inhibitor of complement activation, and optionally followed by one or more tertiary doses of the inhibitor of complement activation.

[0096] The terms “initial dose,” “secondary doses,” and “tertiary doses,” refer to the temporal sequence of administration of the inhibitor of complement activation. Thus, the “initial dose” is the dose which is administered at the beginning of the treatment regimen (also referred to as the “baseline dose”); the “secondary doses” are the doses which are administered after the initial dose; and the “tertiary doses” are the doses which are administered after the secondary doses. The initial, secondary, and tertiary doses may all contain the same amount of inhibitor of complement activation 20FH13302894.9Attorney Docket No.: CUR-00225but generally may differ from one another in terms of frequency of administration. In certain embodiments, however, the amount of inhibitor of complement activation contained in the initial, secondary and / or tertiary doses varies from one another (e.g., adjusted up or down as appropriate) during the course of treatment. In certain embodiments, two or more (e.g., 2, 3, 4, or 5) doses are administered at the beginning of the treatment regimen as “loading doses” followed by subsequent doses that are administered on a less frequent basis (e.g., “maintenance doses”).

[0097] In certain exemplary embodiments of the present invention, each secondary and / or tertiary dose is administered 1 to 48 hours (e.g., 1, 116, 2, 216, 3, 3 z, 4, 416, 5, 516, 6, 6 2, 7, 716, 8, 816, 9, 916, 10, 1016, 11, 1116, 12, 1216, 13, 1316, 14, 1416, 15, 1516, 16, 1616, 17, 1716, 18, 1816, 19, 1916, 20, 2016, 21, 2116, 22, 2216, 23, 2316, 24, 2416, 25, 2516, 26, 2616, or more) after the immediately preceding dose. The phrase “the immediately preceding dose,” as used herein, means, in a sequence of multiple administrations, the dose of inhibitor of complement activation which is administered to a patient prior to the administration of the very next dose in the sequence with no intervening doses.

[0098] In certain embodiments, the methods may comprise administering to a patient any number of secondary and / or tertiary doses of an inhibitor of complement activation. For example, in certain embodiments, only a single secondary dose is administered to the patient. In other embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8, or more) secondary doses are administered to the patient. Likewise, in certain embodiments, only a single tertiary dose is administered to the patient. In other embodiments, two or more (e.g., 2, 3, 4, 5, 6, 7, 8, or more) tertiary doses are administered to the patient.

[0099] In certain embodiments, the frequency at which the secondary and / or tertiary doses are administered to a patient can vary over the course of the treatment regimen. The frequency of administration may also be adjusted during the course of treatment by a physician depending on the needs of the individual patient following clinical examination.

[0100] Other useful secondary or additional treatments include symptom-alleviating cofactors, including antiseptics, antibiotics, antiviral and antifungal agents and analgesics and anesthetics.

[0101] A combination therapy regimen may be additive, or it may produce synergistic results (e.g., reductions in complement pathway activity more than expected for the combined use of the two agents). In some embodiments, a combination therapy for preventing and / or treating conversion of iAMD to advanced AMD is provided and may include an anti-angiogenic, such as anti-VEGF agent (including Lucentis and Avastin) or photodynamic therapy (such as verteporfin). In additional embodiments, the frequency at which any secondary and / or tertiary doses of at least one inhibitor of complement activation are administered to a patient can vary over the course of the treatment 21FH13302894.9Attorney Docket No.: CUR-00225regimen. The frequency of administration may also be adjusted during the course of treatment by a physician depending on the needs of the individual patient following clinical examination.Kits

[0102] Kits provided herein have a number of embodiments. In certain embodiments, a kit comprises a container, one or more diagnostic complement probes, and instructions for using the probes or other detection reagent for evaluating the presence of one or more diagnostic complement proteins in at least one type of mammalian cell. The kit can further comprise a set of instructions and materials for preparing a plasma sample and a reference or standard to determine elevation of the diagnostic complement factors of interest. The kit may further include a set of references or standards for Clq, C4, C2, MBL, C4b, C3, Factor B, Factor D, Properdin, C3a, C3b / iC3b. C3b, Ba, Bb. Factor H, Factor I, C5, C5a, and SC5b-9 to determine baseline values for the complement factors being analyzed in blood or plasma samples. The kit may further include reagents useful in any of these standard methods.

[0103] In some embodiments, the present disclosure provides a kit for assessing risk of progression from iAMD to advanced AMD in a subject comprising: reagents and instructions for measuring the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in a first plasma sample and the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in a second plasma sample, and instructions providing criteria for classifying the subject as at risk for progressing from iAMD to advanced AMD.EXAMPLES EXAMPLE 1Clinical characterization of Patient Cohort

