TW202448505A - Methods and compositions for treating type 1 diabetes - Google Patents

Abstract

Provided herein are methods and compositions for treating type 1 diabetes. In some embodiments, such method includes administering to a subject in need thereof a 12-day to 14-day course of teplizumab at a total dose of from about 9000 [mu]g/m2 to about 14000 [mu]g/m2 and administering an effective amount of verapamil.

Description

Methods and compositions for treating type 1 diabetes

Cross-references to related applications

This application claims priority to U.S. Provisional Application No. 63/487,856 filed on March 1, 2023, the disclosure of which is incorporated herein by reference in its entirety. Sequence Listing

This application contains a sequence listing submitted electronically in XML format and incorporated herein by reference in its entirety. The XML file was created on February 28, 2024, named 122548_TW059.xml, and is 3,398 bytes in size.

The present disclosure generally relates to methods and compositions for treating type 1 diabetes (T1D) in a subject in need thereof.

Type 1 diabetes (T1D) is caused by autoimmune destruction of insulin-producing beta cells in the islets of Langerhans, resulting in dependence on exogenous insulin injections. Approximately 1.6 million Americans have T1D, one of the most common childhood diseases after asthma. Despite improvements in care, most people with T1D are unable to consistently achieve their desired glycemic goals. Increased risk of morbidity and mortality is a continuing concern for people with T1D. Two recent studies have shown that children diagnosed before age 10 have a 17.7-year shortened life expectancy; Scottish men and women diagnosed as adults have a 11-year and 13-year shortened life expectancy, respectively. Therefore, there remains a pressing need for improved T1D treatments and compositions.

In one aspect, the present disclosure provides a method for treating clinical T1D or delaying the progression of stage 2 T1D to clinical stage 3 T1D, the method comprising administering a 12- to 14-day course of teplizumab to a subject in need thereof, at a total dose of about 9000 μg/m ² to about 14000 μg/m ² (e.g., by intravenous (IV) infusion) and administering an effective amount of a beta cell targeting agent, such as verapamil, to the subject. In some embodiments, the total dose of teplizumab is between about 9000 and about 9500 μg/m ² .

In some embodiments, verapamil can be administered in a dose of about 100 mg to about 480 mg per day (e.g., oral or IV dose). In some embodiments, verapamil can be administered in a dose of about 300 to about 400 mg per day. In some embodiments, verapamil can be administered in a dose of about 360 mg per day. In some embodiments, verapamil can be administered in a slow release form.

In some embodiments, the total dose of telizumab is between about 9000 and about 9500 μg/m ² , or higher. In some embodiments, the cumulative dose of telizumab is about 11,240 μg/m ² .

In some embodiments, a 12-day course of teligrum (e.g., by IV infusion) includes a first dose of 106 μg/m ² of teligrum on day 1, a second dose of 425 μg/m ² of teligrum on day 2, and a dose of 850 μg/m ² each day on days 3 to 12, wherein the total dose is approximately 9031 μg/m ² .

In some embodiments, a 12-day course of teligrum (e.g., by IV infusion) includes a first dose of 211 μg/m ² of teligrum on day 1, a second dose of 423 μg/m ² of teligrum on day 2, and a dose of 840 μg/m ² each day on days 3 to 12, for a total dose of approximately 9034 μg/m ² .

In some embodiments, a 14-day course of tilizumab (e.g., by IV infusion) includes about 60 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,000 μg/m ² each day on days 5 to 14.

In some embodiments, a 14-day course of tilizumab (e.g., by IV infusion) includes about 60 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,030 μg/m ² each day on days 5 to 14.

In some embodiments, a 14-day course of tilizumab (e.g., by IV infusion) includes about 65 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,030 μg/m ² each day on days 5 to 14.

In some embodiments, a 14-day course of tilizumab (e.g., by IV infusion) includes about 100 μg/m ² on day 1, about 425 μg/m ² on day 2, about 850 μg/m ² on day 3, about 850 μg/m ² on day 4, and about 1,000 μg/m ² each day on days 5 to 14.

In some embodiments, a 14-day course of tilizumab (e.g., by IV infusion) includes about 65 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,070 μg/m ² each day on days 5 to 14.

