RU2823427C2 - Dosage and regimen for treating or preventing c5-related diseases by using the anti-c5 crovalimab antibody - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: disclosed is a method of treating or preventing a C5-related disease in a subject, said method being carried out by the following steps of administering: (i) intravenous administration of a loading dose of 1000 mg of anti-C5 antibody to a subject once; (ii) a subcutaneous loading dose of 340 mg of the anti-C5 antibody to subject 1 day after the start of the intravenous administration of the anti-C5 antibody; (iii) a subcutaneous loading dose of 340 mg of the anti-C5 antibody to subject 1 week, 2 weeks and 3 weeks after the start of the intravenous administration of the anti-C5 antibody once a week; (iv) subcutaneously administering a maintenance dose of 680 mg of the anti-C5 antibody to subject 4 weeks after the start of the intravenous administration of the anti-C5 antibody; and (v) repeating step (iv) several times with time intervals of 4 weeks, where said anti-C5 antibody is crovalimab, and said C5 disease is paroxysmal nocturnal haemoglobinuria (PNH).

EFFECT: invention provides long-term and coordinated blockade of terminal complement activity, sufficient reserve of free binding sites for the greater part of dosing interval, safety and therapeutic efficacy.

9 cl, 13 dwg, 1 tbl, 7 ex

Description

The present invention relates to a dosage and dosage regimen of anti-C5 antibodies, particularly the anti-C5 antibody crovalimab, for use in a method of treating or preventing a C5-related disease, including paroxysmal nocturnal hemoglobinuria (PNH), in a subject. The dosage and schedule of administration of the present invention comprises administering an anti-C5 antibody, preferably the anti-C5 antibody crovalimab, with loading doses, followed by administration to the subject(s) of a maintenance dose(s) of the anti-C5 antibody, wherein the initially administered loading dose is given to the subject intravenously , and the remaining loading and maintenance doses are administered subcutaneously in a lower dosage than the loading dose administered intravenously.

BACKGROUND ART

The complement system plays a central role in the clearance of immune complexes and in immune responses to infectious agents, foreign antigens, virus-infected cells, and tumor cells. There are approximately 25-30 complement proteins, which are found as a collection of plasma protein complexes and membrane cofactors. Complement components achieve their immunoprotective functions through interaction in a series of complex enzymatic cleavage and membrane binding events. The resulting complement cascades lead to the formation of products with opsonic, immunoregulatory and lytic functions.

The complement system can be activated through three distinct pathways: the classical pathway, the lectin pathway, and the alternative pathway. These pathways share many common components and, while they differ in their initial steps, they converge and share the same terminal complement components (C5 to C9) responsible for the activation and destruction of target cells.

The classical pathway is usually activated through the formation of antigen-antibody complexes. Independently, the first step in the activation of the lectin pathway is the binding of specific lectins such as mannan binding lectin (MBL), H-ficolin, M-ficolin, L-ficolin and the C-type lectin CL-11. In contrast, the alternative pathway spontaneously produces a low level of metabolic activation that can easily be enhanced on foreign or other abnormal surfaces (bacteria, yeast, virus-infected cells, or damaged tissue). These pathways converge at a point where complement component C3 is cleaved by active protease to produce C3a and C3b.

C3a is an anaphylotoxin. C3b binds to bacterial and other cells, as well as certain viruses and immune complexes, and tags them for removal from the circulation (a role known as opsonin). C3b also forms a complex with other components to form C5 convertase, which cleaves C5 into C5a and C5b.

C5 is a 190 kDa protein found in normal serum at a concentration of approximately 80 μg/ml (0.4 μM). C5 is glycosylated, with approximately 1.5-3.0% of its mass attributable to carbohydrate. Mature C5 is a heterodimer of a 115 kDa alpha chain that is disulfide bound to a 75 kDa beta chain. C5 is synthesized as a single-chain precursor protein (pro-C5 precursor) of 1676 amino acids (see, for example, US-B1 6355245 and US-B1 7432356). This pro-C5 precursor is cleaved to produce a beta chain as an amino-terminal fragment and an alpha chain as a carboxy-terminal fragment. The polypeptide fragments - the alpha chain and the beta chain - are connected to each other through a disulfide bond and make up the mature C5 protein.

The terminal complement pathway begins with the uptake and cleavage of C5. Mature C5 is cleaved into C5a and C5b fragments during activation of the complement pathway. C5a is cleaved from the C5 alpha chain by C5 convertase as an amino-terminal fragment containing the first 74 amino acids of the alpha chain. The remainder of mature C5 is the C5b fragment, which contains the remaining alpha chain linked by a disulfide bond to the beta chain. Approximately 20% of the 11 kDa mass of C5a is attributed to carbohydrate.

C5a is another anaphylatoxin. C5b combines with C6, C7, C8 and C9 to form the membrane attack complex (MAC, C5b-9, terminal complement complex (TCC)) on the surface of the target cell. When sufficient numbers of MAC are inserted into target cell membranes, MAC pores are formed to mediate rapid osmotic lysis of the target cells.

As mentioned above, C3a and C5a are anaphylatoxins. They can trigger mast cell degranulation, which releases histamine and other inflammatory mediators, leading to smooth muscle contraction, increased vascular permeability, leukocyte activation, and other inflammatory phenomena including cell proliferation leading to hypercellularity. C5a also functions as a chemotactic peptide that serves to attract granulocytes such as neutrophils, eosinophils, basophils and monocytes to the site of complement activation.

The activity of C5a is regulated by the plasma enzyme carboxypeptidase N, which removes the carboxy-terminal arginine from C5a, forming a C5a-des-Arg derivative. C5a-des-Arg exhibits only 1% of the anaphylactic activity and polymorphonuclear chemotactic activity of unmodified C5a.

While a properly functioning complement system provides robust protection against infecting microbes, inappropriate regulation or activation of complement has been implicated in the pathogenesis of a number of disorders including, for example, paroxysmal nocturnal hemoglobinuria (PNH); rheumatoid arthritis (RA); lupus nephritis; ischemic reperfusion injury; atypical hemolytic uremic syndrome (aHUS); dense sediment disease (DDD); macular degeneration (eg, age-related macular degeneration (AMD)); hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome; thrombotic thrombocytopenic purpura (TTP); spontaneous fetal loss; weakly immune vasculitis; epidermolysis bullosa; recurrent fetal loss; multiple sclerosis (MS); traumatic brain injury and damage resulting from myocardial infarction, cardiopulmonary bypass and hemodialysis (see, for example, Holers et al., Immunol. Rev. (2008), Vol. 223, pp. 300-316). Therefore, inhibition of excessive or uncontrolled activation of the complement cascade may provide clinical benefit to patients with such disorders.

Paroxysmal nocturnal hemoglobinuria (PNH) is an unusual blood disorder in which red blood cells (RBCs) are compromised and thus destroyed faster than normal red blood cells. PNH occurs due to clonal expansion of hematopoietic stem cells with somatic mutations in the PIG-A (phosphatidylinositol glycan class A) gene, which is located on the X chromosome.

Mutations in PIG-A result in an early block in the synthesis of glycosylphosphatidylinositol (GPI), a molecule that is required to anchor many proteins to cell surfaces. Consequently, PNH blood cells are deficient in GPI-anchored proteins, which include the complement regulatory proteins CD55 and CD59. Under normal circumstances, these complement regulatory proteins block the formation of MAC on cell surfaces, thereby preventing red blood cell lysis. The absence of GPI-anchored proteins causes complement-mediated hemolysis in PNH.

PNH is characterized by hemolytic anemia (low red blood cell count), hemoglobinuria (the presence of hemoglobin in the urine, especially evident after sleep), and hemoglobinemia (the presence of hemoglobin in the bloodstream). Subjects affected by PNH are known to have attacks, which are defined here as the occurrence of episodes of dark-colored urine. Hemolytic anemia is caused by intravascular destruction of red blood cells by complement components. Other known symptoms include dysplasia, weakness, erectile dysfunction, thrombosis and recurrent abdominal pain.

Eculizumab is a humanized monoclonal antibody directed against complement protein C5 and the first therapy approved for the treatment of paroxysmal nocturnal hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS) (see, for example, Dmytrijuk et al., The Oncologist (2008) , 13(9), pp. 993-1000). Eculizumab inhibits the cleavage of C5 into C5a and C5b by C5 convertase, which prevents the formation of the terminal complement complex C5b-9. Both C5a and C5b-9 cause terminal complement-mediated events that are characteristic of PNH and aHUS (see, for example, WO-A2 2005/074607, WO-A1 2007/106585, WO-A2 2008/069889 and WO-A2 2010/054403). For the treatment of PNH, anti-C5 antibodies eculizumab or ravulizumab are common therapies. However, up to 3.5% of individuals of Asian descent carry polymorphisms in C5 affecting Arg885, which corresponds to the binding site of eculizumab or ravulizumab (Nishimura et al., N Engl J Med, Vol. 370, pp. 632-639 (2014); DOI: 10.1056/NEJMoa 1311084). PNH patients with these polymorphisms experience poor control of intravascular hemolysis with eculizumab or ravulizumab, thus constituting a group with high unmet medical need.

Anti-C5 antibodies have been described in several reports. For example, WO 95/29697 describes an anti-C5 antibody that binds to the alpha chain of C5 but does not bind to C5a and blocks C5 activation. WO-A2 2002/30985 describes an anti-C5 monoclonal antibody that inhibits the formation of C5a. On the other hand, WO-A1 2004/007553 describes an anti-C5 antibody that recognizes the proteolytic site for C5 convertase on the C5 alpha chain and inhibits the conversion of C5 to C5a and C5b. WO-A1 2010/015608 describes an anti-C5 antibody that has an affinity constant of at least 1×10 ⁷ M ^-1 . In addition, WO-A1 2017/123636 and WO-A1 2017/132259 describe antibodies against C5. In addition, WO-A 2016/098356 discloses the preparation of an anti-C5 antibody characterized by binding to an epitope within the C5 beta chain with higher affinity at neutral pH than at acidic pH. One of the anti-C5 antibodies disclosed in WO-A1 2016/098356 is the anti-C5 antibody crovalimab (see Example 1 below for details). Crovalimab is an anti-C5 antibody that binds to a distinct epitope on the C5 beta subunit that is different from the eculizumab/ravulizumab binding epitope. In vitro studies have demonstrated that the anti-C5 antibody crovalimab binds equally to and inhibits the activity of wild-type and Arg885 mutant C5 (Fukuzawa et al., Sci Rep, 7(1): 1080. doi: 10.1038/s41598-017-01087- 7 (2017)). In contrast, in WO-A1 2017/104779 in FIG. 21 shows that the anti-C5 antibody eculizumab does not inhibit the C5 Arg855 mutant. Furthermore, WO-A1 2018/143266 relates to pharmaceutical compositions for use in the treatment or prevention of a C5-related disease. In addition, WO-A1 2018/143266 discloses dosages and dosing regimens for the anti-C5 antibody crovalimab as used in the COMPOSER study (BP39144). The COMPOSER study is a global, multicenter, open-label, phase I/II study to evaluate the safety and efficacy, pharmacokinetics (PK) and pharmacodynamics (PD) of the anti-C5 antibody crovalimab in healthy subjects and subjects with PNH. The COMPOSER study contained three parts: part 1 in healthy participants, part 2 and part 3 in patients with paroxysmal nocturnal hemoglobinuria (PNH). Additionally, patients included in part 3 of this study were those treated with the anti-C5 antibody eculizumab for at least 3 months. Participants in Part 1 of the COMPOSER study were designed to include three groups of healthy patients: according to the original design of the protocol, the first group is a group of patients in whom the anti-C5 antibody crovalimab is administered intravenously (IV) at a single dose of 75 mg/body; the second group of patients is a group of subjects to whom the anti-C5 antibody crovalimab is administered intravenously (IV) once at a dose of 150 mg/body, and the third group is a group of subjects to whom the anti-C5 antibody crovalimab is administered subcutaneously (SC). ) once at a dose of 170 mg/body. Because Part 1 of the COMPOSER study is adaptive in nature (based on ongoing evaluation of safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) data), the actual doses given for Part 1 were: 75 mg i.v. for the first group of patients, 125 mg i.v. for the second group of patients, and 100 mg SC for the third group of patients enrolled in part 1 of the COMPOSER study.