[0104] Table 1A shows the clinical characteristics of the cohort of 325 patients with iAMD at enrollment. The majority of the cohort participants were female (65%), and the average age was 76 (SD=7.0) years. 110 (34%;) patients progressed in the 8-year follow-up period (mean = 3.9 years, median = 3.6 years) to any advanced AMD. 64 (20%) progressed to GA and 46 (14%) progressed to NVAMD. None of the risk factors (Table 1A) were associated with time to progression to any advanced AMD (Table IB).Table 1A. Clinical Characteristics of the Intermediate AMD Cohort N = 325Variable n (%) or mean (SD, Range)SexMale 113 (35%)22FH13302894.9Attorney Docket No.: CUR-00225Female 212 (65%) Family History of AMDaNone 146 (45%) Parent 101 (31%) Sibling 22 (6.8%) Uncertain 53 (16%)Age (years)Mean (SD, range) 76.2 (7.0, 58.8 to 96.0) Body Mass Index (kg / m2)bMean (SD, range) 27.3 (5.7, 14.9 to 48.2) SmokingNever 174 (54%) Current 9 (2.8%) Former 142 (44%) Treated Chronic Hypertension 177 (54%) History of Cardiac Disease 115 (35%)aMissing values on 3 patients;bMissing values on 4 patientsTable IB. The Hazard Ratios of Progression to Any Advanced AMD for Clinical Characteristics.Characteristic N HR (95% CI)1p-value Sex 325Male —Female 0.72 (0.49 to 1.07) 0.10 Family History of AMD 322None —Parent 1.00 (0.65 to 1.55) >0.99 Sibling 1.55 (0.76 to 3.18) 0.23 Uncertain 1.45 (0.82 to 2.56) 0.20 Age (years) 325 1.01 (0.98 to 1.04) 0.49 Body Mass Index (kg / m2) 321 1.02 (0.99 to 1.05) 0.22 Smoking 325Never —Current 0.80 (0.19 to 3.26) 0.75 Former 0.79 (0.54 to 1.18) 0.25 Treated Chronic Hypertension 325No —Yes 0.94 (0.64 to 1.37) 0.75 History of Cardiac Disease 325No —Yes 1.10 (0.73 to 1.64) 0.65Abbreviations: HR = Hazard Ratio; CI = Confidence Interval23FH13302894.9Attorney Docket No.: CUR-00225EXAMPLE 2Measuring Complement Factors in Patient Samples

[0105] The analysis of the relationship of longitudinally measured complement factors with time to progression to any advanced AMD is displayed in FIG.2A. The number of complement factors measured at each research visit can be found Table 2.Table 2. Number of Longitudinal Biomarker Samples Used to Fit Linear Mixed Effect Models by Study Visitaat which Plasma was CollectedEnrollment Year Post Enro ImentComplement1 2 3 4 5 6 7 8 FactorClq 298 90 63 66 52 47 26 13 1 C2 298 90 63 66 52 47 26 13 1 C4 298 90 63 66 52 47 26 13 1 C4b 298 90 63 66 52 47 26 13 1 MBL 298 90 63 66 52 47 26 13 1 C3 298 90 63 66 52 47 26 13 1 C3a 298 90 63 66 52 47 26 13 1 C3b-iC3b 298 90 63 66 52 47 26 13 1 Ba 300 90 63 66 51 47 26 13 1 Bb 147 72 63 66 51 47 26 13 1 Factor B 298 90 63 66 52 47 26 13 1 Factor D 298 90 63 66 52 47 26 13 1 Factor H 298 90 63 66 52 47 26 13 1 Factor I 298 90 63 66 52 47 26 13 1 Properdin 228 83 63 66 52 47 26 13 1 C5 298 90 63 66 52 47 26 13 1 C5a 293 90 63 66 52 47 26 13 1sC5b-9 228 83 63 66 52 47 26 13 1aSamples for years post enrollment categorized as the nominal year post enrollment + / - 6 months. An individual may contribute multiple samples over time, although an individual need not contribute a sample at every timepoint before progression to advanced AMD or censoring

[0106] Concentrating on complement factors that were significant following adjustment for the FDR, a significant relationship was identified between higher systemic levels of two factors, C4 and C4b, with the hazard of progression to any advanced AMD. These data also illustrate that a 1 log10(ng / ml) reduction in systemic levels of C3 was associated with a 66.7-fold increase in the hazard of progression to any advanced AMD. Furthermore, a higher ratio of C3a / C3 was significantly related to shorter time to progression any AMD. Higher levels of the inhibitor, Factor I, were associated with hazard of advanced AMD progression. Regarding the TP, a significantly higher risk at any given time24FH13302894.9Attorney Docket No.: CUR-00225of progression was found with lower levels of systemic C5, suggesting cleavage of this protein. Aligned with this finding, a higher systemic C5a / C5 and a higher sC5b-9 / C5 ratio had significant HRs (FIG. 2A).

[0107] Estimated tdROC curves with corresponding tdAUC values for joint models incorporating three complement factor ratios separately, and a multivariable joint model incorporating C3a / C3 and sC5b-9 / C5 (combined) factor ratios was examined. tdROC was estimated utilizing longitudinal complement measurements from enrollment to 24 months, and a predictive period from 24-48 months post-enrollment. N=192 subjects were still at risk at 24 months post-enrollment. Timedependent area under the tdROC (tdAUC) was calculated for each model.

[0108] As shown in FIG. 2B, the tdROC curves were analyzed for all significant complement ratios from the first part of the analysis. The tdAUC for these biomarkers was 0.75 (C3a / C3), 0.69 (C5a / C5), 0.71 (sC5b-9 / C5), and 0.76 (combined C3a / C3 and sC5b-9 / C5). The combined model only included C3a / C3 and sC5b-9 / C5 as C5a / C5 and sC5b-9 / C5 were correlated by sharing the same denominator and residing on the same end of the TP (FIG. 1).