In some embodiments, a 14-day course of tilizumab (e.g., by IV infusion) includes about 65 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,370 μg/m ² each day on days 5 to 14.

In some embodiments, one or more additional courses of tillizumab are administered to the subject, for example, with the same regimen as the first course of tillizumab. The interval between courses may be about 1 to 6 months (e.g., 1, 2, 3, 4, 5, or 6 months), about 7 to 12 months (e.g., 7, 8, 9, 10, 11, or 12 months), about 13 to 24 months (e.g., 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 months), or longer.

In some embodiments, the method can include administering a first and a second 12-day course of tilizumab. In some embodiments, the first and second 12-day courses are administered at intervals of about 1 to 6 months, about 2 to 5 months, or about 3 months.

In some embodiments, the method may include administering a third or more 12-day or 14-day course of teligrumab to a subject in need thereof, with the total dose of each course exceeding about 9000 μg/m ² , and optionally not exceeding 14000 μg/m ² .

In some embodiments, a third or more 12-day course of tilpizumab includes a first dose of 106 μg/m ² of tilpizumab on day 1, a second dose of 425 μg/m ² of tilpizumab on day 2, and a dose of 850 μg/m ² each day on days 3 to 12, wherein the total dose per course is about 9031 μg/m ² .

In some embodiments, a third or more 12-day course of tilpizumab includes a first dose of 211 μg/m ² of tilpizumab on day 1, a second dose of 423 μg/m ² of tilpizumab on day 2, and a dose of 840 μg/m ² each day on days 3 to 12, wherein the total dose per course is approximately 9034 μg/m ² .

In some embodiments, a third or more 12-day courses of telizumab are administered at intervals of about 12 months to about 24 months.

In some embodiments, the method may further include determining the level of TIGIT+KLRG1+CD8+ T cells relative to the baseline of all CD3+ T cells about 3 months after administration, monitoring the level of TIGIT+KLRG1+CD8+CD3+ T cells, and administering an additional 12 or 14 day course of tilizumab when the level of TIGIT+KLRG1+CD8+CD3+ T cells returns to the baseline level. In some embodiments, TIGIT+KLRG1+CD8+CD3+ T cells are measured by flow cytometry. In some embodiments, if the subject has more than about 10% TIGIT+KLRG1+CD8+ T cells among all CD3+ T cells, follow-up monitoring is performed annually. In some embodiments, if the subject has less than about 10% TIGIT+KLRG1+CD8+ T cells among all CD8+ T cells, follow-up monitoring is performed approximately every 3 to 6 months.

In some embodiments, the administering step results in at least a 10% decrease in insulin usage, HbA1c levels, hypoglycemic episodes, or a combination thereof, compared to pre-treatment levels.

In some embodiments, each dose of tilimumab is administered parenterally.

In some embodiments, each dose of teligrumumab is administered by intravenous infusion.

In some embodiments, the subject in need thereof is about 8 to 17 years old, or an adult (18 years or older). In some embodiments, the subject is in clinical stage 3 of T1D. In further embodiments, the subject has new-onset T1D, e.g., within 12 weeks of T1D diagnosis (e.g., within 8 or 6 weeks). In some embodiments, the subject does not yet have clinical diabetes and is in stage 2 of T1D.

In some embodiments, an effective amount of verapamil is administered orally, intraperitoneally, subcutaneously, or by intravenous infusion.

In some embodiments, the subject in need thereof has a peak C-peptide level ≥ 0.2 pmol/mL during a mixed meal tolerance test (MMTT).

In some embodiments, subjects receiving tilimumab have higher mean C-peptide values after treatment compared to controls receiving placebo.

In some embodiments, the method further comprises assessing the area under the time-concentration curve (AUC) of C-peptide at 78 weeks following a mixed meal tolerance test (MMTT).

In some embodiments, the subject in need thereof has at least 20% beta cell function prior to administration of telizumab and verapamil.

In some embodiments, the reduction in insulin use, HbA1c levels, hypoglycemic episodes, or a combination thereof is sustained for 12 months or longer.

The present disclosure also provides tilizumab and verapamil for use in the present treatment method, and the use of tilizumab or verapamil in the preparation of a medicament for use in the present treatment method.