Part 2 of the COMPOSER study was designed to enroll a subset of subjects in whom the anti-C5 antibody crovalimab was administered intravenously three times: according to the original design of the protocol, the anti-C5 antibody crovalimab was initially administered at a dose of 300 mg/body (i.v.), followed by 500 mg/body. (i.v.) one week after the initial administration and finally 1000 mg/body (i.v.) two weeks after the second administration. Starting two weeks after the last intravenous administration, the anti-C5 antibody crovalimab is administered subcutaneously once a week at a dose of 170 mg/body. Based on the emerging clinical data from Part 1 and the PK simulation, the baseline dose for patients in Part 2 of the COMPOSER study was changed from 300 mg to 375 mg IV. Thus, the actual doses given in Part 2 of the COMPOSER study are as follows: the anti-C5 antibody crovalimab is initially administered intravenously (IV) at a dose of 375 mg/body, followed by a dose of 500 mg/body (IV) via week after the initial administration and finally 1000 mg/body (i.v.) two weeks after the second administration. Beginning two weeks after the final IV administration, the anti-C5 antibody crovalimab is administered subcutaneously (SC) once weekly at a dose of 170 mg/body.

Part 3 of this study included patients who had been treated with the anti-C5 antibody eculizumab for three months prior to enrollment in this trial, and these patients were required to receive regular eculizumab infusions. Part 3 of this study was designed to include three groups of subjects. The anti-C5 antibody crovalimab is initially administered to subjects in all groups intravenously at a dose of 1000 mg/body. Starting one week after the initial IV administration (day 8 after the initial IV administration), the anti-C5 antibody crovalimab was administered subcutaneously to subjects in the first group once every week at a dose of 170 mg/body, to subjects in the second group once every two weeks at a dose of 340 mg/body and subjects of the third group once every four weeks at a dose of 680 mg/body. In COMPOSER Part 3, drug-target-drug complexes (DTDCs) between crovalimab, human C5, and the eculizumab antibody were identified in all patients with PNH who switched from the anti-C5 antibody eculizumab to crovalimab. DTDCs trigger a transient increase in crovalimab clearance, which may potentially increase the risk of transient loss of complete terminal complement pathway inhibition (see Röth et al., Blood (2020), Vol. 135, pp. 912-920; doi: 10.1182/blood.2019003399 and Sostelly et al., Blood (2019), Vol. 134, p. 3745).

In addition, WO-A1 2018/143266 describes that immunocomplexes (drug-target-drug) between crovalimab, human C5 and the eculizumab antibody could form in subjects treated with eculizumab. When switching subjects, especially subjects for whom continued complete C5 inhibition is required, such as patients with PNH or aHUS, from the anti-C5 antibody eculizumab to crovalimab, both anti-C5 antibodies are present in the circulation and form drug-target-drug complexes ( DTDC) as they bind to different epitopes of human C5. These DTDCs are built from a repeat chain of eculizumab-C5-crovalimab-C5 molecules and can grow by assembling two DTDCs to form a larger DTDC. The goal of treating patients enrolled in Part 3 of the COMPOSER study with crovalimab is to achieve rapid and sustained complete inhibition of the terminal complement pathway. However, drug-target-drug complexes (DTDCs) consisting of crovalimab, human C5 and eculizumab were identified in all patients switching from eculizumab in COMPOSER Part 3. DTDCs and especially large DTDCs are cleared more slowly and are more likely to cause toxicity. Since the formation of such DTDCs may cause potential risks such as poor circulation, risk of vasculitis due to the size of the complexes, type III hypersensitivity reactions or abnormal activation of the complement system, the formation of such DTDCs should be avoided (see also Röth et al., Blood (2020) , Vol., 135, pp. 912-920; doi: 10.1182/blood.2019003399).

In addition, the anti-C5 antibody crovalimab, based on its mechanism of action, inhibits complement-mediated lysis of red blood cells (RBCs) lacking complement regulatory proteins. If the terminal complement pathway is not temporarily blocked during the treatment interval, these red blood cells (RBCs) will be lysed and this may lead to breakthrough hemolysis, which is a severe clinical complication in patients with PNH. Biological stress (infection, surgery, pregnancy) leads to physiological activation of the complement pathway with up-regulation of C5 (Schutte et al., Int Arch Allergy Appl Immunol. (1975), Vol. 48(5), pp. 706-720). In patients with PNH, it is therefore important not only to maintain complete blockade of terminal complement activity throughout the dosing interval, but also to maintain a reserve of free crovalimab binding sites to minimize the occurrence of breakthrough hemolysis.

Accordingly, there is a need to identify a dosage and administration schedule that (1) minimizes DTDC formation in patients suffering from C5-related diseases, and in particular in patients switching from the anti-C5 antibody eculizumab to crovalimab, (2) maximizes level of free crovalimab binding sites and (3) ensures that patients remain above the target threshold concentration of anti-C5 antibody required for terminal complement inhibition, despite inter-individual variability.

SUMMARY OF THE INVENTION

This need is addressed by the present invention by providing embodiments as defined in the claims.

The present invention provides an anti-C5 antibody for use in a method of treating or preventing a C5-related disease in a subject, wherein the method comprises the following sequential steps:

(a) administering intravenously to a subject a loading dose of 1000 mg of anti-C5 antibody once, followed by subcutaneous administration to the subject of at least one loading dose of 340 mg of anti-C5 antibody; And

(b) administering to the subject subcutaneously at least one maintenance dose of 680 mg of anti-C5 antibody.

In the context of the present invention, the subject to be treated is preferably a patient weighing between 40 kg and 100 kg. In the context of the present invention, the subject to be treated is a subject(s) who suffer(s) from a C5-related disease that requires inhibition of complement activity (eg, PNH and aHUS). In addition, the present invention is directed to the use of an anti-C5 antibody for the treatment or prevention of a C5-related disease, in particular PNH. In the context of the present invention, the present invention is directed to the treatment or prevention of a C5-related disease, particularly PNH, in patients who have been treated with one suitable pharmaceutical product for the treatment or prevention of a C5-related disease, particularly PNH, and wherein the intravenous loading dose is administered anti-C5 antibodies are administered to the subject after the last dose of the pharmacological product. Accordingly, the dosage and dosage regimen of an anti-C5 antibody, particularly the anti-C5 antibody crovalimab, described herein is given to patients who have been treated with one beneficial pharmaceutical product for the treatment or prevention of a C5-related disease, particularly PNH. As explained in more detail below, a useful pharmaceutical product for the treatment of a C5-related disease that was given to subjects prior to initiation of the stated dosage and treatment regimen is the anti-C5 antibody eculizumab or ravulizumab, preferably the anti-C5 antibody eculizumab.

As shown in the accompanying Examples, the dose and treatment regimen as defined in the claims provide long-lasting and consistent blockade of terminal complement activity (with approximately more than 95% of subjects maintained above the target threshold of 100 μg/ml); see Fig. 4 and 7. In addition, terminal complement inhibition was achieved immediately after the initial dose and was generally maintained throughout the dosing interval; see Fig. 8. In addition, the dosage and treatment regimen of the present invention also provides a sufficient reserve of free binding sites for most of the dosing interval in both naïve and eculizumab-pretreated patients; see Fig. 2. Crovalimab and eculizumab bind to different C5 epitopes and thus are expected to form DTDCs. DTDCs are expected to develop if patients are simultaneously exposed to crovalimab and eculizumab (see Figure 5), during the switch period from eculizumab to the anti-C5 antibody crovalimab. DTDC formation may contribute to increased clearance of crovalimab and may cause potential risks such as type III hypersensitivity reactions, as explained above. In patients switching from eculizumab to crovalimab, the dose and regimen as defined in the claims reduces DTDC formation; see Fig. 3 and 12. Accordingly, the dosage and treatment regimen described herein describe a new and improved dosage regimen of anti-C5 antibodies, preferably the anti-C5 antibody crovalimab, for the treatment or prevention of a C5-related disease, preferably PNH. The safety and therapeutic efficacy of the claimed dosage and treatment regimen are further described in FIG. 9-11.

Accordingly, the present invention relates to an anti-C5 antibody, preferably the anti-C5 antibody crovalimab, for use in a method of treating or preventing a C5-related disease in a subject, preferably a subject weighing between 40 and 100 kg, wherein the method comprises the following sequential steps:

(a) administering intravenously to a subject a loading dose of 1000 mg of anti-C5 antibody once, followed by subcutaneous administration to the subject of at least one loading dose of 340 mg of anti-C5 antibody; And

(b) administering to the subject subcutaneously at least one maintenance dose of 680 mg of anti-C5 antibody.

The term "loading dose" refers to the dose of anti-C5 antibody administered to a subject suffering from a C5-related disease, preferably PNH, at the start of treatment, i.e. at the beginning of the treatment regimen. In pharmacokinetics (PK), a "loading dose" is an initial higher dose of a drug that can be given to a patient early in a course of treatment before tapering to a lower dose. In the context of the present invention, a loading dose is first given to subjects to be treated by intravenous administration, followed by subcutaneous administration. In the context of the present invention, the loading dose is given once at a dose of 1000 mg. Accordingly, in the context of the present invention, a loading dose of a composition prepared for intravenous administration is given to a subject intravenously once before one loading dose or more than one loading dose of a pharmaceutical composition prepared for subcutaneous administration is given subcutaneously.

