CN121127494A

CN121127494A - Anti-CD 38 antibodies for the treatment of autoimmune diseases

Info

Publication number: CN121127494A
Application number: CN202380090542.XA
Authority: CN
Inventors: D·T·博尔格; J·霍姆斯; K·奥利克美特斯
Original assignee: Takeda Pharmaceutical Co Ltd
Current assignee: Takeda Pharmaceutical Co Ltd
Priority date: 2023-01-06
Filing date: 2023-12-20
Publication date: 2025-12-12
Also published as: KR20250135226A; WO2024147934A1; EP4646435A1; AU2023421723A1; MX2025007885A; JP2026501785A

Abstract

Methods of treating patients suffering from autoimmune diseases such as Myasthenia Gravis (MG) by administering isolated anti-CD 38 antibodies are disclosed. Also disclosed are unit dosage forms of the anti-CD 38 antibodies for use in treating patients suffering from autoimmune diseases such as Myasthenia Gravis (MG).

Description

Anti-CD 38 antibodies for the treatment of autoimmune diseases

Cross Reference to Related Applications

The present application claims priority from U.S. c. ≡119 (e) to U.S. provisional application serial No. 63/478,884 filed on 6 th 1 year 2023 and U.S. provisional application serial No. 63/515,285 filed on 24 th 7 year 2023, the entire disclosures of both of which are incorporated herein by reference.

Incorporation of materials submitted in electronic form by reference

The present application contains a sequence table that has been submitted electronically in an XML file format and is hereby incorporated by reference in its entirety. The XML file created at 12 of 2023 was named 101588-5017-WO Sequence listing. XML and was 16,384 bytes in size.

Technical Field

Background

Myasthenia Gravis (MG) is a rare autoimmune disorder in which autoantibodies target the neuromuscular junction (NMJ) and postsynaptic membrane and interfere with neuromuscular transmission, resulting in progressive skeletal muscle weakness. In the United states, the prevalence of MG is about 77.7 per million to 14 to 40 per 100,000 (Breiner et al (2016) neuromousul. Disord.26 (1): 41-6; carr et al (2010) BMC neuron.10:46; heldal et al (2012) Muscle Nerve 45 (6): 815-819; santos et al (2016) Muscle Nerve54 (3): 413-21).

As a feature of MG, skeletal muscle weakness and fatigability worsen with physical activity, improving with rest (Ludwig et al (2017) front. Immunol. 8:603). In some cases, muscle weakness can lead to respiratory and cardiac dysfunction (Phillips and Vincent (2016) F1000Res.5:F1000 Faculty Rev-1513). The disease may be life threatening, and in the myasthenia crisis, the muscles that control breathing become too weak, which may lead to death from respiratory failure.

MG is caused by pathogenic autoantibodies produced by plasma cells. Most MG patients (70%) produced immunoglobulin (Ig) G1 and IgG3 autoantibodies against acetylcholine receptor (AChR), while the remaining patients produced IgG4 autoantibodies against muscle-specific tyrosine kinase (MuSK; 1-10% of MG patients), igG1-3 antibodies against low-density lipoprotein receptor-related protein 4 (1-5% of MG patients), or no detectable autoantibodies (10% of MG patients). Binding of autoantibodies to proteins in NMJ eventually leads to damage to postsynaptic membranes (Ludwig et al (2017) front. Immunol. 8:603).

Reducing the level of pathogenic autoantibodies is challenging. Autoantibody-producing plasma cells are resistant to many conventional pharmacological strategies because they do not actively circulate and express relatively few surface antigens.

Current MG care criteria consist of a combination of symptomatic therapy (acetylcholinesterase inhibitors that increase the level of acetylcholine in the synapse) and immunosuppression. Immunosuppression therapy or immunomodulation therapy (such as corticosteroids, azathioprine, methotrexate, cyclosporine, tacrolimus, cyclophosphamide, plasmapheresis/plasma exchange and intravenous immunoglobulins [ IVIg ]) is administered to patients who have not met with satisfactory results with symptomatic therapy alone. However, about 10% of patients suffer from refractory disease, and up to 80% of patients fail to achieve complete stable remission (Mant egazza and Antozzi (2018) ter. Adv. Neurol. Dis. 11:1756285617749134; silvesti and Wolfe (2014) j. Clin. Neurokucul. Dis.15 (4): 167-178). Immunosuppressant drugs have several drawbacks, including limited efficacy and severe dose-limiting toxicity. Furthermore, these drugs do not directly affect autoantibody production.

Autoantibody levels can be reduced by targeting B cell progenitors of plasma cells. Rituximab (an anti-CD 20 antibody) targets these plasma cell progenitors, indirectly reducing autoantibody production by preventing the recruitment of autoreactive plasma cells. Rituximab, however, has limited efficacy in MG, probably because long-lived plasma cells thought to be responsible primarily for the production of anti-AChR antibodies do not express CD20 and are therefore not targeted by rituximab (Ludwig et al (2017) front. Immunol. 8:603).

There are several therapeutic options available for reducing autoantibody levels by increasing clearance of pathogenic autoantibodies, e.g., plasmapheresis/plasmapheresis, administration of IVIg or neonatal Fc receptor (FcRn) antagonists. Plasmapheresis and IVIg are mainly used before, before or during surgery or for myasthenia crisis, because of their rapid but transient effect. An alternative approach to increasing autoantibody clearance may be achieved by blocking FcRn, several FcRn antagonists are currently in clinical development and a therapy has recently been approved (Heo (2022) Drugs 82 (3): 341-348). These drugs reduce pathogenic IgG by inhibiting FcRn-mediated IgG recycling, thereby accelerating its clearance. However, these three treatments do not directly eliminate the source of pathogenic autoantibodies. Furthermore, the duration of action is relatively short, as shown in the data of the initial publication (Heo (2022) Drugs 82 (3): 341-348). Thus, long-term administration is required to maintain low levels of pathogenic autoantibodies (Kiessling et al (2017) sci. Transl. Med.9 (414): eaan 1208:1208).

Another therapeutic strategy in MG that does not eliminate the root cause of the disease is to reduce complement-mediated damage to the postsynaptic membrane at NMJ. This can be achieved with eculizumab, a monoclonal antibody that targets complement protein C5. While showing moderate efficacy, eculizumab therapy is associated with increased risk of meningococcal infection and is therefore limited by risk assessment and mitigation strategies (Howard et al (2017) Lancet. Neurol.16 (12): 976-986). Other complement inhibitors are under development, however, these agents are expected to be beneficial only in AChR positive patients because AChR autoantibodies effectively activate complement and cause postsynaptic membrane cleavage, while MuSK autoantibodies do not bind complement (Yi et al (2018) Muscle Nerve 57 (2), 172-84).

Thus, there is a need for new therapies for the treatment of MG that act on the pathogenesis of disease and provide a more sustained response and a favorable safety profile, treatments such as these may have the potential to reduce the use of corticosteroids and improve the quality of life of patients. As mentioned above, available conventional drug therapies do not target autoantibody-producing plasma cells, particularly long-lived plasma cells, which are the source of pathogenic autoantibody formation in MG.

Disclosure of Invention

Provided herein are methods and unit dosage forms comprising an anti-CD 38 antibody or antigen-binding fragment thereof for treating patients suffering from an autoimmune disease such as Myasthenia Gravis (MG). AB79 (the drug substance component of the micheliab (mezagitamab)) is a fully human recombinant monoclonal antibody (mAb) against CD38, CD38 is an antigen that is highly expressed on plasma cells, plasmablasts and Natural Killer (NK) cells and induced on activated T cells and B cells. AB79 specifically binds to CD38 with high affinity (kd=3.5 nM) (U.S. patent No. US 8,362,211, the contents of which are hereby incorporated by reference in their entirety). Administration of AB79 results in depletion of cells expressing high levels of CD38 through mechanisms involving apoptosis, antibody-dependent cell-mediated cytotoxicity, and complement-dependent cytotoxicity (Smithson et al (2017) J.Immunol.198 (1 journal): 224.20). AB79 depletes cells (plasmablasts, plasma cells, especially long-lived plasma cells) that produce pathogenic autoantibodies. It is expected that the reduction of plasmacytoid and longevity of plasmacytoid by micheliab will result in a reduction of pathogenic autoantibody levels, thereby ameliorating autoantibody-mediated pathology in MG, e.g., reducing damage at NMJ and ameliorating reversible neuromuscular defects in these patients.

It is an object of the present invention to provide a method for treating patients suffering from autoimmune diseases such as MG by subcutaneous administration of mezetuzumab.

In one aspect, the present disclosure provides a method of treating myasthenia gravis in a subject comprising administering to the subject an isolated human anti-CD 38 antibody or antigen-binding fragment thereof, wherein the isolated antibody or antigen-binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

In a second aspect, the present disclosure provides a method of reducing the level of plasmablasts, plasma cells, and/or NK cells in a subject diagnosed with myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen binding fragment thereof, wherein the isolated antibody or antigen binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

In a third aspect, the present disclosure provides a method of reducing the level of an immunoglobulin cell in a subject diagnosed as having myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen-binding fragment thereof, wherein the isolated antibody or antigen-binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

In a fourth aspect, the present disclosure provides a method of reducing myasthenia gravis disease activity and/or progression in a subject diagnosed with myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen-binding fragment thereof, wherein the isolated antibody or antigen-binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800.

In a fifth aspect, the present disclosure provides a unit dosage form comprising an isolated antibody or antigen-binding fragment thereof comprising a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4 and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7 and CDR3 having the amino acid sequence of SEQ ID NO:8, wherein the isolated antibody or antigen-binding fragment thereof binds to human CD38 (SEQ ID NO: 1) and is formulated for subcutaneous administration of the isolated antibody or antigen-binding fragment thereof in a dose of 100 mg to 800 mg in the treatment of myasthenia gravis.

Drawings

The objects and features of the present invention may be better understood by reference to the drawings described below.

Figure 1 shows a patient treatment summary of a safety analysis set. AE, adverse events, SAE, severe adverse events, W, weeks. * Relevant AE/SAE's were collected throughout LFP with non-resolved AE and post-SFP attacks by week 16.

FIG. 2 shows the observed mean change in the total score of myasthenia gravis daily living activity (MG-ADL) over time from baseline. Descriptive statistics do not include any assessment obtained after receiving rescue therapy or after prematurely discontinuing study medication. The reference line indicates a 2 point decrease in the total MG-ADL score from baseline.

Fig. 3 shows the observed mean change of the Quantitative Myasthenia Gravis (QMG) total score over time from baseline. Descriptive statistics do not include any assessment obtained after receiving rescue therapy or after prematurely discontinuing study medication. The reference line indicates that the QMG total score decreases by 3 points from baseline.

Figure 4 shows the observed mean change in the quantitative composite myasthenia gravis (MCG) total score over time from baseline. Descriptive statistics do not include any assessment obtained after receiving rescue therapy or after prematurely discontinuing study medication. The reference line indicates that the MGC total score is reduced by 3 points from baseline.

Fig. 5 shows the observed mean change over time of the revised 15-item myasthenia gravis quality of life scale (MG-QoL 15 r) total score from baseline. Descriptive statistics do not include any assessment obtained after receiving rescue therapy or after prematurely discontinuing study medication.

Figure 6 shows the proportion of subjects who decreased the total MG-ADL score from baseline to week 16 by at least 2 (full analysis set). CI is confidence interval, MG-ADL is myasthenia gravis daily life activity, TAK-079 is Meizumab. The error bars are the lower and upper limits of 95% CI in the ratio.

FIG. 7 shows the proportion of responders (subjects with a clinically significant decrease of > 2 score in MG-ADL score from baseline) in the 300MG MAIzetuzumab panel, the 600MG MAIzetuzumab panel and the placebo group. The overall MG-ADL score was reduced by at least two score responders relative to baseline. If the subject receives rescue therapy or prematurely discontinues the study medication, the subject is not thereafter considered a responder. MG-ADL, myasthenia gravis, activities of daily living. TAK-079, micheltuzumab.

Fig. 8 shows the proportion of subjects (full analysis set) who decreased the QMG total score from baseline to week 16 by at least 3 points. CI, confidence interval, QMG, TAK-079, mizituzumab. The error bars are the lower and upper limits of 95% CI in the ratio.

FIG. 9 shows a temporal sensitivity analysis of the proportion of responders (subjects with a clinically significant decrease of > 2 score in MG-ADL and a clinically significant decrease of > 3 score in QMG score relative to baseline) in the 300MG, 600MG and placebo groups. Responders, QMG decreased by at least three points and MG-ADL overall score decreased by at least two points relative to baseline. If the subject receives rescue therapy or prematurely discontinues the study medication, the subject is not thereafter considered a responder. MG-ADL, myasthenia gravis, activities of daily living. QMG for quantifying myasthenia gravis, TAK-079 for quantifying Meizumab. * There was a statistically significant difference compared to placebo.

Figure 10 shows the proportion of subjects who decreased the total MGC score from baseline to week 16 by at least 3 (full analysis set). CI is confidence interval, MGC is compound myasthenia gravis, TAK-079 is Meizumab. The error bars are the lower and upper limits of 95% CI in the ratio.

FIG. 11 shows a Mixed Model Repeat Measurement (MMRM) analysis of the percent change in anti-AChR values (nmol/L) over time from baseline. SEM, standard error of average value, TAK-079, michelituzumab. The percent change from baseline results from a repeated measure mixed effect model (MMRM) analysis for all post-baseline visits, with the percent change from baseline as a result, the treatment group, the visit, and the treatment/visit interactions as factors, and adjusted for baseline values and baseline-visit interactions. The model uses an unstructured covariance matrix. Any assessment obtained after receiving rescue therapy or after prematurely discontinuing study medication is not included in MMRM analysis. The percent change values for subjects 47503-512 in the 600mg TAK-079 (Micheliab) group on study day 22 (week 4) and day 29 (week 5) were not included in the calculation of the mixed effect model estimates for this figure, no. 1707.

Figure 12 shows individual observed anti-MuSK titres over time for two subjects in the 300mg micturition mab group. Musk, muscle-specific tyrosine kinase. Week 1 visit refers to baseline. Titer values are reported as the reciprocal of the observed titer.

Fig. 13 shows the observed mean change in the total score of Myasthenia Gravis Injury Index (MGII) over time from baseline. Descriptive statistics do not include any assessment obtained after receiving rescue therapy or after prematurely discontinuing study medication. The reference line indicates MGII a 8 points decrease in total score from baseline.

Figure 14 shows a log linear plot of mean/SD serum concentration of micturition mab versus time following multi-dose administration of micturition mab at 300mg and 600mg Subcutaneous (SC) injections.

Figure 15 shows the percent change in IgG over time from baseline (pharmacodynamic analysis set).

FIG. 16 shows the observed mean change from baseline in total score for MG-ADL per region over time. MG-ADL, myasthenia gravis activities of daily living, SEM, standard error of average value, TAK-079, mizituzumab.

Fig. 17 shows the observed mean change of the QMG total score per region over time from the baseline. QMG, SEM, standard error of average value, TAK-079, and MAIZOMETAMINE.

FIG. 18 shows the observed mean change in total MG-ADL score over time from baseline with the use of acetylcholinesterase inhibitors. AchE-i is an acetylcholinesterase inhibitor, MG-ADL is myasthenia gravis activities of daily living, SEM is standard error of average value, TAK-079 is Mezetuzumab.

Fig. 19 shows the observed mean change in QMG total score over time from baseline with the use of acetylcholinesterase inhibitors. AchE-i, acetylcholinesterase inhibitor, QMG, SEM, standard error of average value, TAK-079, and Mezetuzumab.

Figure 20 shows the pharmacodynamic effects of moderate total IgG reduction and consistent depletion of anti-AChR antibodies. Fig. 20A shows the change in IgG levels from baseline. Fig. 20B shows the change in anti-AChR antibody levels from baseline.

Figure 21 shows IgA and IgM depletion from week 8 to week 32 post dosing. Fig. 21A shows IgA and fig. 21B shows IgM.

Fig. 22 shows PD response of mictuzumab compared to Iguratimod (efgartigimod).

Figure 23 shows a high degree of agreement between QMG response and IgG depletion in the 300mg dose group, but no placebo. The red dotted line indicates a 3 point decrease in QMG score.

FIG. 24 shows a high degree of agreement between QMG/ADL response and IgG depletion at 300 mg. The red dotted line indicates a3 point decrease in QMG score.

Fig. 25 shows the change from baseline (secondary endpoint) in anti-MuSK antibody levels.

Figure 26 shows that the placebo response of MGII and MGQOL-15-R was less pronounced (based on patient assessment without investigator administration/intervention).

FIG. 27 shows individual MG-ADL and QMG responses at week 16.

FIG. 28 shows the placebo response of MAIzetuzumab compared to the comparative study, MG-ADL.

FIG. 29 shows QMG compared to the comparative study with Mezetuzumab.

Figure 30 shows the placebo response of the mictuzumab compared to the comparative study, QMG.

Fig. 31 shows that exposure of the mictuzumab on the expected range, the PK profile was consistent with MM.

Fig. 32 shows the michelvetuzumab exposure parameters for responders and non-responders.

Figure 33 shows the IgG exposure-response assessment (best% reduction of IgG) in MM and MG studies.

FIG. 34 shows an exposure response assessment of MG-ADL. The orange dotted line indicates a clinically significant threshold for a2 point decrease in MG-ADL.

Fig. 35 shows background therapy.

FIG. 36 shows a mixed model repeat measurement analysis (full analysis set) of changes in MG-ADL scores from baseline.

Fig. 37 shows a mixed model repeated measure analysis (full analysis set) of the change in QMG scores from baseline.

Detailed Description

Increased expression of CD38 has been described in a variety of diseases, including autoimmune diseases such as MG (YIlmaz et al (2018) Ann. Clin. Transl. Neurol.5 (11): 1408-1414). CD38 is a type II glycoprotein that is highly uniformly expressed on antibody-producing plasmablasts and plasma cells (Sullivan et al (2017) Blood 129 (22): 3033-7; which is incorporated herein by reference in its entirety) and makes it a potential target for the treatment of myasthenia gravis. Recent studies have found that circulating CD38+ plasmablasts in MG patients are significantly more frequent than in healthy subjects (Yamamoto et al (2021) Neurol. Neurolimunol. Neurolim. 8 (6): e 1087), which is incorporated herein by reference in its entirety).

CD38 expression on plasma cells and plasmablasts was significantly higher compared to other immune cells, suggesting that it is possible to selectively deplete these cells with anti-CD 38 antibodies. Daratumumab (daratumumab) is a commercially available anti-CD 38 antibody that provides substantial clinical improvement in myasthenia gravis patients as measured by quantitative myasthenia gravis score (from 16 to 8 minutes, n=1) by clinically relevant autoreactive long-life plasma cell depletion (Scheibe et al (2022) eur.j. Neurol.29 (6): 1847-1854; which is incorporated herein by reference in its entirety). Intravenous darimumab has been approved for use in patients with multiple myeloma (relapsed and newly diagnosed). However, the most common adverse reactions (. Gtoreq.20%) of darimumab monotherapy or in combination with standard anti-myeloma regimens are infusion-related reactions (IRR), neutropenia, thrombocytopenia, fatigue, nausea, diarrhea, constipation, vomiting, muscle spasms, joint pain, back pain, fever, chills, dizziness, insomnia, cough, dyspnea, peripheral oedema, peripheral sensory neuropathy and upper respiratory tract infections (Darzalex USPI). Darimumab can cause severe and/or severe infusion reactions, including allergic reactions, and is reported in about half of all patients (Darzalex USPI). Care must also be taken that darimumab interferes with certain laboratory assays, which importantly can complicate blood compatibility testing. (Darzalex USPI).

Other antibodies targeting CD38 are known (see, e.g., WO 2006/125640, which is incorporated herein by reference in its entirety, disclosing four human antibodies MOR03077, MOR03079, MOR03080 and MOR03100, and two murine antibodies OKT10 and IB 4). These prior art antibodies are inferior to micheltuzumab for a number of reasons. MOR03080 binds to human CD38 and cynomolgus monkey CD38, but has low affinity for human CD38 (Biacore kd=27.5 nm). OKT10 binds to human CD38 and cynomolgus monkey CD38, but has low/moderate affinity for human CD38 (Biacore kd=8.28 nm). MOR03079 binds to human CD38 with high affinity (Biacore kd=2.4 nm), but not to cynomolgus monkey CD38.MOR03100 and MOR03077 bind to human CD38 with medium or low affinity (Biacor kd=10 nm and 56nm, respectively). In contrast, micturizumab binds to human and cynomolgus monkey CD38 with high affinity (Biacore kd=5.4 nm for human CD 38). Furthermore, prior art antibodies have poor ADCC and CDC activity.

A more effective ADCC has the advantage of being able to deliver anti-CD 38 therapeutics in a small volume injection. Safety profiles and PD target effects were observed following subcutaneous administration of up to 0.6mg/kg dose of mezetuzumab to healthy subjects. A single subcutaneous dose of 0.6mg/kg of mezetuzumab decreased PB levels in peripheral blood by >90% and NK cell levels by >80%, with no comparable decrease in monocytes as well as B cells and T cells. 21 days after administration, PB and NK cell levels recovered to 50% of baseline levels. At this dose, no Serious Adverse Events (SAE), death in the study, or Adverse Events (AEs) leading to study discontinuation occurred (WO 2019/140410, which is incorporated herein by reference in its entirety). Further studies have shown that no drug-related SAE, mortality in the study, or AE leading to discontinuation of the study were reported following subcutaneous administration of a dose of 45mg, 135mg, 300mg, or 600mg of mezetuzumab following administration to patients with relapsed and/or refractory multiple myeloma (RRMM). Administration of the meizetuzumab reduces plasma cell levels in blood and bone marrow aspirates and in bone marrow aspirates in a dose-dependent manner. In patients with advanced RRMM, michelzumab also showed early signs of anti-tumor activity, as evidenced by at least 50% reduction in disease burden in some patients and prolonged disease stabilization in others (WO 2019/186273, incorporated herein by reference in its entirety). However, the feasibility and efficacy of administering the micturition mab to treat patients with myasthenia gravis is unknown.

The methods and unit doses of the present disclosure provide for the first time subcutaneous administration of a therapeutically effective dose of an anti-CD 38 antibody in the treatment of patients suffering from myasthenia gravis.

The present disclosure provides methods and unit dosage forms for subcutaneously administering a therapeutically effective amount of an isolated anti-CD 38 antibody or antigen-binding fragment to a patient suffering from myasthenia gravis. In some embodiments, an antibody or antigen binding fragment for subcutaneous administration comprises a variable heavy chain (VH) region comprising or consisting of SEQ ID NO 9 (or a sequence having at least 80%, 85%, 90%, 95%, 97% or 99% sequence identity thereto) and a variable light chain (VL) region comprising or consisting of SEQ ID NO 10 (or a sequence having at least 80%, 85%, 90%, 95%, 97% or 99% sequence identity thereto). In some embodiments, the antibody or antigen binding fragment thereof is administered subcutaneously at a dose of 100 mg to 800 mg.

Unless otherwise defined herein, scientific and technical terms used in connection with the present disclosure should have meanings commonly understood by one of ordinary skill in the art. The meaning and scope of the terms should be clear. However, if there are any implicit ambiguities, the definitions provided herein take precedence over any dictionary or extraneous definitions. In addition, unless the context requires otherwise, singular terms shall include the plural and plural terms shall include the singular. The term "or" includes "and/or" unless specified otherwise. Furthermore, the use of the terms "include," "include," or "comprise (included)" is not limiting. Unless specifically stated otherwise, terms such as "element" and "component" encompass elements and components that make up one unit, as well as elements and components that make up more than one sub-unit.

Unless otherwise indicated, the methods and techniques of the present disclosure are generally performed according to conventional methods well known in the art and as described in various general and more specific references cited and discussed throughout the present specification. Standard techniques are used for chemical synthesis, chemical analysis, pharmaceutical preparation, formulation, delivery, and treatment of patients. Commercial enzymatic reactions and purification techniques are performed according to manufacturer's instructions, as commonly accomplished in the art or as described herein.

All headings and chapter names are used for clarity and reference purposes only and should not be construed as limiting in any way. For example, those skilled in the art will recognize the usefulness of combining various aspects of the present disclosure from the different headings and chapters as appropriate in light of the spirit and scope of the present disclosure as described herein.

For easier understanding of the present disclosure, selected terms are defined below.

The terms "human CD38" and "human CD38 antigen" refer to the amino acid sequence of SEQ ID NO.1 or a functional part thereof, such as an epitope (Table 1), as defined herein. Typically, CD38 has a short cytoplasmic tail, a transmembrane domain, and an extracellular domain. The terms "cynomolgus monkey CD38" and "cynomolgus monkey CD38 antigen" refer to the amino acid sequence of SEQ ID NO.2, which is 92% identical to the amino acid sequence of human CD38 (Table 1). Synonyms for CD38 include cyclic ADP ribose hydrolase, cyclic ADP ribose-hydrolase 1, ADP ribosyl cyclase, ADP-ribosyl cyclase 1, cADPr hydrolase 1, CD38-rs1, I-19, NIM-R5 antigen, 2 '-phospho-cyclic-ADP-ribosyl cyclase, 2' -phospho-ADP-ribosyl cyclase, and T10.

TABLE 1 amino acid sequences of human and cynomolgus monkey CD38

The terms "therapeutically effective amount" and "therapeutically effective dose" refer to an amount of a therapy sufficient to reduce or ameliorate the severity and/or duration of a disorder or one or more symptoms thereof, to prevent progression of a disorder, to cause regression of a disorder, to prevent recurrence, development, onset, or progression of one or more symptoms associated with a disorder, or to enhance or ameliorate the prophylactic or therapeutic effects of another therapy (e.g., a prophylactic or therapeutic agent) at dosages and for periods of time required to achieve a desired therapeutic outcome. The therapeutically effective amount may vary depending on factors such as the disease state, age, sex and weight of the individual, and the ability of the drug to elicit a desired response in the individual. A therapeutically effective amount of an antibody or antigen-binding fragment thereof is an amount in which any toxic or detrimental effects of the antibody or antigen-binding fragment thereof are exceeded by the therapeutically beneficial effect.

The terms "patient" and "subject" include both humans and other animals. Thus, the compositions, dosages and methods disclosed herein are suitable for use in human and veterinary therapy. In one embodiment, the patient is a mammal, such as a human.

The term "isolated antibody" refers to an antibody that is substantially free of other antibodies having different antigen specificities. For example, an isolated antibody that specifically binds to CD38 is substantially free of antibodies that specifically bind to antigens other than CD 38. However, an isolated antibody that specifically binds to an epitope, isoform or variant of human CD38 or cynomolgus monkey CD38 may have cross-reactivity to other related antigens, for example related antigens from other species (e.g. CD38 species homologs). In addition, the isolated antibodies may be substantially free of other cellular material and/or chemicals.

The term "about" refers to a degree of closeness in terms of number, degree, volume, time, etc., with only a minimal change in size of up to 10%.

The term "pharmaceutically acceptable carrier" refers to a pharmaceutically acceptable material, composition, or vehicle suitable for administering a compound of the present disclosure to a mammal. The carrier includes a liquid or solid filler, diluent, excipient, solvent or encapsulating material that involves carrying or transporting the subject compound from one organ or portion of the body to another organ or portion of the body. Each carrier must be "acceptable" in the sense of being compatible with the other ingredients of the formulation and not deleterious to the patient. In one embodiment, the pharmaceutically acceptable carrier is suitable for subcutaneous administration.

The term "pharmaceutical composition" refers to a formulation suitable for administration to a subject and treatment of a disease. When the anti-CD 38 antibodies of the present disclosure are administered to a mammal (e.g., a human) as a medicament, they may be administered "as is" or as a pharmaceutical composition containing the anti-CD 38 antibody in combination with pharmaceutically acceptable carriers, excipients, and/or stabilizers. The pharmaceutical composition may be in unit dosage form for administration of a specific dose of an anti-CD 38 antibody at a specific concentration, a specific amount, or a specific volume. Pharmaceutical compositions comprising anti-CD 38 antibodies alone or in combination with prophylactic, therapeutic and/or pharmaceutically acceptable carriers are provided. Suitably, the pharmaceutical composition may comprise a unit dosage form according to the present disclosure alone or in combination with a prophylactic, therapeutic and/or pharmaceutically acceptable carrier. Suitably, the pharmaceutical composition may comprise a human anti-CD 38 antibody as described herein, alone or in combination with a prophylactic, therapeutic and/or pharmaceutically acceptable carrier.

Conventional antibody building blocks typically comprise tetramers. Each tetramer typically consists of two identical pairs of polypeptide chains, each pair having one "light" chain (typically having a molecular weight of about 25 kDa) and one "heavy" chain (typically having a molecular weight of about 50-70 kDa). Human Light Chains (LCs) are classified as kappa light chains and lambda light chains. Heavy Chains (HC) are classified as μ, δ, γ, α or ε, and the isotypes of the antibodies are defined as IgM, igD, igG, igA and IgE, respectively. IgG has several subclasses including, but not limited to, igG1, igG2, igG3, and IgG4.IgM has subclasses including, but not limited to, igM1 and IgM2. Thus, an "isotype" refers to any subclass of immunoglobulin defined by the chemical and antigenic properties of its constant region. Known human immunoglobulin isotypes are IgG1, igG2, igG3, igG4, igA1, igA2, igM1, igM2, igD and IgE. Therapeutic antibodies may also comprise hybrids of isotypes and/or subclasses.

Each of the VH and VL regions (about 100 to 110 amino acids in length) consists of three hypervariable regions called "complementarity determining regions" (CDRs) and four Framework Regions (FRs) (about 15-30 amino acids in length) arranged from amino-terminus to carboxy-terminus in the following order FR1-CDR1-FR2-CDR2-FR3-CDR3-FR4. "variable" means that the CDRs vary widely in sequence from antibody to antibody and thereby define unique antigen binding sites.