[0109] Time-dependent receiver operating characteristic curves (tdROC) estimated from joint models estimated for complement ratios significantly associated with time to progression to any advanced AMD: C3a / C3, C5a / C5, and sC5b-9 / C5, and for a multivariable joint model which incorporated C3a / C3 and sC5b-9 / C5 (Combined).

[0110] The relationship between the complement factors with the described secondary outcomes, progression to specifically GA or NVAMD as competing phenotypes is shown in FIG. 2C and abbreviated for only the significant factors in FIG. 2B. As displayed, two ratios C3a / C3 and C5a / C5 were significantly associated with an elevated hazard of progression to GA. Prior to FDR adjustment there was a significant association between sC5b-9 / C5 hazard of progression to NVAMD.

[0111] FIG. 3 shows the relationship of C3a / C3 (fg / ng) and C5a / C5 (fg / ng) with time to progression to either GA or NVAMD. Hazard ratio point estimates flanked by 95% credible intervals estimated from a competing risks joint model with log10-transformed complement factor ratios. A dashed horizontal line at y=l represents the null value of the hazard ratio, with abbreviations: GA = Geographic atrophy, NVAMD = Neovascular AMD.

[0112] These results demonstrate that overactivation of certain complement pathways increases the risk of conversion to advanced AMD and specifically to GA. These data illustrate how to identify an at-risk group of patients for personalized ophthalmic care and targeted systemic treatments to attenuate the risk of progression to advanced AMD, and in particular GA.25FH13302894.9Attorney Docket No.: CUR-00225

[0113] A number of main findings of this study conducted in an iAMD cohort followed over time were: Firstly, a significant contribution of select systemic complement factors from the CP, C4 and C4b, with time to progression to any advanced AMD; secondly a higher hazard of progression to any advanced AMD with elevated levels of specifically the C3a / C3, C5a / C5, and the sC5b-9 / C5 ratios; thirdly a significant relationship between the complement ratios, C3a / C3 and C5a / C5, with the hazard of progression to GA. Finally, a significantly higher hazard of progression to any advanced AMD with higher levels of Factor I. In an exploratory analysis we found tdAUCs of between 0.69 and 0.76 for the complement ratios examined individually and when combined, which indicates the good performance of the predictive model described herein.

[0114] In aggregate, these results suggest overactivity of the complement system in the systemic circulation of iAMD patients who progress to advanced AMD. The results of the analysis of complement ratios (activation fragment / substrate) were especially informative and indicate activation of the complement pathways (consumption of the parent complement protein with more production of activation fragment). It is noteworthy that these results also demonstrated complement overactivity in the TP as suggested by a high C5a / C5 and sC5b-9 / C5 for the primary outcome and of the C3a / C3 and C5a / C5 ratios for GA. It is likely that the higher levels of Factor I found to be significantly associated progression to any advanced AMD may be explained as a compensatory response to attenuate the systemic inflammatory milieu triggered by complement overactivation. The discriminative performance of the models used for these studies was meaningful as assessed by tdAUC.

[0115] This longitudinal study also resulted in the novel finding of a significant relationship between select components of the CP, underexplored in clinical AMD research, with time to progression to any advanced AMD. These results suggest that the CP should receive more attention in the study of the pathogenesis of AMD as activation of this pathway may be a significant driver of the downstream effect of uncontrolled complement activation that potentially may influence iAMD progression.

[0116] Complement components identified herein as related to time to progression to GA are also the targets of two intravitreal complement inhibitors recently approved by the United States Food and Drug Administration to slow the growth of GA lesions. The first drug, pegcetacoplan (Syfovre®), inhibits C3 and its activation fragment C3b. The objective of this targeted complement inhibition was to prevent the downstream local effects of complement mediated inflammation. The second drug, avacincaptad pegol (Izervay®) was developed to prevent cleavage of C5 and therefore the adverse biological events linked with local activation of the TP. In clinical trials, both drugs reduced the growth of the GA lesion compared with sham. Although the results of these trials are promising and 26FH13302894.9Attorney Docket No.: CUR-00225represent a significant advance in the treatment of GA, follow-up of patients in these trials suggests an increased frequency of adverse ocular events in the treated compared with the untreated group. Importantly, these targeted intravitreal complement inhibitors do not reverse the loss of the photoreceptors that has already occurred in patients with GA. Based on the results of our study in patients with iAMD, we suggest that signals of systemic complement overactivation may be present prior to progression to any advanced AMD. These findings should prompt exploration of systemic therapies to target and inhibit complement pathways in the early stages of AMD before the AMD-related macular pathology becomes irreversible.

[0117] Important strengths of the study include the longitudinal follow-up of iAMD patients, measurement of a large number of complement factors at each research visit, and robust characterizations of patient AMD phenotypes. Additionally, a novel application of a joint statistical model was used for the first time to estimate the hazard of progression to advanced AMD from dynamic biomarker measurements. Although the sample size was meaningful for the main outcome, progression to any advanced AMD, there was some reduced statistical power when the cohort was stratified into GA and NVAMD. In certain patients, a limitation included the interval censoring of the outcome, in that that progression occurred between visits, such that the exact time to conversion could not be determined.