T1D typically develops during childhood and adolescence; however, it can also present in the fifth and sixth decades of adulthood, albeit with much lower frequency (Atkinson 2014, Bluestone 2010, Streisand 2014). In addition to being more susceptible to a number of short- and long-term complications, there are differences in the clinical course and response to immunotherapy between children/younger adults and the elderly. Children and adolescents often present with severe symptoms of diabetes (including thirst, polyuria, and weight loss) in the days or weeks before the initial diagnosis, which can lead to clinical manifestations of DKA and shock requiring hospitalization (Atkinson 2014, Bluestone 2010, Streisand 2014, Mittermayer 2017). Children and young adults with new-onset T1D often require exogenous insulin urgently.

This is in stark contrast to the experience of adults who develop T1D, who often have months or years of nonspecific symptoms or are asymptomatic on routine blood glucose screening. Such individuals can usually be managed long-term (months or years) with diet or oral glucose-lowering medications before insulin is clearly needed. More definitive research shows that the rate of beta cell decline varies with age (Greenbaum 2012; Ludvigsson 2013). After decades of research, the Diabetes TrialNet network concluded that “age is the most important factor affecting the rate of postdiagnostic C-peptide decline,” as children and adolescents have significantly faster rates of decline compared with younger and older adults with new-onset disease. This more rapid decline appears to be due to the more virulent and aggressive autoimmune processes in children compared to adults, ostensibly supporting important differences in the immune etiology of T1D in younger and older adults (Greenbaum 2012, Campbell-Thompson 2016). Given these fundamental differences, it is reasonable to expect that adults and children may respond differently to immune-based disease-modifying therapies. In other words, a treatment may be very effective in children but completely ineffective in adults, and vice versa (Rigby 2014).

Children and adolescents are at the highest risk for disease and have the highest short- and long-term morbidity and mortality, and therefore this group stands to benefit the most from disease-modifying therapies (Wherrett 2015). This was recently confirmed by a large study showing that individuals diagnosed with T1D during childhood and adolescence had a 4- to 6-fold increased lifetime risk of mortality, including a 7-fold increased risk of cardiovascular disease mortality, compared with their peers without T1D. This mortality risk is in stark contrast to individuals diagnosed with T1D as adults, who have an approximately 3-fold increased risk of all-cause and cardiovascular disease-related mortality compared with otherwise healthy peers (Rawshani 2017, Rawshani 2018). Recent reports indicate that patients with T1D have a life expectancy of approximately 11-13 years less than otherwise healthy age-matched individuals (Lind 2014, Huo 2016). Although the goal of T1D research is to reduce morbidity and mortality in all patients with T1D, it is clear that the most pressing need is for patients with T1D who develop during childhood and adolescence.

Therefore, there is a need to develop a therapy for children who are most likely to benefit from it. This therapy also benefits adolescents and adults with T1D.

T1D is characterized by the destruction of most insulin-producing beta cells by an autoimmune response. Patients with T1D have residual beta cells, but these cells do not thrive due to the autoimmune disease, which destroys them as they proliferate. There are 4 stages of T1D: Stage 1 - multiple (at least 2) islet antibodies, normal blood sugar, pre-symptomatic; Stage 2 - multiple islet antibodies, elevated blood sugar, pre-symptomatic; Stage 3 - islet autoimmunity, elevated blood sugar, symptomatic; Stage 4 - long-standing type 1 diabetes. In some aspects of the disclosure, the method results in the regeneration of beta cells.

Various aspects of the present disclosure relate to methods of treating T1D in a subject in need thereof. Provided herein are methods of preserving beta cell function, regenerating beta cells/increasing pancreatic beta cell proliferation, and/or improving the clinical management of T1D in a subject in need thereof, compared to the natural course of the disease and current standard of care including exogenous insulin therapy. Preservation and/or improvement of beta cell function is expected to translate into clinical and/or metabolic benefits, consistent with an improved ability to maintain glycemic control and short-term and/or long-term outcomes.

Various aspects of the present disclosure relate to combination therapies for treating T1D. In some embodiments, a method of treating T1D comprises administering to a subject in need thereof an effective amount of one or more anti-CD3 antibodies in combination with an effective amount of verapamil.