Hypervariable regions typically encompass amino acid residues from about amino acid residues 24-34 (LCDR 1; L "means light chain), 50-56 (LCDR 2) and 89-97 (LCDR 3) and approximately 31-35B (HCDR 1; H" means heavy chain), 50-65 (HCDR 2) and 95-102 (H CDR 3) in the VL region (Kabat et al (1991) Sequences Of Proteins Of Im munological Interest, 5 th edition Public HEALTH SERVICE, national Institutes of Health, bethesda, MD; which are incorporated herein by reference in their entirety) and/or those residues forming hypervariable loops (e.g., residues 26-32 (LCDR 1), 50-52 (LCDR 2) and 91-96 (LCDR 3)) in the VL region and 26-32 (HCDR 1), 53-55 (HCDR 2) and 96-101 (HCDR 3) (Chothia and Lesk (J.1987) J.901-196; incorporated herein by reference in their entirety).

The Kabat numbering system is generally used in reference to residues in the variable domain (about residues 1-107 of the VL region and residues 1-113 of the VH region) (e.g., kabat et al (1991) Se quences of Proteins of Immunological Interest, 5 th edition Public HEALTH SERVICE, national Institutes of Health, bethesda, MD; which is incorporated herein by reference in its entirety), wherein the EU numbering system is used for the Fc region.

The term "immunoglobulin (Ig) domain" refers to an immunoglobulin region having a distinct tertiary structure. Ig domains include VH and VL regions, CDRs, framework regions, constant region domains, and hinge regions. Each HC and LC has a constant region domain known as a constant heavy Chain (CH) domain and a constant light Chain (CL) domain. In the case of IgG antibodies, igG isotypes each have a constant region that comprises three CH domains. The carboxy-terminal portion of each HC and LC defines a constant region primarily responsible for effector function. Thus, the "CH" domain in the case of IgG is as follows, "CH1" refers to positions 118-220 according to the EU index as in Kabat. "CH2" refers to positions 237-340 according to the EU index as in Kabat, and "CH3" refers to positions 341-447 according to the EU index as in Kabat.

Another type of Ig domain of HC is the hinge region. The term "hinge region" refers to a flexible polypeptide comprising amino acids between a first constant domain and a second constant domain of an antibody. Structurally, the IgG CH1 domain ends at EU position 220 and the IgG CH2 domain begins at residue EU position 237. Thus, for IgG, the antibody hinge is defined herein to include positions 221 (D221 in IgG 1) to 236 (G236 in IgG 1), wherein the numbering is according to the EU index as in Kabat. In some embodiments, for example, in the case of an Fc region, a lower hinge is included, which "lower hinge" generally refers to position 226 or 230.

The term "Fc region" refers to a polypeptide comprising the constant region of an antibody, excluding the CH1 domain and, in some cases, the portion of the hinge. Thus, fc refers to the last two constant region Ig domains (CH 2 and CH 3) of IgA, igD, and IgG, the last three constant region Ig domains of IgE and IgM, and the flexible hinge located N-terminal to these domains. For IgA and IgM, the Fc may include the J chain. For IgG, the Fc domain includes Ig domains cγ2 and cγ3 (cγ2 and cγ3) and a lower hinge region between cγ1 (cγ1) and cγ2 (cγ2). Although the boundaries of the Fc region may vary, a human IgG HC Fc region is generally defined to include residues C226 or P230 at its carboxy-terminus, where numbering is according to the EU index as in Kabat. In some embodiments, the Fc region is subjected to amino acid modifications, for example, to alter binding to one or more fcγr receptors or FcRn receptors, as described more fully below.

CD38 antibodies

Accordingly, the present disclosure provides isolated anti-CD 38 antibodies that specifically bind to human and primate CD38 proteins, which antibodies are useful in methods of subcutaneous administration and unit dosage forms for treating patients with Myasthenia Gravis (MG). Antibodies or antigen binding fragments thereof used in the present disclosure bind to both human and primate CD38 proteins, particularly primates used in clinical testing, such as cynomolgus monkey (Macaca fascicularis, cynomolgus monkey (Crab eating macaque), also referred to herein as "cyno").

"Mizetuzumab" or "TAK-079" is a therapeutic protein comprising a fully human immunoglobulin IgG1 monoclonal antibody that specifically binds to CD38 with high affinity (Kd=3.5 nM), referred to herein as AB79 (U.S. Pat. No.3, 8,362,211, the contents of which are incorporated herein by reference in their entirety). The amino acid sequences of the mictuzumab ozogamicin are shown in table 2.

TABLE 2 amino acid sequence of MAIZUOMAIN

Mezetuzumab inhibits the growth of tumor cells expressing CD38 by cell depletion via antibody-dependent cytotoxicity (ADCC) and complement-dependent cytotoxicity (CDC). Mezetuzumab also reduces the levels of plasma cells and plasmablasts in blood isolated from healthy subjects and patients with autoimmune diseases. Anti-human CD38 mAb darimumab also depletes CD38 expressing plasmablasts and plasma cells in samples from patients with autoimmune diseases in a dose-dependent manner in vitro. For example, in patients with refractory autoantibody-mediated neurological diseases such as myasthenia gravis, darum mab provides clinically relevant depletion of autoreactive long-lived plasma cells (Scheibe et al (2022) Eur. J. Neuron. 29 (6): 1847-1854).

Unlike darimumab, mezetuzumab cross-reacts with cynomolgus monkey-expressed CD38, providing a unique opportunity to determine whether decreasing the level of CD 38-expressing cells would affect inflammation and tissue damage in a non-human primate autoimmune disease model. In healthy cynomolgus monkeys, the depletion efficiency of lymphocytes, as well as B, T and NK cells, is positively correlated with CD38 expression levels and AB79 dose levels (PCT application No. PCT/US2017/042128; U.S. patent No. US 8,362,211; which is incorporated herein by reference in its entirety).

In some embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof of the present disclosure interacts with CD38 at a number of amino acid residues including K121, F135, Q139, D141, M142, E239, W241, S274, C275, K276, F284, V288, K289, N290, P291, E292, D293, and S294 based on human sequence numbering. Suitably, the anti-CD 38 antibodies or antigen-binding fragments thereof of the present disclosure may interact with CD38 at a number of amino acid residues including K121, F135, Q139, D141, M142, E239, W241, S274, C275, K276, F284, V288, K289, N290, P291, E292, D293 and S294 of SEQ ID No.1 based on human sequence numbering. Suitably, the anti-CD 38 antibodies or antigen-binding fragments thereof of the present disclosure interact with CD38 at a number of amino acid residues including K121, F135, Q139, D141, M142, E239, W241, F274, C275, K276, F284, V288, K289, N290, P291, E292, D293 and S294 of SEQ ID No. 2. It should be noted that these residues are identical in both humans and cynomolgus monkeys, except that S274 is actually F274 in cynomolgus monkeys. These residues may represent immunodominant epitopes and/or residues within the occupied region of the specific antigen binding peptide.

In some embodiments, anti-CD 38 antibodies used in accordance with the present disclosure comprise a heavy chain (H C), and the HC comprises the following CDR amino acid sequences GFTFDDYG (SEQ ID NO: 3; HCDR1 Mizetuzumab), ISWNGGKT (SEQ ID NO:4; HCDR2 Mizetuzumab) and ARGSLFHDSSGFYFGH (SEQ ID NO:5; HCDR3 Mizetuzumab), or variants of those sequences having up to three amino acid changes. In some embodiments, antibodies used in accordance with the present disclosure comprise a Light Chain (LC) comprising the C DR amino acid sequences SSNIGDNY (SEQ ID NO:6; LCDR1 Mizetuzumab), RDS (SEQ ID NO:7; LCDR2 Mizetuzumab) and QSYDSSLSGS (SEQ ID NO:8; LCDR3 Mizetuzumab), or variants of those sequences having up to three amino acid changes. In some embodiments, antibodies used in accordance with the present disclosure comprise HC comprising the following CDR amino acid sequences GFTFDDYG (SEQ ID NO:3; H CDR1 MAZUZUZOMA), ISWNGGKT (SEQ ID NO:4; HCDR2 MAZUZUZUZUZUZUZUZUZUZUZUZUZUZO), ARGSLFHDSSGFYFGH (SEQ ID NO:5; HCDR3 MAZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZO) or variants of up to three amino acid changes; and LC comprising the following CDR amino acid sequences SSNIGDNY (SEQ ID NO:6; LCDR1 Mizetuzumab), RDS (SEQ ID NO:7; LCDR2 Mizetuzumab) and QSYDSSLSG S (SEQ ID NO:8; LCDR3 Mizetuzumab) or variants of those sequences with up to three amino acid changes. In some embodiments, the anti-CD 38 antibody comprises HC GFTFDDYG (SEQ ID NO:3; HCDR1 Mizetuzumab), ISWNGGKT (SEQ ID NO:4; HCDR2 Mizetuzumab) and ARG SLFHDSSGFYFGH (SEQ ID NO:5; HCDR3 Mizetuzumab) comprising the following CDR amino acid sequences. In some embodiments, the antibody comprises LC SSNIGD NY (SEQ ID NO:6; LCDR1 Mizetuzumab), RDS (SEQ ID NO:7; L CDR2 Mizetuzumab) and QSYDSSLSGS (SEQ ID NO:8; LCDR3 Mizetuzumab) comprising the following CDR amino acid sequences. In some embodiments, the antibody comprises HC GFTFDDYG (SEQ ID NO:3; HCDR1 Mizetuzumab), ISWNG GKT (SEQ ID NO:4; HCDR2 Mizetuzumab), ARGSLFHDSSGFYFG H (SEQ ID NO:5; HCDR3 Mizetuzumab), and LC SSNIGDNY (SEQ ID NO:6; LCDR1 Mizetuzumab), RDS (SEQ ID NO:7; LCDR2 Mizetuzumab) and QSYDSSLSGS (SEQ ID NO: 8; LCDR3 Mizetuzumab) comprising the following CDR amino acid sequences. In some embodiments, the antibody comprises an HC comprising a VH region amino acid sequence that has at least 80% sequence identity to SEQ ID NO 9. Suitably, the VH region may comprise a CDR sequence as defined in SEQ ID NO. 3, SEQ ID NO. 4 and SEQ ID NO. 5 and the remainder of the VH region sequence may have at least 80% sequence identity to SEQ ID NO. 9. Suitably, the VH region may comprise a CDR sequence as defined by SEQ ID NO. 3, SEQ ID NO. 4 and SEQ ID NO. 5 and the remainder of the VH region sequence may have at least 85% sequence identity to SEQ ID NO. 9. Suitably, the VH region may comprise a CDR sequence as defined in SEQ ID NO 3, SEQ ID NO 4 and SEQ ID NO 5 and the remainder of the VH region sequence may have at least 90% sequence identity to SEQ ID NO 9. Suitably, the VH region may comprise a CDR sequence as defined in SEQ ID NO 3, SEQ ID NO 4 and SEQ ID NO 5 and the remainder of the VH region sequence may have at least 95% sequence identity to SEQ ID NO 9. Suitably, the V H region may comprise a CDR sequence as defined by SEQ ID NO. 3, SEQ ID NO. 4 and SEQ ID NO. 5 and the remainder of the VH region sequence may have at least 97% sequence identity to SEQ ID NO. 9. Suitably, the VH region may comprise a CDR sequence as defined in SEQ ID NO 3, SEQ ID NO 4 and SEQ ID NO 5 and the remainder of the VH region sequence may have at least 99% sequence identity to SEQ ID NO 9.

In some embodiments, the antibody comprises an HC comprising the amino acid sequence of the VH region of SEQ ID NO. 9.

In some embodiments, the antibody comprises an LC comprising a VL region amino acid sequence having at least 80% sequence identity to SEQ ID No. 10. Suitably, the VL region may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the VL region sequence may have at least 80% sequence identity to SEQ ID NO. 10. Suitably, the VL region may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the VL region sequence may have at least 85% sequence identity to SEQ ID NO. 10. Suitably, the VL region may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the VL region sequence may have at least 90% sequence identity to SEQ ID NO. 10. Suitably, the VL region may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the VL region sequence may have at least 95% sequence identity to SEQ ID NO. 10. Suitably, the VL region may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the VL region sequence may have at least 97% sequence identity to SEQ ID NO. 10. Suitably, the VL region may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the VL region sequence may have at least 99% sequence identity to SEQ ID NO. 10.

In some embodiments, the antibody comprises an LC comprising the VL region amino acid sequence of SEQ ID NO. 10.

In some embodiments, the antibody comprises an HC comprising the amino acid sequence of the VH region of SEQ ID NO. 9, or a variant thereof, as described herein, and an LC comprising the amino acid sequence of the VL region of SEQ ID NO. 10, or a variant thereof, as described herein.

As will be appreciated by those skilled in the art, the VH and VL regions may be linked to a human IgG constant domain sequence (typically IgG1, igG2 or IgG 4).

In some embodiments, the antibody comprises a Heavy Chain (HC) comprising or consisting of an amino acid sequence having at least 80%, 85%, 90%, 95%, 97% or 99% sequence identity to SEQ ID NO. 11. Suitably, the HC may comprise a CDR sequence as defined in SEQ ID NO.3, SEQ ID NO.4 and SEQ ID NO.5 and the remainder of the HC may have at least 80% sequence identity with SEQ ID NO. 11. Suitably, the HC may comprise a CDR sequence as defined in SEQ ID NO.3, SEQ ID NO.4 and SEQ ID NO.5 and the remainder of the HC may have at least 85% sequence identity with SEQ ID NO. 11. Suitably, the HC may comprise a CDR sequence as defined in SEQ ID NO.3, SEQ ID NO.4 and SEQ ID NO.5 and the remainder of the HC may have at least 90% sequence identity with SEQ ID NO. 11. Suitably, the HC may comprise a CDR sequence as defined in SEQ ID NO.3, SEQ ID NO.4 and SEQ ID NO.5 and the remainder of the HC may have at least 95% sequence identity with SEQ ID NO. 11. Suitably, the HC may comprise a CDR sequence as defined in SEQ ID NO.3, SEQ ID NO.4 and SEQ ID NO.5 and the remainder of the HC may have at least 97% sequence identity with SEQ ID NO. 11. Suitably, the HC may comprise a CDR sequence as defined in SEQ ID NO.3, SEQ ID NO.4 and SEQ ID NO.5 and the remainder of the HC may have at least 99% sequence identity with SEQ ID NO. 11.

In some embodiments, the antibody comprises the HC amino acid sequence of SEQ ID NO. 11. In some embodiments, the antibody comprises a Light Chain (LC) comprising or consisting of an amino acid sequence having at least 80%, 85%, 90%, 95%, 97% or 99% sequence identity to SEQ ID No. 12. Suitably, the LC may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the LC may have at least 80% sequence identity to SEQ ID NO. 12. Suitably, the LC may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the LC may have at least 85% sequence identity to SEQ ID NO. 12. Suitably, the LC may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the LC may have at least 90% sequence identity to SEQ ID NO. 12. Suitably, the LC may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the LC may have at least 95% sequence identity to SEQ ID NO. 12. Suitably, the LC may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the LC may have at least 97% sequence identity to SEQ ID NO. 12. Suitably, the LC may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the LC may have at least 99% sequence identity to SEQ ID NO. 12.

In some embodiments, the antibody comprises the LC amino acid sequence of SEQ ID NO. 12.

In some embodiments, the antibody comprises or consists of the HC amino acid sequence of SEQ ID NO:11 or a variant thereof as described herein and the LC amino acid sequence of SEQ ID NO:12 or a variant thereof as described herein.

The present disclosure encompasses antibodies that bind to both human and cynomolgus monkey CD38 and interact with at least 80%, 85%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98% or 99% of the amino acid residues of SEQ ID No. 1 and K121, F135, Q139, D141, M142, E239, W241, S274, C275, K276, F284, V288, K289, N290, P291, E292, D293 and S294 based on human numbering. Suitably, the antibody may interact with at least 90% of these amino acid residues. Suitably, the antibody may interact with at least 95% of these amino acid residues. Suitably, the antibody may interact with at least 97% of these amino acid residues. Suitably, the antibody may interact with at least 98% of these amino acid residues. Suitably, the antibody may interact with at least 99% of these amino acid residues. Suitably, the antibody may interact with at least 14 (e.g., at least 15 or at least 16) of the amino acids of SEQ ID NO:1 and K121, F135, Q139, D141, M142, E239, W241, S274, C275, K276, F284, V288, K289, N290, P291, E292, D293 and S294 based on human numbering.

In some embodiments, the antibody is a full length antibody. "full length antibody" herein refers to a structure comprising the native biological form of an antibody, said structure comprising a variable region and a constant region, comprising one or more modifications as outlined herein.

Alternatively, the antibodies may be of various structures including, but not limited to, antibody fragments, antigen binding fragments, monoclonal antibodies, bispecific antibodies, minibodies, domain antibodies, synthetic antibodies (sometimes referred to herein as "antibody mimics"), chimeric antibodies, humanized antibodies, antibody fusions (sometimes referred to herein as "antibody conjugates"), and respective fragments, respectively. Specific antibody fragments include, but are not limited to, (i) Fab fragments consisting of the VL, VH, CL and CH1 domains, (ii) Fd fragments consisting of the VH and CH1 domains, (iii) Fv fragments consisting of the VL and VH domains of a single antibody, (iv) dAb fragments consisting of a single variable region (Ward et al (1989) Nature 341:544-546), (v) isolated CDR regions, (vi) F (ab') 2 fragments, which are bivalent fragments comprising two linked Fab fragments, (vii) single chain Fv molecules (scFv), wherein the VH and VL domains are linked by a peptide linker which associates the two domains to form an antigen binding site (Bird et al (1988) Scce 242:423-426; huston et al (1988) Proc. Natl. Acad. I. USA 85:5879-5883), (viii) bispecific Fv (WO 03/11161) and (three functional antibodies "or" three functional "are multivalent antibodies" that are constructed by their genes (WO 03/11161; see: table 94/4. Scuted).

Suitably, the antibody may be a Fab fragment. Suitably, the antibody may be an Fv fragment. Suitably, the antibody may be an Fd fragment. Suitably, the antibody structure may be an isolated CDR region. Suitably, the antibody may be a F (ab') 2 fragment. Suitably, the antibody may be an scFv fragment.

In some embodiments, the antibodies of the present disclosure, or antigen binding fragments thereof, further comprise one or more engineered glycoforms. In some embodiments, the engineered glycoforms comprise glycosylation of one or more polypeptides. In some embodiments, the glycosylation is N-linked glycosylation or O-linked glycosylation. In some embodiments, the glycosylation is an N-linked glycosylation. In some embodiments, the glycosylation is O-linked glycosylation.

In some embodiments, the isolated antibody of the present disclosure is a mictuzumab.

Antibody modification

The disclosure further provides variant anti-CD 38 antibodies. That is, many modifications may be made to the antibodies of the present disclosure, including, but not limited to, amino acid modifications in the CDRs (affinity maturation), amino acid modifications in the VH and/or VL regions, amino acid modifications in the HC and/or LC, amino acid modifications in the Fc region, glycosylation variants, other types of covalent modifications, and the like.

The term "variant" means a polypeptide that differs from the parent polypeptide. Amino acid variants may include amino acid substitutions, insertions, and deletions. In general, variants can include many modifications as long as the function of the protein is still present, as described herein. That is, in the case of amino acid variants generated, for example, using CDRs of a michelzumab, the antibody should still specifically bind to human and cynomolgus CD38. The term "variant Fc region" refers to an Fc sequence that differs from a wild-type or parent Fc sequence by at least one amino acid modification. An Fc variant may refer to the Fc polypeptide itself, a composition comprising an Fc variant polypeptide, or an amino acid sequence. If, for example, an amino acid variant is produced using the Fc region, the variant antibody should retain the desired function for the particular application or indication of the antibody. For example, 1,2, 3, 4, 5, 6,7, 8, 9 or 10 amino acid substitutions may be used, such as 1-10, 1-5, 1-4, 1-3 and 1-2 substitutions. Suitable modifications may be made at one or more positions as generally outlined, for example, in U.S. patent application Ser. No. 11/841,654;12/341,769, U.S. patent publication No. 2004013210;20050054832;20060024298; 2006021032; 20060235208;20070148170, and U.S. patent Nos. 6,737,056;7,670,600; and 6,086,875, all of which are expressly incorporated by reference in their entireties, particularly for specific amino acid substitutions that increase binding to Fc receptors.

Variants may be viewed from the perspective of similarity (i.e. amino acid residues with similar chemical properties/functions), variants are preferably expressed from the perspective of sequence identity.

Sequence comparison may be performed visually or, more generally, by means of readily available sequence comparison procedures. These published and commercially available computer programs can calculate sequence identity between two or more sequences.

For example, it may be desirable to have 1 to 5 modifications in the Fc region of a wild-type or engineered protein, and 1 to 5 modifications in the Fv region. The variant polypeptide sequence will preferably have at least about 80%, 85%, 90%, 91%, 92%, 93%, 94%, 95%, 96%, 97%, 98% or 99% identity to the parent sequence (e.g., VH or VL regions, constant regions, and/or HC and LC sequences of the micturition mab). Suitably, the variant may have at least 80% sequence identity to the parent sequence. Suitably, the variant may have at least 85% sequence identity to the parent sequence. Suitably, the variant may have at least 90% sequence identity to the parent sequence. Suitably, the variant may have at least 92% sequence identity to the parent sequence. Suitably, the variant may have at least 95% sequence identity to the parent sequence. Suitably, the variant may have at least 97% sequence identity to the parent sequence. Suitably, the variant may have at least 98% sequence identity to the parent sequence. Suitably, the variant may have at least 99% sequence identity to the parent sequence.

In one embodiment, sequence identity is determined across the entire sequence. In one embodiment, sequence identity is determined across the entire candidate sequence compared to the sequences described herein.

The term "amino acid substitution" refers to the replacement of an amino acid at a particular position in a parent polypeptide sequence with another amino acid. For example, substitution S100A refers to a variant polypeptide in which serine at position 100 is replaced with alanine. Suitably, the amino acid substitution may be a conservative amino acid substitution. Suitably, the variant may comprise one or more, for example two or three, conservative amino acid substitutions. Amino acids with similar biochemical properties may be defined as amino acids that may be substituted via conservative substitutions.

Unless explicitly indicated otherwise herein by reference to a particular single amino acid, conservative substitutions as described below may be used to replace the amino acid. The aliphatic polar uncharged amino acid may be a cysteine, serine, threonine, methionine, asparagine or glutamine residue. The aliphatic polar charged amino acid may be an aspartic acid, glutamic acid, lysine, or arginine residue. The aromatic amino acid may be a histidine, phenylalanine, tryptophan or tyrosine residue. Conservative substitutions may be made, for example, according to table 3 below. Amino acids in the same block in the second column and preferably in the same row in the third column may be substituted for each other:

TABLE 3 conservative substitutions

Aliphatic type	Nonpolar material	G AP
			I L V
	Polarity-uncharged	C S T M
			N Q
	Polarity-charge	D E
			K R
Aromatic series		H F W Y

The term "amino acid insertion" refers to the addition of an amino acid at a specific position in the parent polypeptide sequence.

The term "amino acid deletion" refers to the removal of an amino acid at a particular position in a parent polypeptide sequence.

The terms "parent antibody" and "precursor antibody" refer to an unmodified antibody that is subsequently modified to produce a variant. In embodiments, the parent antibody herein is a mictuzumab. In embodiments, the parent antibodies herein comprise a VH region having the amino acid sequence of SEQ ID NO. 9 and a VL region having the amino acid sequence of SEQ ID NO. 10. In embodiments, the parent antibodies herein comprise the HC amino acid sequence of SEQ ID NO. 11 and the LC amino acid sequence of SEQ ID NO. 12. A parent antibody may refer to the polypeptide itself, a composition comprising the parent antibody, or an amino acid sequence encoding the polypeptide. Thus, the term "parent Fc polypeptide" refers to an Fc polypeptide that has been modified to produce a variant.

The terms "wild-type", "WT" and "natural" refer to amino acid sequences or nucleotide sequences found in nature, including allelic variations. WT proteins, polypeptides, antibodies, immunoglobulins, igG, etc., have amino acid sequences or nucleotide sequences that are not intentionally modified.

In some embodiments, one or more amino acid modifications are made in one or more CDRs of the anti-CD 38 antibody. In general, only 1,2 or 3 amino acids are substituted in any single CDR, and in general no more than 4, 5, 6, 7, 8, 9 or 10 changes are made within a set of CDRs. However, it is understood that any combination of 1,2 or 3 substitutions in any CDR may be independently and optionally combined with any other substitution.

In some cases, amino acid modifications in CDRs are referred to as "affinity maturation". An "affinity matured" antibody is an antibody that has one or more alterations in one or more CDRs, resulting in an improved affinity of the antibody for the antigen as compared to the parent antibody without those alterations. In some cases, it may be desirable to reduce the affinity of an antibody for its antigen.

Affinity maturation may be performed to increase the binding affinity of an antibody for an antigen by at least about 10% to 50%, 100%, 150% or more, or 1-5 fold, as compared to a "parent" antibody. Preferred affinity matured antibodies have nanomolar or even picomolar affinity for the target antigen. Affinity matured antibodies are produced by known procedures (e.g., marks et al (1992) Biotechnol.10:779-783; barbas et al (1994) Proc. Nat. Acad. Sci. USA91:3809-3813; shier et al (1995) Gene 169:147-155; yelton et al (1995) J. Immunol.155:1994-2004; jackson et al (1995) J. Immunol.154 (7): 3310-9; and Hawkins et al (1992) J. Mol. Biol.226:889-896; which are incorporated herein by reference in their entirety).

Alternatively, a "silent" amino acid modification, e.g., an amino acid modification that does not significantly alter the affinity of the antibody for an antigen, may be made, e.g., in one or more CDRs of an antibody of the present disclosure. These modifications may be made for a number of reasons, including optimizing expression (e.g., modifications that may be made to nucleic acids encoding antibodies of the present disclosure).

Thus, variant CDRs and antibodies are included within the definition of CDRs and antibodies of the disclosure, i.e., antibodies of the disclosure may comprise amino acid modifications in one or more of the CDRs shown in SEQ ID NOs 3 through 8. Furthermore, amino acid modifications can also be made independently and optionally in any region other than the CDRs (including framework regions and constant regions), as outlined below.

In some embodiments, variant antibodies of MAzetuzumab specific for human CD38 (SEQ ID NO: 1) and cynomolgus CD38 (SEQ ID NO: 2) are described. The antibody consists of six CDRs, wherein each CDR of the antibody may differ from SEQ ID NO. 3, SEQ ID NO. 4, SEQ ID NO. 5, SEQ ID NO. 6, SEQ ID NO. 7 and/or SEQ ID NO. 8 by 0,1 or 2 amino acid substitutions.

Glycosylation

Another type of modification is a change in glycosylation. In one embodiment, the antibodies disclosed herein can be modified to comprise one or more engineered glycoforms. As used herein, "engineered glycoform" means a carbohydrate component covalently attached to an antibody, wherein the carbohydrate component is chemically different from the carbohydrate component of the parent antibody. Engineered glycoforms can be used for a variety of purposes including, but not limited to, enhancing or reducing effector function. One preferred form of engineered glycoform is afucosylation, which has been demonstrated to be associated with increased ADCC function, presumably by more intimate binding to the fcγriiia receptor. In this context, "afucosylated" means that most of the antibodies produced in the host cell are substantially free of fucose, e.g., 90-95-98% of the antibodies produced do not have significant fucose as part of the carbohydrate portion of the antibody (typically attached at N297 of the Fc region). Functionally defined, afucosylated antibodies typically exhibit an affinity of at least 50% or more for fcyriiia receptors.

The engineered sugar forms can be produced by a variety of methods known in the art (U.S. Pat. No. 3, 8,362,211; incorporated herein by reference in its entirety). Engineered glycoforms generally refer to different carbohydrates or oligosaccharides, and thus, antibodies may include engineered glycoforms.

Alternatively, an engineered glycoform may refer to an IgG variant comprising different carbohydrates or oligosaccharides. As is known in the art, the glycosylation pattern can depend on the sequence of the protein (e.g., the presence or absence of a particular glycosylated amino acid residue, as discussed below), or the host cell or organism from which the protein is produced. Specific expression systems are discussed below.

Glycosylation of polypeptides is typically either N-linked or O-linked. N-linked refers to the attachment of the carbohydrate moiety to the side chain of an asparagine residue. Tripeptide sequences asparagine-X-serine and asparagine-X-threonine (where X is any amino acid other than proline) are identifying sequences for the enzymatic attachment of a carbohydrate moiety to an asparagine side chain. Thus, the presence of any of these tripeptide sequences in a polypeptide creates a potential glycosylation site. O-linked glycosylation refers to the attachment of one of the sugars N-acetylgalactosamine, galactose or xylose to a hydroxy amino acid, most commonly serine or threonine, but 5-hydroxyproline or 5-hydroxylysine may also be used.

The addition of glycosylation sites to antibodies is conveniently accomplished by altering the amino acid sequence to contain one or more of the tripeptide sequences described above (for N-linked glycosylation sites). Alterations may also be made by adding one or more serine or threonine residues to the starting sequence (for O-linked glycosylation sites) or by replacing the starting sequence with the one or more serine or threonine residues. For convenience, the amino acid sequence of an antibody is preferably altered by a change in the level of DNA, in particular by mutating the DNA encoding the polypeptide of interest at preselected bases such that codons are produced which will translate into the desired amino acids.

Another means of increasing the number of carbohydrate moieties on an antibody is by chemically or enzymatically coupling a glycoside to a protein. The advantage of these procedures is that they do not require the production of proteins in host cells with glycosylation capabilities for N-and O-linked glycosylation. Depending on the coupling scheme used, the saccharide may be attached to (a) arginine and histidine, (b) a free carboxyl group, (c) a free sulfhydryl group such as that of cysteine, (d) a free hydroxyl group such as that of serine, threonine or hydroxyproline, (e) an aromatic residue such as that of phenylalanine, tyrosine or tryptophan, or (f) an amide group of glutamine. These methods are described in WO87/05330 and Aplin and Wriston (1981) CRC crit.Rev.biochem.10 (4): 259-306, both of which are incorporated by reference in their entirety.