[0118] Although AMD presents as a local disease, these data show that systemic complement activation contributes to iAMD progression. These findings indicate that the macula is a sensitive target for systemic inflammatory processes, specifically complement components and fragments, circulating in the vascular network of the choriocapillaris. The choroidal blood vessels have a direct connection with the systemic circulation, are highly permeable to plasma proteins, and supply the outer retina with oxygen and nutrients. It is likely that proteins linked with complement activation fragments permeate the choroid and affect the RPE and outer retina. This is demonstrated by the specifically elevated sC5b-9 / C5 in the present results.

[0119] These findings support clinically relevant methods for identifying a high-risk group of iAMD patients for personalized ophthalmic care and targeted systemic treatments to attenuate the risk of progression to advanced AMD and to preserve vision.MethodsUniversity of Colorado AMD Registry

[0120] The source of data was records and samples from the University of Colorado AMD registry and repository. Research from the registry, is approved by the Colorado Multiple Institutional 27FH13302894.9Attorney Docket No.: CUR-00225Review and follows the ethical principles of the Declaration of Helsinki. Patients with AMD who are between ages 55 and 99 years who attend the UC Health Sue Anschutz-Rodgers Eye Center retina clinics and have given informed consent make up this registry.Recruitment, follow-up, and exclusion criteria

[0121] Details of the registry are described elsewhere.(17, 19, 29, 30) At enrollment each patient is consented for a medical history review, collection of a plasma sample [ethylenediaminetetraacetic acid (EDTA)], using methods previously described (17, 31) to optimally stabilize the complement system, and review of multimodal imaging (MMI) (color fundus photo, fundus autofluorescence, and spectral domain optical coherence tomography of the macula) to determine AMD phenotype (3). Following the enrollment visit, the MMI and plasma sample are collected annually at a routine visit to the retina clinic. If the patient misses the annual follow-up visit, the blood and imaging are collected at the next scheduled visit. Regular follow-up of research participants to minimize attrition is conducted as described in (32). Ocular exclusion criteria include the presence of active retinal or uveitic diseases affecting the macula, described in (29).Image Review

[0122] The initial image review to assign AMD phenotype to patients is conducted by two vitreoretinal specialists. Discrepancies identified are resolved by a third vitreoretinal specialist. We use the Beckman Initiative for Macular Research Classification Committee Image criteria to classify AMD participants into the AMD phenotypes. (3) GA is classified using the Classification of Atrophy Meeting (CAM) criteria (33) and NVAMD by the presence of choroidal neovascularization on MMI. A progression review is conducted on iAMD patients approximately every 6 months.Inclusion criteria and main study outcomes

[0123] The analytic dataset for this study was restricted to participants with iAMD enrolled into the registry between July 2014 and June 2022 who had at least 1 month of follow-up. A review for progression to advanced AMD was conducted on this cohort in February 2024 using the imaging methodology described above. The primary outcome of the study was time to progression of the first eye to any form of advanced AMD defined as either GA or NVAMD. Secondary outcomes were time to progression to NVAMD or GA.28FH13302894.9Attorney Docket No.: CUR-00225Collection and Processing of the Plasma Sample

[0124] Detailed methods are described elsewhere. In brief, using a cooled (40 Celsius) centrifuge the EDTA tube was spun at 3000 revolutions per minute for 10 minutes to isolate plasma. Aliquots of plasma were stored in a -80 C freezer.Complement Factor Panel Analysis

[0125] The complement factor panel analysis was conducted by Exsera BioLabs, a CAP / CLIA certified laboratory. Plasma complement biomarkers levels for: Clq, C4, C2, MBL, C4b, C3, Factor B, Factor D, Properdin, C3a, C3b_iC3b, C3b, Ba, Bb, Factor H, Factor I, C5, C5a, and SC5b-9 were measured by one of two methods. The Ba, Bb, C3a and SC5b-9 levels were measured by ELISA (Quidel Corp, San Diego CA, USA). The remaining measurements were performed by multiplex Luminex immunoassays (Millipore Sigma, Burlington MA, USA). Both assays were run masked to progression status. The methods were optimized and validated to the level required for regulated laboratory analysis and are described in detail below.Detailed Description of Complement Factor Panel Analysis