In the context of the present invention, one loading dose or more than one loading dose of anti-C5 antibody is administered to patients subcutaneously after intravenous administration of a loading dose of 1000 mg of anti-C5 antibody. Subcutaneous loading dose(s) is administered subcutaneously at a dose of 340 mg of anti-C5 antibody at least once to a given subject from 1 day to 3 weeks (21 days) after the start of intravenous administration of anti-C5 antibody. Accordingly, in the context of the present invention, a loading dose of 340 mg of anti-C5 antibody is administered to the subject subcutaneously at least once every 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 or 21 days after the start of intravenous administration of anti-C5 antibody. Preferably, a loading dose of 340 mg of anti-C5 antibody is administered to the subject 1 day after the start of intravenous administration of anti-C5 antibody. More preferably, one loading dose of 340 mg of anti-C5 antibody is administered subcutaneously 1 day after the start of intravenous administration. In the context of the present invention, at least one additional loading dose of 340 mg of anti-C5 antibody is administered to the subject subcutaneously 1 week (7 days), 2 weeks (14 days) or 3 weeks (21 days) after the start of intravenous administration of anti-C5 antibody. Most preferably, additional loading doses of 340 mg of anti-C5 antibody are administered subcutaneously 1 week (7 days), 2 weeks (14 days) and 3 weeks (21 days) after the start of intravenous administration of anti-C5 antibody. Accordingly, within the context of the present invention, 1, 2, 3, 4 and/or 5 loading doses are given to a subject, where one loading dose, preferably an initial loading dose, is administered to the subject intravenously at a dose of 1000 mg, and where 1, 2, 3 or 4 loading doses are given to the patient subcutaneously at a dose of 340 mg. In the context of the present invention, it is preferred to administer 4 subcutaneous loading doses, each having a dosage of 340 mg of anti-C5 antibody, where additional subcutaneous loading doses are administered 1 day after the start of intravenous administration of anti-C5 antibody, followed by subcutaneous loading doses once a week thereafter. 1 week, 2 weeks and 3 weeks after starting IV anti-C5 antibody. Accordingly, a total amount of 2360 mg of anti-C5 antibody may be administered to the patient using loading doses. This total amount refers to the total doses of anti-C5 antibody administered after 22 days of treatment, i.e. to the dose achieved at the end of day 22 of treatment, which is calculated by adding the loading doses on days 1 (a loading dose of 1000 mg, initially administered intravenously), 2 (the first subcutaneous loading dose of 340 mg, which is given to the patient 1 day after the start of intravenous administration anti-C5 antibodies), 8 (second subcutaneous loading dose of 340 mg given 1 week after initiation of intravenous administration), 15 (third subcutaneous loading dose of 340 mg given 2 weeks after initiation of intravenous administration), and 22 (fourth subcutaneously administered loading dose of 340 mg, which is given 3 weeks after the start of intravenous administration). For example, the total amount of anti-C5 antibody given via (a) loading dose(s) corresponding to 1000 mg intravenously (day 1), followed by subcutaneous administration of 340 mg (day 2), 340 mg ( day 8), 340 mg (day 15) and 340 mg (day 22) is 2360 mg.

According to the present invention, the initial dose or doses are followed by subsequent doses of equal or lesser amounts of anti-C5 antibody at sufficiently close intervals to maintain the concentration of anti-C5 antibody at or above the effective target level. Accordingly, in the context of the present invention, (a) maintenance dose(s) are administered to patients after the loading dose(s). “Maintenance dose” refers to the dose of anti-C5 antibody that is given to a subject suffering from a C5-related disease to maintain the concentration of anti-C5 antibody above a certain effective threshold concentration of anti-C5 antibody. In the context of the present invention, the target level of anti-C5 antibody is approximately 100 μg/ml or greater. The target concentration level of the anti-C5 antibody within the scope of the present invention can be determined in a biological sample of the subject to be treated. Means and methods for determining the concentration of anti-C5 antibody in a biological sample are within the ordinary knowledge of one skilled in the art, and it can, for example, be determined by immunoassay. Preferably, in the context of the present invention, the immunoassay is an ELISA (enzyme-linked immunosorbent assay). Likewise, hemolytic activity can be used as a parameter for the effective treatment of patients suffering from C5-related disease through the stated dosage and treatment regimen. In the context of the present invention, complete inhibition of terminal complement (complete inhibition of the terminal complement pathway) can be determined by hemolytic activity that is less than 10 U/ml. In this context, hemolytic activity can be determined in a biological sample of the patient being treated. It is preferred that the hemolytic activity is less than 10 U/ml, i.e. 10, 9, 8, 7, 6, 5, 4, 3, 2, 1 or 0 U/ml. The means and method for determining hemolytic activity in a biological sample of patients to be treated by means of the dosage and administration schedule according to the invention are known to the person skilled in the art. As an example, hemolytic activity can be determined by immunoassay. Preferably, in the context of the present invention, the immunoassay is an ex vivo liposome immunoassay (LIA). In the context of the present invention, the biological sample is a blood sample. Preferably, the blood sample is a red blood (RBC) sample. Preferably, the maintenance dose(s) is administered to patients subcutaneously at a dose or doses of 680 mg of anti-C5 antibody. Accordingly, within the context of the present invention, the subject is given at least one maintenance dose or more than one maintenance dose(s), wherein the maintenance dose(s) are administered subcutaneously at a dose of 680 mg. In the context of the present invention, at least one maintenance dose of 680 mg of anti-C5 antibody is administered to the subject subcutaneously 4 weeks (28 days) after the start of intravenous administration of anti-C5 antibody. Preferably, a maintenance dose of 680 mg is administered to subjects subcutaneously once 4 weeks after initiation of intravenous anti-C5 antibody administration. Accordingly, in the context of the present invention, at least one maintenance dose of 680 mg is administered to the patient subcutaneously 4 weeks (28 days) after the start of intravenous administration of the anti-C5 antibody, i.e. on day 29 of the treatment regimen. Accordingly, in the context of the present invention, a maintenance dose of 680 mg is administered subcutaneously, preferably once every 4 weeks (28 days) after the start of intravenous administration of anti-C5 antibody. In the context of the present invention, a total amount of 3040 mg of anti-C5 antibody may be administered to a patient with loading doses and a maintenance dose according to the present invention. This total amount refers to the total doses of anti-C5 antibody administered after 29 days of treatment, i.e. dose achieved at the end of day 29 of treatment, which is calculated by adding loading doses on day 1 (loading dose of 1000 mg, initially administered intravenously), 2 (first subcutaneously administered loading dose of 340 mg, which is given to the patient 1 day after the start of intravenous administration of the antibody vs. C5), 8 (second subcutaneously administered loading dose of 340 mg, given 1 week after the start of intravenous administration), 15 (third administered subcutaneous loading dose of 340 mg, given 2 weeks after the start of intravenous administration), 22 (fourth administered a subcutaneous loading dose of 340 mg, given 3 weeks after the start of intravenous administration) and a subcutaneously administered maintenance dose of 680 mg (day 29). For example, the total amount of anti-C5 antibody given by loading dose and maintenance dose corresponding to 1000 mg intravenously (day 1), followed by subcutaneous administration of 340 mg (day 2), 340 mg (day 8), 340 mg (day 15) ), 340 mg (day 22) and 680 mg (day 29) is 3040 mg.

A subcutaneous maintenance dose of 680 mg may be repeated several times at 4-week intervals (Q4W). In the context of the present invention, it is preferred that the maintenance dose of 680 mg is repeated for at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 24, 36, 48 months. Preferred in the context of the present invention is the repetition of a maintenance dose of 680 mg at intervals of 4 weeks and continuation throughout the life of the patient.

In particular, the present invention relates to an anti-C5 antibody for use in a method of treating or preventing a C5-related disease in a subject, preferably a subject weighing between 40 kg and 100 kg, wherein the method comprises the following sequential steps:

(i) intravenously administering a loading dose of 1000 mg of anti-C5 antibody to the subject once;

(ii) subcutaneous administration of a loading dose of 340 mg of anti-C5 antibody to the subject 1 day after the start of intravenous administration of anti-C5 antibody;

(iii) subcutaneous administration of a loading dose of 340 mg of anti-C5 antibody to the subject 1 week (7 days), 2 weeks (14 days) and 3 weeks (21 days) after the start of intravenous administration of anti-C5 antibody once a week;

(iv) administering subcutaneously a maintenance dose of 680 mg of anti-C5 antibody to the subject 4 weeks (28 days) after initiation of intravenous administration of anti-C5 antibody; And

(v) repeating stage (iv) several times at intervals of 4 weeks (28 days).

The terms "intravenous administration"/"administering intravenous administration" refer in the context of the present invention to the administration of an anti-C5 antibody into a vein of a subject such that the patient being treated receives the anti-C5 antibody in about 15 minutes or less, preferably in 5 minutes or less. For intravenous administration, the anti-C5 antibody must be formulated such that it is administered through a suitable device, such as (but not limited to) a syringe. In the context of the present invention, the intravenous preparation contains from 50 to 350 mg of anti-C5 antibody, from 1 to 100 mM of a buffering agent such as histidine/aspartic acid having a pH of 5.5 plus/minus 1.0, from 1 to 100 mM an amino acid such as arginine; and 0.01 to 0.1% of a nonionic surfactant such as a poloxamer. Preferably, in the context of the present invention, a preparation for intravenous administration in a 2 ml glass vial is provided, containing the following components: 170 mg/ml crovalimab, 30 mm histidine/aspartic acid (pH 5.8), 100 mm arginine hydrochloride and 0.05% Poloxamer 188 ™. The drug is then administered to the patient within a tolerable period of time, such as 5 minutes, 15 minutes, 30 minutes, 90 minutes or less. In addition, the intravenous preparation is given to patients to be treated in an injection volume of 1 ml to 15 ml, preferably about 6 ml.