Removal (e.g., post-translational) of the carbohydrate moiety present on the starting antibody may be accomplished chemically or enzymatically. Chemical deglycosylation requires exposing the protein to the compound trifluoromethanesulfonic acid or equivalent compound. This treatment results in cleavage of most or all of the sugars except the linking sugar (N-acetylglucosamine or N-acetylgalactosamine) while maintaining the integrity of the polypeptide. Chemical deglycosylation is described by Hakimuddin et al, 1987, arch. Biochem. Biophys.259:52 and Edge et al, 1981, anal. Biochem.118:131, both of which are incorporated by reference in their entirety. Enzymatic cleavage of the carbohydrate moiety on the polypeptide can be achieved by using a variety of endo-and exo-glycosidases, as described by Thotakura et al, 1987, meth. Enzymol.138:350, incorporated by reference in its entirety. Glycosylation at potential glycosylation sites can be prevented by the use of the compound tunicamycin (tunicamycin), as described in Duskin et al (1982) J.biol. Chem.257:3105, which is incorporated by reference in its entirety. Tunicamycin blocks the formation of protein-N-glycosidic bonds.

Another type of covalent modification of antibodies includes attaching the antibodies to various non-protein polymers, including but not limited to various polyols such as polyethylene glycol, polypropylene glycol, or polyalkylene oxide, in a manner such as shown in U.S. Pat. Nos. 4,640,835, 4,496,689, 4,301,144, 4,670,417, 4,791,192, or 4,179,337, all of which are incorporated by reference in their entirety, for example, in the 2005-2006PEG catalog of Nektar Therapeutics (available on the Nektar website). Furthermore, amino acid substitutions may be made at various positions within the antibody, as is known in the art, to facilitate the addition of polymers such as PEG. See, for example, U.S. publication No. 2005/0110237 Al, which is incorporated by reference in its entirety.

In addition to the modifications outlined above, other modifications may be made. For example, the molecule may be stabilized by incorporating a disulfide bridge linking the VH and VL domains (Reiter et al (1996) Nature Biotech.14:1239-1245; incorporated herein by reference in its entirety). Furthermore, there are a variety of covalent modifications of antibodies that can be made as outlined below.

Covalent modification of antibodies is included within the scope of the present disclosure and is typically, but not always, performed post-translationally. For example, several types of covalent modifications of antibodies are introduced into the molecule by reacting specific amino acid residues of the antibody with an organic derivatizing agent capable of reacting with selected side chains or N-or C-terminal residues.

In some embodiments, the anti-CD 38 antibodies of the present disclosure specifically bind to one or more residues or regions in CD38, but also do not cross-react with other proteins having homology to CD38, such as BST-1 (bone marrow stromal cell antigen-1) and/or Mo5 (also referred to as CD 157).

In general, the lack of cross-reactivity means that there is less than about 5% relative competitive inhibition between molecules when assessed by ELISA and/or FACS analysis using a sufficient amount of the molecules under suitable assay conditions.

Reducing side effects

An Adverse Event (AE) is defined as any adverse medical event that occurs in a clinical study subject administered a drug, and is not necessarily causally related to the treatment. Adverse Events (TEAEs) occurring in treatment were defined as AEs occurring after receiving the first dose of study drug during the treatment period until the end of the safety follow-up. In this document, the terms "severe TEAE" and "SAE occurring in therapy" and "SAE" may be considered interchangeable. PTE and AE verbatim are encoded by SOC and PT using med dra version 24.0. TEAE is commonly referred to as stage 1, stage 2, stage 3, stage 4 and stage 5, with stage 1 being the least severe and stage 5 being the most severe TEAE. Based on the FDA and other oncology general adverse event terminology standard (CTCAE) guidelines (see, e.g., U.S. department of health and public service, general adverse event terminology standard (CTCAE), 2010 version 4.03 and Nilsson and Koke (2001) Drug Inform. J.35:1289-1299; which is incorporated herein by reference in its entirety), the following is a way to generally determine such ratings. Grade 1 is mild, asymptomatic or mild, only clinically or diagnostically observed, no intervention indicated. Grade 2 is moderate, indicating minimal, local or non-invasive intervention, limiting age-matched instrumental activities of daily living ("ADL"). Grade 3 is severe or medically significant, but is not immediately life threatening, indicating hospitalization or prolonged hospitalization, disability, limiting self-care ADL. Grade 4 is a life threatening consequence, indicating emergency intervention. Grade 5 is AE related mortality.

The anti-CD 38 antibodies of the present disclosure allow for reduced side effects compared to prior art anti-CD 38 antibodies. In some embodiments, antibodies, such as mezetuzumab, used according to the present disclosure do not induce TEAE. In some embodiments, the antibodies, e.g., michelzumab, used according to the present disclosure allow for a reduction in the incidence of TEAE in a patient population as compared to other anti-CD 38 antibodies, such as MOR 202. In some embodiments, the antibodies used according to the present disclosure, e.g., michelzumab, allow for a reduction in the grade of TEAE in a patient population as compared to other anti-CD 38 antibodies, such as MOR 202. In some embodiments, antibodies used according to the present disclosure, such as mezetuzumab, allow the grade of TEAE to be reduced from grade 5 to grade 4 as compared to other anti-CD 38 antibodies. In some embodiments, antibodies used according to the present disclosure, such as mezetuzumab, allow the grade of TEAE to be reduced from grade 4 to grade 3 as compared to other anti-CD 38 antibodies. In some embodiments, antibodies used according to the present disclosure, such as mezetuzumab, allow the grade of TEAE to be reduced from grade 3 to grade 2 as compared to other anti-CD 38 antibodies. In some embodiments, antibodies used according to the present disclosure, such as mezetuzumab, allow the grade of TEAE to be reduced from grade 2 to grade 1 as compared to other anti-CD 38 antibodies.

In some embodiments, antibodies, such as mezetuzumab, used according to the present disclosure allow for a reduction in the grade of one or more TEAEs selected from the group consisting of anemia (including hemolytic anemia), thrombocytopenia, fatigue, infusion-related reactions (IRR), leukopenia, lymphopenia, and nausea. In some embodiments, antibodies, such as mezetuzumab, used according to the present disclosure allow for reduction of the occurrence of one or more TEAEs selected from the group consisting of anemia (including hemolytic anemia), thrombocytopenia, fatigue, infusion-related reactions (IRR), leukopenia, lymphopenia, and nausea.

In some embodiments, administration of an antibody or antigen binding fragment thereof of the present disclosure results in a less than 10% incidence of grade 3 or grade 4 of one or more TRAE or TEAE, optionally wherein TRAE or TEAE is selected from the group consisting of gastrointestinal disorders, nausea, infection, fever, shingles, urinary tract infections, skin and skin tissue disorders, headache, fever, chill/chills, vomiting, diarrhea, joint pain, myalgia, hypotension, respiratory, chest and mediastinal disorders, thrombocytopenia, leukopenia, lymphopenia, heart disorders, palpitations, and dyspnea.

In some embodiments, administration of an antibody or antigen binding fragment thereof of the present disclosure results in one or more TRAEs or TEAEs with maximum intensity of grade 1 or grade 2 of the common terminology for adverse events (CTCAE).

Disease indication

The antibodies, or antigen binding fragments thereof, methods, and dosage units of the present disclosure are useful in treating patients with Myasthenia Gravis (MG).

Myasthenia Gravis (MG)

Myasthenia Gravis (MG) is a rare autoimmune disorder in which autoantibodies target the neuromuscular junction (NMJ) and postsynaptic membrane and interfere with neuromuscular transmission, resulting in progressive skeletal muscle weakness. The prevalence of myasthenia gravis in the United states is about 14 to 40 per 100,000 (Breiner et al (2016) Neuromuscul. Disord.26 (1): 41-6; carr et al (2010) BMC Neurol.10:46; heldal et al (2012) Muscle Nerve45 (6): 815-819; santos et al (2016) Muscle Nerve 54 (3): 413-21).

Myasthenia gravis is defined by the U.S. Myasthenia Gravis Foundation (MGFA) clinical classification, which classifies MGs into 5 major classes based on clinical characteristics and disease severity (Jaretzki III et al (2000) Neurology 55 (1): 16-23; gilhus et al (2011) Autoimmune dis.2011:847393; try et al (2012) Autoimmune dis.2012: 874680), each of which is incorporated herein by reference in its entirety). Each class has a different prognosis or response to therapy.

Clinical classification of myasthenia gravis

Class I, any muscle weakness of the eye, possible eye closure weakness, all other muscle forces normal.

Class II, mild weakness affecting muscles other than ocular muscles, and possibly ocular muscle weakness of any severity. Type IIa, mainly affects the limbs, the medial axis, or both, and may also have less involvement of the oropharyngeal muscles. Class IIb, primarily affects oropharyngeal, respiratory or both, and may have less or equal involvement of the limb, medial or both.

Class III, moderate weakness affecting other muscles than the eye muscle, and possibly eye muscle weakness of any severity. Group IIIa, primarily affects the limb, the medial axis, or both, and may also have less involvement of the oropharyngeal muscles. Group IIIb, which affects mainly the oropharyngeal, respiratory or both, may also have less or equal involvement of the limb, the medial or both.

Class IV-severe weakness affecting other muscles than the eye muscle-eye muscle weakness of any severity is also possible. Class IVa, primarily affects the limb and/or central axis muscles, and may also have less involvement of the oropharyngeal muscles. IVb, mainly affects oropharyngeal, respiratory or both, and may have less or equal involvement of the limb, central axis or both.

Class V is defined by cannulae with or without mechanical ventilation, except when employed during conventional post-operative management. The patient was placed in class IVb using the feeding tube without a cannula.

Myasthenia gravis subtype

The MG subtypes are broadly classified as (1) early onset MG with an age of onset <50 years, thymic hyperplasia, typically female, (2) late onset MG with an age of onset >50 years, thymic atrophy, primarily male, (3) thymoma-related MG (10% -15%), (4) MG with anti-MUSK antibodies, (5) ocular MG (oMG) with symptoms affecting only extraocular muscles, and (6) MG with no AChR and muscle-specific tyrosine kinase (MUSK) antibodies detected.

In order to determine the diagnosis of MG, necessary studies include AChR antibodies, muSK antibodies and CT/MR of the anterior mediastinum of thymoma or thymic hyperplasia. Neurophysiologic examination and jitter measurements with repeated neurostimulation are important in determining primary diagnosis, particularly in patients without detectable antibodies.

In some embodiments, the present disclosure provides methods of treating myasthenia gravis in a subject. In some embodiments, the present disclosure provides methods of treating systemic myasthenia gravis in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis type I in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis type II in a subject. In some embodiments, the present disclosure provides methods of treating type IIa myasthenia gravis in a subject. In some embodiments, the present disclosure provides methods of treating type IIb myasthenia gravis in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis type III in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis type IIIa in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis type IIIb in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis type IV in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis type IVa in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis type IVb in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis type V in a subject.

In some embodiments, the present disclosure provides methods of treating myasthenia gravis early-onset in a subject. In some embodiments, the present disclosure provides methods of treating late onset myasthenia gravis in a subject. In some embodiments, the present disclosure provides methods of treating a subject for a thymoma-associated myasthenia gravis. In some embodiments, the disclosure provides methods of treating myasthenia gravis with an anti-MUSK antibody in a subject. In some embodiments, the present disclosure provides methods of treating an ocular myasthenia gravis antibody in a subject. In some embodiments, the present disclosure provides methods of treating myasthenia gravis in a subject in which AChR and muscle-specific tyrosine kinase (MuSK) antibodies are not detected.

The therapeutic anti-CD 38 antibodies of the present disclosure bind to CD38 positive cells, resulting in depletion of these cells through a variety of mechanisms of action, including CDC and ADCC pathways.

In some embodiments, the present disclosure provides a method of treating myasthenia gravis in a subject comprising administering to the subject an isolated human anti-CD 38 antibody or antigen-binding fragment thereof, wherein the isolated antibody or antigen-binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

In some embodiments, the present disclosure provides a method of reducing the level of plasmablasts, plasmablasts and/or NK cells in a subject diagnosed as having myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen binding fragment thereof, wherein the isolated antibody or antigen binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4 and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7 and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800.

In some embodiments, the present disclosure provides a method of reducing immunoglobulin levels in a subject diagnosed with myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen-binding fragment thereof, wherein the isolated antibody or antigen-binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO. 3, CDR2 having the amino acid sequence of SEQ ID NO. 4, and CDR3 having the amino acid sequence of SEQ ID NO. 5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO. 6, CDR2 having the amino acid sequence of SEQ ID NO. 7, and CDR3 having the amino acid sequence of SEQ ID NO. 8, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the immunoglobulin is IgA, igG, and/or IgM. In some embodiments, the immunoglobulin is IgA. In some embodiments, the immunoglobulin is IgG. In some embodiments, the immunoglobulin is IgM.

In some embodiments, the present disclosure provides a method of reducing the level of one or more autoantibodies in a subject diagnosed with myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen binding fragment thereof, wherein the isolated antibody or antigen binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the one or more autoantibodies are selected from the group consisting of anti-AChR and anti-MuSK.

In some embodiments, the present disclosure provides a method of reducing myasthenia gravis disease activity and/or progression in a subject diagnosed with myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen-binding fragment thereof, wherein the isolated antibody or antigen-binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the myasthenia gravis disease activity is measured by scoring one or more selected from the group consisting of myasthenia gravis daily life activity (MG-ADL), quantitative Myasthenia Gravis (QMG), composite Myasthenia Gravis (MGC), revised 15 items of the myasthenia gravis quality of life scale (MG-QOL 15 r), and/or Myasthenia Gravis Impairment Index (MGII). In some embodiments, myasthenia gravis disease activity is measured by myasthenia gravis daily life activity (MG-ADL). In some embodiments, myasthenia gravis disease activity is measured by Quantitative Myasthenia Gravis (QMG). In some embodiments, myasthenia gravis disease activity is measured by a composite Myasthenia Gravis (MGC). In some embodiments, myasthenia gravis disease activity is measured by a revised 15-item myasthenia gravis quality of life scale (MG-QoL 15 r). In some embodiments, myasthenia gravis disease activity is measured by a myasthenia gravis damage index (MGII).

In some embodiments, the disclosure provides methods as disclosed herein, wherein the antibody or antigen binding fragment thereof further comprises one or more engineered glycoforms.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the engineered glycoforms comprise glycosylation of one or more polypeptides, and wherein the glycosylation is N-linked glycosylation or O-linked glycosylation.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the glycosylation is an N-linked glycosylation.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the glycosylation is O-linked glycosylation.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the VH region of the antibody or antigen-binding fragment thereof comprises an amino acid sequence having at least 90% identity to SEQ ID No. 9, and/or the VL region of the antibody or antigen-binding fragment thereof comprises an amino acid sequence having at least 90% identity to SEQ ID No. 10.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the VH region comprises an amino acid sequence with at least 95% identity to SEQ ID No. 9.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the VL region comprises an amino acid sequence having at least 95% identity to SEQ ID No. 10.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the VH region comprises an amino acid sequence having at least 99% identity to SEQ ID No. 9.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the VL region comprises an amino acid sequence having at least 99% identity to SEQ ID No. 10.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the HC of the antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 95% identity to SEQ ID No. 11.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the LC of the antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 95% identity to SEQ ID No. 12.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof interacts with at least K121, F135, Q139, D141, E239, W241, C275, K276, F284, P291, and E292 of SEQ ID No. 1 and SEQ ID No. 2 based on human sequence numbering.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof binds to human CD38 (SEQ ID NO: 1) with an affinity of 10 ^-8 M or greater, and wherein the affinity is measured by a standard Biacore assay.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the VH region comprises SEQ ID No. 9 and the VL region comprises SEQ ID No. 10.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof comprises HC as set forth in SEQ ID No. 11 and LC as set forth in SEQ ID No. 12.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the antibody or antigen binding fragment thereof further comprises an Fc domain.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the Fc domain is a human Fc domain. In some embodiments, the Fc domain is a variant Fc domain.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the isolated antibody or antigen binding fragment is a human IgG antibody. In some embodiments, the human IgG antibody is a human IgG1 antibody.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the subject receives a background myasthenia gravis drug.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the background myasthenia gravis drug is selected from the group consisting of immunosuppressants, steroids, anticholinergic agents, and cholinesterase inhibitors, and combinations thereof. In some embodiments, the present disclosure provides methods as disclosed herein, wherein the background myasthenia gravis drug is selected from the group consisting of methylprednisolone, prednisone, budesonide, fluticasone propionate, pistigmine, mycophenolate mofetil, dicyclopirine, azathioprine, and cyclosporine, and combinations thereof.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the background myasthenia gravis drug is administered in combination with the antibody or antigen-binding fragment thereof.

In some embodiments, the disclosure provides methods as disclosed herein, wherein the antibody or antigen-binding fragment thereof is administered at a dose selected from the group consisting of about 100mg, about 125mg, about 150mg, about 175mg, about 200mg, about 225mg, about 250mg, about 275mg, about 300mg, about 325mg, about 350mg, about 375mg, about 400mg, about 425mg, about 450mg, about 475mg, about 500mg, about 525mg, about 550mg, about 575mg, about 600mg, about 625mg, about 650mg, about 675mg, about 700mg, about 725mg, about 750mg, about 775mg, or about 800mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of about 300 mg. In some embodiments, wherein the antibody or antigen binding fragment thereof is administered at a dose of about 600 mg.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the dose is a weekly, biweekly, tricyclically or weekly dose administered.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the antibody or antigen binding fragment thereof is administered in the form of a pharmaceutically acceptable composition.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the pharmaceutically acceptable composition comprises the isolated antibody or antibody fragment thereof and at least one pharmaceutically acceptable carrier, excipient, or stabilizer.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the isolated antibody or antigen-binding fragment thereof comprises HC as set forth in SEQ ID NO. 11 and LC as set forth in SEQ ID NO. 12, and wherein the antibody or antigen-binding fragment thereof is administered subcutaneously once a week for 8 weeks. In some embodiments, the disclosure provides methods as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof further comprises one or more engineered glycoforms, wherein the engineered glycoforms comprise glycosylation of one or more polypeptides, and the glycosylation is N-linked glycosylation.

In some embodiments, the present disclosure provides methods as disclosed herein, wherein the isolated antibody or antigen-binding fragment thereof is a michelzumab.

In some embodiments, the disclosure provides methods as disclosed herein, wherein administering the antibody or antigen binding fragment thereof results in a less than 10% incidence of one or more treatment-related adverse events (TRAEs) or adverse events (TEAEs) occurring in treatment, grade 3 or grade 4. In some embodiments, the TRAE or TEAE is selected from the group consisting of gastrointestinal disorders, nausea, infection, fever, shingles, urinary tract infection, skin and skin tissue disorders, headache, fever, chills/chills, vomiting, diarrhea, joint pain, myalgia, hypotension, respiratory, thoracic and mediastinal disorders, thrombocytopenia, leukopenia, lymphopenia, heart disorders, palpitations, and dyspnea.

In some embodiments, the disclosure provides methods as disclosed herein, wherein administering the antibody or antigen binding fragment thereof results in one or more TRAEs or TEAEs with maximum intensity of grade 1 or grade 2 of the adverse event common terminology standard (CTCAE).

Antibody compositions for in vivo administration

Formulations of antibodies or antigen-binding fragments thereof for use according to the present disclosure are prepared for storage by mixing the antibodies of the desired purity, together with an optional pharmaceutically acceptable carrier, excipient or stabilizer (Remington's Pharmaceutical Sciences, 16 th edition (1980) Osol, a. Edit; which is incorporated herein by reference in its entirety), in the form of a lyophilized formulation or an aqueous solution.

The formulations herein may also contain more than one active compound as required for the particular indication being treated, preferably compounds having complementary activity and which do not adversely affect each other. For example, it may be desirable to provide antibodies or antigen-binding fragments thereof with other specificities. Alternatively or in addition, the composition may comprise a cytotoxic agent, a cytokine, a growth inhibitory agent, and/or a small molecule antagonist. Such molecules are suitably present in combination in an amount effective for the intended purpose.

In some embodiments, two formulations of a pharmaceutical product of mezetuzumab have been developed, referred to as process a and process B disclosed herein.

In one embodiment, the process a micturizumab drug product is a clear to milky colorless solution containing arginine hydrochloride, anhydrous citric acid, sodium citrate, polysorbate 80, and an aqueous solution of AB79 (20 mg/mL) with water for injection having a pH of about 6.5. Process A placebo is a clear colorless solution containing arginine hydrochloride, anhydrous citric acid, sodium citrate, polysorbate 80 and an aqueous solution of water for injection having a pH of about 6.5. Process A Mizituzumab drug product and placebo were supplied in sterile filled disposable, clear, type I borosilicate glass vials with fluoropolymer coated butyl rubber stoppers and flip-top aluminum crimp seals.

In another embodiment, the process B-Mezetuzumab drug product is formulated at 2 intensities (i.e., 5mg/mL or 100 mg/mL). Each intensity was a clear to milky white, colorless to brown-yellow solution containing mezetimab in aqueous solutions of histidine, histidine hydrochloride monohydrate, sucrose, polysorbate 20 and water for injection at a pH of about 5.9. Process B placebo is a clear colorless solution containing histidine, histidine hydrochloride monohydrate, sucrose, polysorbate 20 and an aqueous solution of water for injection having a pH of about 5.9. Process B the Micheliab drug product and placebo were supplied in sterile filled disposable, clear, type I borosilicate glass vials with fluoropolymer coated butyl rubber stoppers and flip-top aluminum crimp seals.

Subcutaneous administration

The anti-CD 38 antibodies described herein (such as mictuzumab) can be administered in a therapeutically effective sufficient dose to allow subcutaneous administration. Subcutaneous administration is a minimally invasive mode of administration and is considered the most common and therefore desirable mode of administration that can be used for short-term and long-term therapies. In some embodiments, subcutaneous administration may be by injection. In some embodiments, when multiple injections or multiple devices are desired, the site or device of injection may be rotated.

Subcutaneous formulations are therefore easier for the patient to self-administer, especially because the formulation may have to be taken regularly throughout the patient's life. Furthermore, the ease and speed of subcutaneous delivery enables increased patient compliance and faster drug availability when needed. Thus, the subcutaneous formulations of anti-CD 38 antibodies provided herein provide substantial benefits over the prior art and address certain unmet needs.

In some embodiments, the antibodies of the disclosure are administered to a subject via a subcutaneous route according to known methods. In some embodiments, the antibodies of the disclosure may be administered by subcutaneous injection. In particular embodiments, the subcutaneous formulation is subcutaneously injected into the same site of the patient (e.g., applied to the upper arm, the anterior surface of the thigh, the lower portion of the abdomen, or the upper back) for repeated or continuous injections. In other embodiments, the subcutaneous formulation is subcutaneously injected into a patient at a different or alternate site. Single or multiple administrations of the formulation may be employed.

In some embodiments, the subcutaneous unit dosage forms described herein can be used to treat myasthenia gravis. In some embodiments, the subcutaneous unit dosage forms described herein can be used to treat systemic myasthenia gravis.

In some embodiments, the antibodies of the present disclosure, or antigen binding fragments thereof, result in the depletion of plasmablasts, plasma cells, NK cells, B cells, and/or T cells upon subcutaneous administration to a subject. In some embodiments, the antibodies of the disclosure, or antigen binding fragments thereof, result in the depletion of plasmablasts. In some embodiments, the antibodies of the disclosure, or antigen binding fragments thereof, result in the depletion of plasma cells. In some embodiments, the antibodies of the disclosure, or antigen binding fragments thereof, allow for increased NK cell depletion compared to depletion of B cells or T cells. In some embodiments, the antibodies of the present disclosure, or antigen binding fragments thereof, allow for increased NK cell depletion compared to B cells, as well as increased NK cell depletion compared to T cells. In some embodiments, the antibodies of the present disclosure, or antigen binding fragments thereof, allow for increased NK cell depletion compared to B cells, as well as increased B cell depletion compared to T cells. In some embodiments, the antibodies of the present disclosure, or antigen binding fragments thereof, allow for increased NK cell depletion compared to B cells and increased B cell depletion compared to T cells. Suitably, the antibodies of the disclosure, or antigen binding fragments thereof, may allow for increased depletion of CD38 ⁺ cells compared to CD38 ^- cells.

In some embodiments, an antibody or antigen binding fragment thereof of the present disclosure results in a decrease in the level of one or more immunoglobulins upon subcutaneous administration to a subject. In some embodiments, the immunoglobulin is IgA, igG, and/or IgM. In some embodiments, the immunoglobulin is IgA. In some embodiments, the immunoglobulin is IgG. In some embodiments, the immunoglobulin is IgM.

In some embodiments, an antibody or antigen binding fragment thereof of the disclosure results in a decrease in one or more autoantibodies upon subcutaneous administration to a subject. In some embodiments, the one or more autoantibodies are selected from the group consisting of anti-AChR and anti-MuSK.

In certain embodiments, the bioavailability of an anti-CD 38 antibody described herein after subcutaneous administration is between at least 50% and at least 80% compared to intravenous administration normalized to the same dose. In certain embodiments, the bioavailability of an anti-CD 38 antibody described herein after subcutaneous administration is between at least 60% and at least 80% compared to intravenous administration normalized to the same dose. In certain embodiments, the bioavailability of an anti-CD 38 antibody described herein after subcutaneous administration is between at least 50% and 70% compared to intravenous administration normalized to the same dose. In certain embodiments, the bioavailability of an anti-CD 38 antibody described herein after subcutaneous administration is between at least 55% and 65% compared to intravenous administration normalized to the same dose. In certain embodiments, the bioavailability of an anti-CD 38 antibody described herein after subcutaneous administration is between at least 55% and 70% as compared to intravenous administration normalized to the same dose.

In certain embodiments, the bioavailability of an anti-CD 38 antibody described herein after subcutaneous administration is at least 40%, at least 45%, at least 50%, at least 51%, at least 52%, at least 53%, at least 54%, at least 55%, at least 56%, at least 57%, at least 58%, at least 59%, at least 60%, at least 61%, at least 62%, at least 63%, at least 64%, at least 65%, at least 66%, at least 67%, at least 68%, at least 69%, at least 70%, at least 71%, at least 72%, at least 73%, at least 74%, at least 75%, at least 76%, at least 77%, at least 78%, at least 79%, at least 80%, at least 81%, at least 82%, at least 83%, at least 84%, or at least 85% as compared to intravenous administration normalized to the same dose. Suitably, the bioavailability may be at least 50% compared to intravenous administration normalized to the same dose. Suitably, the bioavailability may be at least 60% compared to intravenous administration normalized to the same dose. Suitably, the bioavailability may be at least 70% compared to intravenous administration normalized to the same dose. Suitably, the bioavailability may be at least 80% compared to intravenous administration normalized to the same dose. Suitably, the bioavailability may be at least 90% compared to intravenous administration normalized to the same dose.

In some embodiments, the disclosure provides a method wherein the bioavailability of the antibodies of the disclosure after subcutaneous administration is 50% -80% compared to intravenous administration normalized to the same dose.

In some embodiments, the disclosure provides a method wherein the bioavailability of the antibodies of the disclosure after subcutaneous administration is at least 50% compared to intravenous administration normalized to the same dose.

In some embodiments, the disclosure provides a method wherein the bioavailability of the antibodies of the disclosure after subcutaneous administration is at least 55% as compared to intravenous administration normalized to the same dose.

In some embodiments, the disclosure provides a method wherein the bioavailability of the antibodies of the disclosure after subcutaneous administration is at least 60% compared to intravenous administration normalized to the same dose.

In some embodiments, the disclosure provides a method wherein the bioavailability of the antibodies of the disclosure after subcutaneous administration is at least 65% compared to intravenous administration normalized to the same dose.

In some embodiments, the disclosure provides a method wherein the bioavailability of the antibodies of the disclosure after subcutaneous administration is at least 70% compared to intravenous administration normalized to the same dose.

In some embodiments, the disclosure provides a method wherein the bioavailability of the antibodies of the disclosure after subcutaneous administration is at least 75% compared to intravenous administration normalized to the same dose.

In some embodiments, the disclosure provides a method wherein the bioavailability of the antibodies of the disclosure after subcutaneous administration is at least 80% compared to intravenous administration normalized to the same dose.

In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously in a single bolus injection. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously monthly. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously every two weeks. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously weekly. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously twice a week. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously daily. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously every 12 hours. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously every 8 hours. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously every 6 hours. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously every 4 hours. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously every 2 hours. In certain embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as described herein is administered subcutaneously per hour. In some embodiments, an antibody or antigen binding fragment thereof as disclosed herein is administered subcutaneously once a week for 8 weeks.

In some embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as disclosed herein is administered subcutaneously at a dose of about 100 milligrams to about 800 milligrams. In some embodiments, an anti-CD 38 antibody or antigen-binding fragment thereof as disclosed herein is administered subcutaneously at a dose selected from the group consisting of about 100mg, about 125mg, about 150mg, about 175mg, about 200mg, about 225mg, about 250mg, about 275mg, about 300mg, about 325mg, about 350mg, about 375mg, about 400mg, about 425mg, about 450mg, about 475mg, about 500mg, about 525mg, about 550mg, about 575mg, about 600mg, about 625mg, about 650mg, about 675mg, about 700mg, about 725mg, about 750mg, about 775mg, or about 800mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of about 300mg or about 600 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of about 300 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of about 600 mg.