In some embodiments, the method comprises administering to a subject in need thereof a combination therapy comprising a course of anti-CD3 antibody therapy and a course of verapamil therapy to induce immune tolerance to regenerative beta cells in a T1D patient. In some embodiments, the anti-CD3 antibody comprises or consists of otelixizumab. In some embodiments, the anti-CD3 antibody can be ChAglyCD3 (otelixizumab), visilizumab, or foralumab.

In some embodiments, the course of treatment with the anti-CD3 antibody is 8 to 16 days. In some embodiments, the course of treatment with the anti-CD3 antibody is 12 days (see U.S. application No. 63/192,402, filed on May 24, 2021, which is incorporated herein by reference in its entirety). In some embodiments, the method comprises administering to a subject in need thereof a first course of daily doses of tilezumab for 12 days, and a second course of daily doses of tilezumab for 12 consecutive days, wherein the first course and the second course are separated by 6 months.

In some embodiments, the anti-CD3 antibody is teliguzumab.

In some embodiments, the method comprises administering to a subject in need thereof a combination therapy comprising a 12-day course of anti-CD3 antibody therapy and a course of verapamil therapy to induce immune tolerance to regenerative beta cells in T1D patients. In some embodiments, the anti-CD3 antibody comprises or consists of tilizumab. In some embodiments, the anti-CD3 agent is not tilizumab. In some embodiments, the anti-CD3 antibody can be ChAglyCD3 (Oxizumab), Visilizumab, or Forasunomab.

In some embodiments, the method comprises diagnosing a patient with T1D. In some embodiments, the patient is in stage 2 (pre-symptomatic), stage 3 (newly diagnosed), or stage 4 (established disease).

In some embodiments, the patient has other variants of autoimmune diabetes: LADA, type 2 diabetes with autoimmune features (evidenced by at least 1 T1D AA), stage 1 with a single high-affinity AA, post-viral diabetes, post-checkpoint inhibitor diabetes, or post-gestational diabetes T1D.

In some embodiments, the method comprises determining the presence of residual beta cell mass by: (1) an oral-glucose-tolerance test (OGTT, 2-hour or 4-hour test) prior to treatment, (2) demonstration of detectable C-peptide prior to treatment, or a combination thereof. In some embodiments, the subject in need thereof has at least 20% beta cell function prior to administration of the combination therapy.

In some embodiments, the method comprises administering to the patient a first course of daily doses of tilpizumab for 12 days and a second course of daily doses of tilpizumab for 12 days within 6 weeks after diagnosis, wherein the first course and the second course are separated by 6 months.

In some embodiments, the method further comprises assessing the area under the time-concentration curve (AUC) of C-peptide at 78 weeks (18 months or 1.5 years) after a mixed meal tolerance test (MMTT), and/or assessing clinical endpoints such as insulin use, HbA1c levels, and hypoglycemic episodes.

In some embodiments, the method comprises diagnosing a patient with T1D, administering to the patient (e.g., within 6 weeks after diagnosis) a first course of a daily dose of tilizumab for 12 days, and a second course of a daily dose of tilizumab for 12 days, wherein the first course and the second course are separated by 6 months. In some embodiments, the method further comprises assessing the area under the time-concentration curve (AUC) of C-peptide at 78 weeks (18 months or 1.5 years) after a mixed meal tolerance test (MMTT), and/or assessing clinical endpoints, such as insulin use, HbA1c levels, and hypoglycemic episodes. Definition

Certain terms are defined below. Additional definitions are provided throughout this application.

As used herein, the articles "a" and "an" refer to one or more, e.g., at least one, of the grammatical object of the article. When used with the term "comprising" herein, the use of the words "a" and "an" may mean "one", but it is also consistent with the meaning of "one or more", "at least one", and "more than one".

As used herein, "about" and "approximately" generally refer to an acceptable degree of error in a measurement given the quality or precision of the measurement. Exemplary degrees of error are within 20 percent (%) of a given value range, typically within 10%, and more typically within 5%. The term "substantially" means greater than 50%, preferably greater than 80%, and most preferably greater than 90% or 95%.

As used herein, the term "comprising" or "comprises" refers to compositions, methods and their respective components that are present in a given embodiment but may include unspecified elements.