The terms "subcutaneous administration"/"subcutaneous administration" refer in the context of the present invention to the introduction of an anti-C5 antibody under the skin of an animal or human patient, preferably within a pocket between the skin and the underlying tissue, through a relatively slow, sustained delivery from the drug receptacle. This pocket can be created by compressing or pulling the skin upward and away from the underlying tissue. For subcutaneous administration, the anti-C5 antibody must be formulated such that it can be administered through a suitable device, such as, but not limited to, a syringe, prefilled syringe, injection device, infusion pump, injection pen, needleless device, or delivery system based on a transdermal patch. In the context of the present invention, the subcutaneous preparation contains from 50 to 350 mg of anti-C5 antibody, from 1 to 100 mM of a buffering agent such as histidine/aspartic acid having a pH of 5.5 plus/minus 1.0, from 1 to 100 mM an amino acid such as arginine; and 0.01 to 0.1% of a nonionic surfactant such as a poloxamer. Preferably, the present invention provides a preparation for intravenous administration in a 2.25 ml pre-filled syringe containing the following components: 170 mg/ml crovalimab, 30 mM histidine/aspartic acid (pH 5.8), 100 mM arginine hydrochloride and 0.05 % Poloxamer 188™. In the context of the present invention, the preparation for subcutaneous administration is provided in the form of a pre-filled syringe with a needle safety device. Subcutaneous injection devices contain from about 1 to 15 ml or more, preferably 2.25 ml of a subcutaneous preparation containing an anti-C5 antibody. Under normal conditions, the injection volume to be administered subcutaneously is from 1 to 15 ml, preferably either 2 ml (340 mg crovalimab) or 6 ml (680 mg crovalimab). In the context of the present invention, subcutaneous administration refers to the introduction of an anti-C5 antibody under the skin of the patient being treated through a relatively slow, sustained delivery from the drug receptacle over a period of time including, but not limited to, 30 minutes or less, 90 minutes or less. Optionally, administration may be accomplished by subcutaneous implantation of a drug delivery pump implanted under the skin of the patient being treated, wherein the pump delivers a predetermined amount of anti-C5 antibody over a predetermined period of time, such as 30 minutes, 90 minutes, or a period of time spanning the duration treatment regimens.

In the context of the present invention, the above dosages and treatment regimens may be useful for treating or preventing a C5-related disease in a subject who has been treated with at least one pharmacological product for use in treating or preventing the disease on one or more occasions. For example, a treatment regimen of the present invention may be useful for treating a patient having a C5-related disease who has received prior treatment with at least one pharmacological product for use in a method of treating or preventing the disease, but is expected to respond better to the treatment regimen according to the present invention. In such cases, a drug switch may be made from this pharmacological product to anti-C5 antibodies for use in the treatment or prevention of a C5-related disease according to the present invention. Preferably, an intravenous loading dose of the anti-C5 antibody is given to the subject being treated following the final dose of the pharmaceutical product. This intravenous loading dose of anti-C5 antibody is preferably 1000 mg.

In the context of the present invention, the pharmacological product contains an active substance that is different from the anti-C5 antibody that is given according to the present invention either intravenously or subcutaneously. This active substance of the pharmacological product in the context of the present invention may be an siRNA (small interfering RNA) targeting C5 mRNA or an anti-C5 antibody that is different from the anti-C5 antibody administered subcutaneously or intravenously to the subject to be treated according to the present invention. This pharmacological product may contain an anti-C5 antibody, which is a different antibody from the anti-C5 antibody that is given to patients in the context of the present invention. The antibody contained in this pharmaceutical product, which has been used in previous treatment, may be ravulizumab or eculizumab, or variants thereof. Preferably, the antibody contained in this pharmacological product, which has been used in previous treatment, is eculizumab or variants thereof. Exemplary sequence variants of the anti-C5 antibody eculizumab are shown in SEQ ID NOs: 11 and 12.

Variant antibodies in the context of the present invention may be anti-C5 antibodies that contain a variant Fc region in which one or more amino acid modifications have been introduced into the Fc region of the naturally occurring sequence antibody. A given Fc region variant may comprise a human Fc region sequence (eg, human IgG1, IgG2, IgG3, or IgG4 Fc region) containing an amino acid modification (eg, substitution) at one or more amino acid positions. In the context of the present invention, the antibody variant has some, but not all, effector functions, making it a desirable candidate for applications in which the in vivo half-life of the antibody is important, but certain effector functions (such as complement and ADCC) are important. ) are unnecessary or harmful. In vitro and/or in vivo cytotoxicity assays can be performed to confirm reduction/depletion of CDC (complement dependent cytotoxicity) and/or ADCC activities. For example, Fc receptor (FcR) binding assays can be performed to ensure that the antibody does not bind to R (receptor) Fc gamma (thus likely to have no ADCC activity) but retains the ability to bind to FcRn. The primary cells for mediating ADCC, NK (natural killer) cells, express only RIII Fc gamma, whereas monocytes express RI Fc gamma, RII Fc gamma and RIII Fc gamma. FcR expression on hematopoietic cells is summarized in Table 3 on page 464 Ravetch and Kinet, Annu. Rev. Immunol. 9:457-492 (1991). Non-limiting examples of in vitro assays for assessing the ADCC activity of a molecule of interest are described in US-B1 5500362 (see, for example, Hellstrom et al., Proc. Nat'l Acad. Sci. USA (1983), Vol. 83, pp. 7059- 7063) and Hellstrom et al., Proc. Nat'l Acad. Sci. USA (1985), Vol. 82, pp. 1499-1502; US-B1 5821337 (see Bruggemann et al., J. Exp. Med. (1987), Vol. 166, pp. 1351-1361). Alternatively, non-radioactive assays may be used (see, for example, the ACTI™ Non-Radioactive Cytotoxicity Assay for Flow Cytometry (CellTechnology, Inc. Mountain View, CA) and the CytoTox 96 Non-Radioactive Cytotoxicity Assay (registered trademark) (Promega, Madison, WI )). Useful effector cells for such assays include peripheral blood mononuclear cells (PBMCs) and natural killer (NK) cells. Alternatively or additionally, the ADCC activity of a molecule of interest can be assessed in vivo, for example, in an animal model such as the model disclosed in Dynes et al., Proc. Nat'l Acad. Sci. USA (1998), Vol.95, pp.652-656. C1q binding assays can also be performed to confirm that the antibody is unable to bind to C1q and therefore does not have CDC activity. See, for example, ELISA (enzyme-linked immunosorbent assay) binding to C1q and C3c in WO-A2 2006/029879 and WO-A1 2005/100402. The CDC assay can be used to assess complement activation (see, for example, Gazzano-Santoro et al., J. Immunol. Methods (1996), Vol. 202, pp. 163; Cragg et al., Blood (2003), Vol. 101, pp. 1045-1052 and Cragg et al., Blood (2004), Vol. 103, pp. 2738-2743). FcRn binding and in vivo clearance/half-life determinations can also be made using methods known in the art (see, e.g., Petkova et al., Int'l. Immunol. (2006), Vol. 18(12), pp. 1759-1769).

Antibodies with reduced effector function include those with substitution of one or more residues of the Fc region 238, 265, 269, 270, 297, 327 and 329 (US-B1 6737056). Such Fc mutants include Fc mutants with substitutions at two or more of amino acid positions 265, 269, 270, 297 and 327, including the so-called “DANA” Fc mutant with residues 265 and 297 replaced by alanine (US-B1 7332581).

Certain antibody variants with improved or decreased binding to FcRn are described. (See, for example, US-B1 6737056; WO-A2 2004/056312 and Shields et al., J. Biol. Chem. (2001), Vol. 9(2), pp. 6591-6604).

In some embodiments, the antibody variant comprises an Fc region with one or more amino acid substitutions that improve ADCC, such as substitutions at positions 298, 333, and/or 334 of the Fc region (EU residue numbering).

In some embodiments, changes are made to the Fc region that result in altered (i.e., either improved or decreased) binding to C1q and/or complement dependent cytotoxicity (CDC), for example, as described in US-B1 6194551, WO 1999/51642 and Idusogie et al., J. Immunol. (2000), Vol. 164, pp. 4178-4184.

Antibodies with extended half-lives and improved binding to the neonatal Fc receptor (FcRn), which is responsible for the transfer of maternal IgG to the fetus (Guyer et al., J. Immunol. (1976), Vol. 117, pp. 587 and Kim et al. , J. Immunol. (1994), Vol. 24, pp. 249), are described in US 2005/0014934. These antibodies contain an Fc region with one or more substitutions therein that improves the binding of the Fc region to FcRn. Such Fc variants include variants with substitutions at one or more than one residue of the Fc region: 238, 256, 265, 272, 286, 303, 305, 307, 311, 312, 317, 340, 356, 360, 362, 376, 378 , 380, 382, 413, 424 or 434, for example, substitution of residue 434 of the Fc region (US-B1 7371826). See also Duncan, Nature (1988), Vol. 322, pp. 738-740, US-B1 5648260; US-B15624821 and WO 1994/29351 provide other examples of Fc region variants.

In the context of the present invention, the initial dose of the composition for intravenous injection in the present invention is administered on the same day or after 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days (1 week), 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days (two weeks), 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, 21 days (3 weeks) or more days after that , as the patient to be treated is administered the last dose of the pharmacological product. Preferably, in the context of the present invention, an intravenous loading dose of anti-C5 antibody is administered on day 3 or after 3 days, 4 days, 5 days, 6 days, 7 days (1 week), 8 days, 9 days, 10 days, 11 days, 12 days, 13 days, 14 days (two weeks), 15 days, 16 days, 17 days, 18 days, 19 days, 20 days, 21 days (3 weeks) or more days after the final dose of the pharmacological product. Preferably, an intravenously administered loading dose of the anti-C5 antibody is given to the patient 7 days (1 week) or more than a day after the last dose of the pharmacological product. Also preferred in the context of the present invention is intravenous administration of a loading dose 14 days (2 weeks) or more than a day after the final dose of the pharmacological product. Most preferred in the context of the present invention is intravenous administration of the anti-C5 antibody 21 days (3 weeks) after the last dose of the pharmacological product.

In the context of the present invention, the term "week" refers to a time period of 7 days.

In the context of the present invention, the term "month" refers to a period of 4 weeks.

The term "treatment" in the context of the present invention includes a sequential series of "induction treatment" and at least one "maintenance treatment". Typically, treatment according to this invention includes an "induction treatment" and at least one "maintenance treatment". Typically, treatment according to this invention may last 1 month, 2 months, 3 months, 4 months, 5 months, 6 months, 7 months, 8 months, 9 months, 10 months, 11 months, 1 year (12 months), 2 years ( 24 months), 3 years (36 months) or 4 years (48 months). Preferred in the context of the present invention is treatment that continues throughout the life of the patient.

The “induction treatment” consists of a sequential series of (i) intravenously administering to the subject a loading dose, preferably a 1000 mg dose, of an anti-C5 antibody and (ii) subcutaneously administering to the subject at least one loading dose, preferably a 340 mg dose, of an anti-C5 antibody. As explained herein above, within the context of the present invention, it is preferred that a loading dose of 340 mg of anti-C5 antibody is given to the subject at 1 day, 1 week (7 days), 2 weeks (14 days), and 3 weeks (21 days). after an intravenously administered loading dose. Preferably, the loading dose to be administered intravenously is 1000 mg. The loading dose, which is given to the subject to be treated subcutaneously, has a dose of 1360 mg. Thus, in the context of the present invention, during induction treatment, a loading dose of 2360 mg is administered to the subject being treated either intravenously or subcutaneously. “Maintenance treatment” consists of a sequential series of (i) maintenance periods where subjects are given one or more than one maintenance dose subcutaneously. In the context of the present invention, it is preferred that the subject is given a maintenance dose of 680 mg of anti-C5 antibody, preferably once 4 weeks (1 month) after the start of an intravenous loading dose of anti-C5 antibody. As explained above, a subcutaneous maintenance dose of 680 mg can be repeated several times at 4-week intervals (Q4W). Preferred in the context of the present invention is the repetition of a maintenance dose of 680 mg at intervals of 4 weeks and continuing throughout the life of the patient.