Unit dosage form

In some embodiments, the therapeutic anti-CD 38 antibody or antigen-binding fragment thereof is formulated as part of a unit dosage form. In some embodiments, the anti-CD 38 antibody or antigen-binding fragment thereof comprises a HC comprising the following CDR amino acid sequences GFTF DDYG (SEQ ID NO:3; HCDR1 Mizetuzumab), ISWNGGKT (SEQ ID NO:4; HCDR2 Mizetuzumab) and ARGSLFHDSSGFYFGH (SEQ ID NO:5; HCDR3 Mizetuzumab), or variants of those sequences having up to three amino acid changes. In some embodiments, the antibody or antigen binding fragment thereof comprises an LC comprising the following CDR amino acid sequences SSNIGDNY (SEQ ID NO:6; L CDR1 Michelituzumab), RDS (SEQ ID NO:7; LCDR2 Michelituzumab) and Q SYDSSLSGS (SEQ ID NO:8; LCDR3 Michelituzumab), or variants of those sequences having up to three amino acid changes. In some embodiments, the antibody comprises a HC comprising the following CDR amino acid sequences GFTFDDYG (SEQ ID NO: 3; HCDR1 Mizetuzumab), ISWNGGKT (SEQ ID NO:4; HCDR2 Mizetuzumab), ARGSLFHDSSGFYFGH (SEQ ID NO:5; HCDR3 Mizetuzumab) or variants of those sequences having up to three amino acid changes, and a LC comprising the following CDR amino acid sequences SSNIGDNY (SEQ ID NO:6; LCDR 1 Mizetuzumab), RDS (SEQ ID NO:7; LCDR2 Mizetuzumab) and QSYD SSLSGS (SEQ ID NO:8; LCDR3 Mizetuzumab) or variants of those sequences with up to three amino acid changes. in some embodiments, the antibody comprises HC GFTFDDYG (SEQ ID NO:3; HCDR1 MAZtuzumab), ISWNGGKT (SEQ ID NO:4; HCDR2 MAZtuzumab) and A RGSLFHDSSGFYFGH (SEQ ID NO:5; HCDR3 MAZtuzumab) comprising the following CDR amino acid sequences. In some embodiments, the antibody comprises LC SSN IGDNY (SEQ ID NO:6; LCDR1 Mizetuzumab), RDS (SEQ ID NO:7; LCDR2 Mizetuzumab) and QSYDSSLSGS (SEQ ID NO:8; LCDR3 Mizetuzumab) comprising the following CDR amino acid sequences. In some embodiments, the antibody comprises HC GFTFDDYG (SEQ ID NO:3; HCDR1 Mizetuzumab), IS WNGGKT (SEQ ID NO:4; HCDR2 Mizetuzumab), ARGSLFHDSSGF YFGH (SEQ ID NO:5; HCDR3 Mizetuzumab), and LC SSNIGDNY (SEQ ID NO:6; LCDR1 Mizetuzumab), R DS (SEQ ID NO:7; LCDR2 Mizetuzumab) and QSYDSSLSGS (SEQ ID NO:8; LCDR3 Mizetuzumab) comprising the following CDR amino acid sequences. In some embodiments, the antibody or antigen binding fragment thereof comprises an HC comprising an amino acid sequence having at least 80% sequence identity to SEQ ID No. 9. Suitably, the HC may comprise the following CDR amino acid sequences GFTFDDYG (SEQ ID NO:3; HCDR1 Mizetuzumab), ISWN GGKT (SEQ ID NO:4; HCDR2 Mizetuzumab) and ARGSLFHDSSGFYF GH (SEQ ID NO:5; HCDR3 Mizetuzumab), and the remainder of the HC may have at least 80% sequence identity with SEQ ID NO 9. In some embodiments, the antibody comprises an HC comprising the amino acid sequence of the VH region of SEQ ID NO. 9.

EVQLLESGGGLVQPGGSLRLSCAASGFTFDDYGMSWVRQAPGKGLEWVSDISWNGGKTHYVDSVKGQFTISRDNSKNTLYLQMNSLRAEDTAVYYCARGSLFHDSSGFYFGHWGQGTLVTVSSASTKGPSVFPLA(SEQ ID NO:9).

In some embodiments, the antibody comprises an LC comprising an amino acid sequence having at least 80% sequence identity to SEQ ID No. 10. Suitably, the LC may comprise the following CDR sequences SSNIGDNY (SEQ ID NO:6; LCDR1 Mizetuzumab), RDS (SEQ ID NO:7; LCDR2 Mizetuzumab) and QSYDSSLSGS (SEQ ID NO:8; LCDR3 Mizetuzumab), and the remainder of the LC may have at least 80% sequence identity with SEQ ID NO: 10. In some embodiments, the antibody comprises an LC comprising the VL region amino acid sequence of SEQ ID NO. 10.

QSVLTQPPSASGTPGQRVTISCSGSSSNIGDNYVSWYQQLPGT APKLLIYRDSQRPSGVPDRFSGSKSGTSASLAISGLRSEDEADYYC QSYDSSLSGSVFGGGTKLTVLGQPKANPTVTLFPPSSEEL(SEQ ID NO:10).

As will be appreciated by those skilled in the art, the VH and VL regions may be linked to a human IgG constant domain sequence (typically IgG1, igG2 or IgG 4). In some embodiments, the antibody comprises an HC having an amino acid sequence with at least 80% sequence identity to SEQ ID NO. 11. Suitably, the HC may comprise a CDR sequence as defined in SEQ ID NO. 3, SEQ ID NO. 4 and SEQ ID NO. 5 and the remainder of the HC may have at least 80% sequence identity with SEQ ID NO. 11. In some embodiments, the antibody comprises the HC amino acid sequence of SEQ ID NO. 11.

EVQLLESGGGLVQPGGSLRLSCAASGFTFDDYGMSWVRQAPGKGLEWVSDISWNGGKTHYVDSVKGQFTISRDNSKNTLYLQMNS LRAEDTAVYYCARGSLFHDSSGFYFGHWGQGTLVTVSSASTKGPSVFPLAPSSKSTSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSSLGTQTYICNVNHKPSNTKVDKRVEPKSCDKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK(SEQ ID NO:11).

In some embodiments, the antibody comprises an LC having an amino acid sequence with at least 80% sequence identity to SEQ ID No. 12. Suitably, the LC may comprise a CDR sequence as defined in SEQ ID NO. 6, SEQ ID NO. 7 and SEQ ID NO. 8 and the remainder of the LC may have at least 80% sequence identity to SEQ ID NO. 12. In some embodiments, the antibody comprises the LC amino acid sequence of SEQ ID NO. 12.

QSVLTQPPSASGTPGQRVTISCSGSSSNIGDNYVSWYQQLPGTAPKLLIYRDSQRPSGVPDRFSGSKSGTSASLAISGLRSEDEADYYCQSYDSSLSGSVFGGGTKLTVLGQPKANPTVTLFPPSSEELQANKATLVCLISDFYPGAVTVAWKADGSPVKAGVETTKPSKQSNNKYAASSYLSLTPEQWKSHRSYSCQVTHEGSTVEKTVAPTECS(SEQ ID NO:12).

In some embodiments, the antibody comprises the HC amino acid sequence of SEQ ID NO. 11, or a variant thereof, as described herein and the LC amino acid sequence of SEQ ID NO. 12, or a variant thereof, as described herein.

In some embodiments, the formulation comprising the anti-CD 38 antibody is in unit dosage form. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 100mg to about 800mg, e.g., about 100mg to about 500mg, about 150mg to about 450mg, about 200mg to about 400mg, about 400mg to about 800mg, about 450mg to about 750mg, or about 500mg to about 700 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose selected from the group consisting of about 100mg, about 125mg, about 150mg, about 175mg, about 200mg, about 225mg, about 250mg, about 275mg, about 300mg, about 325mg, about 350mg, about 375mg, about 400mg, about 425mg, about 450mg, about 475mg, about 500mg, about 525mg, about 550mg, about 575mg, about 600mg, about 625mg, about 650mg, about 675mg, about 700mg, about 725mg, about 750mg, about 775mg, or about 800mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of about 300mg or about 600 mg.

In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 100 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 125 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 150 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 175 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 200 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 225 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 250 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 275 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 300 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 325 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 350 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 375 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 400 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 425 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 450 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 475 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 500 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 525 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 550 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 575 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 600 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 625 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 650 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 675 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 700 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 725 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 750 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 775 mg. In some embodiments, the unit dosage form comprises an amount sufficient to administer a dose of about 800 mg.

In some embodiments, the anti-CD 38 antibody unit dosage forms provided herein may further comprise one or more pharmaceutically acceptable excipients, carriers, and/or diluents. In some embodiments, the anti-CD 38 antibodies are provided in the form of a pharmaceutical composition comprising a unit dosage form according to the present disclosure. Suitably, the pharmaceutical composition may further comprise one or more pharmaceutically acceptable excipients, carriers and/or diluents.

The dosage regimen is adjusted to provide the best desired response (e.g., therapeutic response). For example, a single bolus may be administered, several divided doses may be administered over time, or the doses may be proportionally reduced or increased depending on the degree of urgency of the treatment situation. The compositions may be formulated in dosage unit form for ease of administration and uniformity of dosage. In some embodiments, dosage unit forms as used herein may refer to physically discrete units suitable as unitary dosages for subjects to be treated, each unit containing a predetermined quantity of active compound calculated to produce the desired therapeutic effect upon association with the desired pharmaceutical carrier.

The specifications of the dosage unit forms of the present disclosure are governed by and directly dependent upon (a) the unique characteristics of the active compound and the particular therapeutic effect to be achieved, and (b) the limitations inherent in the art of compounding such active compounds for the treatment of individuals.

The effective dosage and dosage regimen of an anti-CD 38 antibody or antigen-binding fragment thereof used in the present disclosure depends on the severity of the disease or condition to be treated and can be determined by one skilled in the art.

In some embodiments, the anti-CD 38 antibody or antigen-binding fragment thereof is administered at a dose of about 100mg to about 800mg by subcutaneous administration once every week, once every two weeks, once every three weeks, or once every four weeks. In some embodiments, the anti-CD 38 antibody or antigen-binding fragment thereof is administered at a dose of about 100mg to about 800mg once weekly by subcutaneous administration. In some embodiments, the anti-CD 38 antibody or antigen-binding fragment thereof is administered at a dose of about 100mg to about 800mg once every two weeks by subcutaneous administration. In some embodiments, the anti-CD 38 antibody or antigen-binding fragment thereof is administered at a dose of about 100mg to about 800mg once every three weeks by subcutaneous administration. In some embodiments, the anti-CD 38 antibody or antigen-binding fragment thereof is administered at a dose of about 100mg to about 800mg once every four weeks by subcutaneous administration.

Suitably, the weekly dose may be about 100mg. Suitably, the weekly dose may be about 125mg. Suitably, the weekly dose may be about 150mg. Suitably, the weekly dose may be about 175mg. Suitably, the weekly dose may be about 200mg. Suitably, the weekly dose may be about 225mg. Suitably, the weekly dose may be about 250mg. Suitably, the weekly dose may be about 275mg. Suitably, the weekly dose may be about 300mg. Suitably, the weekly dose may be about 325mg. Suitably, the weekly dose may be about 350mg. Suitably, the weekly dose may be about 375mg. Suitably, the weekly dose may be about 400mg. Suitably, the weekly dose may be about 425mg. Suitably, the weekly dose may be about 450mg. Suitably, the weekly dose may be about 475mg. Suitably, the weekly dose may be about 500mg. Suitably, the weekly dose may be about 525mg. Suitably, the weekly dose may be about 550mg. Suitably, the weekly dose may be about 575mg. Suitably, the weekly dose may be about 600mg. Suitably, the weekly dose may be about 625mg. Suitably, the weekly dose may be about 650mg. Suitably, the weekly dose may be about 675mg. Suitably, the weekly dose may be about 700mg. Suitably, the weekly dose may be about 725mg. Suitably, the weekly dose may be about 750mg. Suitably, the weekly dose may be about 775mg. Suitably, the weekly dose may be about 800mg. Such administration as disclosed herein may be repeated, for example, 4 to 12 times. In some embodiments, such administration as disclosed herein may be repeated 4 times, i.e., weekly, for a total of 4 weeks. In some embodiments, such administration as disclosed herein may be repeated 5 times, i.e., weekly, for a total of 5 weeks. In some embodiments, such administration as disclosed herein may be repeated 6 times, i.e., weekly, for a total of 6 weeks. In some embodiments, such administration as disclosed herein may be repeated 7 times, i.e., weekly, for a total of 7 weeks. In some embodiments, such administration as disclosed herein may be repeated 8 times, i.e., weekly, for a total of 8 weeks. In some embodiments, such administration as disclosed herein may be repeated 9 times, i.e., weekly, for a total of 9 weeks. In some embodiments, such administration as disclosed herein may be repeated 10 times, i.e., weekly, for a total of 10 weeks. In some embodiments, such administration as disclosed herein may be repeated 11 times, i.e., weekly, for a total of 11 weeks. In some embodiments, such administration as disclosed herein may be repeated 12 times, i.e., weekly, for a total of 12 weeks.

In one embodiment, the anti-CD 38 antibody or antigen-binding fragment thereof is administered at a weekly dose of about 100mg to about 800mg. Suitably, the weekly dose may be from about 100mg to about 500mg. Suitably, the weekly dose may be from about 150mg to about 450mg. Suitably, the weekly dose may be from about 200mg to about 400mg. Suitably, the weekly dose may be from about 400mg to about 800mg. Suitably, the weekly dose may be from about 450mg to about 750mg. Suitably, the weekly dose may be from about 500mg to about 700mg. The dosage can be determined or adjusted by measuring the amount of a compound of the present disclosure in the blood after administration, for example, by taking a biological sample and using an anti-idiotype (anti-idiotypic) antibody that targets the antigen-binding region of the anti-CD 38 antibody.

In one embodiment, the therapeutic antibody is formulated at a concentration of about 5 mg/ml. In another embodiment, the therapeutic antibody is formulated at a concentration of about 20 mg/ml. In another embodiment, the therapeutic antibody is formulated at a concentration of about 50 mg/ml. In another embodiment, the therapeutic antibody is formulated at a concentration of about 100 mg/ml. In another embodiment, the therapeutic antibody is formulated at a concentration of about 120 mg/ml. In another embodiment, the therapeutic antibody is formulated at a concentration of about 150 mg/ml. In some embodiments, a volume of 0.8mL, 0.9mL, 1.8mL, 2.7mL, or 2.8mL is injected in the thigh, abdomen, or arm. In another embodiment, the therapeutic antibody is formulated at a concentration of about 75 mg/ml. In some embodiments, a volume of 0.53mL, 0.6mL, 1.2mL, 1.8mL, or 1.87mL is injected in the thigh, abdomen, or arm. In another embodiment, the therapeutic antibody is formulated at a concentration of about 90 mg/ml. In some embodiments, a volume of 0.44mL, 0.5mL, 1.0mL, 1.5mL, or 1.56mL is injected in the thigh, abdomen, or arm. In another embodiment, the therapeutic antibody is formulated at a concentration of about 100 mg/ml. In some embodiments, a volume of 0.4mL, 0.45mL, 0.9mL, 1.35mL, or 1.4mL is injected in the thigh, abdomen, or arm. In some embodiments, the dose is administered over a period of 1,2, 4, 6, 8, or 10 hours. In some embodiments, the dose is administered weekly. In some embodiments, the dose is administered every 2 weeks. In some embodiments, the dose is administered every 3 weeks. In some embodiments, the dose is administered every 4 weeks.

In some embodiments, the present disclosure provides a unit dosage form comprising an isolated antibody or antigen-binding fragment thereof comprising a VH region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a VL region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, wherein the isolated antibody or antigen-binding fragment thereof binds to human CD38 (SEQ ID NO: 1), and the unit dosage form is formulated for subcutaneous administration of the antibody or antigen-binding fragment thereof at a dose of 100 mg to 800 mg in the treatment of myasthenia gravis.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the antibody or antigen binding fragment thereof further comprises one or more engineered glycoforms. In some embodiments, the engineered glycoforms include glycosylation of one or more polypeptides, and the glycosylation is N-linked glycosylation or O-linked glycosylation. In some embodiments, the glycosylation is an N-linked glycosylation. In some embodiments, the glycosylation is O-linked glycosylation.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the VH region of the antibody or antigen-binding fragment thereof comprises an amino acid sequence having at least 90% identity to SEQ ID No. 9, and/or the VL region of the antibody or antigen-binding fragment thereof comprises an amino acid sequence having at least 90% identity to SEQ ID No. 10.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the VH region comprises an amino acid sequence having at least 95% identity to SEQ ID No. 9.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the VL region comprises an amino acid sequence having at least 95% identity to SEQ ID No. 10.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the VH region comprises an amino acid sequence having at least 99% identity to SEQ ID No. 9.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the VL region comprises an amino acid sequence having at least 99% identity to SEQ ID No. 10.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the HC of the antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 95% identity to SEQ ID No. 11.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein LC of the antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 95% identity to SEQ ID No. 12.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof interacts with at least K121, F135, Q139, D141, E239, W241, C275, K276, F284, P291, and E292 of SEQ ID No. 1 and SEQ ID No. 2 based on human sequence numbering.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof binds human CD38 (SEQ ID NO: 1) with an affinity of 10 ^-8 M or greater, and wherein the affinity is measured by a standard Biacore assay.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the VH region comprises SEQ ID No. 9 and the VL region comprises SEQ ID No. 10.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof comprises HC as shown in SEQ ID No. 11 and LC as shown in SEQ ID No. 12.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof further comprises an Fc domain. In some embodiments, the Fc domain is a human Fc domain. In some embodiments, the Fc domain is a variant Fc domain.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the isolated antibody or antigen binding fragment is a human IgG antibody. In some embodiments, the human IgG antibody is a human IgG1 antibody.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein further comprising a background myasthenia gravis drug.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof is used in combination with one or more background myasthenia gravis drugs. In some embodiments, the background myasthenia gravis drug is selected from the group consisting of immunosuppressants, steroids, anticholinergic and cholinesterase inhibitors, and combinations thereof. In some embodiments, the background myasthenia gravis drug is selected from the group consisting of methylprednisolone, prednisone, budesonide, fluticasone propionate, pistigmine, mycophenolate mofetil, dicyclopirine, and azathioprine and cyclosporine, and combinations thereof. In some embodiments, a unit dosage form as disclosed herein comprises the one or more background myasthenia gravis drugs.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the antibody or antigen binding fragment thereof is administered at a dose selected from the group consisting of about 100mg, about 125mg, about 150mg, about 175mg, about 200mg, about 225mg, about 250mg, about 275mg, about 300mg, about 325mg, about 350mg, about 375mg, about 400mg, about 425mg, about 450mg, about 475mg, about 500mg, about 525mg, about 550mg, about 575mg, about 600mg, about, about 625mg, about 650mg, about 675mg, about 700mg, about 725mg, about 750mg, about 775mg, or about 800mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 100 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 125 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 150 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 175 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 200 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 225 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 250 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 275 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 300 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 325 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 350 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 375 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 400 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 450 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 475 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 500 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 525 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 550 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 575 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 600 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 625 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 650 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 675 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 700 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 725 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 750 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 775 mg. In some embodiments, the antibody or antigen binding fragment thereof is administered at a dose of 800 mg.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the dose is a weekly, biweekly, tricyclically or quarterly administered dose.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein further comprising at least one pharmaceutically acceptable carrier, excipient, or stabilizer.

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein administration of the antibody or antigen binding fragment thereof results in a 3-or 4-grade incidence of one or more treatment-related adverse events (TRAEs) or adverse events (TEAEs) occurring in treatment of less than 10%. In some embodiments, the TRAE or TEAE is selected from the group consisting of gastrointestinal disorders, nausea, infection, fever, shingles, urinary tract infection, skin and skin tissue disorders, headache, fever, chills/chills, vomiting, diarrhea, joint pain, myalgia, hypotension, respiratory, thoracic and mediastinal disorders, thrombocytopenia, leukopenia, lymphopenia, heart disorders, palpitations, and dyspnea. In some embodiments, administration of the antibody or antigen binding fragment thereof results in one or more TRAEs or TEAEs with maximum intensity of grade 1 or grade 2 of the common terminology for adverse events standard (CTCAE).

In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the isolated antibody or antigen-binding fragment thereof comprises HC as set forth in SEQ ID NO. 11 and LC as set forth in SEQ ID NO. 12, and wherein the antibody or antigen-binding fragment thereof is administered subcutaneously once a week for 8 weeks. In some embodiments, the present disclosure provides a unit dosage form as disclosed herein, wherein the isolated antibody or antigen binding fragment thereof further comprises one or more engineered glycoforms, wherein the engineered glycoforms comprise glycosylation of one or more polypeptides, and the glycosylation is an N-linked glycosylation.

Therapeutic mode

In the methods of the present disclosure, therapies are used to provide a positive therapeutic response to a disease or disorder. The term "positive therapeutic response" refers to an improvement in a disease or disorder and/or an improvement in symptoms associated with a disease or disorder.

Positive therapeutic response for any given disease or disorder can be determined by a standardized response standard specific for that disease or disorder. In addition to this positive therapeutic response, subjects undergoing therapy may experience an improved beneficial effect of symptoms associated with the disease.

The measure of efficacy of treating myasthenia gravis can be evaluated based on the myasthenia gravis disease activity scale according to the SOE study activity scale (table 8, example 1). The myasthenia gravis disease assessment is based on scores as disclosed in example 1, including, but not limited to, myasthenia gravis daily life activity (MG-ADL), quantitative Myasthenia Gravis (QMG), composite Myasthenia Gravis (MGC), revised 15 items of the myasthenia gravis quality of life scale (MG-QoL 15 r), and/or Myasthenia Gravis Impairment Index (MGII).

Treatment according to the present disclosure includes a "therapeutically effective amount" of the drug used. The terms "therapeutically effective amount" and "therapeutically effective dose" refer to an amount of a therapy sufficient to reduce or ameliorate the severity and/or duration of a disorder or one or more symptoms thereof, to prevent progression of a disorder, to cause regression of a disorder, to prevent recurrence, development, onset, or progression of one or more symptoms associated with a disorder, or to enhance or ameliorate the prophylactic or therapeutic effects of another therapy (e.g., a prophylactic or therapeutic agent) at dosages and for periods of time required to achieve a desired therapeutic outcome. The therapeutically effective amount may vary depending on factors such as the disease state, age, sex and weight of the individual, and the ability of the drug to elicit a desired response in the individual. A therapeutically effective amount is also an amount in which any toxic or detrimental effects of the antibody or antibody portion are exceeded by the therapeutically beneficial effects.

Anti-CD 38 antibody kit

In another aspect, a kit for treating MG is provided. In some embodiments, kits for treating systemic SLE are provided. In one embodiment, the kit comprises a dose of an anti-CD 38 antibody described herein, such as TAK-079. In one embodiment, the kit comprises a dose of an anti-CD 38 antibody described herein, such as a michelitumumab. In some embodiments, a kit provided herein may contain one or more doses of a liquid or lyophilized formulation as provided herein. When the kit comprises a lyophilized formulation of an anti-CD 38 antibody described herein (such as a micturition mab), typically, the kit will also contain a suitable liquid for reconstitution of the liquid formulation, such as sterile water or a pharmaceutically acceptable buffer. In some embodiments, the kit may comprise an anti-CD 38 antibody formulation described herein pre-packaged in a syringe for subcutaneous administration by a healthcare professional or for home use.

In certain embodiments, the kit will be used for single administration or administration of an anti-CD 38 antibody described herein, such as a micturition mab. In other embodiments, the kit may contain multiple doses of an anti-CD 38 antibody described herein, such as a mezetuzumab, for subcutaneous administration. In one embodiment, the kit may comprise an anti-CD 38 antibody formulation described herein pre-packaged in a syringe for subcutaneous administration by a healthcare professional or for home use.

Article of manufacture

In other embodiments, an article of manufacture is provided that contains materials useful in the treatment of the above-described conditions. The article includes a container and a label. Suitable containers include, for example, bottles, vials, syringes, and test tubes. The container may be formed from a variety of materials, such as glass or plastic. The container contains a composition effective for treating a disease and may have a sterile access port (STERILE ACCESS port) (e.g., the container may be an intravenous infusion bag or vial having a stopper pierceable by a hypodermic injection needle). The active agent in the composition is the antibody. A label on or associated with the container indicates that the composition is to be used to treat the selected condition. The article of manufacture may further comprise a second container comprising a pharmaceutically acceptable buffer such as phosphate buffered saline, ringer's solution, or dextrose solution. The article of manufacture may further include other materials desirable from a commercial and user standpoint, including other buffers, diluents, filters, needles, syringes, and package inserts with instructions for use.

Examples

EXAMPLE 1 phase 2 randomization, tolerability and efficacy of TAK-079 in systemic myasthenia gravis patients, placebo-controlled study

Study purpose and study plan

The main objective of this study was to evaluate the safety and tolerability of micturition mab in subjects with systemic Myasthenia Gravis (MG) who are receiving stable MG background therapy.

A secondary objective of this study was to evaluate the effect of mictuzumab on MG disease activity using a clinical rating scale and autoantibody levels.

The exploratory purposes of this study were (1) determining the Pharmacokinetics (PK) of the micturizumab, (2) determining the Pharmacodynamics (PD) profile of the micturizumab, (3) exploring the effect of repeated administration of the micturizumab on MG disease activity using a novel clinical disease assessment scale, (4) exploring the duration of clinical significant effect on MG disease severity (using at least 1 MG clinical rating scale), (5) exploring the frequency and proportion of subjects in need of rescue therapy, (6) exploring vaccine-induced protective antibodies, and (7) exploring the effect of repeated administration of the micturiab on exploratory biomarkers of disease activity.

This is a phase 2, randomized, double-blind, placebo-controlled study designed to assess the safety, tolerability and efficacy of micturition mab in combination with standard background therapies in subjects with systemic MG.

Approximately 36 subjects were randomly assigned to the study. Following a screening period of up to 28 days, eligible subjects were randomly assigned to one of the following treatment groups at a 1:1:1 ratio (a) 300mg of Mezetuzumab was added to stable standard background therapy, (b) 600mg of Mezetuzumab was added to stable standard background therapy, and (c) matched placebo was added to stable standard background therapy.

The study was divided into 3 consecutive phases, 8 week dosing phase, 8 week safety follow-up (SFP) and 16 week long follow-up (LFP).

During the 8 week dosing period, the micturition mab/matched placebo was administered via Subcutaneous (SC) injection once a week for 8 weeks.

Weekly prior to subsequent dosing, safety assessments, including safety laboratory tests, were performed. For safety reasons, the subject may have modified the dose (e.g., discontinued or delayed) of the study drug (michelzumab/placebo).

After completion of the 8 week dosing period, subjects entered 8 week blind SFP, with safety and efficacy assessments completed every 2 weeks. After completion of week 16 visit in SFP, subjects were blind prior to entering LFP visit at week 20.

MG clinical activity scores and autoantibody levels were followed every 4 weeks from week 20 to week 32 of LFP for subjects who received random micturizumab, and study end visits occurred at week 32 of LFP. For subjects randomly assigned placebo, the study end visit occurred at week 20 of LFP. The schematic of the study is outlined in figure 1.

Adverse Events (AEs) that were occurring at 16 weeks of SFP visit (including non-resolved clinical/laboratory parameters) were monitored by LFP until these adverse events resolved, recovered to baseline, or were clearly determined to be due to stable or chronic illness or complications in the subject. Study drug-related AEs/Severe AEs (SAE) with onset after SFP were collected throughout LFP.

Overall, the longest follow-up period was about 24 weeks after the last dose of study drug.

As determined by the investigator, subjects were allowed to receive rescue medications (e.g., IVIg, high dose corticosteroids, or plasmapheresis/plasma exchange, or increasing ongoing background medications). If the subjects are undergoing rescue therapy, they will automatically enter the SFP. Rescue therapy is defined as the administration of additional concomitant medications to control and manage potential MG lesions according to institutional practices or the best medical judgment of a physician.

Selection of study population

Inclusion criteria

Each subject must meet all of the following inclusion criteria in order to randomly distribute treatment (a) the subject understands and agrees to participate in the study, provides signed and dated written Informed Consent (ICF) and any required privacy authorizations (as applicable, the subject's legal representative may provide written informed consent according to local and regional regulatory requirements) and is able to comply with protocol requirements in view of the researcher, (b) the subject's age is 18 years or more, (c) serological test positive support against AChR or against MuSK antibodies at the time of screening supports diagnosis of MG, (d) the U.S. Myasthenia Gravis Foundation (MGFA) clinical classification II to IV at the time of screening, (e) the total score of myasthenia gravis daily life activity (MG-ADL) at the time of screening is 6 or more, wherein at least 4 minutes belong to non-ocular items, (f) if an immunosuppressive drug (i.e.e., mycophenolate, methotrexate, cyclosporine, tacrolimus, cyclophosphamide) is being received for at least 6 months, (c) a stable oral administration of a therapeutic regimen of at least 3 months if at least 3 months is being received as a stable oral therapeutic regimen, if at least 3 months is being received at least one stable oral therapeutic regimen is being received before the same oral therapeutic regimen, a stable dose of treatment is required at least 2 weeks prior to screening, (i) the dose accompanying standard background treatment is expected to remain stable throughout the study unless a dose reduction is required due to toxicity, (ii) allowable background therapy is defined as no more than cholinesterase inhibitor + -corticosteroid + -1 steroid-retaining immunosuppressant drug (limited to azathioprine, mycophenolate mofetil, methotrexate, cyclosporine, tacrolimus or cyclophosphamide), the subject must receive at least one allowable background drug, (j) female subjects requiring fertility are tested negative for pregnancy, (j) both male and female subjects must perform an effective, reliable and approved contraceptive regimen for up to 90 days or5 half-lives (whichever is longer) during the study and after cessation of treatment, and (k) the subject is able and willing to follow the study procedure.