As used herein, the term "consisting essentially of" refers to those elements required for a given embodiment. The term permits the presence of additional elements that do not materially affect the basic and novel or functional characteristics of the embodiment of the present disclosure.

The term "consisting of" refers to the compositions, methods, and their respective components described herein, which do not include any elements not mentioned in the description of the embodiment.

The term "antibody" herein is used in the broadest sense and includes various antibody structures, including but not limited to monoclonal antibodies, polyclonal antibodies, multispecific antibodies (e.g., bispecific antibodies) and antibody fragments, as long as they exhibit the desired antigen-binding activity.

"Antibody fragment" refers to a molecule other than an intact antibody, which comprises a portion of an intact antibody that binds to an antigen that the intact antibody binds to. Examples of antibody fragments include, but are not limited to, Fv, Fab, Fab', Fab'-SH, F(ab') ₂ ; diabodies; linear antibodies; single-chain antibody molecules (e.g., scFv); and multispecific antibodies formed from antibody fragments.

As used herein, the term "onset" with respect to T1D refers to patients who meet the criteria established by the American Diabetes Association for the diagnosis of T1D (see, Mayfield et al., 1998, Am. Fam. Physician 58:1355-1362).

As used herein, "regimen" includes both dosing schedules and dosing regimens. Regimens herein are methods of use and include treatment regimens. A "dosing regimen," "dosage regimen," or "course of treatment" may include administration of multiple doses of a therapeutic agent over 1 to 20 days.

As used herein, the terms "subject" and "patient" are used interchangeably. As used herein, the term "subject" refers to an animal, preferably a mammal, including non-primates (e.g., cows, pigs, horses, cats, dogs, rats, and mice) and primates (e.g., monkeys or humans), more preferably humans. In some embodiments, the patient population includes children. In some embodiments, the patient population includes children newly diagnosed with T1D. In some embodiments, the patient population receives treatment within 6 weeks of T1D diagnosis. In some embodiments, the patient population includes children who are positive for at least one T1D-associated autoantibody at screening and have a peak stimulated C-peptide of ≥ 0.2 pmol/mL.

As used herein, the term "child" (and variations thereof) includes children between about 8 and 17 years of age.

As used herein, the terms "effective amount" and "therapeutically effective amount" are used interchangeably and refer to an amount of an active agent sufficient to treat T1D. For example, an effective amount of tilizumab is an amount of tilizumab sufficient to delay or prevent the development, recurrence, or attack of one or more symptoms of T1D. An effective amount of verapamil is an amount sufficient to protect beta cells.

As used herein, the terms "treat", "treatment" and "treating" refer to the improvement of one or more symptoms associated with T1D caused by the administration of one or more CD3 binding molecules and verapamil. In some embodiments, such terms refer to reducing the average number of hypoglycemic episodes in humans. In other embodiments, such terms refer to maintaining a reference level of C-peptide in peripheral blood.

In some embodiments, the effective amount reduces one or more T1D symptoms by at least 5%, at least 10%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, at least 50%, at least 55%, at least 60%, at least 65%, at least 70%, at least 75%, at least 80%, at least 85%, at least 90%, at least 95%, at least 96%, at least 97%, at least 98%, or at least 99%.

As used herein, the term "β cell regeneration" refers to at least partial restoration of normal β cell function by increasing the number of β cells secreting functional insulin and/or by restoring the normal function of β cells with impaired function.

As used herein, the terms "synergistic effect" and "synergistic" mean that the effect achieved by the compounds used together is greater than the sum of the effects produced by the compounds used alone, that is, greater than the effect predicted based on the two active ingredients taken alone.

Various aspects of the present disclosure are described in further detail below. Other definitions are listed in the specification. Anti -CD3 antibodies and pharmaceutical compositions containing anti- CD3 antibodies

The terms "anti-CD3 antibody" and "antibody that binds to CD3" refer to an antibody or antibody fragment that is capable of binding to CD3 with sufficient affinity such that the antibody can be used as a preventive, diagnostic and/or therapeutic agent targeting CD3. In some embodiments, the extent of binding of the anti-CD3 antibody to unrelated non-CD3 proteins is less than about 10% of the binding of the antibody to CD3, for example, as measured by radioimmunoassay (RIA). In some embodiments, the antibody binds to CD3 with a dissociation constant (Kd) of < 1 μM, < 100 nM, < 10 nM, < 1 nM, < 0.1 nM, < 0.01 nM, or < 0.001 nM (e.g., ^10-8 M or less, e.g., ^10-8 M to ^10-13 M, e.g., ^10-9 M to ^10-13 M). In some embodiments, the anti-CD3 antibody binds to an epitope of CD3 that is conserved in CD3 from different species.