In the context of the present invention, a C5-related disease is a complement-mediated disease or condition that involves excessive or uncontrolled activation of C5. In some embodiments, the C5-related disease is at least one selected from the group consisting of paroxysmal nocturnal hemoglobinuria (PNH), rheumatoid arthritis (RA), lupus nephritis, ischemic reperfusion injury, atypical hemolytic uremic syndrome (aHUS), dense sludge (DDD), macular degeneration, hemolysis syndrome, elevated liver enzymes and decreased platelet count (HELLP), thrombotic thrombocytopenic purpura (TTP), spontaneous fetal loss, weakly immune vasculitis, epidermolysis bullosa, recurrent fetal loss, multiple sclerosis (MS), traumatic brain damage, damage due to myocardial infarction, cardiopulmonary bypass and hemodialysis, refractory generalized myasthenia gravis (gMG) and neuromyelitis optica (NMO). Preferably, in the context of the present invention, the C5-related disease is at least one selected from the group consisting of PNH, aHUS, gMG and NMO. Most preferably, the C5 associated disease is PNH. Additionally, in the context of the present invention, a subject suffering from C5-related PNH disease may be tested for the presence of the C5 Arg885 mutation. Accordingly, the dosage regimen disclosed herein can also be used for the treatment and/or prevention of subjects suffering from PNH, characterized in that the subjects have the Arg885 C5 mutation. In this context, the Arg885 mutation means a genetic change in C5, where the Arg at position 885 is replaced by His. As used herein, the term “C5” refers to a protein having the amino acid sequence as shown in SEQ ID NO: 13.

In the context of the present invention, the anti-C5 antibody is preferably crovalimab. Sequence details of the anti-C5 antibody crovalimab (CAS number: 1917321-26-6) are disclosed in List No. 119 of the proposed International Nonproprietary Names for pharmaceutical substances (INN), as published on pages 302 and 303 of WHO Drug Information (2018), Vol. 32, No. 2. The anti-C5 antibody sequences of crovalimab are also shown in SEQ ID NO: 3 (heavy chain) and SEQ ID NO: 4 (light chain). The preparation of the anti-C5 antibody crovalimab used in the present invention is described in WO 2016/098356 (see Example 1 for details). Moreover, in the context of the present invention, the anti-C5 antibody crovalimab is administered to patients through either an intravenous or subcutaneous formulation. Preferred in the context of the present invention is intravenous or subcutaneous administration of the dosages proposed herein in the form of (a) fixed dose(s).

The intravenous formulation contains 50 to 350 mg of the anti-C5 antibody crovalimab, 1 to 100 mM of a buffering agent such as histidine/aspartic acid having a pH of 5.5 plus/minus 1.0, 1 to 100 mM of an amino acid such such as arginine, and from 0.01 to 0.1% of a nonionic surfactant such as a poloxamer. The drug preferred in the context of the present invention for intravenous administration is provided in a 2 ml glass vial containing the following components: 170 mg/ml crovalimab, 30 mm histidine/aspartic acid (pH 5.8), 100 mm arginine hydrochloride and 0.05% Poloxamer 188 ™.

The subcutaneous formulation contains 50 to 350 mg of the anti-C5 antibody crovalimab, 1 to 100 mM of a buffering agent such as histidine/aspartic acid having a pH of 5.5 plus/minus 1.0, 1 to 100 mM of an amino acid such such as arginine, and from 0.01 to 0.1% of a nonionic surfactant such as a poloxamer. The preferred intravenous preparation in the context of the present invention is provided in a 2.25 ml pre-filled syringe containing the following components: 170 mg/ml crovalimab, 30 mM histidine/aspartic acid (pH 5.8), 100 mM arginine hydrochloride and 0.05 % Poloxamer 188™.

The anti-C5 antibody eculizumab is marketed under the trade name Soliris® by Alexion Pharmaceuticals, Inc. The sequences of the anti-C5 antibody eculizumab are shown in SEQ ID NO: 1 (heavy chain) and SEQ ID NO: 2 (light chain). In addition, sequence variants of the anti-C5 antibody eculizumab are shown in SEQ ID NOs: 11 and 12.

The anti-C5 antibody sequences of ravulizumab are marketed under the trade name Ultomiris® by Alexion Pharmaceuticals, Inc. The sequences of the anti-C5 antibody ravulizumab (CAS number: 1803171-55-2) are disclosed in List No. 117 of the proposed International Nonproprietary Names of pharmaceutical substances (INN), as published on pages 319 and 320 of WHO Drug Information (2017), Vol. 31, No. 2. The sequences of the anti-C5 antibody ravulizumab are also shown in SEQ ID NO: 5 (heavy chain) and SEQ ID NO: 6 (light chain).

The patients described in the context of the present invention are patients suffering from a C5-related disease. Preferred patients in the context of the present invention are those with a body weight between 40 kg and 100 kg. In the context of the present invention, a C5-related disease is a complement-mediated disease or condition that involves excessive or uncontrolled activation of C5. In some embodiments, the C5-related disease is at least one selected from the group consisting of paroxysmal nocturnal hemoglobinuria (PNH), rheumatoid arthritis (RA), lupus nephritis, ischemic reperfusion injury, atypical hemolytic uremic syndrome (aHUS), dense sludge (DDD), macular degeneration, hemolysis syndrome, elevated liver enzymes and decreased platelet count (HELLP), thrombotic thrombocytopenic purpura (TTP), spontaneous fetal loss, weakly immune vasculitis, epidermolysis bullosa, recurrent fetal loss, multiple sclerosis (MS), traumatic brain damage, damage resulting from myocardial infarction, cardiopulmonary bypass or hemodialysis, refractory generalized myasthenia gravis (gMG) and neuromyelitis optica (NMO). Preferably, in the context of the present invention, the C5-related disease is at least one selected from the group consisting of PNH, aHUS, gMG and NMO. Most preferably, the C5 associated disease is PNH.

In addition, the present invention provides a method for treating or preventing a C5-related disease in a subject, wherein the method comprises the following sequential steps:

(a) administering an intravenous loading dose of 1000 mg of anti-C5 antibody to the subject once, followed by subcutaneous administration of at least one loading dose of 340 mg of anti-C5 antibody to the subject; And

(b) subcutaneously administering at least one maintenance dose of 680 mg of anti-C5 antibody to the subject.

In the context of the present invention, it is preferred that the method of treating or preventing a C5-related disease in a subject is carried out through the following steps of administration:

(i) intravenously administering a loading dose of 1000 mg of anti-C5 antibody to the subject once;

(ii) subcutaneous administration of a loading dose of 340 mg of anti-C5 antibody to the subject 1 day after the start of intravenous administration of anti-C5 antibody;

(iii) subcutaneous administration of a loading dose of 340 mg of anti-C5 antibody to the subject at 1 week, 2 weeks and 3 weeks after the start of intravenous administration of anti-C5 antibody once a week;

(iv) administering subcutaneously a maintenance dose of 680 mg of anti-C5 antibody to the subject 4 weeks after initiation of intravenous administration of anti-C5 antibody; And

(v) repeat stage (iv) several times at 4 week intervals.

As explained above, in the context of the present invention, it is preferred that the anti-C5 antibody used in the context of the dosage and administration schedule is crovalimab. Moreover, the above definition is similarly applicable to the above methods of treating or preventing a C5-related disease. In the context of the present invention, it is also preferable that the subject to be treated has a body weight of from 40 kg to 100 kg. In FIG. shown:

Fig. 1: Association between anti-C5 antibody crovalimab and hemolytic activity measured by liposomal immunoassay (LIA) in healthy subjects and subjects with the C5-related disease paroxysmal nocturnal hemoglobinuria (PNH)

Evaluation of the exposure-response relationship demonstrates that approximately 100 μg/mL of crovalimab is required to achieve complete inhibition of terminal complement. Complete inhibition of terminal complement (complete inhibition of the terminal complement pathway) is defined as hemolytic activity less than 10 U/ml. The vertical dotted line marks the pharmacodynamics (PD) threshold of 100 μg/mL crovalimab.

Fig. 2: available free binding sites for anti-C5 antibody crovalimab

Gray lines correspond to a simulation of 15 individuals based on parameters estimated from COMPOSER data (BP39144). Data from the COMPOSER study were used for the simulations. The ordinate shows the concentration of the anti-C5 antibody crovalimab (RO7112689; SKY59). The abscissa shows the time in days. Dark gray lines correspond to median values for data from 15 patients: S0: COMPOSER part 3 diagram; S5: Proposed design in COMPOSER trial part 4 and phase III.

Fig. 3: Time profile of drug-target-drug complex (DTDC)

Gray lines correspond to a simulation of 15 individuals based on parameters estimated from COMPOSER data (BP39144). Data from the COMPOSER study were used for the simulations. Dark gray lines correspond to median values for data from 15 patients: S0: COMPOSER part 3 diagram; S5: Proposed design in COMPOSER Part 4 and Phase III; RO7112689: crovalimab (SKY59).

Fig. 4: Simulated concentration-time profiles of crovalimab in treatment-naïve patients (top panel) and PNH patients switching from eculizumab to crovalimab treatment (bottom panel)

The gray interval corresponds to the 90% prediction interval, and the gray line corresponds to the predicted median. The black dotted line represents the target concentration level of 100 μg/mL of the anti-C5 antibody crovalimab.

Fig. 5: model describing how drug-target-drug complexes (DTDCs) between crovalimab, human C5 and the antibody eculizumab are cleared, recycled and sequentially built from smaller DTDCs

When patients switch from the anti-C5 antibody eculizumab to crovalimab, both anti-C5 antibodies are present in the circulation and form DTDCs as they bind to different epitopes of human C5. These DTDCs are built from a repeat chain of eculizumab-C5-crovalimab-C5 molecules and grow over time as two DTDCs are assembled to form a larger DTDC. This model (Figure 5) describes how DTDCs are cleared and recycled by FcRn receptors to anti-C5 crovalimab antibodies. (1) DTDC develops if patients are simultaneously exposed to crovalimab and eculizumab during a drug switch period due to differential recognition of the C5 epitope by these antibodies. These DTDCs are taken up into endosomes through phagocytosis. (2) The antibody crovalimab, which pH-dependently binds to human C5, dissociates from the soluble human C5 that was bound to the anti-C5 antibody crovalimab under acidic conditions (pH 6.0) in the endosome, while the anti-C5 antibody eculizumab still bound to soluble human C5 under acidic conditions in the endosome. (3) Anti-C5 antibodies (anti-C5 antibody crovalimab and C5-eculizumab complex) are taken up by cells through binding to FcRn expressed on the cell membrane. The C5-eculizumab complex is translocated into the lysosome for degradation or recycling with the C5 protein still bound to the antibody. In contrast, the anti-C5 antibody crovalimab has improved functionality/efficacy as it dissociates from FcRn in the endosome under acidic conditions to be released back into plasma without C5 protein. (4), (5) The released anti-C5 antibody crovalimab is again available to bind to human C5 and to generate other, smaller DTDCs. This has the effect of “recycling” the anti-C5 antibody crovalimab. DTDCs and, in particular, C5-eculizumab complexes are then degraded again via endosomes, while the anti-C5 antibody crovalimab is recycled again to build smaller DTDCs.