Exclusion criteria

Subjects meeting any of the following exclusion criteria were not randomly assigned to the treatment group (a) had a history of thymoma (allowing removal of the past history of fully packaged thymoma for No. 12 months prior to screening) or invasive thymic malignancy unless adequately treated for No. 5 years prior to screening and no sign of recurrence were considered to be cured, (b) had a history of thymoectomy within 12 months prior to screening, (c) class MGFAI or class V, (d) received IVIg, subcutaneous Ig or plasmapheresis/plasmapheresis within 4 weeks prior to screening, or expected that any therapy other than standard background therapy of the subject could be used between screening and administration to treat MG (e.g., rescue therapy), (e) Chronic Obstructive Pulmonary Disease (COPD) or asthma, 1 second prior to bronchodilation of which was 50% of the predicted normal value, required FEV1 testing for patients with COPD or asthma, and (f) received rituximab within 6 months prior to first administration, Belimumab (belimumab), eculizumab (eculizumab), or any monoclonal antibody for immunomodulation; the CD19 count of subjects previously exposed to rituximab must be within the normal range at the time of screening, (g) known autoimmune diseases other than MG that might interfere with the course and performance of the study, (h) live vaccine vaccination was vaccinated within 4 weeks prior to screening or any live vaccine vaccination was planned during the study, (i) any medical condition that the researcher thought to potentially interfere with the participation of the subject in the study (such as significant cardiovascular, pulmonary, blood, gastrointestinal, endocrine, liver, kidney, renal, Neurological, malignant or infectious diseases), constitutes an additional risk to the patient, or may confound the assessment of the patient, (j) gestation or lactation day 1 during the screening period or prior to the first dose of study drug, (k) participation in or exposure to any other study drug within 4 weeks or 5 half-lives (whichever is longer) prior to day 1, (l) opportunistic infections of less than or equal to 12 weeks prior to initial study dosing or currently undergoing treatment for chronic opportunistic infections such as Tuberculosis (TB), pneumocystis pneumonia, cytomegalovirus, herpes simplex virus, herpes zoster or atypical mycobacteria, mild within 12 weeks of study dosing, Limited herpes simplex infection is permissible as long as lesions have resolved without systemic treatment by day 1, (m) organ and bone marrow dysfunction, (i) ALT (alanine aminotransferase) or AST (aspartate aminotransferase) > 3 times the Upper Limit of Normal (ULN), (ii) total bilirubin > 1.5 times ULN (based on this criterion, subjects with confirmed diagnosis and documented Gilbert syndrome are not excluded), (ii) platelets <75,000/mm ³, (iv) absolute neutrophil count <1500/mm ³, (v) hemoglobin <8g/dL, (vi) IgG <5g/L (500 mg/dL), or (vii) lymphocyte count <500/mm ³, (n) T cell interferon-gamma release assay (TIGRA) is positive at the screening visit (results obtained by QuantiFERON-TB Gold test or T-Spot/elpost), note that (i) TIGRA may not be used if the test is available, (v) hemoglobin <8g/dL, (vi) IgG <5g/L (500 mg/dL) lymphocyte count (500 mg/dL) or (35) lymphocyte assay is positive at the screening visit, (35) the skin has been defined as a low risk of having been met, avoiding intimate contact with TB positive individuals) and/or chest X-ray examination less than or equal to 6 months prior to screening visit is consistent with no evidence of latent or active TB, (o) researchers believe that any serious medical or psychiatric disorder that might interfere with treatment according to protocol is completed, (p) hepatitis b surface antigen at screening, hepatitis B core antibody, hepatitis C antibody or HIV antibody/antigen test results are positive, however, individuals known to have a history of chronic hepatitis C and who have been treated and completely cured of the disease, are confirmed to be negative by the hepatitis C virus RNA polymerase chain reaction test at the time of screening and are not excluded based on positive hepatitis C antibody alone, or (q) have a history of severe allergic or anaphylactic reaction to recombinant proteins or excipients used in the MAzetuzumab/placebo formulation.

Removal of subjects from therapy or assessment

For subjects meeting any of the criteria that (a) the subject is withdrawn and (b) pregnancy may be permanently discontinued.

Treatment with study drugs may also be discontinued for any of (a) AE/SAE, (b) protocol bias, (c) worsening of symptoms, (d) unsatisfactory response to treatment, (e) termination of study by sponsor, or (f) failure to visit.

Demographic and medical history data collection

A complete medical history was compiled for each subject during the screening period (i.e., 28 days prior to study day 1) including previous medical history, complications and concomitant therapy evaluations and documentation. This includes assessment of current MG signs, symptoms, morbidity (e.g., by disease activity tools, evaluation and scoring), and previous and current MG therapies.

Demographics include age, gender, race, and race (optional depending on country).

Treatment of

Treatment administered

Prodrugs

On each dosing day, subjects were pre-dosed with an antipyretic (such as acetaminophen) and an antihistamine (such as diphenhydramine) 1 to 3 hours prior to administration of the micturition mab/placebo. The prodrug regimen is in accordance with, but not limited to, (a) antipyretic oral acetaminophen (650-1000 mg) and (b) antihistamine oral or intravenous diphenhydramine (25-50 mg, or equivalent).

Mezetuzumab/placebo

Subjects received 300mg of micturizumab, 600mg of micturiab, or matched placebo via SC injection once a week for 8 weeks according to their assigned treatment. A summary of the dosing of the micturition mab/placebo is summarized in table 4.

TABLE 4 summary of dosage administration of MAIZUOTAMINE/placebo

Treatment group	Treatment a	Dosage of	Number of subjects
				Group 1	Mezetuzumab	300mg	12
Group 2	Mezetuzumab	600mg	12
				Group 3	Matched placebo	Is not suitable for	12

Subjects will receive a combination of a-mezetuzumab or matched placebo, i.e., a total of 8 doses, via subcutaneous administration once a week over a course of 8 weeks.

Post-administration medicament

Subjects were closely monitored at the clinic for at least 2 hours after the first and second mazetuzumab/placebo doses, and subject allergic reactions and possible signs and symptoms of Cytokine Release Syndrome (CRS) were examined prior to departure from the clinic.

Following the first dose of study drug, subjects received a low dose of methylprednisolone (≤20 mg) or equivalent to prevent delayed injection-related reactions. Considering the timing of the maximum pharmacological effect of the micturition mab, the post-dose drug was administered 2 hours (±15 minutes) after the first dose of the first injection and 1 day in the morning after the first dose of the study drug.

After subsequent doses of Mezetuzumab/placebo (weeks 2-8), the low dose of methylprednisolone after administration (20 mg) was not mandatory, however, if clinically indicated and at the discretion of the first investigator, the low dose of methylprednisolone after administration may have been administered.

Subjects at higher risk of respiratory complications (e.g., subjects with a history of COPD and subjects with asthma) may be administered (at the discretion of the researcher) after each study dose (a) an antihistamine (diphenhydramine or equivalent) on the first and second days after study dosing, (b) a short acting β2 adrenergic receptor agonist such as albuterol (albuterol) aerosol, (c) a pulmonary disease controlling drug such as (i) an inhaled corticosteroid with or without a long acting β2 adrenergic receptor agonist for subjects with asthma, or (ii) a long acting bronchodilator such as tiotropium bromide (tiotropium) or salmeterol for subjects with COPD with or without an inhaled corticosteroid.

The clinical site is responsible for finding the source of treatment administered either pre-or post-administration of the micturition mab/placebo.

Based on the emerging data, the physician/prescriber may have undergone an enhancement treatment prior to or after the injection of the micturition mab/placebo to ensure the safety of the subject.

Study of Identity of drugs (Identity)

The mictuzumab is a full-length human IgG1 monoclonal antibody directed against human CD 38. The antibody consists of 2 light chains and 2 heavy chains of the lambda (lambda) subclass linked together by 2 disulfide bridges.

The intensity of the MAZUOTAMINE used by SC in this study was 100mg MAZUOTAMINE (100 mg/mL) in 1mL (Table 5).

TABLE 5 study of drug identity

Research medicament	Product dose strength and form	Study dosage	Mode of administration
				Mezetuzumab	Mezetuzumab 100mg/mL	100mg/ml	SC
Placebo	NA	NA	SC

NA inapplicable, SC subcutaneous.

Packaging, labeling and storage

The micetoitumumab and matched placebo are supplied in sterile filled disposable, clear, type I borosilicate glass vials with fluoropolymer coated butyl rubber stoppers and flip top aluminum crimp seals.

The supply of mictuzumab is marked according to the current guidelines of the international coordination committee (ICH) for Good Clinical Practice (GCP) and good production specifications and includes any statement of local requirements.

During transport, the vials were kept protected from light and kept within the temperature range specified in the pharmacy manual. Each batch of the mictuzumab shipments included a packaging sheet listing the shipment contents and any applicable forms. The researcher or prescribing personnel must confirm that all of the received micturition antibodies remain in the proper temperature conditions and report any differences and get resolved prior to use.

After receiving the study drug, the researcher or prescribing personnel must check the shipping contents against the shipping unit. The verifier must ensure that the quantity is correct, that the drug is received under the conditions of storage of the label, and that the condition is good. If the quantity and conditions are acceptable, the researcher or prescribing personnel confirms receipt of the goods by signing in the lower half of the packing list and faxing according to the instructions provided on the form. If there is any discrepancy between the packing list and the actual product received, the Wuta-tsu corporation is contacted to solve the problem. The packing slip is archived in a basic document file of the investigator. Any temperature deviations and shipping and handling or storage differences will be immediately notified to the sponsor. All clinical study material must be kept in place, restricted access, safe places prior to use, destruction, or return to the sponsor or designated personnel. The mictuzumab must be stored as specified on the label (see pharmacy manual for additional information) according to manufacturer's specifications. The instructions section of the pharmacy manual provides detailed instructions for the preparation of the dosage. Complete receipt, inventory, responsibility, reconciliation, and destruction records of all used and unused study drug vials must be maintained. Details of these activities and related forms are in the pharmacy manual. The drug supplies are counted and checked at this site prior to return to the wuta-tsu corporation or designated personnel or destruction.

A researcher or prescribing person must ensure that the study medication is used according to approved protocols and is only distributed to patients who are enrolled in the study. To document the proper use of a study drug (mezetuzumab), a researcher must keep a record of all study drug deliveries to the site, site inventory, use per patient, and return to the sponsor or to the designated personnel.

During study performance, researchers are informed of any expiration date or review date extension of clinical study material. Upon receipt of the sponsor or designated personnel expiration date notification, the site must complete all of the instructions outlined in the notification, including quarantining the expired clinical study material for return to the sponsor or designated personnel thereof.

Drug liability

All clinical study material remains in place, restricted access, safe, prior to use, destruction, or return to the sponsor or designated personnel. The mictuzumab is stored according to manufacturer's specifications, as specified on the label. The instructions section of the pharmacy manual provides detailed instructions for the preparation of the dosage. The complete receipt, inventory, responsibility, reconciliation, and destruction records of all used and unused study drug vials were maintained. Details of these activities and related forms are included in the pharmacy manual. The drug supplies are counted and checked at this site prior to return to the wuta-tsu corporation or its designated personnel or destruction.

A researcher or prescribing person must ensure that the study drug is used according to approved protocols and is only distributed to subjects who are enrolled in the study. In order to document the proper use of the study drug (mezetuzumab), the researcher must keep a record of all study drug deliveries to the site, stock of the site, use per subject, and return to the sponsor or designated personnel thereof.

During study performance, researchers are informed of any expiration date or review date extension of clinical study material. Upon receipt of the sponsor or designated personnel expiration date notification, the site must have completed all of the instructions outlined in the notification, including quarantining the expired clinical study material for return to the sponsor or designated personnel thereof.

Overdose of medicine

Overdose is defined as the deliberate or accidental administration of a study drug to or by a study subject at a dose that is known to be higher than the dose allocated to that particular subject according to the study protocol.

To date, there is no experience of overdosing with mezetuzumab.

If overdosing occurs, close monitoring and supportive treatment according to medical requirements will be recommended.

Placebo

Matched placebo was supplied in sterile filled disposable, clear, type I borosilicate glass vials with fluoropolymer coated butyl rubber stoppers and aluminum crimp seals with flaps.

Methods of assigning subjects to treatment

According to a randomized schedule generated by the interactive voice/network response system (IXRS), subjects were randomized to 1 of the 3 treatment groups outlined in table 4 at a 1:1:1 ratio after completion of study screening and prior to study day 1 dosing.

Selection of dose in study

Criteria for selecting a dosage and regimen of a mazetuzumab for treating an MG patient are based on identifying a safe and well-tolerated dose that exhibits relevant Pharmacodynamic (PD) activity.

Clinical experience before the start of the study has demonstrated that mezetuzumab is safe and well-tolerated in a broad dosage (. Ltoreq.1200 mg), vascular concentration and exposure in 3 different populations, i.e., healthy subjects, subjects with relapsed and/or refractory multiple myeloma (RRMM) and subjects with systemic lupus erythematosus [ SLE ].

In healthy subjects, single doses of Mezetuzumab were well tolerated with intravenous injection of up to 0.06mg/kg and SC injection of 0.6 mg/kg. In dose escalation studies in healthy subjects, subjects with RRMM, and subjects with SLE, the overall safety, tolerability, and PD profile of the micturition mab indicates that the optimal dose and schedule of micturition mab for MG patients consisted of 8 weekly doses of 300 or 600 MG.

Dose selection and scheduling for each subject

Prior to the administration of the mictuzumab/placebo, the subjects received the prodrug and were evaluated for safety.

Since the dose levels (300 mg and 600 mg) required multiple SC injections to administer the full dose, the dose at week 1 was administered by giving each SC injection an interval of 30 minutes (+ -10 minutes) until the full pre-determined dose was administered. On all other drug administration days, if the investigator believes the subject does not have a clinically significant infusion response, the SC injection should be given simultaneously without waiting periods.

The study staff assessed the subjects prior to each dose. For the first dose, laboratory evaluations were evaluated using the results obtained at the time of screening. Otherwise, laboratory results were obtained one day or the day prior to dosing. In the event that the clinical parameters do not meet the continuous administration criteria, the study medication is temporarily disabled until the parameters meet the administration level or are discontinued at the discretion of the first investigator. For any given subject, the administration of the mictuzumab/placebo must not be reduced or increased.

If 2 doses were to be discontinued for study dosing due to safety issues or other circumstances outlined below, the subject would discontinue study dosing and enter SFP. If 2 or more subjects discontinue the study, the clinician or prescribing personnel must review the available safety data to determine whether to adjust the treatment plan.

Subjects must maintain a stable dose of their standard background therapy throughout the study unless a dose reduction is required due to toxicity. The allowable background therapy is defined as no more than cholinesterase inhibitors + -corticosteroids + -1 steroid-sparing immunosuppressants (limited to azathioprine, mycophenolate mofetil, methotrexate, cyclosporine, tacrolimus or cyclophosphamide). The subject is subjected to at least one allowable background drug.

Blind setting

The assignment of study subjects to 1 of the 3 study groups was performed by blind randomization of the schedule that was available to the chief investigator in the case of a medical emergency. Otherwise, site workers were blinded to study week 16 (SFP).

To maintain study integrity, all researchers, including researchers, site personnel, contract Research Organization (CRO) medical inspectors, study clinicians, and sponsors, are blinded to treatment assignments during treatment. Treatment assignments were obtained by IXRS according to the procedure outlined in the study manual or related training materials. Information about treatment assignments is securely maintained at the designated personnel according to standard operating procedures.

A record of subject number, date study medication was dispensed, and treatment distribution was maintained by the study site.

Emergency blinding may be performed via IXRS if necessary. No emergency blind uncovering event occurred during this study.

Past therapy and concomitant therapy

Concomitant medication and procedure for exclusion

The excluded concomitant medications are presented in table 6. If the subjects received the excluded drug they will discontinue from the dosing period and automatically enter SFP.

TABLE 6 concomitant drug exclusion

AE, adverse event, MG, myasthenia gravis.

A after sponsors and chief researchers discuss and agree, exceptions to medications are allowed for treatment AEs.

B subjects who had any therapy between screening and dosing (except standard background therapies allowed by MG) were reasonably expected to be excluded from study participation.

Allowable concomitant drugs and procedures

The allowable concomitant medications are summarized in table 7.

TABLE 7 allowable concomitant drugs

A azathioprine administration must be stable for at least 6 months prior to screening visit.

Rescue therapy

Rescue therapy is defined as the administration of additional concomitant medications to control and manage potential MG lesions according to institutional practices or the best medical judgment of a physician. Rescue medications may already include, but are not limited to, high dose corticosteroids, IVIg, and plasmapheresis/plasma exchange.

Throughout the course of the study, subjects will maintain their stable doses of immunosuppressive therapy and corticosteroid therapy (consistent with protocol requirements). If the subjects are undergoing rescue therapy, they will automatically enter the SFP.

Adding, or altering background immunosuppressive therapy, or adding a drug that is not within protocol limits, as deemed necessary by the first investigator to treat MG performance, results in the subject discontinuing study dosing and entering SFP.

Compliance with treatment

Under supervision of a researcher or established assistant researcher, only the eligible subjects are administered or distributed with the mictuzumab/placebo. Appropriate researchers keep records of the receipt and distribution of study drugs.

Efficacy, pharmacokinetic (PK), pharmacodynamic (PD), biomarkers, immunogenicity, and safety variables

Evaluated measurement and flow chart

The study schedule is presented in table 8.

TABLE 8 study procedure timetable

AChR, acetylcholine receptor, ADA, AE, adverse events, CRS, cytokine release syndrome, COVID-19, coronavirus disease 2019, ecg, electrocardiogram, eCRF, electronic case report forms, HBV, hepatitis b virus, HCV, hepatitis c virus, ICF, informed consent, ig, immunoglobulin, IRB, institutional review board, IVIg, intravenous immunoglobulin, LFP, MG, myasthenia gravis, MG-ADL, myasthenia gravis-daily life activities, MGC, composite myasthenia gravis, MGII, myasthenia gravis impairment index, MG-QoL15r, myasthenia gravis quality of life scale, muSK, muscle specific tyrosine kinase, PGIC, patient global impression-change, PGIS patient global impression-severity, PK, pharmacokinetic, QMG, quantitative myasthenia gravis, SAE serious adverse events, SC, subcutaneous, SFP, adverse events during treatment, adverse events occurring during treatment.

A based on the best medical judgment of the primary investigator, the subject may make additional laboratory evaluations and observations, if desired, and as permitted by the clinical signs or symptoms exhibited at each study clinic visit.

B subjects were visited at screening, weeks 1-4, week 8, week 12, week 16, week 20 and week 32, and were present at the study site. Other visits may be made at the clinic, or through an optional home care visit (or a mix of tele/tele-medicine and home care) to expand flexibility for the patient during COVID-19 public health emergencies. Home healthcare visits are recorded in study records and eCRF.

^c Subjects were blinded after 16 weeks. At week 16, clinical parameters of continued administration (including ongoing drug-related AEs) at levels below those in table 11 are monitored until the parameters/AEs are resolved, returned to baseline, or unequivocally determined to be due to stable or chronic illness or complications in the subject.

^d The 20 th week visit to LFP was the study end visit of subjects randomized to placebo. Subjects randomized to placebo only required a symptom-oriented physical examination during this visit.

^e Prior to the initiation of any screening procedures relevant to the study, informed consent was noted.

^f The screening period was 28 days (i.e., day-28 to day-1). Subject qualification needs to be confirmed by the project clinician or by a designated person prior to group entry and prior to receiving study medication.

^g Physical examination should be directed at symptoms and MG disease, with important clinical findings recorded as AE. In LFP, this is only required when there is a drug related AE being sent at the 16 th week of evaluation. Women with fertility are asked about their menstrual history at each visit. Serum pregnancy tests were performed on delayed menstruation.

^h The evaluation may be performed on the day prior to or on the day of the prescribed visit prior to dosing.

ⁱ Vital signs (temperature, blood pressure, respiratory rate and heart rate) were measured 2 hours (+ -10 minutes) before all of the micturition antibodies were administered and after the first and second dose of micturition antibodies/placebo. Furthermore, vital signs were assessed at any time clinically relevant. At the discretion of the investigator, vital sign measurements need not be collected at week 14 visit during COVID-19 epidemic if symptom-directed physical examination does not cause problems.

^j Urine pregnancy test results were available and negative prior to administration of the micturition mab. If the subject has a delayed menstrual period, or if IRB requires, the serum pregnancy test is completed and a negative result is obtained prior to administration with the study drug. Serum pregnancy tests may be used instead of urine pregnancy tests, with sponsor pre-approval.

^k Hematology and chemistry laboratory samples were collected locally. Local laboratory evaluations may be performed more frequently (e.g., acute management for TEAE) at the discretion of the researcher and may be used for dosing decisions.

Clinical laboratory evaluation of disease assessment (anti AChR antibodies and anti MuSK antibodies) pooled test.

Samples were collected prior to m administration of the mictuzumab.

ⁿ CD19 evaluation was only performed in patients previously exposed to rituximab, and CD19 counts were eligible for screening within normal ranges.

^o Circulating biomarkers may include assessment of complement C3 and C4 levels. Samples for cytokine markers were also drawn. If CRS is suspected, additional cytokine marker samples are withdrawn.

^p Additional PK and biomarker sampling may be required.

^q Quantitative immunoglobulins were tested in a central laboratory and therefore no results could be obtained before weekly dosing. However, according to standard medical practice, once the results are available, the researcher must review the results and take appropriate clinical actions, which may include, but are not limited to, disabling research drugs and treatment with IVIg, e.g., in the case of severe infections.

^r If a remote visit is made, the physician review portion of the present assessment may be omitted.

^s If a remote visit is made, the procedure may be omitted. For COVID-19 related reasons, the forced vital capacity assessment of QMG tests may be omitted.

^t Prodrugs and post-administration drugs before and after administration of the micturizumab.

^u The time and the anatomical site of each injection were recorded. The subjects were closely monitored at the clinic for at least 2 hours after the first and second doses of mezetuzumab and for possible signs and symptoms of allergic reactions and CRS prior to departure from the clinic.

^v Post-dose drug was administered 2 hours (±15 minutes) after the first dose of the first study drug and 1 day in the morning after the first dose of the study drug. If clinically indicated and at the discretion of the first investigator, the post-administration drug may be administered subsequently in subsequent doses.

^w AE evaluation should include symptomatic examination according to standard medical practice.

Assessment at the end of a security follow-up

SFP end clinical parameters as outlined in table 9 were evaluated at week 16 of SFP (see SOE in table 8). If the clinical manifestations and parameters do not meet the SFP end criteria and are deemed study-related by the chief investigator, study-related parameters that do not meet the study end criteria continue to be evaluated in LFP until they normalize or return to baseline levels.

TABLE 9 clinical parameters at the end of the safety follow-up period

CRS, cytokine release syndrome, NCICTCAE, adverse event terminology standard common to the national cancer institute, hgb, hemoglobin, ig, immunoglobulin, IRR, infusion-related reactions;

LLN, lower normal limit.

^a Laboratory and infection grading is based on NCICTCAE V4.03.

Efficacy measurement

The study's first investigator, or appropriately trained and commissioned study site staff, assessed each subject's disease activity based on the following MG disease activity scale outlined in the following section and according to SOE in table 8.

MG-ADL score MG-ADL is a validated measurement of the outcome of MG symptoms for 8 problems reported by patients (Muppidi et al (2011) music Nerve44 (5): 727-31; wolfe et al (1999) Neurology 52 (7): 1487-9), both of which are incorporated herein by reference in their entirety). MG-ADL assessed the associated MG symptoms and their functional effects on the subject. Subjects were assessed for functional disability secondary to ocular (2), bulbar (3), respiratory (1), and gross motor or limb impairment (2). Each item was individually rated from 0 (normal) to 3 (severe). The overall score for MG-ADL ranged from 0 points to 24 points, with higher scores indicating more severe functional impairment and disability. A2 point decrease in the total MG-ADL score is considered to be a clinically significant improvement.

QMG score for disease severity Quantitative Myasthenia Gravis (QMG) score is a validated 13 disease severity assessment tool reported by physicians. QMG scores were based on quantitative tests and clinician assessment of sentinel muscle groups to evaluate muscle strength, eye (2), face (1), bulbar (2), gross motor (6), shaft (1), and respiratory system (1). Each item was rated on a scale of 0 to 3, with 3 being the most severe. The overall score ranged from 0 to 39, with higher scores representing a heavier disease burden (Barohn et al (1998) Ann.NY Acad.Sci.841:769-772; katzberg et al (2014) Muscle Nerve 49 (5): 661-665), both of which are incorporated herein by reference in their entirety). A3 point decrease in the total QMG score is considered to be a clinically significant improvement.

MGII score Myasthenia Gravis Injury Index (MGII) is a novel and validated method of measuring MG severity with proven feasibility, reliability and structural effectiveness (Barnett et al (2016) Neurology 87 (9): 879-886; barnett et al (2017) Neurology 89 (23): 2357-2364), both of which are incorporated herein by reference in their entirety). The MGII score was developed using patient input and consisted of 6 physician exams and 22 patient report entries. MGII have a smaller lower limit effect (i.e., a greater dynamic range at the lower end of the gauge) than other commonly used measurement methods and are therefore more sensitive to detection variations. The overall score ranged from 0 to 84 (higher scores indicate poorer MG disease activity), with a 8-score decrease in group levels reflecting the smallest clinically significant difference (MCID). The MCID at the group level (estimated sample size for the trial) was 8.1 points and the MCID at the individual level (categorizing subjects as responders) was 5.5 points.

MGC score the composite Myasthenia Gravis (MGC) scale is a 10-item assessment tool reported by validated subjects and physicians for the assessment of signs and symptoms of MG (Barnett et al (2018) neurol clin.36 (2): 339-353, which is incorporated herein by reference in its entirety). Physician evaluation included evaluation of ptosis (upward gaze), presbyopia at lateral gaze, eye closure, neck flexion or extension, shoulder abduction, and hip flexion, subject evaluation included self-reporting of speech, chewing, swallowing, and respiration. Items were scored based on 4 potential impact levels, normal, mild, moderate or severe. The overall score ranges from 0 to 50, with higher scores indicating greater impact of MG on functional activity (Benatar et al (2012) Muscle Nerve,45 (6), 909-917; burns et al (2012) Ann.NY Acad.Sci.1274:99-106; sadjadi et al (2012) Muscle Nerve 45 (6): 820-825, each incorporated herein by reference in its entirety). A 3 point decrease in MGC overall score is considered a clinically significant improvement.

MG-QoL15r: revised 15 items of the myasthenia gravis quality of life scale (MG-QoL 15 r) are validated tools containing 15 items reported by 15 subjects regarding the subjects 'perception of impairment and disability and the subject's tolerance to disease manifestations (Burns et al (2010) Muscle Nerve 41 (2): 219-226; burns et al (2011) Muscle Nerve 43 (1): 14-18; burns et al (2016) Muscle Nerve 54 (6): 1015-1022), each of which is incorporated herein by reference in its entirety). The total score ranges from 0 to 30, with higher scores indicating poorer MG disease activity. The MCID of this Clinical Outcome Assessment (COA) tool has not been fully determined (Barnett et al (2018) Neurol. Clin.36 (2): 339-353, which is incorporated herein by reference in its entirety).

PGIC patient global impression-change (PGIC) is an anchoring scale used to help explain the aforementioned MG disease activity tools (MG-ADL, MGII, MGC, QMG and MG-QoL15 r) mentioned above. PGICs can be used to analyze meaningful changes and other psychometric characteristics as well as performance characteristics of these tools.

PGIS patient global impression-severity (PGIS) is an anchoring scale used to help explain the aforementioned MG disease activity tools (MG-ADL, MGII, MGC, QMG and MG-QoL15 r). PGIS can be used to analyze meaningful changes and other psychometric characteristics as well as performance characteristics of these tools.

Ig quantification serum samples of IgM, igG and IgA were obtained at the time points specified in Table 8 at the screening time and throughout the study, and the tests were performed at a central laboratory.

PK, pharmacodynamic/biomarker samples were collected by venipuncture or indwelling catheter at time points detailed in SOE table 8 for measurement of serum concentration of micturition mab and biomarker assessment. Samples were tested in a central laboratory.

PK measurements serum samples for measuring the concentration of micturition mab were collected at various time points specified by SOE in table 8. Additional PK samples may be required for a particular event or AE of clinical interest if deemed necessary by a medical inspector.

Pharmacodynamics/biomarker measurements in this study several biomarkers were evaluated to test for correlation with safety, PK and (if possible) efficacy. These biomarkers are used to identify subjects with a higher response or likelihood of adverse reactions to michelitumumab. Biomarker sample analysis is performed if or when needed. Samples were collected for pharmacodynamic measurements as detailed in table 8. If the subject exhibits signs or symptoms that may be assessed by a researcher as CRS, then blood is drawn for central assessment, including but not limited to immune markers and cytokine markers.

Autoantibodies

Serum samples were collected to detect anti-AChR and anti-MuSK antibodies and analyzed by the central laboratory as summarized in table 8.

Pharmacodynamics blood samples were collected before, during and at the end of treatment for analysis of cd38+ expression and monitoring of immune cell changes by flow cytometry. These evaluations were performed in a central laboratory.

Circulating biomarkers serum samples of cytokines/chemokines were collected before, during and at the end of treatment to help identify subjects with a higher response to or likelihood of experiencing adverse effects with the michelzumab.

Immune profiling analysis blood samples for immune profiling analysis were collected for profiling analysis of immune cells before, during and at the end of treatment. These blood samples are analyzed for the presence and changes of immune cells by flow cytometry or mass cytometry.

Vaccine-induced protective antibodies serum samples of vaccine-induced protective antibodies (measles, mumps, rubella, tetanus and diphtheria) were collected before, during and at the end of the treatment.

Immunogenic sample collection serum samples for measurement of anti-micheltuzumab antibodies (anti-drug antibody and ADA are interchangeable terms in the protocol) were collected at various time points as specified by SOE in table 8. Samples were collected prior to each administration. Detailed information about the preparation, handling and transportation of immunogenic samples is provided in the laboratory manual. The research center laboratory further tested positive ADA screening samples for true positives and titers.

Safety measurements safety was assessed by frequency, severity, and AE type of AE, as well as by changes in subject vital signs, body weight, and clinical laboratory results from baseline using a safety analysis set. Study of drug exposure and discontinuation causes has been tabulated. Adverse Events (TEAEs) occurring in the treatment occurring after the administration of the first study drug to the end of SFP have been tabulated. AE is tabulated according to the regulatory active medical dictionary (MedDRA) version 25.0 and the data is summarized using the Preferred Term (PT) and major System Organ Classification (SOC). All security analyses were performed using a security analysis population.

Physical examination at the time specified in SOE Table 8, a full body examination and a symptom-oriented body examination were completed according to the standard of care, and MG signs and symptoms were evaluated. Women with fertility are asked about their menstrual history at each visit. Serum pregnancy tests were performed on delayed menstruation.

Height and weight height was measured only during the screening period (within 28 days prior to the first dose of TAK 079). Body weight was measured during screening and at weeks 10, 16 and 32 as summarized in table 8.

Vital signs (body temperature, respiratory rate, heart rate and blood pressure) were evaluated at the visits specified in table 8 and recorded in source documents and eCRF. Furthermore, vital signs are assessed at any time clinically relevant, i.e., when the subject exhibits signs or symptoms of Injection Site Response (ISR), CRS, or hypersensitivity. Vital signs were assessed before each study dose and 2 hours (±10 minutes) after the first and second doses of micturition mab/placebo administration, as shown in table 8. Clinically significant values as determined by the first investigator are noted as AE and closely monitored for follow-up.