In some embodiments, the anti-CD3 antibody can be ChAglyCD3 (Oxyzumab). Oxyzumab is a humanized Fc non-binding anti-CD3 that was initially evaluated by the Belgian Diabetes Registry (BDR) in a Phase 2 study, then developed by Tolerx, and then in collaboration with GSK in the Phase 3 DEFEND de novo T1D trial (NCT00678886, NCT01123083, NCT00763451). Oxyzumab is administered by IV infusion for 8 days. See, e.g., Wiczling et al., J Clin Pharmacol. (2010) 50(5):494-506; Keymeulen et al., N Engl J Med. (2005) 352:2598-608; Keymeulen et al., Diabetologia. (2010) 53:614-23; Hagopian et al., Diabetes. (2013) 62:3901-8; Aronson et al., Diabetes Care. (2014) 37:2746-54; Ambery et al., Diabet Med. (2014) 31:399-402; Bolt et al., Eur J Immunol. (1993) 23:403-411; Vlasakakis et al., Br J Clin Pharmacol. (2019) 85:704-14; Guglielmi et al., Expert Opinion on Biological Therapy (2016) 16(6):841-6; Keymeulen et al., N Engl J Med. (2005) 352:2598-608; Keymeulen et al., Blood (2010) 115(6):1145-55; Sprangers et al., Immunotherapy (2011) 3(11):1303-16; and Daifotis et al., Clinical Immunology (2013) 149:268-78; incorporated herein by reference.

In some embodiments, the anti-CD3 antibody can be Visilizumab (also known as HuM291; Nuvion). Visilizumab is a humanized anti-CD3 monoclonal antibody characterized by a mutant IgG2 isotype, lacking binding to Fcγ receptors, and capable of selectively inducing apoptosis in activated T cells. It has been evaluated in patients with graft-versus-host disease (NCT00720629; NCT00032279) and ulcerative colitis (NCT00267306) and Crohn's disease (NCT00267709). See, e.g., Sandborn et al., Gut (2010) 59(11):1485-92, incorporated herein by reference.

In some embodiments, the anti-CD3 antibody can be forlezumab (also known as TZLS-401). Forlezumab is a fully human monoclonal antibody that binds to CD3ε. (See U.S. Patent No. 10,688,186, incorporated by reference in its entirety.)

In some embodiments, the anti-CD3 antibody can be teliguzumab. Teliguzumab, also known as hOKT3yl(Ala-Ala) (containing alanine at positions 234 and 235), is an anti-CD3 antibody that is engineered to alter the function of T lymphocytes that mediate the destruction of insulin-producing beta cells of the pancreatic islets. Teliguzumab binds to an epitope of the CD3 epsilon chain expressed on mature T cells, thereby altering their function. Following teliguzumab treatment, circulating T cells (and other lymphocytes) are temporarily reduced in a process that may include marginalization and exhaustion (Long 2017, Sherry 2011). In addition to reducing the effector function of T cells, tilimumab appears to increase the number and function of regulatory T cells (Tregs) (Ablamunits 2010, Bisikirska 2005, Long 2017, Waldron-Lynch 2012). Recent studies have shown that tilimumab induces immune “exhaustion” in effector CD8+ T cell subsets, potentially making them more susceptible to regulation or deletion (Long 2016, Long 2017). Taken together, these mechanistic data suggest that tilizumab not only exerts an “inhibitory” effect on the β-cell immune destruction process, but is also an immune “modulator” that favors the rebalance of the effector and regulatory arms associated with T1D autoimmunity and supports the notion that tilizumab may have the ability to help reintroduce β-cell self-tolerance (Lebastchi 2013).