[0126] The complement factor panel analysis was conducted by Exsera BioLabs, a CAP / CLIA certified laboratory, housed on the University of Colorado Anschutz Medical Campus in the Division of Rheumatology. Plasma Complement factors levels Clq, C4, C2, MBL, C4b, C3, Factor B, Factor D, Properdin, C3a, iC3b / C3b, Ba, Bb, Factor H, Factor I, C5, C5a, and SC5b-9 were measured. Measurement of complement components and activation fragment levels was performed by two methods. The Ba, Bb, C3a and SC5b-9 levels were measured by ELISA (Quidel Corp, San Diego CA, USA). The remaining measurements were performed by multiplex Luminex immunoassays (Millipore Sigma, Burlington MA, USA). For both methods, the assays were run masked to progression status. The methods were optimized and validated to the level required for regulated laboratory analysis. All analyses were performed in duplicate with the resulting mean values reported. For the multiplex Luminex data the mean fluorescent intensity was the raw value and for the ELISA analysis the raw values were optical density. Standard curves and a four parameter parametric curve fit (for all Luminex and C3a) or linear curve fit (Ba, Bb and sC5b-9) were utilized to calculate the absolute quality in ng / mL or pg / mL, as appropriate. A minimum of three quality controls (QC) were included in each run, including at least one laboratory developed and characterized QC. The QCs were monitored for performance and for all testing in the study all runs met required acceptance criteria, demonstrating assay performance. Human plasma reference ranges 29FH13302894.9Attorney Docket No.: CUR-00225for the analytes tested have been determined within Exsera by the measurement of greater than 100 normal. During validation, the inter-assay and inter-assay precision were tested for all the analytes at three concentrations across the analytical measurement range over 18 replicates. The result were as follow: Luminex Panel 1 (C2, C4b, C5, C5a, Factor D, MBL, and Factor I); intra-assay max 12.2 %CV, average 6.8%CV and for inter-assay max 15.2 %CV, average 8.8 %CV: Luminex Panel 2, (Clq, C3, C3b / iC3b, C5, Factor B, Factor H, and Properdin) intra- assay max 10.9 %CV, average 4.7 %CV; inter-assay max 19.6 %CV, average 12.5 %CV: ELISAs intra-assay max 10.5 %CV, average 5.3 %CV; inter-assay max 16.7 %CV, average 9.8%CV. The methods were optimized and validated to the level required for regulated laboratory analysis.Statistical Analysis

[0127] The association between baseline clinical characteristics and time to progression to any advanced AMD was assessed using Cox Proportional Hazards (Cox PH) models. With the exception of Clq and C5, all complement variables were logio transformed. Sample time was defined as the duration from study enrollment to the sample collection date. Time to progression was defined as the duration from study enrollment to the time of the image which revealed the progression. The Beckman Initiative for Macular Research Classification Committee Image criteria was used to classify AMD participants into the AMD phenotypes. (3) GA is classified using the Classification of Atrophy Meeting (CAM) criteria(33) and NVAMD by the presence of choroidal neovascularization on MMI. Patients who did not progress were censored at their last appointment with retina specialists at our clinics.

[0128] Joint models were used to assess the association between dynamic complement factor measurements and time to progression to any advanced AMD (primary), and progression to NVAMD or GA (secondary). Joint models estimate the association between a dynamically changing factor (the biomarker) with a time-to-event outcome while accounting for measurement error in the biomarker and that their values are only observed at specific times. These models use linear mixed effect models to estimate predicted individualized dynamic values of each biomarker that is then incorporated into a Cox PH model. The measure of association was the hazard ratio (HR), which is interpreted as a factor increase in risk of progression at any time for a unit increase in the complement factor variable. False discovery rate (FDR)(34) - corrected p-values were used to account for multiple comparisons.

[0129] An exploratory analysis was conducted to assess the discriminative performance of these joint models for complement factor ratios identified as statistically significant in the primary analysis 30FH13302894.9Attorney Docket No.: CUR-00225using time-dependent receiver operating characteristic curves (tdROC) and the time-dependent Area Under Curve (tdAUC) metric. Twenty-four months of biomarker data was utilized, and a 24-month predicted time window. All analyses were performed using R, version 4.4.1, and joint models were fit using the JMbayes2 package. Details on the statistical analysis are shown below.Detailed Statistical Analysis of Complement Factors and Complement Factor Ratios

[0130] The joint model of the functional form was chosen= / i0(t)exp{yrw£+j y£(t) = m£(t) + e£(t)I mz(t) = +zTbt.

[0131] In this parameterization, the hazard h for individual i(i = 1,..., A) at time= 1,..., T*) was modeled, where T* is the time that the event of interest occurs, given Mi(t) = {mt s) < s < t}, which represents the expected value of the longitudinal biomarker of interest prior to time t. This hazard is a function of some baseline hazard at time t, h0(t), a set of baseline covariates wt(i.e., sex, age at enrollment, etc.) with regression coefficients y, and the expected value of the longitudinal exposure at time t, m^t). The parameter of interest is a, which associates m£(t) with hi(t) at each time point t. a is thus interpreted such that a one unit increase in m£(t) is associated with an exp{a}-fold increase in the risk of the event of interest at time t. This “current value association” is one of the many possible parameritizations of the joint model, each of which offers varying options to associate m£(t)with Many of these parameterizations are conveniently available in the JMbayes2 package and provide a very powerful tool to implement joint modeling for a wide variety of applications.

[0132] To estimate m^t), a linear mixed effects model was used, where yi(t) =+ e£(t) = x (t) / ? + z bt+ e£(t), where yi(t) is the observed value of the longitudinal outcome of subject i at time t, xtis a design matrix of fixed effects with corresponding regression coefficients / ?, z£is a subject- specific design matrix with corresponding subject- specific random effects bt, and 6i(t) is the error from the true unobserved value of the longitudinal exposure at time t. It is further noted bt~ A(0, 6), where G is a 2 x 2 covariance matrix if random intercepts and random slopes are modeled, and e£(t) ~ A(0, cr2). Linear mixed effects models are conveniently fit in R using the lme4 and nlme packages, although JMbayes2 requires the use of the nlme package.