12 Lead ECG A single 12 lead Electrocardiogram (ECG) was taken at screening visit (qualification evaluation) and at weeks 10 and 16 of SFP and week 32 of LFP and read locally. Additional ECG may be performed at the discretion of the researcher. Each ECG recording was performed according to standard institutional practices. Any ECG findings judged by the investigator to have clinically significant (except at the screening visit) were considered AEs and recorded in the source document and eCRF and monitored.

Adverse events serious and non-serious AEs were monitored throughout the study as specified in table 8.

Clinical laboratory assessment hematology, serum chemistry and serology assessments are performed locally, with reference ranges provided in an electronic data acquisition (EDC) system. Throughout the course of the study, clinical laboratory evaluations were performed according to SOE in table 8. Instructions for handling and transporting clinical laboratory samples are provided in the research laboratory manual.

Clinical chemistry and hematology

Blood samples for analysis of clinical chemistry and hematology parameters shown in table 10 were obtained as specified in SOE table 8.

TABLE 10 clinical chemistry and hematology tests

ANC, absolute neutrophil count.

If 2 or more subjects discontinued study drug administration based on the dose-discontinuation criteria set forth in Table 11, the clinician/prescriber reviews the available safety data to determine whether treatment plan adjustments are to be made.

TABLE 11 standard summary of subsequent administrations

ANC absolute neutrophil count, CRS cytokine release syndrome, CTCAE general adverse event terminology standard, hgb hemoglobin, IRR infusion-related response, MG myasthenia gravis, NCI, national cancer institute, SFP, safety follow-up period.

^a Subjects whose clinical parameters met the dose-maintenance criteria did not receive the predetermined dose of micturition mab, and instead returned for re-evaluation and evaluation at the next scheduled visit.

^b Subjects whose clinical parameters meet the dose-discontinuation criteria will permanently discontinue study dosing and subjects will enter SFP, completing all relevant evaluations. Standard background therapies for MG will be administered at the discretion of the first investigator.

^c Laboratory, IRR, allergy, anaphylaxis and infection grading is based on NCI CTCAE V4.03.

^d For any suspicious event of any class of CRS, a complete cytokine set should be obtained.

^e According to Sampson et al (2006) j.allegy Clin, incorporated herein by reference in its entirety.

Immunol.117 (2): 391-397 for diagnosis of allergic reactions.

^f CRS is classified according to Lee et al (2014) Blood 124 (2): 188-195, which is incorporated herein by reference in its entirety.

^g According to Lee et al (2014) Blood 124 (2): 188-195, symptomatic treatment is allowed.

Pregnancy with a new pattern of medicine

Serum pregnancy (human chorionic gonadotrophin [ hCG ]) tests were completed for all female subjects, performed at screening and during SFP, and were negative for randomly assigned and study-continued subjects.

Urine pregnancy tests were completed for all female subjects prior to the first dose of micturition mab/placebo and at week 5 of the dosing period. If the subject reports a delayed menstruation, the serum pregnancy test is completed and a negative result is obtained prior to administration of the study drug.

All study pregnancy tests will be conducted at the designated local laboratory as determined and validated by the sponsor and appropriate laboratory documentation provided prior to the study test.

Scheduling of pregnancy tests

Women with fertility must complete pregnancy tests at the schedule outlined below. (a) Before initial study dosing, (i) screening period: serum pregnancy test negative (hCG <5 mIU/mL), and (ii) baseline (day 1 before initial study dosing, or day 1 before study dosing) urine pregnancy test negative with a sensitivity of at least 50 mIU/mL. If the urine test is not determined, a serum pregnancy test is mandatory. (b) During study inclusion, (i) at week 5, prior to dosing (urinary pregnancy test), (ii) during SFP and LFP as outlined in table 8 (serum pregnancy test), (iii) if menstrual period is delayed (serum pregnancy test), and (iv) additional pregnancy tests were performed according to IRB requirements and/or local regulatory requirements.

Measurement of appropriateness

Safety and efficacy assessments used in the study are criteria for disease populations and study stages.

Endpoint (endpoint)

Primary endpoint

The percentage of patients who developed TEAE (including grade 3 or higher events), SAE and AE that caused termination of the micturition mab.

Secondary endpoint

The secondary endpoints are as follows. (a) A change in the score from baseline in (i) MG daily activity (MG-ADL) score, (ii) quantitative myasthenia gravis score, (iii) composite Myasthenia Gravis (MGC) score, and (iv) a revised 15-item myasthenia gravis quality of life scale (MG-QoL 15 r). (b) Changes in anti-AChR antibody or anti-MuSK antibody levels from baseline. (c) The percentage of patients meeting the MCID criteria in the corresponding MG clinical impairment scale (MG-ADL, QMG, MGC).

Exploratory endpoint

The exploratory endpoint is as follows. (a) Serum concentration-time curves for the merozotocab PK parameters include, but are not limited to, the time-varying concentrations observed at the end of the dosing interval (C _{Cereal grain}). (b) changes in serum Ig levels. (c) Pharmacodynamic analysis of the presence and changes of immune cells in peripheral blood prior to and during therapy. (d) MGII score change from baseline. (e) Duration of clinically significant impact on severity of MG disease (in all clinical disease impairment scales: MG-ADL, QMG, MGC, MGII). (f) Percentage of subjects meeting MCID criteria on MGII scale. (g) frequency and proportion of subjects in need of rescue therapy. (h) Immunogenicity evaluation of mezetuzumab (including anti-drug antibodies (ADA)) in peripheral blood. (i) Biomarkers of disease activity, such as complement levels (C3, C4, complement cleavage products), and specific markers of CD38 pathway modulation. (j) The protective antibody levels of the vaccine were varied from measles, mumps, rubella, diphtheria and tetanus.

Statistical method and determination of sample quantity

Analysis set

Total analysis set: all subjects entered into the group. In efficacy analysis, only subjects with both baseline values and at least 1 effective post-baseline value were included.

Safety analysis set subjects who received at least 1 dose of study drug.

PK analysis set subjects who received at least 1 dose and at least 1 measurable serum concentration of micheltuzumab.

Pharmacodynamic analysis set subjects who underwent baseline assessment and at least 1 post-baseline PD sample assessment.

Immunogenicity analysis set subjects from safety populations were subjected to baseline evaluation and at least 1 post-baseline immunogenicity sample evaluation.

Efficacy analysis

Efficacy was not the primary endpoint for this study. Secondary efficacy measures include (a) a change in score from baseline in (i) MG-ADL score, (ii) QMG score, (iii) MGC score, and (iv) MG-QoL15r, (b) a change in anti-AChR antibody or anti-MuSK antibody levels from baseline, and (c) a percentage of subjects meeting MCID criteria in the corresponding MG clinical impairment scale (MG-ADL, QMG, MGC).

Exploratory efficacy measurements included (a) a change in score from baseline for MGII, (b) duration of clinically significant impact on MG disease severity (in all clinical disease impairment scales: MG-ADL, QMG, MGC, MGII), (c) percentage of subjects meeting MCID criteria in the MGII scale, and (d) frequency and proportion of subjects in need of rescue therapy.

Efficacy endpoints were summarized by descriptive statistics and presented by treatment group. Efficacy endpoints are analyzed, where appropriate, by (a) analyzing binary endpoints using Fisher's exact test, and (b) repeatedly measured changes over time relative to baseline endpoints using a mixed model repeated measurement analysis including treatment, visit, and (treatment X visit) interactions as factors, with baseline values as covariates.

All tests of the work-treating effect were performed at a double-sided alpha level of 0.05 and provided a 95% CI of the scale difference and Least Squares (LS) mean. No inferential hypothesis test was performed on these endpoints, and therefore, CI and p values were not adjusted for multiplicity.

All efficacy assays were performed using the full assay set.

PK analysis

A descriptive summary of the concentration-time profile of serum micturition mab is provided. PK parameters include C _{Cereal grain}. A population PK model may be developed. If a population PK model is developed, it should be reported separately. PK/PD analysis may be performed on selected PD and/or efficacy measurements, where data permits. If any population PK/PD analysis is performed, it should be reported separately.

Immunogenicity analysis

The immunogenicity status (ADA incidence) of the micheltuzumab was analyzed and summarized using descriptive statistics (as applicable) and using an immunogenicity analysis set. The impact of immunogenicity on PK, PD, safety and efficacy can be explored. The immunogenicity analysis is based on available data from subjects who have undergone a baseline assessment and at least 1 post-baseline immunogenicity assessment.

Security analysis

Safety was assessed by frequency, severity, and AE type of AE, as well as by changes in subject vital signs, body weight, and clinical laboratory results from baseline using a safety analysis set. Study of drug exposure and discontinuation causes has been tabulated.

TEAE, which occurs after administration of the first dose of study drug to the end of SFP, has been tabulated.

AE was tabulated according to MedDRA and data was summarized using PT and primary SOC. All security analyses were performed using a security analysis population.

In this study, starting with the first 12 subjects with safety assessments, each 12 subjects with safety assessments were then monitored for drug-related toxicity at a level of 2 or higher. If the termination limit of >3 out of 12 and > 5 out of 24 is reached, study accumulation is suspended (accrual) for blind investigation of the security profile. Through the consideration of the research team (which may include security administration team as the case may be), especially in cases where blind uncovering is necessary, a decision is made as to whether accumulation can be restored. AE grading limitations are based on the international guidelines for myasthenia gravis management (International Consensus Guidelines for THE MANAGEMENT of MYASTHENIA GRAVIS) with the goal of no more than grade 1 CTCAE (universal adverse event terminology) drug side effects. The statistical bounds are based on a Bayesian strategy (Bayesian strategy) to monitor the outcome of the clinical trial. If the termination rule is satisfied, then there is a 80% likelihood that the true toxicity rate is greater than 10% and the parameters of the a priori beta distribution are 0.2 and 1.8 for the binomial distribution toxicity rate.

The clinician reviews SAE and related clinical parameters to ensure acceptable benefit-risk ratios are met throughout the study. If >2 subjects experience the same SAE, the study is suspended to allow the study group (which may include the safety administration group described above) to conduct blind surveys, after which a decision is made as to whether accumulation can be resumed.

Determination of sample quantity

Approximately 36 subjects were scheduled to randomly distribute treatment (300 mg of mictuzumab, 600mg of mictuzumab, or placebo) at a 1:1:1 ratio. This study was exploratory and did not address any pre-defined assumptions.

EXAMPLE 2 study subject

Treatment of a subject

Subject treatment data for the full analysis set are summarized in table 12 and dosing regimens are summarized in fig. 1. A total of 76 subjects were screened, however, 40 subjects did not enter the study. The reasons for the screening failure were that the entry criteria (38 subjects) and the withdrawal of subjects (2 subjects) were not met.

36 Subjects were randomly distributed among 5 study sites in the united states, poland, selveya, spain and canada. Of the 36 subjects, 4 subjects (2 in each of the 300mg and 600mg groups of matuzumab) discontinued the study and the reason for discontinuation was subject withdrawal.

Table 12 patient treatment (Whole analysis set)

SFP, security follow-up period.

Percentages are based on all subjects in the total analysis set within each column.

Protocol deviation

Significant protocol deviations are summarized in table 13. A total of 13 subjects reported significant protocol bias, the most common reason for significant bias is under the category of missing endpoint assessment (19.4%; 7 subjects), typically associated with missing MG-ADL, QMG, MGC or MG-QoL15r assessments due to site personnel shortage, subject quarantine requirements, missing visits, or tool loss. Other categories of significant protocol bias reported in more than 1 subject are administration of additional concomitant background drugs, data privacy, administration/distribution of study treatment, and study treatment supply/control (2 subjects each; 5.6%). These deviations are unlikely to compromise the integrity of the study.

TABLE 13 significant protocol bias (safety analysis set)

GCP, good clinical practice, ICF, informed consent.

Percentages are based on all subjects in the safety analysis set within each column.

^a Subjects with multiple protocol deviations are counted once in each deviation category.

Example 3 efficacy, PK, PD, biomarkers and immunological evaluation

Analytical data set

The analysis population is summarized in table 14.

Table 14 analysis set (all randomly assigned subjects)

Percentages are based on all subjects randomly assigned in each column.

A full analysis set consisted of all randomly assigned subjects who underwent baseline efficacy assessment and at least 1 post-baseline efficacy assessment.

B safety analysis set consisted of subjects receiving at least 1 dose of study drug.

C the immunogenicity analysis set consisted of subjects from the safety population who underwent baseline assessment and at least 1 post-baseline immunogenicity sample assessment.

^d The PK analysis set consisted of subjects receiving at least 1 dose of study drug and at least 1 measurable serum concentration of michelituab.

^e The PD analysis set consisted of subjects receiving at least 1 dose of study drug and at least 1 post-baseline PD sample evaluation.

Demographic characteristics

Table 15 provides a summary of demographics of subjects enrolled in the study. Demographics were substantially equivalent between all groups. In general, most subjects were white ethnic (91.7%), especially white ethnic (72.2%) from europe. The median age was 50.0 years for all study groups with a maximum age of 81 years. There was some age imbalance between the study groups, and the median age of the 600mg group of micturizumab was approximately 18 and 16 years old compared to the placebo and 300mg groups, respectively. Regarding sex distribution in the total study population, female subjects (n= 22,61.1%) were numerically more than male subjects (n=14), however, sex distribution was less balanced within each study group, since the placebo group had a strong female dominance (75%), the 300mg meizetuzumab group had an equal number of men and women, and the 600mg meizetuzumab group had a slightly greater number of women (58.3%).

TABLE 15 demographic data (safety analysis set)

Medical history and other baseline characteristics

Of the 36 subjects in the group study, 29 (80.6%) reported data related to their medical history.

Key baseline disease characteristics are summarized in table 16. Based on MGFA classification, MG severity was class IIIb (33%), class IIa (27.8%) in 10 subjects, and class IIb (16.7%) in 6 subjects. MG IIIa and IVa were reported in less than 15% of all subjects. The median time since MG diagnosis was overall 8.8 years, with no significant differences between study groups. Most subjects (91.7%) had achr+ antibodies, and 3 out of 36 subjects had musk+ antibodies. In all of the clinical disease damage scales evaluated, the baseline scores were lower in the placebo group than in the mictuzumab treatment group, indicating that the placebo group subjects were less severely ill at baseline. In addition, subjects in the 300mg group of micturition mab appeared to have more severe disease at baseline than subjects in the other 2 study groups based on the average clinical disease damage scale baseline score. With regard to past MG drugs, all subjects in the study have been treated with acetylcholinesterase inhibitors (100%), and most of them have also received a combination of corticosteroids (83.3%) and/or immunosuppressants (72.2%), consistent with refractory disease.

Table 16 baseline characteristics of treatment group (safety analysis set)

ECG = electrocardiogram, MG = myasthenia gravis, MG-ADL = myasthenia gravis daily life activity, QMG = definite

Muscle weakness, mgc=composite muscle weakness, MG-qol15r=revised 15 quality of life scales of muscle weakness, MGII =index of injury to muscle weakness.

BMI = body mass index, calculated as [ weight (kg)/height (m)/(2) ].

A time (year) since MG diagnosis was calculated as (date of informed consent-date of diagnosis)/365.25. If the diagnosis date is a partial date with missing days, it is estimated as 1 st day of the month if the month is known, and if only the year is known, the date and month are estimated as 1 st day of 7 months.

* Using the trade name Calcort, replaced with the common name dif-cort.

Medical history, ongoing background medicine and rescue therapy

Ongoing background MG drugs

All subjects in the study received background MG therapy (table 17). These include acetylcholinesterase inhibitors (pistigmine) administered to 32 subjects (88.9%), oral corticosteroids (mainly prednisone) administered to 27 subjects (75%), and immunosuppressants administered to 23 subjects (63.9%), with azathioprine and cyclosporine being the most commonly used immunosuppressants. These drugs persist and stabilize throughout the time the subject is enrolled in the group and continue to be administered during the period that the subject is engaged in the study. The background therapy administered to subjects in this study met the study inclusion criteria and the therapeutic algorithm used to treat subjects with systemic MG. At baseline, there was no significant imbalance in MG background drug.

TABLE 17 ongoing background MG drugs (safety analysis set) divided by category and drug name and treatment group

MG drug is defined as drug whose start date is within 28 days prior to the first dose of study treatment and is ongoing at the time the subject is enrolled in the group, or is ended during the study, or is administered to the subject as recorded in eCRF to participate in the study.

Subjects were counted once per category and once per drug name in each treatment group.

Use of rescue therapy

By week 16, 2 subjects in the placebo group (17%) and 1 subject in the 600mg group of micturition mab (8%) were in need of rescue therapy.

During the course of the study, a total of 5 subjects required rescue therapy, 2 subjects in the placebo and micturition mab 600mg each and 1 subject in the micturition mab 300mg each required rescue therapy. Table 18 provides a summary of subject levels used for rescue therapy in the study.

TABLE 18 subjects in need of rescue therapy during the study period

Efficacy, PK, PD, biomarker, and immunogenic outcome

Efficacy results

Secondary efficacy endpoint analysis

Total score for MG-ADL

At baseline, the mean (SD) MG-ADL overall score was lower for placebo, 7.9 (1.78), compared to the Micheltuzumab-treated group; 300MG of Mezetuzumab, 9.3 (2.49), and 600MG of Mezetuzumab, 8.4 (2.23) (Table 19). At week 16, the mean (SD) change in MG-ADL response from baseline was-4.1 (3.21), -4.3 (2.79), and-3.1 (3.48) for placebo, 300MG of MAzetuzumab and 600MG of MAzetuzumab, respectively. All 3 study groups achieved clinically significant improvement (total MG-ADL score ≡2 score from baseline), although the timing and duration were slightly different. The placebo and micturition mab 300mg group achieved an earlier clinical response (week 4), while the micturition mab 600mg group was lagging. In all study groups, the clinically significant improvement achieved with 300mg of mezetuzumab seemed to be the most durable, occurring from week 4 to the end of the study (week 32), however, no placebo could be compared after week 16, since no placebo data was collected after week 16 of the study. In MMRM analysis, there was no statistically significant difference between placebo, 300mg of mictuzumab and 600mg of mictuzumab at any of the evaluation time points.

Table 19 shows summary statistics (baseline, week 16 and week 32) of total MG-ADL scores. FIG. 2a shows a plot of the observed mean change in total MG-ADL score over time relative to baseline.

TABLE 19 summarizing and analyzing changes from baseline in total score for myasthenia gravis daily life activity (MG-ADL) per visit and treatment group (full analysis set)

N/a inapplicable, SD: standard deviation baseline value was defined as the last observation before study drug at the first dose.

* Placebo data were not collected after study week 16 according to protocol design.

QMG general score

At baseline, the mean (SD) QMG overall score was lower for the placebo group compared to the MAZOMEGA treatment group, placebo, 11.4 (5.21), MAZOMEGA 300mg,12.9 (6.47), and MAZOMEGA 600mg,12.8 (4.26) (Table 20). For placebo, 300mg of mezetuzumab and 600mg of mezetuzumab, the mean (SD) change of QMG scores from baseline at week 16 was-1.2 (3.22), 3.3 (3.43), and-0.3 (4.81), respectively. From week 8 to week 16, a clinically significant improvement was observed in the 300mg group of Mezetuzumab (QMG total score > 3 score from baseline reduction) and peak response (mean [ SD ] change: 3.9[2.55 ]) was observed at week 12. At week 16, no statistically significant difference in the change from baseline QMG total score was observed between placebo, 300mg of micturizumab (mean difference in LS compared to placebo, -1.37) and 600mg of micturiab (mean difference in LS compared to placebo, 1.20).

Table 20 shows summary statistics of QMG total scores (baseline, week 16 and week 32). Fig. 3 shows the observed mean change of QMG total scores over time relative to baseline.

TABLE 20 summarizing and analyzing the changes in QMG total scores from baseline by visit and treatment groups (full analysis set)

N/A inapplicable, SD standard deviation

Baseline value was defined as the last observation before the study drug of the first dose.

If the baseline assessment of the QMG scale of the subject with the Force Vital Capacity (FVC) term is absent and the QMG scale of the subject

Absent other term, the missing FVC term score is estimated as the average of all non-missing baseline FVC values in the randomly assigned subject set. If any post-baseline QMG-assessed FVC term is missing, the missing term is estimated using the last observed value of the subject, the forward (LOCF), only for that term.

* Placebo data were not collected after week 16 according to protocol design.

MgC general score

At baseline, the mean (SD) MGC overall score was lower for placebo, 14.7 (5.80), compared to the micturin-treated group; 300mg of Mezetuzumab, 16.8 (6.58), and 600mg of Mezetuzumab, 15.3 (6.00) (Table 11. J). The mean (SD) change from baseline in MGC scores at week 16 for placebo, 300mg of MAzetuzumab and 600mg of MAzetuzumab was 6.6 (4.95), 9.2 (5.18) and 2.9 (6.45), respectively. As early as study week 4, a clinically significant response was observed in placebo and 300mg of Mezetuzumab (MGC total score decreased by 3 points relative to baseline). This clinically significant response persisted from week 4 to the end of the study (week 32) in the 300mg group of micturition mab and to week 16 in the placebo group (placebo data was available just prior to week 16). In the 600mg group of mictuzumab, clinically significant improvement was observed only intermittently at weeks 6, 12, 24 and 28. In MMRM analysis, no statistically significant difference was observed between placebo, 300mg of micturizumab (LS mean difference compared to placebo, -1.01) and 600mg of micturiab (LS mean difference compared to placebo, 4.81) at week 16.

Table 21 shows the aggregate statistics of MGC total scores. Fig. 4 shows a plot of the observed mean change in MGC total score over time relative to baseline.

Table 21. Changes from baseline in MGC total score were summarized and analyzed by visit and treatment group (full analysis set)

N/A inapplicable, SD standard deviation

Baseline values were defined as the last observations prior to the first dose of study medication.

* Placebo data were not collected after week 16 according to protocol design.

MG-QoL15r Total score

The mean at baseline (SD) MG QoL15r total score was 11.5 (4.15) in the placebo group, 17.1 (6.76) in the 300MG group and 13.9 (4.72) in the 600MG group of micturizumab (table 22). For placebo, 300MG of Mezetuzumab and 600MG of Mezetuzumab, the mean (SD) change in MG-QoL15r score from baseline at week 16 was-3.8 (4.44), 5.8 (6.83), and 2.3 (6.43), respectively. Although the MCID of MG-QoL15r has not been determined, a greater numerical decrease in score was observed for the 300MG group of micturizumab compared to placebo and 600MG of micturizumab during the 16 weeks prior to the study. In addition, the decrease in MG-QoL15r score for the 300MG group of micturition mab persisted from week 6 to the end of the study, indicating the potential trend of this dose of micturition mab to have a persistent impact on the quality of life of the subjects. In MMRM analysis, no significant difference was observed between placebo, 300mg of micturizumab (LS mean difference compared to placebo, 0.20) and 600mg of micturiab (LS mean difference compared to placebo, 2.48) at week 16.

Table 22 shows aggregate statistics for MG-QoL15r total scores. FIG. 5 shows a graph of the observed mean change in the total MG-QoL15r score over time relative to baseline.

Table 22. Changes from baseline (full analysis set) were summarized and analyzed for revised 15 MG-QoL15r total scores per visit and treatment group

* Placebo data were not collected after week 16 following protocol study design.

Responder analysis of MG-ADL

At week 16, the percentage of responders (i.e., subjects meeting MCID criteria) in both the placebo and 300mg groups of micturizumab was 66.67% (8 subjects), and the 600mg group of micturiab had 33.33% (4 subjects) responders. At week 32, both of the therapeutic dosage levels of micturition mab showed 41.67% responders (5 subjects) (placebo was not evaluated after 16 weeks).

Figure 6 shows the proportion of responders in study groups from week 4 to week 16.

FIG. 7 shows the proportion of responders (subjects with a clinically significant decrease of > 2 score in MG-ADL score from baseline) in the 300MG MAIzetuzumab panel, the 600MG MAIzetuzumab panel and the placebo group.

Responder analysis of QMG

At week 16, the percentage of responders (i.e., subjects meeting MCID criteria) was 33.33% in the placebo group (4 subjects), 58.33% in the 300mg group of micturizumab (7 subjects), and 33.33% in the 600mg group of micturiab (4 subjects).

The response rate was higher than 40% from week 16 to week 28 in the 300mg group of micturition mab (41.67%; 5 subjects), while the percentage of responders to these time points was lower for 600mg of micturition mab (placebo: not evaluated after week 16). At week 32, 16.67% of responders (2 subjects each) were found in both the 300mg and 600mg groups of micturition mab.

Figure 8 shows the proportion of responders in study groups from week 4 to week 16.

FIG. 9 shows a temporal sensitivity analysis of the proportion of responders (subjects with a clinically significant decrease of > 2 score in MG-ADL and a clinically significant decrease of >3 score in QMG score relative to baseline) in the 300MG, 600MG and placebo groups. The provisional analysis uses a composite endpoint that defines the responders as subjects meeting both MG-ADL and QMG clinical-related thresholds.

Responder analysis of MGC

At week 16, the percentage of responders was 66.67% in the placebo group (8 subjects), 75.00% in the 300mg group of micturition mab (9 subjects), and 41.67% in the 600mg group of micturition mab (5 subjects). The 300mg group of micturition mab showed 41.67% responders (5 subjects) compared to 25.00% (3 subjects) in the 600mg group of micturition mab (no placebo evaluation after week 16).

Figure 10 shows the proportion of responders in study groups from week 4 to week 16.

Anti-AChR antibody levels

At baseline, the mean (SD) anti-AChR antibody levels (nmol/L) were higher for the placebo group (119.66 [207.98 ]) than for the 300mg group (89.86 [110.93 ]) and for the 600mg group (36.12 [74.80 ]) (Table 23).

At the very fast week 2, a decrease in anti-AChR antibodies was observed in both micturizumab groups, which persisted until the end of the study. In contrast, an increase in anti-AChR antibody levels was observed in the placebo group at various time points. Significant differences in the levels of anti-AChR antibodies from baseline between the 300mg group of micturition mab and the placebo group were observed at week 8 and weeks 10, 14 and 16 (week 16: LS mean difference: -62.98;95% CI: -100.64, -25.31; p=0.001). A significant difference in the change in anti-AChR antibody levels from baseline was also observed between the 600mg group and placebo group for michelitumumab at week 14 (LS mean difference: -36.94;95% CI:71.39, -2.48; p=0.036).

As for the percentage change from baseline, an average (SD) increase of 1.23% (18.26) was observed in the placebo group compared to 35.74% (41.58) and 33.69% (37.73) average (SD) decrease in the 300mg and 600mg groups of mictuzumab, respectively. However, these differences were not statistically significant, probably due to low sample size and large variability (300 mg of micturition mab versus placebo with a difference in LS mean of-13.18%, 600mg of micturition mab versus placebo with a difference in LS mean of-21.39%). However, the differences between placebo and the 600mg group of Mizetuzumab were statistically significant at week 7 (LS mean difference: 36.41;95% CI: -69.53, -3.29; p=0.032) and week 8 (LS mean difference: -30.54;95% CI:55.68, -5.41; p=0.019) (FIG. 11). At week 32, the mean (SD) percent decrease in anti-AChR antibody levels from baseline in the 300mg dose group and the 600mg dose group was 35.77% (33.69) and 24.41% (69.13), respectively.

Table 23 shows summary statistics (nmol/L) of anti-AChR antibody levels.

TABLE 23 percent change from baseline in AChR values (nmol/L) per visit and treatment group (complete analysis set) were summarized and analyzed

Baseline value was defined as the last observation before the study drug of the first dose. NA, inapplicable, SD, standard deviation. * Placebo data were not collected after week 16 following protocol study design.

Anti-MuSK antibody levels

For 3 MuSK-positive subjects, the baseline anti-MuSK titer values (1:2560) were higher for placebo-group subjects than for 2 subjects in the 300mg group of micturition mab (1:160 and 1:640, respectively). No change in anti-MuSK titer was observed in subjects in placebo group at any of the evaluation time points, while a gradual decrease in anti-MuSK titer was observed in one of the 300mg subjects of micturition antibody (see fig. 12, a plot of changes over time in the observed values of 300mg subjects of micturition antibody). Since the number of cases is small, statistical analysis of these 3 cases is not appropriate.

Table 24 shows a summary of the percent change in anti-MuSK titer levels from baseline for the per-visit and treatment groups.

Table 24. Summary of percent changes in anti-MuSK titre levels from baseline for each visit and treatment group (full analysis set)

NA, inapplicable, SD, standard deviation. SD of 1 participant was not estimated.

Exploratory efficacy endpoint analysis

MGII Total score

At baseline, the mean (SD) MGII total score was 30.0 (9.17), 38.3 (12.43), and 34.8 (10.07) for placebo, 300mg and 600mg groups of MAZUZUOMA, respectively. At week 16, the mean (SD) change from baseline for the MGII total score was-11.9 (9.76), 16.4 (12.29), and-6.6 (15.13) for placebo, 300mg and 600mg groups of MAZUXUM, respectively. In the 300mg group of Mizetuzumab, a clinically significant decrease was observed as early as week 4, and this improvement continued until the end of the study. The placebo and the 600mg groups also intermittently reached the MCID of the scale, however MGII showed a smaller magnitude of the overall score drop and a duration of less than 300mg of the micturing antibody. The placebo and the 600mg groups also intermittently reached the MCID of the scale, however MGII showed a smaller magnitude of the overall score drop and a duration of less than 300mg of the micturing antibody. The difference in the mean MGII total score from baseline between the 300mg group and placebo group of the michelitumumab was statistically significant (difference in LS mean change from baseline: -8.00;95% CI: -14.17, -1.83; p=0.013) at week 6.

Fig. 13 shows a plot of observed mean change over time for MGII total scores relative to baseline.