Fig. 6: COMPOSER part 4 included patients with PNH

Part 4 of COMPOSER assessed the safety, pharmacokinetics (PK) and pharmacodynamics (PD) effects of an optimized crovalimab regimen in patients with PNH who did not receive anti-C5 therapy, preferably crovalimab therapy, or who switched from eculizumab, with a primary assessment of 20 weeks. . Of the 15 patients enrolled, 8 (53%) were naïve to C5 inhibitor therapy, and 7 (47%) switched from eculizumab to crovalimab.

Fig. 7: Exposure to crovalimab in patients enrolled in Part 4 of the COMPOSER trial

All patients maintained crovalimab levels greater than the C _trough value of approximately 100 mcg/ml, which is associated with inhibition of terminal complement activity. The lines represent the mean and the shaded area shows the 95% confidence interval.

Fig. 8: liposome immunoassay (LIA) progression showing median complement activity in patients enrolled in Part 4 of the COMPOSER trial

Terminal complement inhibition was achieved immediately after the initial dose and was generally maintained throughout the study period. The lines represent the median value and the whiskers indicate the 95% confidence interval. The lower limit of quantification of the LIA assay is 10 U/mL. LIA - liposomal immunoassay.

Fig. 9: Measurement of total and free C5 levels in patients enrolled in Part 4 of the COMPOSER study

(A) Limited overall accumulation of C5 was observed in untreated patients, and a decrease was observed in switched patients. (B) Free C5 levels decreased rapidly after the initial dose and remained low throughout the follow-up period.

Fig. 10: Measurement of normalized lactate dehydrogenase (LDH) levels in patients enrolled in Part 4 of the COMPOSER study

In naïve patients, median lactate dehydrogenase (LDH) levels decreased to levels less than or equal to 1.5× upper limit of normal (ULN) by day 15 and remained below this level throughout the follow-up period. In patients who switched from eculizumab to crovalimab, the median baseline LDH level was less than or equal to 1.5× ULN and remained so throughout follow-up. LDH - lactate dehydrogenase; ULN - upper limit of normal.

Fig. 11: Summary of adverse events (AEs) associated with crovalimab treatment

Crovalimab was well tolerated and no treatment-related serious adverse events (AEs) were observed.

Fig. 12: Observed DTDC profiles over time with part 3 and part 4 crovalimab regimens of the COMPOSER study

Solid lines represent the sum of the median percentages of crovalimab eluted in fractions 1–4 (left panels) and fractions 5–6 (right panels) of size exclusion filtration (SEC). The dosing schedule for Part 3 of the COMPOSER study is shown in light gray, and the dosing schedule for Part 4 is shown in dark gray.

Fig. 13: Normalized LDH levels of PNH patients carrying the C5 Arg885His mutation treated with crovalimab

Crovalimab achieved sustained terminal complement inhibition in PNH patients with the Arg885 polymorphism. All patients achieved complete inhibition of terminal complement as measured by liposome immunoassay (LIA). LIA levels ranged from 32-42 U/ml at baseline, decreased to less than 10 U/ml by day 2 and were maintained thereafter. The lower limit of quantitation for the LIA assay is 10 U/mL. LIA - liposomal immunoassay.

The following examples illustrate this invention

Example 1: anti-C5 antibodies

The sequences of the anti-C5 antibody crovalimab are shown in SEQ ID NO: 3 (heavy chain) and SEQ ID NO: 4 (light chain). In addition, the preparation of the anti-C5 antibody crovalimab used in the present invention is described in WO 2016/098356. Briefly, genes encoding the heavy chain variable domain (VH) 305LO15 (SEQ ID NO: 7)) were combined with genes encoding a modified SG115 variant of the human IgG1 heavy chain constant (CH) domain (SEQ ID NO: 8). The genes encoding the light chain variable domain (VL) 305LO15 (SEQ ID NO: 9)) were combined with the genes encoding the human light chain constant domain (CL) (SK1, SEQ ID NO: 10). Antibodies were expressed in HEK293 cells cotransfected with a combination of heavy and light chain expression vectors and protein purified.

Example 2: Dosages and Dosing Schedules Used in the COMPOSER Study (BP39144; ClinicalTrials.gov Identifier: NCT03157635)

The Phase I/II COMPOSER study (BP39144) was initiated to determine appropriate dosing and administration schedules. This study initially consisted of three parts: part 1 in healthy participants, part 2 and part 3 in patients with paroxysmal nocturnal hemoglobinuria (PNH). In addition, patients included in part 3 of this study were patients who were treated with the anti-C5 antibody eculizumab for at least 3 months.

Part 1 of this study was designed to include three groups of healthy patients. The first group is a group of patients who receive the anti-C5 antibody crovalimab intravenously (IV) once at a dose of 75 mg/body. The second group of patients is a group of participants in whom the anti-C5 antibody crovalimab is administered intravenously (IV) once at a dose of 150 mg/body. The third group is a group of subjects in whom the anti-C5 antibody crovalimab is administered subcutaneously (SC) once at a dose of 170 mg/body. Because Part 1 of the COMPOSER study is adaptive in nature (based on ongoing evaluation of safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) data), the actual doses reported for Part 1 were: 75 mg i.v. for the first group of patients, 125 mg i.v. for the second group of patients and 100 mg SC for the third group of patients enrolled in part 1 of the COMPOSER study.

Part 2 of this study was designed to enroll a subset of subjects in whom the anti-C5 antibody crovalimab was administered intravenously three times: according to the original protocol design, the anti-C5 antibody crovalimab was initially administered at a dose of 300 mg/body (i.v.), followed by 500 mg/body (i.v.). i.v.) one week after the initial administration and finally 1000 mg/body (i.v.) two weeks after the second administration. Beginning two weeks after the last intravenous administration, the anti-C5 antibody crovalimab is administered subcutaneously (s.c.) once weekly at a dose of 170 mg/body. Based on emerging clinical data from Part 1 and the PK simulation, the baseline dose for patients in Part 2 of the COMPOSER trial was changed from 300 mg to 375 mg IV. Therefore, the actual doses reported in Part 2 of the COMPOSER study are as follows: the anti-C5 antibody crovalimab is initially administered intravenously (IV) at a dose of 375 mg/body, followed by a dose of 500 mg/body (IV) via a week after the initial administration and finally 1000 mg/body (i.v.) two weeks after the second administration. Beginning two weeks after the last intravenous administration, the anti-C5 antibody crovalimab is administered subcutaneously (s.c.) once weekly at a dose of 170 mg/body.

Part 3 of this study included patients who had been treated with the anti-C5 antibody eculizumab for at least three months prior to enrollment in this clinical trial, and these patients were required to receive regular eculizumab infusions. Part 3 of this study was designed to include three groups of subjects. The anti-C5 antibody crovalimab is initially administered to subjects in all groups intravenously at a dose of 1000 mg/body. Starting one week after the initial intravenous administration (day 8 after i.v. administration), the anti-C5 antibody crovalimab was administered subcutaneously (s.c.) to subjects in the first group once every week at a dose of 170 mg/body, to subjects in the second group once every two weeks at a dose of 340 mg/body and subjects in the third group once every four weeks at a dose of 680 mg/body. 15 healthy patients were enrolled in part 1 of the COMPOSER study. Part 1 was randomized such that only 9 of the original 15 patients received crovalimab. Nineteen patients were enrolled in Part 3 of the COMPOSER study, but three patients discontinued participation.

Details regarding patients included in the COMPOSER study (Part 1, Part 2 and Part 3) can be summarized as follows:

After receiving the above details for patients enrolled in parts 1-3 of the COMPOSER study, one additional patient in part 3 of the COMPOSER study withdrew from the study.

Example 3: Determination of a dosing regimen to achieve complete and maintained terminal complement inhibition throughout treatment with the anti-C5 antibody crovalimab

The treatment goal for crovalimab in C5-related diseases, preferably paroxysmal nocturnal hemoglobinuria (PNH), is to provide rapid and sustained complete inhibition of the terminal complement pathway. In patients switching from eculizumab to crovalimab, a washout period is clinically inappropriate. Therefore, by design, residual concentrations of eculizumab are present when crovalimab dosing is initiated. Drug-target-drug complexes (DTDCs) consisting of crovalimab, human C5 and eculizumab were identified in all patients switching from eculizumab in COMPOSER Part 3 using a multiplex assay combining gel filtration (SEC) with enzyme-linked immunosorbent assay (ELISA). SEC is a separation technique based on differences in Stokes radius and protein geometry: SEC separates molecules according to size differences as they pass through a gel filtration medium packed into a column to form a packed layer. Unlike ion exchange or affinity chromatography, the molecules are not bound to the chromatographic medium in such a way that the composition of the buffered medium does not directly affect resolution (the degree of separation between peaks). The medium is a porous matrix of spherical particles with chemical and physical stability and inertness (lack of reactivity and adsorption properties). SEC was used in fractionation mode to separate multiple components in a sample based on differences in their size. For a complex sample composition with different proteins, similar to serum, the combination of SEC with an ELISA specific for the analyte (crovalimab) provided the desired specificity and sensitivity to detect the concentrations of crovalimab in each of the separated fractions. To enable detection of crovalimab concentrations using ELISA, the SEC separation is fractionated into eight fractions. For each individual, the DTDC profile over time was described using this approach. To identify a dosing regimen that is expected to achieve complete and sustained terminal complement inhibition throughout the dosing interval, two complementary model-informed drug development (MIDD) approaches were developed to recommend the dose to be used in a given clinical trial (phase III dose):

• An empirical population pharmacokinetic model used to recommend subcutaneous (SC) dosing and regimens to maintain crovalimab concentrations above the target threshold concentration of 100 mcg/mL throughout the dosing interval in patients.

• A biochemical model simultaneously describing the kinetics of total and free C5, the pharmacokinetics of crovalimab and eculizumab, and the kinetics of DTDC used to recommend a dose and regimen that minimizes the formation of large DTDCs in patients switching from eculizumab to crovalimab and maximizes the level of free crovalimab binding sites in all patients.