The sequence and composition of telizumab are disclosed in U.S. Patent Nos. 6,491,916; 8,663,634; and 9,056,906, each of which is incorporated herein by reference in its entirety. The molecular weight of telizumab is approximately 150 kD. The complete sequences of the light and heavy chains are shown below. The bolded portions are complementary determining regions. Tiletizumab light chain (SEQ ID NO: 1): DIQMTQSPSSSLSASVGDRVTITC SASSSVSYMN WYQQTPGKAPKRWIY DTSKLAS GVPSRFSGSGSGTDYTFTISSLQPEDIATYYC QQWSSNPFTF GQGTKLQITRTVAAPSVFIFPPSDEQLKSGTASVVCLLNNFYPREAKVQWKVDNALQSGNSQESVTEQDSKDSTYSLSSTLTLSKADYEKHKVYACEVTHQGLSSPVTKSFNRGEC Tiletizumab heavy chain (SEQ ID NO: 2): QVQLVQSGGGVVQPGRSLRLSCKASKASGYTFT RYTMH WVRQAPGKGLEWIG YINPSR GYTNYNQKVKD RFTISRDNSKNTAFLQMDSLRPEDTGVYFCAR YYDDHYCLDY WGQGTPVTVSSASTKGPSVFPLAPSSKSGGTAALGCLVKDYFPEPVTVSWNSGALTSGVHTFPAVLQSSGLYSLSSVVTVPSSSLGTQTYICNVNHKPSNTKVDKKVEPKSCDKTHTCPPCPAPEAAGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPEVKFN WYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSRDELTKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPGK

In some embodiments, a pharmaceutical composition is provided herein. Such a composition comprises an effective amount of an anti-CD3 antibody and a pharmaceutically acceptable carrier. In some embodiments, the term "pharmaceutically acceptable" refers to a composition approved by a regulatory agency of the U.S. federal or state government or listed in the U.S. Pharmacopeia or other generally recognized pharmacopeia for use in animals, particularly humans. The term "carrier" refers to a diluent, adjuvant (e.g., Freund's adjuvant (complete and incomplete)), excipient, or vehicle administered with a therapeutic agent. Such a pharmaceutical carrier can be a sterile liquid, such as water and oil, including liquids of petroleum, animal, plant, or synthetic origin, such as peanut oil, soybean oil, mineral oil, sesame oil, and the like. When the pharmaceutical composition is administered intravenously, water is a preferred carrier. Saline solutions and aqueous dextrose and glycerol solutions can also be employed as liquid carriers, particularly for injectable solutions. Suitable drug excipients include starch, glucose, lactose, sucrose, gelatin, malt, rice, flour, chalk, silica, sodium stearate, glyceryl monostearate, talc, sodium chloride, skimmed milk powder, glycerol, propylene, ethylene glycol, water, ethanol, and the like (see, e.g., Handbook of Pharmaceutical Excipients, Arthur H. Kibbe (ed., 2000, incorporated herein by reference in its entirety), Am. Pharmaceutical Association, Washington, D.C.).

If necessary, the composition may also contain a small amount of a wetting agent or emulsifier, or a pH buffer. Such compositions may be in the form of solutions, suspensions, emulsions, tablets, pills, capsules, powders, sustained-release preparations, and the like. Oral formulations may include standard carriers, such as pharmaceutical grade mannitol, lactose, starch, magnesium stearate, sodium saccharin, cellulose, magnesium carbonate, and the like. E. W. Martin describes examples of suitable pharmaceutical carriers in "Remington's Pharmaceutical Science". Such compositions contain a therapeutically effective amount of a therapeutic agent, preferably in a purified form, and an appropriate amount of a carrier to provide a form of appropriate administration to the patient. The formulation should be suitable for the mode of administration. In some embodiments, the pharmaceutical composition is sterile and in a suitable form for administration to a subject, preferably an animal subject, more preferably a mammalian subject, and most preferably a human subject.

In some embodiments, it may be desirable to administer the pharmaceutical composition locally to the area in need of treatment; this can be achieved, for example but not limited to, by local infusion, by injection, or by implants of porous, non-porous or gel-like materials, including membranes, such as salivary membranes or fibers. Preferably, when administering anti-CD3 antibodies, care must be taken to use materials that are not absorbed by the anti-CD3 antibodies.