MGII eye fraction scoring

At baseline, the mean (SD) MGII eye-partition scores between study groups were placebo, 6.9 (5.32), MAIZUZUZUZUZUZU 300mg,8.8 (4.37), and MAIZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZUZO 600mg,8.4 (4.89). At week 16, the mean change in the MGII eye-segmentation scores from baseline was-3.9 (3.93), -2.9 (4.04), and-1.7 (6.24) for placebo, 300mg, and 600mg groups of micturition mab, respectively. No significant difference in mean MGII eye portion scores from baseline between placebo and either micturion group was observed at any of the evaluation time points.

MGII systemic symptom score

At baseline, the mean between study groups (SD) MGII systemic symptom score was as follows placebo, 8.4 (3.23), 300mg of Mezetuzumab, 9.7 (3.92), and 600mg of Mezetuzumab, 9.1 (3.37). At week 16, the mean change from baseline in MGII systemic symptom scores was-3.6 (3.63), -3.2 (4.61), and-1.3 (4.00) for placebo, 300mg and 600mg groups of micturition mab, respectively. Similar to MGII total scores, the greatest difference in mean MGII systemic symptom score from baseline was observed between placebo and 300mg groups at week 6 (the difference from baseline LS mean change: 2.84;95% CI:5.11,0.57; p=0.016).

MGII responder-based analysis

At week 16, the percentage of responders (i.e., subjects meeting MCID criteria) was 66.67% for placebo (8 subjects), 58.33% for 300mg of matuzumab (7 subjects), and 41.67% for 600mg of matuzumab (5 subjects). At the end of the open label follow-up period (week 32), there were 6 responders in the 300mg group of micturizumab (50.00%) and 4 responders in the 600mg group of micturiab (33.33%) (placebo was not evaluated after 16 weeks).

The duration of the clinically significant impact on MG disease severity on the clinical disease damage scale below

MG-ADL

By week 16, the percentage of subjects with clinically significant improvement in total MG-ADL score accumulated for at least 12 weeks was 33.33% for placebo (4 subjects), 66.67% for 300MG of micturition mab (8 subjects), and 25% for 600MG of micturition mab (3 subjects) (table 24). On week 16, based on cumulative response data (. Gtoreq.12 weeks), the risk difference (95% CI) between 300mg of MAzetuzumab and placebo was 0.33 (-0.11,0.69), and the risk difference between 600mg of MAzetuzumab and placebo was-0.08 (-0.45,0.30).

By week 32, the percentage of subjects who responded for accumulation for 12 weeks or more was 75% in the 300mg group of micturition mab (9 subjects) and 50.00% in the 600mg group of micturition mab (6 subjects) (placebo was not evaluated after week 16).

Table 25 shows the cumulative duration of clinically significant impact on MG disease severity assessed by MG-ADL at weeks 16 and 32 for the study group. Table 26 shows the percentage of participants who reduced the total MG-ADL score by 2 points.

TABLE 25 cumulative duration of clinical impact on the severity of myasthenia gravis by treatment group on MG-ADL by week 16 and week 32 (full analysis set)

N/A, inapplicable.

The clinically significant effect is the minimal clinically significant difference in MG-ADL. It is defined as a2 point decrease in the total MG-ADL score from baseline.

The cumulative duration is defined as the sum of all time periods during which the least clinically significant difference from baseline is obtained. The maximum possible cumulative duration at week 16 was 13 weeks and the maximum possible cumulative duration at week 32 was 29 weeks since the first efficacy assessment was started at week 4.

TABLE 26 percentage of participants who reduced the total MG-ADL score by 2 points (Whole analysis set)

N/A, inapplicable.

QMG

By week 16, the percentage of subjects with clinically significant improvement in accumulating QMG for at least 12 weeks was 8.33% for placebo (1 subject), 25% for 300mg of micturition mab (3 subjects), and 16.67% for 600mg of micturition mab (2 subjects) (table 27). On week 16, based on the difference in risk of the number of subjects exhibiting cumulative responses ∈8 weeks and ∈10 weeks (95% CI), the 300mg group of Mizetuzumab was statistically significant (weeks ∈8:0.50 [0.08,0.80]; weeks ∈10:0.42 [0.04,0.73 ]) compared to the placebo group, but not for the number of subjects exhibiting cumulative responses ∈12 weeks. For these cumulative responses, no statistically significant difference was observed between placebo and 600mg of mictuzumab.

By week 32, the percentage of subjects who responded for accumulation for 12 weeks or more was 66.67% in the 300mg group of mictuzumab (8 subjects) and 33.33% in the 600mg group of mictuzumab (4 subjects) (placebo not evaluated after week 16).

TABLE 27 cumulative duration of clinical impact on the severity of myasthenia gravis by treatment group on QMG by week 16 and week 32 (full analysis set)

N/A, inapplicable.

The clinically significant impact is the least clinically significant difference in QMG. It is defined as a3 point decrease in QMG overall score from baseline.

The cumulative duration is defined as the sum of all time periods during which the least clinically significant difference from baseline is obtained. The maximum cumulative duration at week 16 was 13 weeks and the maximum cumulative duration at week 32 was 29 weeks since the first efficacy assessment from week 4.

Table 28 shows the percentage of participants whose QMG overall score was reduced by 3 points.

TABLE 28 percentage of participants with 3 score decrease in QMG total score (full analysis set)

N/A, inapplicable.

The clinically significant impact is the least clinically significant difference in QMG. It is defined as

The QMG total score was reduced by 3 points from baseline.

MGC

By week 16, MGC total scores of placebo group 33.33% (4 subjects), micturition mab 300mg group 66.67% (8 subjects), and micturition mab 600mg group 33.33% (4 subjects) were clinically significant improvement over baseline, accumulating for at least 12 weeks. At week 16, the risk difference (95% CI) based on cumulative data (. Gtoreq.12 weeks) between 300mg of MAzetuzumab and placebo was 0.33 (-0.11,0.69), and the risk difference between 600mg of MAzetuzumab and placebo was 0 (-0.38,0.38).

By week 32, the percentage of subjects with clinically significant improvement in MGC total score from baseline for accumulation for 12 weeks or more was 83.33% (10 subjects) in the 300mg group of micturition mab and 58.33% (7 subjects) in the 600mg group of micturition mab (placebo not evaluated after week 16).

Table 29 shows the percentage of participants who reduced the MCG total score by 3 points.

TABLE 29 percentage of participants who reduced the MGC total score by 3 points (full analysis set)

N/A, inapplicable.

The clinically significant impact is the least clinically significant difference in MGC. It is defined as

The MGC total score was reduced by 3 points from baseline.

MGII

By week 16, the MGII total score of placebo group 16.67% (2 subjects), micturition mab 300mg group 58.33% (7 subjects), and micturition mab 600mg group 16.67% (2 subjects) had clinically significant improvement over baseline, accumulating for at least 12 weeks. The risk difference (95% CI) between 300mg of Mizituzumab and placebo based on cumulative data (. Gtoreq.12 weeks) was statistically significant at week 16, 0.42 (0.01,0.73).

By week 32, the percentage of subjects with a MGII total score that was clinically significant relative to baseline accumulated for 12 weeks or more was 75% (9 subjects) in the 300mg group of micturition mab and 33.33% (4 subjects) in the 600mg group of micturition mab (placebo was not evaluated after week 16).

PK results

Serum concentrations of micturizumab were detectable at both dose levels in all subjects (fig. 14). In the 300mg and 600mg dose groups, respectively, the concentration of micturition mab was measurable after baseline for all subjects until week 12 and week 16.

A 2-fold increase in dose from 300mg to 600mg resulted in an approximately 2.5-fold increase in mean micturition antibody trough concentration (collected prior to dosing) from 85323ng/mL to 216741ng/mL at week 8. A greater than dose-proportional increase in drug concentration was observed at the earlier time points. No PK samples were collected to capture the peak concentration of micheluximab.

Greater variability in drug concentration was observed after week 8 compared to the data during dosing. After the end of the treatment period, the average drug concentration showed a decrease over the course of 24 weeks, reaching values below the lower limit of quantification (LLOQ) by 32 weeks for 100% and 50% of subjects in the 300mg and 600mg groups, respectively.

PD and biomarker results

Biomarker validation

Flow cytometry was performed to assess the levels of cd45+ lymphocytes, T cells, B cells, NK cells, monocytes, granulocytes, plasmablasts and plasma cells in whole blood, completing pre-validation characterization and technical validation. In addition, the assay was validated to quantitatively determine CD38 receptor occupancy in the corresponding cell types.

PD and biomarker measurements

Individual values and percent change from baseline for the two tested amounts of mezetuzumab (300 mg and 600 mg) from week 1 to week 32 prior to dosing were calculated. The total number of subjects (N) for each study group is listed in the corresponding table. Graphs of average receptor occupancy (percent receptor occupancy) and cell depletion (percent change from baseline) of cd38+ NK cells and plasmablasts in whole blood were generated.

Target engagement based on receptor occupancy flow cytometry analysis

CD38 receptor occupancy assays were developed to evaluate the changes in cd45+ lymphocytes, T cells, B cells, NK cells, monocytes, granulocytes, plasmablasts and plasma cells in whole blood. In addition, CD38 expression and micturing antibody receptor occupancy on the corresponding cell types were assessed by comparing CD38 fluorescence signals of two independent flow cytometry samples containing either labeled micturing antibody (for quantification of "free" CD38 receptor) or labeled TSF-19 (for quantification of non-competitive CD38 antibody to "total" CD38 receptor).

NK cells are the most abundant population of CD38 expressing cells in peripheral blood, and the receptor occupancy on this cell type can be used as a surrogate marker for CD38 engagement on target cells. At week 4, the CD38 receptor occupancy rates of 300mg and 600mg of micheltuzumab on cd38+ NK cells reached an average of 76.6% and 74.3%, respectively. NK cell target engagement was approximately smooth between week 4 and week 12 for both dose groups and returned to near baseline by week 32.

Target engagement is accompanied by a change in the absolute cell count of cd38+ NK cells. The maximum average decrease in cd38+ NK cells was comparable for both of the micturin dose groups, with-83.3% and-80.3% changes from baseline observed for 300mg and 600mg, respectively. NK cell counts continue to decrease during the 8 week dosing period and they continue to deplete throughout SFP and LFP period, highlighting the persistence of the response. Throughout the study, subjects receiving placebo showed only a slight change in cd38+ NK cells from baseline.

The change in plasmablast receptor occupancy and absolute counts were examined, as these cells represent target cells of the matuzumab that can be quantified in peripheral blood. The maximum average receptor occupancy on plasmablasts at therapeutic doses of 300mg and 600mg were 86.8% and 95.9%, respectively. The plasmablastoid receptor occupancy of the two dose groups reached plateau between week 4 and week 16 dosing and returned to near baseline by week 32.

In the mictuzumab-treated group, the decrease in absolute plasmablast cell count was substantially similar. Maximum effect was observed at week 4, with average changes from baseline of the 300mg and 600mg dose groups of-84.5% and-57.7%, respectively. By week 32, the plasmablast absolute count returned to near baseline.

Downstream pharmacology targeting CD38

The concentration of total IgA, igG and IgM in serum was evaluated as surrogate biomarkers for the effect of michelizumab on CD38 expressing antibody secreting target cells. Serum immunoglobulin depletion showed similar magnitude between the two mictuzumab treatment groups.

The administration of the 300mg and 600mg doses of micturition mab once a week resulted in 28.3% (9.6) and 25.8% (12.7) decrease in mean (SD) of the week 16 IgG from baseline, respectively (fig. 15). For the combined dose group, igG showed a sustained depletion pattern, with a 24.4% mean decrease observed at week 32 (the last time point examined in the study).

300Mg and 600mg of Mizituzumab treatment resulted in a 36.4% (13.0) and 37.8% (15.4) decrease in the maximum mean (SD) of IgM from baseline, respectively. Partial return to baseline was observed during the long-term follow-up period, which was more pronounced in the 300mg dose group.

IgA depletion showed maximum amplitude, decreasing by 56.8% (9.4) and 52.6% (17.2) relative to the maximum mean (SD) of baseline in the 300mg and 600mg dose groups, respectively. In all subjects treated with micheltuzumab, igA did not show a complete return to baseline by week 32.

In the placebo group, the maximum mean (SD) of IgG was reduced to 8.5% (6.1), igA 8.5% (8.1) and IgM 15.4% (21.8).

The altered disease-specific PD effects of autoantibodies were evaluated. The anti-AChR antibodies and total IgG exhibited consistent longitudinal profiles. The decrease in anti-AChR concentration appeared to be dose-independent, with maximum mean (SD) decreases of 49.6% (29.8) and 42.7% (24.6) for 300mg and 600mg, respectively, from baseline. In the placebo group, the anti-AChR reduction showed a 17.4% decrease (30.5) in the maximum mean (SD) from baseline. Depletion of anti-AChR showed substantial variability at the individual level. anti-MuSK antibody depletion data using mictuzumab was limited.

Results of immunogenicity

All 36 subjects in the immunogenicity set were subjected to baseline assessment and at least 1 post-baseline ADA assessment.

ADA responses in both the baseline sample and post-baseline sample were positive, and subjects with maximum titers of post-baseline ADA below 4 times the baseline titer value were considered pre-existing ADA positive subjects. One subject in the placebo group had pre-existing ADA and no subject in each of the 300mg group and 600mg group had pre-existing ADA, resulting in a total pre-existing ADA occurrence of 2.78%.

Subjects with positive baseline ADA results and a ≡4-fold increase in post-baseline titers over baseline titers were considered to have treatment-enhanced ADA, however, no subjects met these criteria in this study. Subjects with negative baseline ADA results and positive ADA results after any dosing were considered to have ADA present in the treatment. No subjects in placebo, 1 subject in 300mg of micturition mab and 1 subject in 600mg of micturition mab had an overall incidence of on-treatment ADA of 5.56% (table 30).

The overall ADA prevalence was 8.33% (3 out of 36 subjects), including pre-existing ADA at any time point and ADA present in the treatment.

The minimum dilution or titer required in this study was 40 and only the ADA positive samples were evaluated for titer. In all subjects with ADA present in the treatment, the range was 40 to 1280 (table 31). No correlation between ADA titer and the dose of drug administered was observed.

ADA responses were accompanied by a decrease in individual levels of micturition mab concentration. In the mictuzumab treatment group, ADA positive subjects (1 each dose group) had lower drug concentrations at the ADA positive sample visit than ADA negative subjects. No obvious correlation was observed between ADA response and PD or efficacy. For 2 subjects with ADA present in the treatment, no clinically significant AE was observed.

TABLE 30 immunogenicity status (immunogenicity analysis set)

ADA, drug-resistant antibody.

^a ADA negative includes subjects with no positive ADA response at baseline and in all post-baseline assessments.

B pre-existing ADA positives include subjects with positive ADA responses in the baseline sample but no post-baseline sample, or subjects with positive ADA responses in both the baseline sample and post-baseline sample but a maximum titer of post-baseline ADA < 4-fold the baseline titer value.

C treatment-boosted ADA positives included subjects with positive ADA responses in both baseline and post-baseline samples, and maximum titer of post-baseline ADA > = baseline titer value 4-fold.

ADA positives that occur in d-treatment include subjects that are negative for ADA in the baseline sample, as well as subjects that have a positive ADA response in any post-baseline assessment.

E transient ADA positives include subjects with positive ADA responses in 3 or less post-baseline assessments.

F-persistent ADA positives include subjects with positive ADA responses in more than 3 post-baseline assessments.

G high ADA titers include at least one subject with post-baseline ADA titers > 320.

H low ADA titers include at least one subject with post-baseline ADA titers < = 320.

Table 31 summary of immunogenicity for the treatment and per visit groups (immunogenicity analysis set)

ADA, drug-resistant antibody, SD, standard deviation, NA.

The percentages are based on the measured subjects in the set of immunogenicity assays at a given visit within each column.

The measured subjects represent the number of subjects who did not develop a missing result at a given visit.

Statistics and analysis of problems

And (5) performing covariate adjustment, wherein covariate adjustment is not performed.

Processing of missing information (Dropout) or missing data efficacy data is analyzed using observed case data based solely on the "random missing" assumption.

Metaphase analysis and data monitoring this study did not conduct metaphase analysis or data monitoring.

Multicenter study this is a multicenter study. No statistical adjustments were made to compensate for the multicenter nature of the study.

Multiple comparisons/multiplicity, no statistical adjustments were made to the multiple comparisons.

Use of subject efficacy subset efficacy analysis was performed on a full analysis set consisting of all enrolled patients with baseline values and at least 1 valid post-baseline value.

Active control study intended to show equivalence this is not an active control study intended to show equivalence.

Subgroup examination exploratory post-hoc analysis, comparing clinical responses of subjects assessed by MG-ADL and QMG total scores based on region (north america versus europe). These post hoc analyses have shown that placebo responses in north american subjects are substantially more pronounced for both MG-ADL and QMG than in european subjects (fig. 16 and 17). In addition, sub-group analysis based on the administration schedule of acetylcholinesterase inhibitors showed that the inconsistent scheduling of these symptomatic drugs used between patients and within patients prior to clinical evaluation increased significant variability in clinical response assessed by MG-ADL and QMG (fig. 18 and 19).

Figure 22 shows PD response of mictuzumab compared to Iguratimod.

FIG. 27 shows individual MG-ADL and QMG responses at week 16.

FIG. 29 shows QMG compared to the comparative study with Mezetuzumab.

Fig. 31 shows that exposure of the mictuzumab on the expected range, the PK profile was consistent with MM. Between 300mg and 600mg, there was a dose proportional increase in exposure. The micturizumab PK profile in MG was consistent with the expectation of MM studies, where concentrations tended to expose the predicted higher end. The black dashed and shaded areas represent the median and 90% prediction intervals based on the preliminary MM population PK model simulation. A subject who took 300mg and had abnormal PK profile developed ADA at week 4 (titer: 40) and then at weeks 7 (titer: 40) and 8 (titer: 20). Other visits were considered ADA negative.

Fig. 32 shows the michelvetuzumab exposure parameters for responders and non-responders. A preliminary integrated population PK model (based on the combined SLE and MM final dataset and available MG data) was developed and used to derive the complete concentration-time curve for each subject and calculate exposure index (a) Cavg: average concentration in ng/mL during one week after the last (once a week) dose, (b) Cmax: maximum drug concentration in ng/mL during the study, and (c) cumAUC: cumulative AUC in h x ng/mL up to one week after the last (once a week) dose. There was no significant difference in exposure to micturizumab between responders and non-responders (based on MG-ADL response at week 16).

FIG. 34 shows an exposure response assessment of MG-ADL. The orange dotted line indicates a clinically significant threshold for a2 point decrease in MG-ADL. The increase in exposure was not correlated with an improvement in MG-ADL scores. A similar pattern is also observed for QMG.

Fig. 35 shows background therapy.

PK, efficacy, PD, biomarkers, and immunogenicity conclusions

PK

A two-fold increase in dose from 300mg to 600mg resulted in an approximately 2.5-fold increase in mean micturition antibody trough concentration (collected prior to dosing) from 85323ng/mL to 216741ng/mL at week 8.

After the end of the treatment period, the average drug concentration showed a decrease over the course of 24 weeks, 100% and 50% of the subjects in 300mg and 600mg, respectively, reached a value below the lower limit of quantification (LLOQ) by week 32.

Efficacy of

Total score for MG-ADL

At week 16, the mean (SD) decrease of the total MG-ADL score from baseline was-4.1 (3.21), -4.3 (2.79), and-3.1 (3.48) for placebo, 300MG of MAZUXUM, and 600MG of MAZUXUM, respectively.

At week 16, the percentage of responders was 66.67% in both placebo and 300mg groups of micturition mab and 33.33% in 600mg groups of micturition mab.

By week 16, 33.33%, 66.67% and 25% of subjects receiving placebo, 300mg of mictuzumab and 600mg of mictuzumab, respectively, accumulated for at least 12 weeks with clinically significant improvement over baseline. By week 32, these percentages were 75% and 50% for the 300mg group and 600mg group of micturition mab, respectively.

QMG general score

At week 16, the mean (SD) decrease of QMG total score from baseline was-1.2 (3.22), 3.3 (3.43), and-0.3 (4.81) for placebo, 300mg of MAZUMIMAZOMUMIB, and 600mg of MAZUMIMIMIZUMIZO, respectively. The maximum change observed in the study from baseline was in the 300mg group of micturition mab at week 12 (mean [ SD ] 3.9[2.55 ]).

At week 16, the percentage of responders in placebo, 300mg and 600mg groups of micturition mab was 33.33%, 58.33% and 33.33%, respectively.

By week 16, 8.33%, 25% and 16.67% of subjects receiving placebo, 300mg of mictuzumab and 600mg of mictuzumab, respectively, accumulated for at least 12 weeks with clinically significant improvement over baseline. By week 32, these percentages were 66.67% and 33.33% for the 300mg group and 600mg group of micturition mab, respectively.

MgC general score

At week 16, the mean (SD) decrease of MGC total score from baseline was-6.6 (4.95), -9.2 (5.18), and-2.9 (6.45) for placebo, 300mg of micturin, and 600mg of micturin, respectively.

At week 16, the percentage of responders in placebo, 300mg and 600mg groups of micturition mab was 66.67%, 75% and 41.67%, respectively.

By week 16, 33.33%, 66.67% and 33.33% of subjects receiving placebo, 300mg of MAzetuzumab and 600mg of MAzetuzumab, respectively, accumulated for at least 12 weeks with clinically significant improvement over baseline, and by week 32, these percentages were 83.33% and 58.33% for the 300mg and 600mg groups of MAzetuzumab, respectively.

MG-QoL15r Total score

At week 16, the mean (SD) change in MG-QoL15r scores from baseline was-3.8 (4.44), 5.8 (6.83), and 2.3 (6.43) for placebo, 300MG of MAZtuzumab and 600MG of MAZtuzumab, respectively.

MGII Total score

At week 16, the mean (SD) decrease of MGII total scores from baseline was-11.9 (9.76), 16.4 (12.29), and-6.6 (15.13) for placebo, 300mg and 600mg groups of MAZUXUM, respectively. The difference in mean MGII total score from baseline between placebo and 300mg groups was statistically significant and clinically significant (baseline LS mean change difference: -8.00;95% CI: -14.17, -1.83; p=0.013) at week 6.

At week 16, the percentage of responders in placebo, 300mg and 600mg groups of micturition mab was 66.67%, 58.33% and 41.67%, respectively.

By week 16, 16.67%, 58.33% and 16.67% of subjects receiving placebo, 300mg of mictuzumab and 600mg of mictuzumab, respectively, accumulated for at least 12 weeks with clinically significant improvement. By week 32, these percentages were 75% and 33.33% for 300mg and 600mg of meizetuzumab, respectively.

Rescue therapy

By week 32, 5 subjects required rescue therapy, 2 subjects each in the placebo and micturizumab 600mg groups and 1 subject in the micturiab 300mg group required rescue therapy.

Anti-AChR antibody levels

Reduction of anti-AChR antibodies was observed as early as week 2, which was not dose dependent and continued until the end of the study (week 32).

On week 16, an increase in mean (SD) of 1.23% (18.26) was observed in the placebo group, as compared to a decrease in mean (SD) of 35.74% (41.58) and 33.69% (37.73) in the 300mg and 600mg groups of micturizumab, respectively.

At week 32, the mean (SD) percent decrease in anti-AChR antibody levels from baseline in the 300mg and 600mg groups of micturition antibodies was 35.77% (33.69) and 24.41% (69.13), respectively.

Anti-MuSK antibody levels

Of the 3 MuSK positive subjects, no change in anti-MuSK titer values was observed for subjects in the placebo group at any of the evaluation time points, while a gradual decrease was observed in 1 of the 2 matuzumab 300mg subjects.

PD and biomarkers

The average CD38 receptor occupancy of the micturizumab on cd38+ NK cells reached a near maximum of approximately 75% in the 300mg and 600mg groups of micturition mab, remained stable by week 12 and recovered to near baseline by week 32. Cd38+ NK cells were maximally depleted at about 80% at 300mg or 600mg, and the depletion kinetics reflected receptor occupancy on the same cell type. Placebo-treated subjects showed only a slight change in cd38+ NK cells from baseline throughout the study.

The maximum mean (SD) receptor occupancy on the plasmacytes between the 300mg and 600mg groups of micturition antibodies was approximately comparable (86.8% (22.3) and 95.9% (3.6), respectively). Maximum plasmablast depletion was observed at week 4, with mean (SD) reductions of the 300mg and 600mg groups of micturing antibodies of 84.5% (17.7) and 57.7% (41.1), respectively.

Serum IgG depletion between the two micturizumab treatment groups showed similar magnitudes, with the mean (SD) decrease of the micturiab 300mg group and the micturiab 600mg group at week 16 being 28.3% (9.6) and 25.8% (12.7) mean (SD), respectively, in both micturiab groups, igG depletion continued until week 32. The placebo group showed no substantial reduction in IgG, with a maximum mean (SD) reduction of 8.5% (6.1).

For placebo, 300mg of mezetuzumab and 600mg of mezetuzumab, the maximum mean (SD) decrease in IgM from baseline was 15.4% (21.8), 36.4% (13.0) and 37.8% (15.4), respectively, with partial return to baseline being more pronounced in the 300mg dose group.

For placebo, 300mg of mezetuzumab and 600mg of mezetuzumab, the maximum mean (SD) decrease in IgA from baseline was 8.5% (8.1), 56.8% (9.4) and 52.6 (17.2), respectively, with no significant return to baseline by week 32.

Immunogenicity of

In all subjects with ADA present in the treatment, the range was 40 to 1280. No correlation between ADA titer and the dose of drug administered was observed.

ADA responses were detected simultaneously with drug concentration reduction, but the data were too limited to ultimately determine the effects of ADA on PK. No obvious correlation was observed between ADA response and PD, efficacy or safety.

Example 4 safety and safety biomarker evaluation

Exposure degree

A summary of the study drug exposure and compliance rates is provided in table 32. 24 subjects received at least one dose of micturition mab (12 per dose group), and 12 subjects received at least one dose of placebo. The average compliance rate for the placebo group was 100% and the average compliance rate for the combination of micturizumab group was 99.0%.

TABLE 32 study drug exposure and compliance rates (safety analysis set) divided by treatment group

A compliance is defined as (total number of doses taken/number of doses scheduled to be taken) ×100%.

Dose interruption

Prior to receiving each study drug dose, subjects were evaluated against dosing criteria based on laboratory evaluations and clinical events of interest as defined in table 11.

2 Subjects were discontinued. One subject was in the 300mg group and the other subject was in the 600mg group, based on laboratory evaluation (low lymphocyte count) and clinical events of interest (COVID-19 test positive), respectively. The results of both events have recovered/resolved.

AE

Pre-treatment event (PTE) is defined as the occurrence of any adverse medical event in a subject who has signed an informed consent to participate in a study but who has occurred prior to administration of any study medication, and is not necessarily causally related to study participation.

AE is defined as any adverse medical event occurring in a subject administered a drug and is not necessarily causally related to the treatment. TEAE is defined as AE occurring after receiving the first dose of study drug during the treatment period until the end of the safety follow-up. The severe TEAE is hereinafter referred to as SAE.

PTE and AE verbatim are encoded by SOC and PT using the meddra25.0 version.

Brief overview of adverse events

An overview of TEAE is presented in table 33. Overall, mictuzumab was well tolerated in subjects with MG. There was no substantial imbalance in AE between treatment groups, most of which were of slight severity. SAE was balanced in each study group (placebo group 2 SAE, mizetuzumab 300mg group and Mizetuzumab 600mg group 1 SAE each). The reported SAEs were all independent of study drug. Furthermore, there was no discontinuation of study treatment and no death in the study was reported. TEAE grade 3 or higher was balanced among the study groups. Only 1 relevant TEAE was reported, occurring in 1 subject in the 300mg group of Mizituzumab and consisting of a decrease in lymphocyte count, the outcome of which event had recovered/resolved. Other clinically relevant AEs, such as injection-related and infusion-related responses (IRR), anaemia and lymphopenia, were balanced among the study groups. Thrombocytopenia cases were not reported during the study.

TABLE 33 Total TEAE-dosing and SFP (safety analysis Board) per treatment group

IRR infusion-related response, ISR injection site response, m number of events, n number of subjects experiencing the event, SFP safety follow-up period, TEAE adverse events in treatment.

TEAE is defined as an adverse event with a start date and time equal to or later than the start date and time of the first dose of study drug.

TEAE occurring during dosing and SFP was defined as TEAE on or before day 16 week visit date.

Subjects were counted once per treatment group by category.

The toxicity rating of the deletion was estimated as 3.

Causal deleted TEAE was classified as related to study drug.

* TEAE fractionation is based on NCI CTCAE V4.03.03.

Display of adverse events

The most common TEAE (10% or more in all subjects) and TEAE considered to be relevant to the study drug are presented in tables 34 and 35 as SOC and PT, respectively.

TABLE 34 TEAE-drug administration and SFP (safety analysis set) most commonly (. Gtoreq.10%) divided by SOC, PT and treatment groups

N is the number of subjects experiencing the event, m is the number of events, SFP is the safety follow-up period, medDRA is the supervision active medical dictionary, PT is the preferred term, SOC is the system organ classification, and TEAE is the adverse event occurring in treatment.

Adverse events were classified into system organ categories and preferred terms using MedDRA version 25.0.

Subjects in each treatment group were counted once per SOC and once per PT.

Adverse events with a frequency of > 10% in any treatment are included in the table, divided by PT.

TABLE 35 TEAE-drug administration and SFP (safety analysis Board) considered to be related to study drug by SOC, PT and treatment group

M is the number of events, medDRA is the supervision active medical dictionary, n is the number of subjects experiencing the event;

PT is the preferred term, SFP is the safety follow-up period, SOC is the classification of organs of the system, TEAE is the adverse event occurring in the treatment.

Adverse events were classified into SOC and PT using MedDRA version 25.0.

Subjects in each treatment group were counted once per SOC and once per PT.

Causal deleted TEAE was classified as related to study drug.

The association was assessed by a study investigator.

Analysis of AE

The most common TEAE

The most commonly reported (≥10% of all subjects) TEAE in the safety analysis set in the preferred term is summarized in Table 34.

Overall, 15 subjects (41.7%) underwent 20 TEAEs without regard to causality, including 4 subjects in placebo group (33.3%), 3 subjects in 300mg of micturition mab (25%) and 8 subjects in 600mg of micturition mab (66.7%).