[0133] Once a joint model has successfully been fit, using the joint model to predict the survival probability over a time interval for a new subject given the subject’s specific longitudinal biomarker 31FH13302894.9Attorney Docket No.: CUR-00225profile may be of interest. That is, given the joint model described above, it is of interest to obtain predictions from a new subject j from the same population to which the joint model was fit, who has provided a set of longitudinal biomarker measurements T / y (t) = {jj 0 < tjbI = 1,..., nJ and who will survive at least up to a future time point u. Specifically, for subject j, predicting the probability of survival up to time point u is intended7T7(u|t) = P(T? > U\T;and the predicted longitudinal biomarker profile w at time point uG)J (u\t) = E {yj (u) | T- > t, yj (t)}.

[0134] With a new biomarker sample for subject j at time t' > t, the predictions are updated dynamically to obtain Tij(u\t') and m7(u|t'). Estimates of TT7and m7are based on their posterior predictive distributions.

[0135] We can evaluate the discriminative performance of our joint model over some interval (t, 41] with a prediction rule utilizing 7ij(t + 4t|t) and y^t}. For c E [0,1], we define sensitivity asP (nj(t + 411 t) < c\Tj* E (t, t + 4t))and specificity asP( ij(t + 411 t) > c\Tj* > t + 4t).

[0136] The time-dependent area under the operating characteristic curve (tdAUC) provides a measure of discriminative performance and is obtained by varying c for subject i who experiences the event and subject j who does not, both of whom have longitudinal measurements up to time t. It is expressed astdAUC(t, At')(ni(t + 4t|t) < 7ij(t + 4t|t)|{Ti* E (t, t +4t]} A {7}* > t + At}).Application of Statistical Analysis of Complement Factors

[0137] First fit linear mixed effects models were used to estimate individual- specific longitudinal trajectories of each complement factor or complement factor ratio. When necessary, units of concentration of numerator values of complement factor ratios were converted such that the resulting hazard ratios estimated by the joint models were of a reasonable magnitude. All variables with the exception of Clq and C5a were anchored at 1 and log10transformed due to right-skew. Model 32FH13302894.9Attorney Docket No.: CUR-00225random effect specification was limited to random intercepts and linear random slopes. Where appropriate, polynomial terms or natural cubic splines in fixed effects fit by the ns function of the Splines package were used to model non-linear trajectories of complement factors. Linear mixed effects model specification for each complement factor was chosen based on a balance of quantitative metrics of model performance, and graphical visualization of model fit. Metrics of model fit included Akaike information criterion (AIC), Bayesian information criterion (BIC), 5-fold cross validation with folds on the subject level, 2-fold cross validation with folds on the observation level, marginal R2, and conditional R2. Mean square error was used as a cross validation metric. 2- fold cross validation with folds on the observation level required removal of subjects with only one observation and was repeated 100 times.

[0138] Cox Proportional Hazards (Cox PH) models were fit to model time to progression to any advanced macular degeneration (AMD) and then to time to progression to either geographic atrophy or neovascular AMD as competing risks using the Survival package. No baseline covariates (y above) were included in these models.

[0139] The joint model of the functional form Tij (t | = / i0(t)exp{amj(t)} was then fit for each complement factor and complement factor ratio using the jm function of the JMbayes2 package.

[0140] An additional multivariable joint model was fit which incorporated current values of C3a / C3 and sC5b-9 / C5 complement ratios (longitudinal profiles were estimated separately as in our primary analysis), which were found to be associated with time to progression to any advanced AMD in our primary analysis, and which reside on opposite ends of the terminal pathway, i.e.,= ho(t>)exp{a1mC3ajC3ii(t>) + a2™sC5b-9 / c5,i(O}-

[0141] The discriminative performance of the joint models was then evaluated incorporating these three ratios individually, C5a / C5, as well as the multivariable joint model by estimating the tdAUC for each model utilizing longitudinal biomarker measurements from enrollment out to 24 months, with a 24-month prediction window. Discriminative performance of these models was assessed over the entire dataset, optimism-corrected predictive performance estimates can also be applied to these joint models.

[0142] All analysis was performed using R version 4.4.1. Linear mixed effects models were fit using the nlme package, Cox PH models were fit using the Survival package, joint models were fit using the JMbayes2 package (available on the world wide web at drizopoulos.github.io / JMbayes2 / ), tdROC was estimated using the tvROC function of the JMbayes2 package, tdAUC was estimated using the tvAUC function of the JMbayes2 package, 5-fold cross validation on the subject level was 33FH13302894.9Attorney Docket No.: CUR-00225performed using the cv package, 2-fold cross validation on the observation level was performed using the cv_ng function available on the world wide web at github.com / ncgrove / cv_ng, and R2metrics were calculated using the MuMIn package.EXEMPLARY EMBODIMENTS

[0143] Exemplary Embodiment 1. A method for identifying an intermediate age-related macular degeneration (iAMD) patient at risk for converting to advanced AMD comprising analyzing a plasma sample from the patient, wherein an elevated level in the plasma sample of at least one complement factor, and / or at least one elevated ratio of complement factors, or any combination thereof, when compared with a one unit lower level, indicates that the iAMD patient is at a higher risk of progressing to advanced AMD.