3.1 Population pharmacokinetics model

The concentration-time profiles of the anti-C5 antibody crovalimab were best described using a two-compartment open model with first-order elimination and first-order adsorption to describe subcutaneous (s.c.) administration (see Betts A. et al., mAbs (2018), Vol 10, No. 5, pp. 751-764). Pharmacokinetic (PK) profiles in patients switching from eculizumab treatment in COMPOSER Part 3 demonstrate transient faster clearance not observed in healthy volunteers and untreated PNH patients. To describe the pharmacokinetics (PK) for patients switching from eculizumab treatment to the anti-C5 antibody crovalimab, clearance of crovalimab was modeled as a combination of first-order clearance used for untreated patients and faster clearance that decreases exponentially over time. Body weight (median: 72.3 (40.6-131.5) [kg]) was analyzed as an independent variable for clearances and volumes and was found to significantly influence these parameters when included using allometric scaling with the factor , fixed at 0.75 for clearances and 1 for volumes. The clearance parameter is a measure of the body's ability to eliminate a drug. Clearance is expressed as volume per unit time. The volumes parameter refers to the volume of distribution, a measure of the apparent space in the body available to contain the anti-C5 antibody crovalimab. Age was also found to be an independent variable influencing absorption rate and was entered into the model as a categorical independent variable. Patients aged greater than or equal to 50 years appear to have a slower absorption rate than younger patients. Bioavailability after subcutaneous (SC) administration is estimated to be approximately 100%.

This model could accurately estimate PK parameters and has good predictive performance, which determines its application for simulation purposes.

3.2 Biochemical model of drug-target-drug complexes (DTDCs)

A biochemical mathematical model was developed to study the kinetics of DTDC formation and clearance under the assumption that larger complexes are formed through the reversible binding of smaller complexes (see Figure 5). This model takes into account all complexes formed by repeating the Ab1-Ag-Ab2 unit (antibody 1 (Ab1), antibody 2 (Ab2) and antigen (Ag) are crovalizumab, eculizumab and C5, respectively), starting with the smallest complexes (Ab1-Ag- Ab2) up to the largest complexes containing 4 Ab1, 4 Ab2 and 8 Ag (for example, the complex Ab1-Ag-Ab2-Ag-Ab1-Ag-Ab2-Ag-Ab1-Ag-Ab2-Ag-Ab1-Ag-Ab2- Ag) as observed in in vitro SEC assays. Each possible biochemical reaction describing the formation of a complex through the binding of 2 smaller complexes was described using a ligand binding model. Each binding reaction also took into account the clearance of complexes and recycling of free crovalimab from DTDC (due to SMART-Ig Recycling® releasing C5 from crovalimab under the acidic conditions of the lysosome). Details of the SMART-Ig Recycling® system have been described by Fukuzawa et al., Sci Rep. (2017), Vol.7(1): 1080; doi:10.1038/s41598-017-01087-7. Model parameters were estimated using a nonlinear mixed-effects approach using data collected in the COMPOSER study. To develop the model, we used total crovalimab, total C5 and 8 SEC fractions, where DTDCs are detected according to their molecular weight. The assessment of model adequacy was satisfactory for simulation purposes. This model was calibrated using eculizumab concentrations at the time of switch, time profiles of total Crovaliab levels, total C5 concentrations, and chromatography-based measurements of DTDC size distribution obtained from the phase I/II COMPOSER study (see Röth et al., Blood (2020) , Vol., 135, pp. 912-920; doi: 10.1182/blood.2019003399).

3.3 Dose determination for phase III

Parallel application of both the population pharmacokinetic model and the biochemical DTDC model provided identification of a fixed dose and dosing regimen that (1) minimizes the formation of large DTDCs in patients switching from eculizumab to crovalimab, (2) maximizes the level of unoccupied crovalimab binding sites, and (3 ) ensures that patients remain above the target threshold concentration required for terminal complement inhibition (target C _through above approximately 100 μg/mL of crovalimab), despite the inherent variability between individuals.

Based on its mechanism of action, crovalimab inhibits complement-mediated lysis of red blood cells lacking complement regulatory proteins. If the terminal complement pathway is not temporarily blocked during the treatment interval, these red blood cells will be lysed and this may lead to breakthrough hemolysis, which is a severe clinical complication in patients with PNH. Biological stress (infection, surgery, pregnancy) leads to physiological activation of the complement pathway with up-regulation of C5 (Schutte et al., Int Arch Allergy Appl Immunol (1975), Vol. 48(5), pp. 706-720.). In patients with PNH, it is therefore important not only to maintain complete blockade of terminal complement activity through dosing intervals, but also to maintain a reserve of free crovalimab binding sites to minimize the occurrence of breakthrough hemolysis.

Available pharmacokinetics (PK) and pharmacodynamics (PD) data from parts 1, 2 and 3 from the COMPOSER study were integrated to provide characterization of the PK/PD relationship of crovalimab after i.v. and s.c. administration and to identify the levels of exposure required to completely inhibit the activity of the terminal complement system. By pooling PK and PD data from 9 healthy volunteers in Part 1, 10 PNH patients in Part 2, and 16 PNH patients in Part 3, crovalimab was shown to induce a concentration-dependent inhibition of serum hemolytic activity when measured by an ex vivo liposome immunoassay ( LIA). Evaluation of the exposure-response relationship demonstrates that approximately 100 μg/ml of crovalimab is required to achieve complete terminal complement inhibition, defined as hemolytic activity less than 10 U/ml (see Fig. 1).

In the population PK model, body weight was analyzed as an independent variable for crovalimab clearance and volume of distribution and was found to statistically influence these parameters when included using allometric scaling. As a consequence, for a given dose, larger patients tend to have less exposure to be underexposed compared to smaller patients. To account for compensation for the effect of body weight, a tiered weight-based dosing approach is proposed to ensure that all patients receiving it achieve comparable exposure to crovalimab across the dosing interval.

The following two dosing regimens have been identified:

• For patients weighing more than 40 kg but less than 100 kg

Loading doses: 1000 mg crovalimab administered intravenously (IV) on day 1, followed by 340 mg crovalimab administered subcutaneously (SC) on days 2, 8, 15 and 22.

Maintenance doses: 680 mg crovalimab SC on day 29, followed by subcutaneous administration of 680 mg crovalimab SC once every 4 weeks (Q4W) thereafter.

• For patients with body weight greater than or equal to 100 kg

Loading doses: 1500 mg crovalimab i.v. on day 1, followed by 340 mg crovalimab subcutaneously on days 2, 8, 15 and 22.

Maintenance doses: 1020 mg crovalimab SC on day 29, followed by subcutaneous administration of 1020 mg crovalimab SC once every 4 weeks (Q4W) thereafter.

Example 4: DTDC Model Simulation Results

Simulations conducted from this model were aimed at identifying a dose and dosing regimen that minimizes the formation of large DTDCs in patients switching from eculizumab to crovalimab, and ensuring sufficient reserves of free crovalimab binding sites in patients switching from eculizumab or untreated patients with PNH . The latter criterion provides an objective assessment of the margin of hemolysis control provided by a dosing regimen for protection against breakthrough hemolysis. Simulations were performed using only parameter estimates from patients in COMPOSER Part 3 who switched from eculizumab to crovalimab. A dosing regimen that provides sufficient reserve of free crovalimab epitopes in patients pretreated with eculizumab is also suitable for the treatment of treatment-naïve patients. As shown in FIG. 2 and Fig. 3, it is expected that the above dosing regimens will maximize the availability of free epitopes while minimizing the formation of the largest DTDCs.

Example 5: Population Pharmacokinetic Model Simulation Results

Simulations were performed from a population PK model to recommend dose and dosing regimens to ensure rapid establishment of steady-state concentrations and to maintain trough concentrations above 100 mcg/mL in the majority of patients throughout the dosing interval, both treatment-naive and eculizumab-pretreated patients with PNH.

Crovalimab concentration profiles versus time were simulated for 20,000 untreated PNH patients and 20,000 PNH patients who switched treatment from eculizumab to crovalimab, with a median body weight of 75.6 kg (standard deviation plus/minus 20.3; c 42.2 kg and 109.0 kg at the 5th and 95th percentiles, respectively). The simulations accounted for the age effect with 50% of the simulated population being under 50 years of age and 50% of the simulated population being over 50 years of age. The selection of body weight distribution is based on the observed distribution in the COMPOSER study.

Based on the simulation results (Figure 4), it is predicted that the above dosages and treatment schedule will result in rapid establishment of steady-state concentrations and maintained C _trough values greater than 100 μg/mL in approximately 95% of individuals throughout the dosing interval, regardless of body weight. This dosing regimen is predicted to maintain concentrations above 100 mcg/mL in both untreated patients and patients switching from eculizumab, despite the observed transient increase in crovalimab clearance and the resulting longer time to reach steady-state concentrations in the latter.

The dose and dosing schedule proposed above are expected to provide complete and sustained blockade of terminal complement activity (maintained above the target threshold in approximately 95% of patients) and also provide a sufficient reserve of free binding sites for the majority of the dosing interval in both untreated and untreated patients. in eculizumab-pretreated patients. It is also expected that large DTDC formation will be reduced in patients switching from eculizumab. The above dosages were confirmed in Part 4 of the COMPOSER study in seven patients switching from eculizumab to crovalimab. Part 4 assessed the safety, pharmacokinetics (PK) and pharmacodynamics (PD) effects of the above optimized crovalimab regimen in 15 patients (cut-off date January 29, 2020) with PNH who had not received anti-C5 antibody therapy (8 patients (53 %)), or who had previously been treated with the anti-C5 antibody eculizumab (7 patients (47%)). Baseline characteristics of patients enrolled in Part 4 of the COMPOSER study are shown in Fig. 6. The most appropriate dosage to reduce persistence of DTDC, particularly large DTDC, consisted of a series of loading doses (1000 mg crovalimab administered intravenously (IV) on day 1, followed by 340 mg crovalimab administered subcutaneously (SC). .) on days 2, 8, 15 and 22), followed by maintenance dosing (680 mg crovalimab SC on day 29, followed by subcutaneous administration of 680 mg crovalimab SC once every 4 weeks (Q4W) thereafter) . COMPOSER Part 4 data confirmed that the DTDC size distribution shifted to smaller complexes using the reported optimized dosing schedule. Further results regarding the crovalimab dose and schedule described above (1000 mg crovalimab administered intravenously (IV) on day 1, followed by 340 mg crovalimab administered subcutaneously (SC) on days 2, 8, 15 and 22), followed by maintenance dosing (680 mg crovalimab SC on day 29, followed by subcutaneous administration of 680 mg crovalimab SC once every 4 weeks (Q4W) thereafter) are shown in FIG. 7-11.