In the placebo group, 1 subject (8.3%) each experienced fever and nasopharyngitis, and 2 subjects experienced gastroenteritis (16.7%).

In the 300mg group of mictuzumab, 2 subjects (16.7%) experienced fever and 1 subject (8.3%) experienced fatigue. In the 600mg group of mictuzumab, 3 subjects (25%) each experienced fever and chills, and 2 subjects (16.7%) each experienced fatigue and nasopharyngitis.

Except for 4 TEAEs with toxicity grade 3 (3 independent of study drug, 1 related to study drug), all TEAEs had toxicity grade 1 or grade 2,2 placebo groups, and 1 each of the 300mg and 600mg groups of micturizumab.

Although COVID-19 test of 1 subject was positive, there was no TEAE associated with COVID-19 in this study.

TEAE divided in relation to study drug

The TEAE assessed by the investigator as related to the study drug is summarized in table 35. A total of 15 subjects experienced 27 events, 2 subjects in placebo (16.7%), 5 subjects in 300mg of micturition mab (41.7%), and 8 subjects in 600mg of micturition mab (66.7%). The most commonly reported treatment-related TEAE is fever in the 300mg group of micturizumab, chills and fever in the 600mg group of micturiab.

The results of all relevant TEAEs had recovered/resolved, except for the positive anemia and grade 1 event of blood immunoglobulin a decline in the 600mg group of micturition mab, which did not resolve at the end of the study.

TEAE divided by severity

In this study, most TEAEs were of grade 1 or grade 2 severity. Of 98 TEAE, 4 were of grade 3 severity. Of these 4 events, only 1 event (lymphocyte count reduction) was reported by the investigator as relevant to study treatment. The result of the event has recovered/resolved.

Death, other SAEs and other significant AEs

List of deaths, other SAE and other significant AEs

Death of

No death occurred during the study.

Other serious adverse events

A total of 4 SAE were reported in 3 subjects (table 36). One subject in each of the 300MG and 600MG groups of micturizumab underwent SAE with suicidal ideation and MG (MG worsening), respectively. One subject in the placebo group experienced two SAE, enteritis and gastroenteritis. All SAE are reported as independent of study drug and the result has recovered/resolved.

TABLE 36 serious TEAE-drug administration and SFP (safety analysis Board) divided by SOC, PT and treatment group

M is the number of events, medDRA is the supervision active medical dictionary, n is the number of subjects experiencing the events, PT is the preferred term, SFP is the security follow-up period, SOC is the system organ classification;

TEAE, adverse events occurring during treatment.

Adverse events were classified into SOC and PT using MedDRA version 25.0.

Subjects in each treatment group were counted once per SOC and once per PT.

* Word-by-word text from CIOMS.

Other significant AE

TEAE resulting in discontinuation of study drug

There was no TEAE resulting in discontinuation of the study drug.

TEAE resulting in dose modification

Dose modification in this study consisted of discontinuing the dose or withdrawing the drug. Two subjects stopped dosing.

Injection reaction TEAE

Local reaction at injection site

The injection site local response TEAE is summarized in table 37. A total of 3 subjects (1 in placebo and 2 in 600mg of micturition) underwent a grade 1 injection site response. The results of all events have recovered/resolved.

TABLE 37 local reaction TEAE at injection site (safety analysis set)

ID, medDRA, supervision active medical dictionary, PT, preferred term, SFP, safety follow-up period, TEAE, adverse event in treatment.

* TEAE fractionation is based on NCI CTCAE V4.03.03.

Systemic IRR

As determined by the investigator, an equal number of subjects (3 subjects each) in the 300mg and 600mg groups of micturition mab reported systemic IRR. In the 300mg group of mictuzumab, 3 subjects experienced systemic IRR TEAE with influenza-like disease, vision impairment and fever. In the 600mg group of mictuzumab, 3 subjects experienced a systemic IRR TEAE of chills and fever. Most events were grade 1 in severity and grade 2 fever occurred in 2 subjects in the 600mg group of micturition mab. All events were reported as being related to mictuzumab. Most events subsided within 1 day (median duration of recovery was 1 day) and the results of all events had recovered/subsided.

Analysis and discussion of death, other SAE and other significant AE

There were 3 subjects with SAE present in the treatment, none of which were considered life threatening. SAE equalization in each study group.

Clinical laboratory evaluation

Serum chemistry

AE associated with serum chemistry parameters were observed in both placebo and micheltuzumab treatment groups, with no apparent dose dependence.

15 Subjects (placebo group 5 subjects, 300mg of mezetuzumab group 6 subjects, and 600mg of mezetuzumab group 4 subjects) had been reported to have higher than normal lactate dehydrogenase levels at the time of screening, with lactate dehydrogenase levels remaining high throughout the study. 4 subjects (placebo group 1 subjects, mictuzumab 300mg group 1 subjects and mictuzumab 600mg group 2 subjects) reported a slight and transient increase in LDH in the study, all of which resolved and were within normal range at the end of the study. One subject in the 600mg group of mictuzumab experienced an ALT and AST increase of 3xULN at week 16. This event occurred after administration of the rescue medication and was reported by the investigator as non-study drug related TEAE, as it is believed that this was due to administration of IVIG used in the subject at this point in time of the study to treat disease exacerbation.

Hematology

Overall, the total lymphocyte count of 3 subjects (1 each of 3 study groups) appeared to be abnormal. Only TEAE with reduced lymphocyte counts was observed in the study, which occurred in 1 subject in the 300mg group of micturition mab, which was reported to be relevant to the study drug and the outcome of the event had recovered/resolved. Three cases of anemia TEAE (1 case in 300mg group of micturition mab and 2 cases in 600mg group of micturition mab) were reported. Among them, one anemia TEAE of the 600mg group of micheltuzumab was related to the study drug and was not recovered. The remaining two anaemic events of the 300mg and 600mg groups of micturition mab were independent of the study drug and recovered and recovering, respectively. In addition, anemia reported by one subject in the 300mg group was already present at the beginning of the study and was therefore not considered relevant to the study drug. Some subjects had lower than normal hemoglobin/hematocrit levels at the beginning of the study, possibly due to ongoing immunosuppressive therapy, with a small percentage of subjects experiencing a slight decrease in hemoglobin and hematocrit over the course of the study. With respect to this downward trend, there was no apparent dose dependence, as the number of affected subjects was balanced between placebo and mictuzumab-treated groups. At any time during the study, no subject in the study group experienced any hemoglobin drop below 8 g/dL.

Vital signs and ECG

Vital signs

No mean or trend of change from baseline of vital sign related parameters was observed. In the placebo group, one subject reported vital sign abnormalities, i.e., heart rate >120bpm, systolic blood pressure >180mmHg and body temperature <35.6 degrees celsius. Similarly, in the 600mg group, one subject reported vital parameter outliers, i.e., systolic >180mmHg and diastolic <50mmHg.

The vital sign-related AEs included fever in 6 subjects (1 subject in placebo, 2 subjects in 300mg of micturition mab and 3 subjects in 600mg of micturition mab). Fever presented in subjects in the 300mg and 600mg groups of mictuzumab was reported as being related to study drug. The results of the events had recovered/resolved in all 6 subjects and most of the events resolved within 1 day.

Electrocardiogram

No mean value of the Electrocardiogram (ECG) or trend of change from baseline was observed. At baseline, all subjects had normal or non-clinically significant abnormal ECG results. At any time point, no subject had a shift to clinically significant post-abnormal baseline results.

Safety biomarker

Vaccine-induced antibodies, such as measles, mumps, rubella, diphtheria and tetanus, were evaluated to determine the effect of micturition mab on protective immunity. The maximum average decrease in any of these antibodies was less than 25% change from baseline and was comparable in the micturition mab treated group. The placebo group showed minimal decrease except that the diphtheria antibody showed a maximum average decrease of 13.0%. By week 32, all vaccine-induced antibodies recovered near baseline or showed an increase.

At any point during the study, diphtheria measurements of 3 subjects dropped below LLOQ per dose group of micturition mab. In addition, one subject in the 300mg dose group had a lower rubella value than LLOQ. In the placebo group, 2 subjects had < LLOQ observations, 1 subject each for rubella and tetanus. The baseline value of the corresponding antibodies for all these subjects was close to LLOQ.

Pregnancy with a new pattern of medicine

No pregnancy was reported during the study.

Conclusion of safety

Overall, in this study, micturiab was well tolerated in subjects with systemic myasthenia gravis. There was no substantial imbalance in AEs between treatment groups and no dose-dependent AEs or new safety issues were identified.

In general, 24 subjects received at least one dose of micturition mab (12 per dose group), and 12 subjects received at least one dose of placebo.

TEAE reported in > 10% of subjects was gastroenteritis in placebo group, fever in 300mg group with Mezetuzumab, while fever and chills were most common in 600mg group with Mezetuzumab.

Most TEAEs are of grade 1 or grade 2 in severity. Grade 3 TEAE was reported in only 4 subjects and these were well balanced between study groups. Three subjects reported the appearance of SAE in the treatment in the study, 1 in each study group 1 in placebo group and 2 in gastroenteritis, 1 in 300MG group of micturition mab, and 1 in 600MG group of micturition mab MG SAE (MG exacerbation). These SAEs were not relevant to study treatment and the results of all SAEs had recovered/resolved.

IRR was reported only in the MAIzetuzumab-treated subjects and was observed in 25% of the MAIzetuzumab 300mg group and MAIzetuzumab 600mg group, respectively. Clinical events of interest (such as lymphopenia and anemia) in the study group were balanced.

There were no clinically significant results associated with laboratory evaluations, vital signs or ECG.

Vaccine-induced antibody reduction was not dose-dependent, with less than 25% change from baseline observed in the micturition mab treated group. By week 32, all vaccine-induced antibodies recovered near baseline or showed an increase. In each of the 300mg and 600mg groups of meizetuzumab, only 3 subjects whose antibodies had approached LLOQ at baseline had diphtheria and rubella antibodies decreased below LLOQ.

Example 5 discussion and overview

Execution summary

Demographics and baseline characteristics there was no significant difference between baseline characteristics.

Safety-Mezetuzumab TAK-was well tolerated up to 600mg, and no new safety issues were identified. SAE and TEAEs of grade 3 or higher are not common and balanced among study groups. Infections, anaemia and lymphopenia are unusual and have no apparent dose dependence.

Efficacy the 300MG dose of mezetuzumab showed clinically relevant decreases in both MG-ADL and QMG for both response magnitude and percentage of responders. Despite the biochemical response, the 600mg dose of micturition mab showed a variable efficacy signal. Higher than expected placebo response.

Pharmacodynamics-mictuzumab elicits moderate PD responses with an IgG maximum average depletion of about 30% and an anti-AChR antibody maximum average depletion of about 50%.

Persistence-mazituzumab in most subjects with IgG/AChR antibody data at both dose levels persisted beyond the treatment period to week 32. For both MG-ADL and QMG, the clinical response was sustained for the 300MG dose.

Pharmacokinetic/immunogenicity-exposure amounts are within the expected range, where PK profile is consistent with MM, tending to expose the predicted higher ends. Only 1 subject treated with mezetuzumab (300 mg group) developed a low titer ADA response.

Discussion of the invention

The main objective of this study was to evaluate the safety and tolerability of micetozumab in subjects with systemic MG. This is the second study with the administration of Mizituzumab on the autoimmune patient population following the Systemic Lupus Erythematosus (SLE) study (TAK-079-2001). Unlike SLE study TAK-079-2001 (where the highest dose level was 135MG and once a 3 week administration of mezetuzumab for 12 weeks), MG subjects in this study received a dose of up to 600MG once a week for 8 weeks. All safety data collected in this study showed that micturizumab was well tolerated, with a favorable safety profile at substantially higher doses and thus higher exposure than those assessed in subjects with SLE. The reported MAIZUOTAMINE AE in this study was consistent with that observed in the first human study performed in healthy volunteers (TAK-079-101) and subjects with SLE. No new safety event was identified in myasthenia gravis subjects.

Clinical events of interest based on the mechanism of action of mictuzumab ozogamicin are hypersensitivity, CRS and systemic infections. There were no CRS cases, and the observed IRR cases were mild and reported in 25% of subjects in each of the mictuzumab treatment groups. These IRRs occur primarily with the first dosing event and resolve within days. In relation to the infection, both nasopharyngitis (1 event in one placebo subject and 2 events in two 600mg subjects) and gastroenteritis (2 events in the same placebo subject) were reported in the study, which were considered independent of the study drug and did not show significant dose dependence. All cases of nasopharyngitis were mild (< grade 1). Other clinical events carefully monitored during the study are anemia and thrombocytopenia due to the expression of CD38 on erythrocytes and platelets. In the 600mg group of micturition mab only one drug-related anemia (grade 1) was reported. No thrombocytopenia cases were reported, providing preliminary evidence that higher doses of micturition mab were not expected to increase the risk of anemia or thrombocytopenia. Another clinical event of interest (lymphopenia) was not significantly dose dependent, with only one event reported in the 300mg group of micturition mab. The event was grade 3 and was considered relevant to study drug, however the subject was also receiving moderately high doses of concomitant systemic corticosteroids, which may lead to lymphopenia.

Although both doses evaluated effectively reduced immunoglobulins, its effect on pre-existing vaccine-induced antibodies did not appear to be clinically significant in this study and patient population. This provides preliminary evidence that administration of mezetuzumab may not negatively impact the immunity induced by existing vaccines.

The observed low incidence of ADA in 5.56% of treatments in this study was consistent with previous findings, indicating a lower risk of immunogenicity of the michelzumab. Limited ADA data prevents conclusive determination of the effects of ADA on exposure. ADA responses do not appear to be dose-dependent, and no obvious correlation was observed between ADA response and safety or efficacy.

From the PK point of view, a dose proportional increase in drug concentration from 300mg to 600mg was observed. This suggests that at these doses, the micturition mab exhibited linear PK behavior. It has been reported that in the lower dose range tested in healthy subjects (TAK-079-101) and subjects with systemic lupus erythematosus (TAK-079-2001), as a result of CD38 mediated elimination, MAIzetuzumab has a nonlinear PK, and in this patient population, at doses of 300mg and above, this elimination appears to be saturated.

The secondary objective of this study was to assess the effect of micturition mab on MG disease severity. The 300MG group of Mizituzumab instead of 600MG group met the clinically relevant thresholds of the following clinical scales evaluated in this study, MG-ADL, QMG, MGC and MGII, however, the potential signal for this preliminary clinical benefit was confounded by the higher than expected placebo response observed in this study (Bril et al (2021) Neurology 96 (6): e853-e865; howard et al (2019) Neurology 92 (23), e2661-e2673; howard et al (2020) Neurology 77 (5): 582-592). The exaggerated placebo response is particularly pronounced for MG-ADL, but less pronounced for other clinical scales. When stratified, the MG-ADL placebo response in european subjects was found to be comparable to the response observed in other MG trials, while the placebo response in north american subjects was found to be substantially exaggerated. Many factors in this study can explain the exaggerated placebo response, including but not limited to the exaggeration of baseline scores due to the use of MG-ADL alone (outcome of patient reporting), as well as the predominance of less severe disease women and younger subjects in the placebo group (Katz (2021) Pain rep.6 (1): e845; landin et al (2000) Biometrics (1): 271-278). In addition, MG-ADL has inherent limitations as a tool in capturing accurate and relevant subject symptoms.

Other confounding factors in this study include non-standardized inactivation of acetylcholinesterase inhibitors prior to clinical evaluation, and additional use of prophylactic corticosteroids beyond week 1 in some subjects. For clinical evaluations, particularly QMG, inconsistent timing of administration of acetylcholinesterase inhibitors by subjects may confound the actual therapeutic effect and/or exaggerate placebo response. The use of prophylactic CS with the first dose is necessary to mitigate potential IRR, however, it is believed that additional use of CS after the first treatment produces an unbalanced therapeutic benefit to those subjects who receive additional CS in the study for up to 4 weeks.

From a PD perspective, micturing antibodies exhibit cd38+ target cytopenia and immunoglobulin reduction, including depletion of anti-AChR antibodies. No dose-dependent trend was observed in the immunoglobulin response or any other PD parameter evaluated, indicating significant saturation of the biochemical response at 300mg administered weekly, with no additional benefit at 600mg dose. Moderate depletion of IgG and autoantibodies was observed in some subjects in the 600mg cohort. The substantially greater variation of all Ig isotypes in the micturition mab treated group compared to placebo provided evidence of the mechanism of the disease. Notably, ig depletion was maintained 6 months after treatment was completed. The greatest magnitude of change was observed for the IgA class, consistent with observations from other studies using micheltuzumab.

In this study, subject anti-AChR antibodies were predominantly positive, reflecting the higher prevalence of this autoantibody type in the MG subject population. The decrease in anti-AChR concentration confirms the therapeutic hypothesis that targeting plasma cells and plasmablasts expressing CD38 results in a decrease in the pathogenic antibodies involved in MG. The pathophysiological attenuation between the two test doses was similar, but only with efficacy signal at the 300mg dose group.

Conclusion(s)

The results of this phase 2 study demonstrate that a weekly dose of up to 600MG of mezetuzumab has a favorable safety profile in subjects with systemic MG who are receiving concomitant stable background therapy. No new safety events specific to MG subjects were identified in the study and the dose dependence of AE of clinical interest was not evident.

Improvement in MG symptom severity as assessed by various MG rating scales (i.e., MG-ADL, QMG, MGC, MG-QoL15r and MGII) was present in all 3 cohorts (including placebo) during the 16 week blind study period, although the magnitude and duration of response were different.

Sustained and persistent reductions in IgG and anti-AChR antibody levels were observed in both michizomib treatment groups, confirming that the anti-CD 38 mechanism was involved in modulating this autoantibody driven disease.

In summary, this study established a favorable safety profile of micturition mab in subjects with systemic myasthenia gravis and provided a mechanism demonstration.

Incorporated by reference

The contents of all cited references (including literature references, patents, patent applications, and websites) that may be cited in the present application are hereby expressly incorporated by reference in their entirety for any purpose, wherein the cited references are also hereby expressly incorporated by reference in their entirety to the same extent as if each individual reference were specifically and individually indicated to be incorporated by reference in its entirety for any purpose.

Equivalent scheme

The present disclosure may be embodied in other specific forms without departing from its spirit or essential characteristics. The above embodiments are therefore to be considered in all respects as illustrative and not restrictive of the present disclosure. The scope of the disclosure is, therefore, indicated by the appended claims rather than by the foregoing description, and all changes which come within the meaning and range of equivalency of the claims are therefore intended to be embraced therein. Modifications for implementing the disclosure that are obvious to a person skilled in the art are intended to be within the scope of the appended claims.

Claims

1. A method of treating myasthenia gravis in a subject comprising administering to the subject an isolated human anti-CD 38 antibody or antigen-binding fragment thereof, wherein the isolated antibody or antigen-binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

2. A method of reducing the level of plasmablasts, plasma cells and/or NK cells in a subject diagnosed as having myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen binding fragment thereof, wherein the isolated antibody or antigen binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4 and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7 and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

3. A method of reducing the level of immunoglobulin cells in a subject diagnosed as having myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen-binding fragment thereof, wherein the isolated antibody or antigen-binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

4. The method of claim 3, wherein the immunoglobulin is IgA, igG, and/or IgM.

5. A method of reducing the level of one or more autoantibodies in a subject diagnosed with myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen binding fragment thereof, wherein the isolated antibody or antigen binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

6. The method of claim 5, wherein the one or more autoantibodies are selected from the group consisting of anti-AChR and anti-MuSK.

7. A method of reducing myasthenia gravis disease activity and/or progression in a subject diagnosed with myasthenia gravis, the method comprising administering to the subject an isolated human anti-CD 38 antibody or antigen-binding fragment thereof, wherein the isolated antibody or antigen-binding fragment thereof comprises a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4, and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7, and CDR3 having the amino acid sequence of SEQ ID NO:8, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously at a dose of about 100 to about 800 milligrams.

8. The method of claim 7, wherein the myasthenia gravis disease activity is measured by a score selected from one or more of myasthenia gravis daily life activity (MG-ADL), quantitative Myasthenia Gravis (QMG), composite Myasthenia Gravis (MGC), revised 15 items of the myasthenia gravis quality of life scale (MG-QOL 15 r), and/or Myasthenia Gravis Impairment Index (MGII).

9. The method of any one of the preceding claims, wherein the isolated antibody or antigen binding fragment thereof further comprises one or more engineered glycoforms, wherein the engineered glycoforms comprise glycosylation of one or more polypeptides, optionally wherein the glycosylation is N-linked glycosylation or O-linked glycosylation, and optionally wherein the glycosylation is N-linked glycosylation.

10. The method of any one of the preceding claims, wherein the variable heavy chain region of the isolated antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 90% identity to SEQ ID No. 9 and/or the variable light chain region of the isolated antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 90% identity to SEQ ID No. 10;

Optionally wherein the variable heavy chain region of the isolated antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 95% identity to SEQ ID No. 9 and/or the variable light chain region of the isolated antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 95% identity to SEQ ID No. 10;

Optionally wherein the variable heavy chain region of the isolated antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 99% identity to SEQ ID No. 9 and/or the variable light chain region of the isolated antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 99% identity to SEQ ID No. 10;

Optionally wherein the heavy chain of the isolated antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 95% identity to SEQ ID NO. 11 and/or the light chain of the isolated antibody or antigen binding fragment thereof comprises an amino acid sequence having at least 95% identity to SEQ ID NO. 12;

optionally wherein the isolated antibody or antigen binding fragment thereof interacts with at least K121, F135, Q139, D141, E239, W241, C275, K276, F284, P291, and E292 of SEQ ID No. 1 and SEQ ID No. 2 based on human sequence numbering;

Optionally wherein the isolated antibody or antigen binding fragment thereof binds human CD38 (SEQ ID NO: 1) with an affinity of 10 ^-8 M KD or greater, and wherein said affinity is through standard Measuring by an assay;

optionally wherein the variable heavy chain region comprises SEQ ID NO. 9 and the variable light chain region comprises SEQ ID NO. 10, and

Optionally wherein the isolated antibody or antigen binding fragment thereof comprises a heavy chain as set forth in SEQ ID NO. 11 and a light chain as set forth in SEQ ID NO. 12.

11. The method of any one of the preceding claims, wherein the isolated antibody or antigen binding fragment thereof further comprises an Fc domain;

Optionally wherein said Fc domain is a human Fc domain or a variant Fc domain, and

Optionally wherein the isolated antibody or antigen binding fragment is a human IgG antibody, optionally wherein the human IgG antibody is a human IgG1 antibody.

12. The method of any one of the preceding claims, wherein the subject receives a background myasthenia gravis drug, optionally wherein the background myasthenia gravis drug is selected from the group consisting of immunosuppressants, steroids, anticholinergic agents, and cholinesterase inhibitors, and combinations thereof, optionally wherein the background myasthenia gravis drug is selected from the group consisting of methylprednisolone, prednisone, budesonide, fluticasone propionate, pistin, mycophenolate mofetil, dicycloprid, azathioprine, and cyclosporine, and combinations thereof.

13. The method of claim 12, wherein the background myasthenia gravis drug is administered in combination with the isolated antibody or antigen-binding fragment thereof.

14. The method of any one of the preceding claims, wherein administration of the isolated antibody or antigen binding fragment thereof results in a less than 10% incidence of one or more treatment-related adverse events (TRAEs) or adverse events (TEAEs) occurring in treatment, grade 3 or grade 4;

Optionally wherein the TRAE or TEAE is selected from the group consisting of gastrointestinal disorders, nausea, infection, fever, shingles, urinary tract infection, skin and skin tissue disorders, headache, fever, chills/chills, vomiting, diarrhea, joint pain, myalgia, hypotension, respiratory, thoracic and mediastinal disorders, thrombocytopenia, leukopenia, lymphopenia, heart disorders, palpitations and dyspnea, and

Optionally wherein administration of the isolated antibody or antigen binding fragment thereof results in one or more TRAEs or TEAEs with maximum intensity of grade 1 or grade 2 of the common term standard for adverse events (CTCAE).

15. The method of any one of the preceding claims, wherein the isolated antibody or antigen-binding fragment thereof is administered at a dose selected from the group consisting of about 100mg, about 125mg, about 150mg, about 175mg, about 200mg, about 225mg, about 250mg, about 275mg, about 300mg, about 325mg, about 350mg, about 375mg, about 400mg, about 425mg, about 450mg, about 475mg, about 500mg, about 525mg, about 550mg, about 575mg, about 600mg, about 625mg, about 650mg, about 675mg, about 700mg, about 725mg, about 750mg, about 775mg, or about 800mg, and optionally wherein the isolated antibody or antigen-binding fragment thereof is administered at a dose of about 300mg or about 600 mg.

16. The method of any one of the preceding claims, wherein the isolated antibody or antigen binding fragment thereof is administered weekly, biweekly, tricyclically, or quarterly.

17. The method of any one of the preceding claims, wherein the isolated antibody or antigen-binding fragment thereof is administered in the form of a pharmaceutically acceptable composition, and optionally wherein the pharmaceutically acceptable composition comprises the isolated antibody or antigen-binding fragment thereof and at least one pharmaceutically acceptable carrier, excipient, or stabilizer.

18. The method of any of the preceding claims, wherein the isolated antibody or antigen binding fragment thereof comprises a heavy chain as set forth in SEQ ID NO. 11 and a light chain as set forth in SEQ ID NO. 12, and wherein the antibody or antigen binding fragment thereof is administered subcutaneously once a week for 8 weeks.

19. The method of any one of the preceding claims, wherein the isolated antibody or antigen binding fragment thereof is michelzumab.

20. A unit dosage form comprising an isolated antibody or antigen-binding fragment thereof comprising a Variable Heavy (VH) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:3, CDR2 having the amino acid sequence of SEQ ID NO:4 and CDR3 having the amino acid sequence of SEQ ID NO:5, and a Variable Light (VL) chain region comprising CDR1 having the amino acid sequence of SEQ ID NO:6, CDR2 having the amino acid sequence of SEQ ID NO:7 and CDR3 having the amino acid sequence of SEQ ID NO:8, wherein the isolated antibody or antigen-binding fragment thereof binds to human CD38 (SEQ ID NO: 1) and is formulated for subcutaneous administration of the isolated antibody or antigen-binding fragment thereof at a dose of 100 mg to 800 mg in the treatment of myasthenia gravis.

21. The unit dosage form of claim 20, wherein the isolated antibody or antigen-binding fragment thereof further comprises one or more engineered glycoforms, wherein the engineered glycoforms comprise glycosylation of one or more polypeptides, optionally wherein the glycosylation is N-linked glycosylation or O-linked glycosylation, and optionally wherein the glycosylation is N-linked glycosylation.

22. The unit dosage form of claim 20 or 21, wherein the variable heavy chain region of the isolated antibody or antigen-binding fragment thereof comprises an amino acid sequence having at least 90% identity to SEQ ID No. 9 and/or the variable light chain region of the isolated antibody or antigen-binding fragment thereof comprises an amino acid sequence having at least 90% identity to SEQ ID No. 10;

Optionally wherein the variable heavy chain region comprises an amino acid sequence having at least 95% identity to SEQ ID No. 9 and/or the variable light chain region comprises an amino acid sequence having at least 95% identity to SEQ ID No. 10;

Optionally wherein the variable heavy chain region comprises an amino acid sequence having at least 99% identity to SEQ ID No. 9 and/or the variable light chain region comprises an amino acid sequence having at least 99% identity to SEQ ID No. 10;

23. The unit dosage form of any one of claims 20-22, wherein the isolated antibody or antigen-binding fragment thereof further comprises an Fc domain, optionally wherein the Fc domain is a human Fc domain or a variant Fc domain, and

Optionally wherein the isolated antibody or antigen binding fragment is a human IgG antibody,

Optionally wherein the human IgG antibody is a human IgG1 antibody.

24. The unit dosage form of any one of claims 20-23, wherein the isolated antibody or antigen binding fragment thereof is used in combination with one or more background myasthenia gravis drugs, optionally wherein the background myasthenia gravis drugs are selected from the group consisting of immunosuppressants, steroids, anticholinergic agents, and cholinesterase inhibitors, and combinations thereof, optionally wherein the background myasthenia drugs are selected from the group consisting of methylprednisolone, prednisone, budesonide, fluticasone propionate, pyribenzoxazole, mycophenolate mofetil, dicyclopidogrel, azathioprine, and cyclosporine, and combinations thereof.

25. The unit dosage form of any one of claims 20-24, wherein administration of the isolated antibody or antigen binding fragment thereof results in a less than 10% incidence of one or more treatment-related adverse events (TRAEs) or adverse events (TEAEs) occurring in treatment, grade 3 or grade 4;

26. The unit dosage form of any one of claims 20-25, wherein the isolated antibody or antigen-binding fragment thereof is administered at a dose selected from the group consisting of about 100mg, about 125mg, about 150mg, about 175mg, about 200mg, about 225mg, about 250mg, about 275mg, about 300mg, about 325mg, about 350mg, about 375mg, about 400mg, about 425mg, about 450mg, about 475mg, about 500mg, about 525mg, about 550mg, about 575mg, about 600mg, about 625mg, about 650mg, about 675mg, about 700mg, about 725mg, about 750mg, about 775mg, or about 800mg, and optionally wherein the isolated antibody or antigen-binding fragment thereof is administered at a dose of about 300mg or about 600 mg.

27. The unit dosage form of any one of claims 20-26, wherein the dose is a weekly, biweekly, tricyclically or quarterly administered dose.

28. The unit dosage form of any one of claims 20-27, further comprising at least one pharmaceutically acceptable carrier, excipient, or stabilizer.

29. The unit dosage form of any one of claims 20-28, wherein the isolated antibody or antigen-binding fragment thereof comprises a heavy chain as set forth in SEQ ID NO. 11 and a light chain as set forth in SEQ ID NO. 12, and wherein the isolated antibody or antigen-binding fragment thereof is administered subcutaneously once a week for 8 weeks.

30. The unit dosage form of any one of claims 20-29, wherein the isolated antibody or antigen-binding fragment thereof is michelzumab.