[0144] Exemplary Embodiment 2. The method of exemplary embodiment 1, wherein the elevated complement factor is C4, C4b and / or at least one ratio of C3a / C3, C5a / C5, sC5b-9 / C5, or any combination thereof.

[0145] Exemplary Embodiment 3. The method of any of the previous exemplary embodiments, further comprising ophthalmic imaging of the patient’s eyes, wherein the ophthalmic imaging provides phenotypic classification of AMD.

[0146] Exemplary Embodiment 4. The method of exemplary embodiment 3, wherein the ophthalmic imaging comprises multimodal imaging (MMI).

[0147] Exemplary Embodiment 5. A method for treating age-related macular degeneration (AMD) in a patient with intermediate AMD (iAMD) comprising administering an effective amount of at least one inhibitor of complement activation to the patient when the patient exhibits elevation in a plasma sample of at least one complement factor, and / or at least one elevated ratio of complement factors, when compared with one unit lower level.

[0148] Exemplary Embodiment 6. A method for delaying progression of AMD in a patient with iAMD comprising administering an effective amount of at least one inhibitor of complement activation to the patient when the patient exhibits elevation in a plasma sample of at least one complement factor, and / or at least one elevated ratio of complement factors, when compared with a with one unit lower level.

[0149] Exemplary Embodiment 7. The method of exemplary embodiment 5 or exemplary embodiment 6, wherein the elevated level of at least one complement factor is C4, C4b, and / or the ratios C3a / C3, C5a / C5, and sC5b-9 / C5, or any combination thereof, indicates that the iAMD patient is at a higher risk of progression to advanced AMD.34FH13302894.9Attorney Docket No.: CUR-00225

[0150] Exemplary Embodiment 8. The method of exemplary embodiments 5-7, further comprising ophthalmic imaging of the patient’s eyes, wherein the ophthalmic imaging provides phenotypic classification of AMD.

[0151] Exemplary Embodiment 9. The method of exemplary embodiment 8, wherein the ophthalmic imaging comprises multimodal imaging (MMI).

[0152] Exemplary Embodiment 10. The method of any of exemplary embodiments 5-9, wherein the administering delays or prevents progression to advanced AMD in the patient.

[0153] Exemplary Embodiment 11. The method of any of exemplary embodiments 5-10, wherein the administering is systemic, ophthalmic, or a combination of systemic and ophthalmic.

[0154] Exemplary Embodiment 12. The method of exemplary embodiment 11, wherein the administering is systemic.

[0155] Exemplary Embodiment 13. The method of any of exemplary embodiments 5-12, wherein the at least one inhibitor of complement activation is Lampalizumab, Tesidolumab, CLG561, POT4 (AL-78898A), cemdisiran, Berinert, Cinryze, Ruconest, Enjaymo (Sutimlimab), Soliris (Eculizumab), Ultomiris (Ravulizumab), Zilbrysq (Zilucoplan), Veopoz (Pozelimab), Izervay (Avacincaptad Pegol), Tavneos (Avacopan), Fabhalta (Iptacopan), Voydeya (Danicopan), Pegcetacoplan (Empaveli, or Syfovre for injection), Crovalimab, Iptacopan (Fabhalta), Danicopan (Voydeya), Avacopan (Tavneos), Narsoplimab (OMS721), AMY-101, LNP023, ANX005, or any combination thereof.

[0156] Exemplary Embodiment 14. The method of any one of exemplary embodiments 5-13, further comprising administering at least a second therapeutic agent.

[0157] Exemplary Embodiment 15. A prognostic complement panel for determining whether a subject with intermediate AMD (iAMD) is at a higher risk of progressing to advanced AMD comprising probes for C4, C4b, C3a, C3, C5a, C5, sC5b-9, and instructions comprising standard values for the complement probes that indicate progression from iAMD to advanced AMD.

[0158] Exemplary Embodiment 16. A kit comprising the prognostic complement panel of exemplary embodiment 15, and optional reagents for detecting the probes.EQUIVALENTS AND INCORPORATION BY REFERENCE

[0159] All references cited herein are incorporated by reference to the same extent as if each individual publication, database entry (e.g., Genbank sequences or GenelD entries), patent application, or patent, was specifically and individually indicated incorporated by reference in its entirety, for all purposes. This statement of incorporation by reference is intended by Applicants,35FH13302894.9Attorney Docket No.: CUR-00225pursuant to 37 C. F. R. §1.57(b)(1), to relate to each and every individual publication, database entry (e.g., Genbank sequences or GenelD entries), patent application, or patent, each of which is clearly identified in compliance with 37 C. F. R. §1.57(b)(2), even if such citation is not immediately adjacent to a dedicated statement of incorporation by reference. The inclusion of dedicated statements of incorporation by reference, if any, within the specification does not in any way weaken this general statement of incorporation by reference. Citation of the references herein is not intended as an admission that the reference is pertinent prior art, nor does it constitute any admission as to the contents or date of these publications or documents. While the invention has been particularly shown and described with reference to a preferred embodiment and various alternate embodiments, it is understood by persons skilled in the relevant art that various changes in form and details can be made therein without departing from the spirit and scope of the invention.FH13302894.9