As shown in FIG. 7, with this optimized dosing regimen, crovalimab exposure was consistently maintained above the C _through approximately 100 μg/mL (a level associated with complement inhibition) throughout the 20-week follow-up period (140 days).

In addition, terminal complement inhibition was achieved immediately after the initial dose and was maintained throughout the study period (see Fig. 8).

In addition, limited overall accumulation of C5 was observed in patients with PNH who did not receive anti-C5 antibody therapy (8 patients; Fig. 9(A)), and a decrease in C5 levels was observed in switched patients (patients with PNH who were previously treated with anti-C5 antibody). C5 eculizumab (7 patients; Fig. 9(B)) In addition, Fig. 10 describes that intravascular hemolysis was controlled, the majority of patients had stable hemoglobin levels and avoided blood transfusion: only 10 (67%) patients, including. 5 of 8 untreated patients and 5 of 7 switched patients achieved hemoglobin stabilization (avoiding a greater than or equal to 2 g/dL decrease in hemoglobin level from baseline in the absence of blood transfusion) at week 20. From baseline to week 20 11 (73%) patients, including 5 of 8 untreated patients and 6 of 7 switched patients, were transfusion-free. Over 7.2 total years of patient exposure, no patients experienced breakthrough hemolysis events (BTH). as defined in Kulasekararaj et al., Blood (2019), Vol. 33, pp. 540-549.

In addition, the above dose and treatment regimen of the anti-C5 antibody crovalimab was found to be well tolerated, and no serious treatment-related adverse events (AEs) were observed (see FIG. 11).

In summary, the modeling approach described herein demonstrates that the claimed dosing regimen is superior for the treatment or prevention of C5-related disease such as PNH in both untreated and, in particular, eculizumab-pretreated subjects.

Example 6: Results of comparison of DTDC size distribution between Part 3 and Part 4 of the COMPOSER Study

In COMPOSER Part 3, drug-target-drug complexes (DTDCs) between crovalimab, human C5, and the antibody eculizumab were identified in all patients with PNH who switched from the anti-C5 antibody eculizumab to crovalimab. The purpose of this example is to describe the results of a comparison of the DTDC size distribution between the Part 3 and Part 4 dosing regimens of the COMPOSER study. In Part 3 of the COMPOSER study, the anti-C5 antibody crovalimab is administered initially to subjects intravenously at a dose of 1000 mg/body. Starting one week after the initial intravenous administration (day 8 after IV administration), the anti-C5 antibody crovalimab is administered subcutaneously (s.c.) once every week at a dose of 170 mg/body, once every two weeks at a dose of 340 mg/body or once every four weeks at a dose of 680 mg/body. In Part 4 of the COMPOSER study, crovalimab was administered according to the above dosing and treatment schedule: the data optimized dose and schedule were a series of loading doses of 1000 mg on day 1 and 340 mg sc on days 2, 8, 15 and 22, followed by maintenance dosing 680 mg SC every 4 weeks, starting from day 29 (week 5). Loading dose series increased the total dose of crovalimab received during the first month of treatment, with a decrease in the formation of large DTDCs, consistent with the lattice theory of complex formation. This optimized dosing strategy was studied in part 4 in patients who switched treatments and compared with the 19 patients with PNH who were enrolled in part 3 and switched from eculizumab to crovalimab. DTDC size distributions were measured using size exclusion filtration (SEC) coupled to ELISA. SEC divided DTDCs into fractions according to their size: large DTDCs are in fractions 1–4, and smaller complexes such as single motifs and non-DTDCs are in fractions 5–6. DTDCs were observed in all patients from part 3 (Figure 12; large DTDCs are in fractions 1-4, and smaller complexes such as single motifs and non-DTDCs are in fractions 5-6). Two patients from part 3 experienced clinical manifestations comparable to type III hypersensitivity reactions that were attributed to DTDC. The DTDC size distribution in patients in Part 4 who received the optimized dosing strategy changed differently than in patients in Part 3, as predicted by the model. In patients who switched from part 4 (n = 7; cut-off date January 29, 2020), the amount of DTDC in fractions 1-4 began to decrease on day 8 and continued to decrease, in contrast to part 3. On day 22, the average percentage of the largest DTDC decreased by 56% in patients in part 4 relative to patients in part 3. In addition, serum concentrations of crovalimab remained above 100 mcg/mL for patients in part 4, at a level associated with complement inhibition. Although DTDCs were observed in all part 4 patients who switched from eculizumab, no adverse events suggestive of a type III hypersensitivity reaction occurred. In conclusion, the optimized regimen with crovalimab resulted in lower concentrations of large DTDCs than in patients who received the part 3 regimen.

Case Study 7: Response Results to Crovalimab in PNH Patients with C5 Polymorphism

Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by the loss of endogenous complement regulators CD59 and CD55 on hematopoietic cells. Peripheral blood elements are sensitive to destruction by complement, leading to intravascular hemolysis and thrombosis. Standard therapy is terminal complement inhibition with eculizumab, an anti-C5 monoclonal antibody (mAb). However, up to 3.5% of individuals of Asian descent carry polymorphisms in C5 affecting Arg885, which corresponds to the binding site of eculizumab and ravulizumab (see Nishimura et al., N Engl J Med, Vol. 370, pp. 632-639 (2014 ); DOI: 10.1056/NEJMoa1311084). PNH patients with these polymorphisms experience poor control of intravascular hemolysis with eculizumab, thus constituting a group with a large unmet medical need. Crovalimab is a novel anti-C5 mAb (monoclonal antibody) that binds to a distinct epitope on the C5 beta subunit. In vitro studies demonstrated that crovalimab binds and inhibits the activity of wild-type and Arg885 mutant C5 equally (Fukuzawa et al., Sci Rep, 7(1): 1080. doi: 10.1038/s41598-017-01087-7 (2017) ).

Objectives: The purpose of this case study is to describe the response to crovalimab in PNH patients with the C5 polymorphism.

Methods: the above dose and regimen of crovalimab (1000 mg crovalimab administered intravenously (IV) on day 1, followed by 340 mg administered subcutaneously (SC) on days 2, 8, 15 and 22), with subsequent maintenance dosing (680 mg crovalimab SC on day 29, followed by subcutaneous 680 mg crovalimab SC once every 4 weeks (Q4W) thereafter) was administered to patients with PNH with the C5 polymorphism (Arg885 C5 mutation (SEQ ID NO: 13)). Plasma concentrations of crovalimab, lactate dehydrogenase (LDH), free and total C5, and complement activity were determined at each visit. Patients were monitored for blood transfusions, breakthrough hemolysis events (BIEs), and safety.

Results: Of 44 patients enrolled in Part 2 (n = 10), Part 3 (n = 19), and Part 4 (n = 15) of the COMPOSER study (ClinicalTrials.gov identifier: NCT03157635), four had the c.2654G- nucleotide polymorphism >A, predicting the Arg885His substitution. At the cut-off date of September 2019, follow-up ranged from 12.4 to 98.3 weeks. All four patients were male, diagnosed 44 to 734 weeks prior to enrollment, with PNH granulocyte clone sizes ranging from 89 to 95%. At enrollment, one patient switched from ongoing eculizumab therapy, whereas three had previously discontinued eculizumab treatment. All patients had an LDH level of 3 times the upper limit of normal (ULN) at enrollment, which fell rapidly and was maintained at less than 1.5× ULN throughout the follow-up period (Figure 13). One patient required transfusions after enrollment (12 units of red blood cells (RBC) over 6 months); this patient had an underlying diagnosis of aplastic anemia and required 198 RBC units in the 12 months prior to enrollment. None of the four patients experienced breakthrough hemolysis (BH) events. All four patients achieved complete inhibition of terminal complement when measured by liposome immunoassay (LIA). LIA levels ranged from 32 to 42 U/mL at study entry, fell to less than 10 U/mL (the low end of the quantitation) by day 2, and were then maintained. Likewise, free C5 was maintained at less than 0.5 μg/ml after week 6 (day 43). The safety profile of these patients was similar for the remaining participants. Three serious adverse events (SAEs) were reported, none of which were related to the study treatment. One patient had two SAEs: bile duct stones and cholelithiasis. The second patient had an SAE of an upper respiratory tract infection with hospitalization that occurred after 20 months and ended while on treatment.

Conclusions: Crovalimab achieved complete and sustained inhibition of terminal complement in PNH patients with Arg885 polymorphism. Thus, crovalimab represents a promising anti-C5 antibody for the treatment and/or prevention of patients suffering from PNH, where these patients are distinguished by the presence of the C5 Arg885His mutation.

Claims (15)

1. A method of treating or preventing a C5-related disease in a subject, the method being carried out by the following steps of administration: (i) intravenously administering a loading dose of 1000 mg of anti-C5 antibody to the subject once; (ii) subcutaneous administration of a loading dose of 340 mg of anti-C5 antibody to the subject 1 day after the start of intravenous administration of anti-C5 antibody; (iii) subcutaneous administration of a loading dose of 340 mg of anti-C5 antibody to the subject at 1 week, 2 weeks and 3 weeks after the start of intravenous administration of anti-C5 antibody once a week; (iv) administering subcutaneously a maintenance dose of 680 mg of anti-C5 antibody to the subject 4 weeks after initiation of intravenous administration of anti-C5 antibody; And (v) repeating stage (iv) several times at 4 week intervals, wherein said anti-C5 antibody is crovalimab and said C5 disease is paroxysmal nocturnal hemoglobinuria (PNH). 2. The method of claim 1, wherein the subject has received prior treatment with at least one pharmacological product useful for the treatment or prevention of a C5-related disease, wherein an intravenous loading dose of 1000 mg of anti-C5 antibody is administered to the subject after the last dose of the pharmacological product. 3. The method according to claim 2, wherein an intravenous loading dose of 1000 mg of anti-C5 antibody is administered to the subject on the third day or 3 days after administration of the last dose of the pharmacological product. 4. The method according to claim 2 or 3, wherein said pharmacological product contains a siRNA targeting C5 mRNA or an anti-C5 antibody that is different from the anti-C5 antibody contained in the composition for subcutaneous or intravenous injection. 5. Method according to any one of paragraphs. 2-4, where the specified pharmacological product contains eculizumab, ravulizumab or variants thereof. 6. Method according to any one of paragraphs. 1-5, wherein said subject has a body weight of from 40 to 100 kg. 7. Method according to any one of paragraphs. 1-6, wherein the concentration of the anti-C5 antibody determined in the biological sample of the specified subject is 100 μg/ml or more. 8. Method according to any one of paragraphs. 1-6, where the hemolytic activity determined in the biological sample of the specified subject is less than 10 U/ml. 9. The method according to claim 7 or 8, wherein said biological sample is a blood sample, preferably a red blood sample.