Claims

1. Attorney Docket No.: CUR-00225What is claimed is:

1. A method of diagnosing an intermediate age-related macular degeneration (iAMD) patient as having a high risk of progression from iAMD to advanced AMD comprising:(a) obtaining a first plasma sample from the iAMD patient at a first timepoint;(b) obtaining at least one successive plasma sample from the iAMD patient at a successive timepoint;(c) comparing the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the at least one successive plasma sample; and(d) determining that the iAMD patient has a high risk of progression from iAMD to advanced AMD if the level of any one of or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the at least one successive plasma sample is elevated compared to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample.2 The method of claim 1, wherein each of the at least one successive plasma sample is obtained from the iAMD patient at a timepoint later than the first timepoint.3 The method of claim 1 or 2, wherein the at least one successive plasma sample comprises from 1 to 20 successive plasma samples.4 The method of claim 3, wherein the successive plasma samples are obtained at a regular interval after the first timepoint.5 The method of claim 4, wherein the regular interval is from 1 day to 5 years.6 The method of any one of claims 1-5, wherein the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the at least one successive plasma sample is associated with a shorter time of progression to advanced AMD using a hazard ratio for each of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.7 The method of claim 6, wherein the hazard ratio for C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 is greater than 1.37FH13302894.9Attorney Docket No.: CUR-002258. A method of treating age-related macular degeneration (AMD) comprising:(a) obtaining a first plasma sample from an iAMD patient at a first timepoint and a second plasma sample from the iAMD patient at a second timepoint;(b) measuring the level of at least one systemic complement factor and / or at least one ratio of systemic complement factors in the first plasma sample and in the second plasma sample;(c) identifying the patient as having an elevated risk of progressing from iAMD to advanced AMD; and(d) administering at least one inhibitor of complement activation to the patient if the patient is identified as having an elevated risk of progressing from iAMD to advanced AMD;wherein the second timepoint is later than the first timepoint, andwherein the at least one systemic complement factor is selected from the list consisting of C4 and C4b and the at least one ratio of systemic complement factors is selected from the list consisting of C3a / C3, C5a / C5, and sC5b-9 / C5.9 The method of claim 8, wherein the identifying comprises:(a) comparing the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the second plasma sample; and(b) determining that the patient has an elevated risk of progressing from iAMD to advanced AMD if the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is elevated in the second plasma sample compared to the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the first plasma sample.10 The method of claim 8 or 9, wherein the administering delays progression from iAMD to advanced AMD in the iAMD patient.11 The method of any one of claims 8-10, wherein the administering is systemic, ophthalmic, or a combination thereof.12 The method of any one of claims 8-11, wherein the administering is systemic.38FH13302894.9Attorney Docket No.: CUR-0022513. The method of 8-12, wherein the inhibitor of complement activation targets any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

14. The method of 8-13, wherein the inhibitor of complement activation is Lampalizumab, Tesidolumab, CLG561, POT4 (AL-78898A), cemdisiran, Berinert, Cinryze, Ruconest, Enjaymo (Sutimlimab), Soliris (Eculizumab), Ultomiris (Ravulizumab), Zilbrysq (Zilucoplan), Veopoz (Pozelimab), Izervay (Avacincaptad Pegol), Tavneos (Avacopan), Fabhalta (Iptacopan), Voydeya (Danicopan), Pegcetacoplan (Empaveli, or Syfovre for injection), Crovalimab, Iptacopan (Fabhalta), Danicopan (Voydeya), Avacopan (Tavneos), Narsoplimab (OMS721), AMY-101, LNP023, or ANX005.

15. The method of any one of claims 8-14, further comprising administering a second therapeutic agent.

16. The method of any one of claims 8-15, wherein the second timepoint is from 1 day to 5 years after the first timepoint.

17. The method of any one of claims 8-16, wherein the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the second plasma sample is associated with a shorter time of progression to advanced AMD using a hazard ratio for each of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

18. The method of claim 18, wherein the hazard ratio for C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 is greater than 1.

19. A method of diagnosing an iAMD patient having a high risk of progression from iAMD to advanced AMD comprising:(a) obtaining a plasma sample from the iAMD patient;(b) measuring the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the plasma sample;(c) comparing the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the plasma sample to a reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5; and39FH13302894.9Attorney Docket No.: CUR-00225(d) determining that the iAMD patient has a high risk of progression from iAMD to advanced AMD if the level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 in the plasma sample is elevated compared to a reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

20. The method of claim 19, wherein the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is established from a cohort of reference AMD patients.

21. The method of claim 19 or 20, wherein the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 100% greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

22. The method of any one of claims 19-21, wherein the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 50% greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

23. The method of any one of claims 19-21, wherein the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 25% greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

24. The method of any one of claims 19-21, wherein the elevated level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5 is from about 1% to about 10% greater in the plasma sample compared to the reference level of any one or a combination of C4, C4b, C3a / C3, C5a / C5, and sC5b-9 / C5.

25. A kit for assessing risk of progression from iAMD to advanced AMD in a subject comprising: reagents and instructions for measuring the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in a first plasma sample and the level of C4, C4b, C3a / C3, C5a / C5, and / or sC5b-9 / C5 in a second plasma sample; and instructions providing criteria for classifying the subject as at risk for progressing from iAMD to advanced AMD.40FH13302894.9

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