In some embodiments, the composition can be delivered in a vesicle, particularly a liposome (see Langer, Science (1990) 249: 1527-33; Treat et al., in Liposomes in the Therapy of Infectious Disease and Cancer, Lopez-Berestein and Fidler (eds.), Liss, New York, pp. 353-365 (1989); Lopez-Berestein, supra, pp. 317-327; see generally supra).

In some embodiments, the composition can be delivered in a controlled release or sustained release system. In some embodiments, a pump can be used to achieve controlled release or sustained release (see Langer, supra; Sefton, 1987, CRC Crit. Ref. Biomed. Eng. 14:20; Buchwald et al., 1980, Surgery 88:507; Saudek et al., N Engl J Med. (1989) 321:574). In some embodiments, polymeric materials can be used to achieve controlled or sustained release of the antibodies or fragments thereof disclosed herein (see, e.g., Medical Applications of Controlled Release, Langer and Wise (eds.), CRC Press (CRC Pres.), Boca Raton, Fla. (1974); Controlled Drug Bioavailability, Drug Product Design and Performance, Smolen and Ball (eds.), Wiley, New York (1984); Ranger and Peppas, 1983, J., Macromol. Sci. Rev. Macromol. Chem. 23:61; see also Levy et al., 1985, Science 228:190; During et al., 1989, Ann. Neurol. 25:351; Howard et al., 1989, J. Neurosurg. 71:105); U.S. Patent No. 5,679,377; U.S. Patent No. 5,916,597; U.S. Patent No. 5,912,015; U.S. Patent No. 5,989,463; U.S. Patent No. 5,128,326; PCT Publication No. WO 99/15154; and PCT Publication No. WO 99/20253. Examples of polymers for sustained-release formulations include, but are not limited to, poly(2-hydroxyethyl methacrylate), poly(methyl methacrylate), poly(acrylic acid), poly(ethylene-co-vinyl acetate), poly(methacrylic acid), polyglycolide (PLG), polyanhydrides, poly(N-vinyl pyrrolidone), poly(vinyl alcohol), polyacrylamide, poly(ethylene glycol), polylactide (PLA), poly(lactide-co-glycolide) (PLGA), and polyorthoesters. In some embodiments, the polymer for sustained-release formulations is inert, free of leachable impurities, stable in storage, sterile, and biodegradable. In some embodiments, a controlled or sustained release system can be placed near the therapeutic target (i.e., the lungs), thereby requiring only a fraction of the systemic dose (see, e.g., Goodson, in Medical Applications of Controlled Release, supra, Vol. 2, pp. 115-138 (1984)).

Langer (1990, Science 249:1527-1533) discusses controlled release systems in a general review. Any technique known to those skilled in the art can be used to prepare sustained-release formulations containing one or more antibodies or fragments thereof of the present disclosure. See, e.g., U.S. Patent No. 4,526,938; PCT Publication No. WO 91/05548; PCT Publication No. WO 96/20698; Ning et al., 1996, Radiotherapy & Oncology 39:179-189; Song et al., 1995, PDA Journal of Pharmaceutical Science & Technology 50:372-397; Cleek et al., 1997, Pro. Int'l. Symp. Control. Rel. Bioact. Mater. 24:853-854; and Lam et al., 1997, Proc. Int'l. Symp. Control Rel. Bioact. Mater. 24:759-760, each of which is incorporated herein by reference in its entirety.

The pharmaceutical composition can be formulated to be compatible with its intended route of administration. Examples of routes of administration include, but are not limited to, parenteral, such as intravenous, intradermal, subcutaneous, oral, intranasal (e.g., inhalation), transdermal (topical), transmucosal, and rectal administration. In some embodiments, the composition is formulated according to conventional procedures as a pharmaceutical composition suitable for intravenous, subcutaneous, intramuscular, oral, intranasal, or topical administration to humans. In some embodiments, the pharmaceutical composition is formulated according to conventional procedures for subcutaneous administration to humans. Typically, the composition for intravenous administration is a solution in a sterile isotonic buffer. If necessary, the composition may also include a solubilizer and a local anesthetic, such as lidocaine, to reduce pain at the injection site.

The composition can be formulated for parenteral administration by injection, for example by bolus injection or continuous infusion. Injectable preparations can be provided in unit dosage form, for example, in ampoules or multi-dose containers, with added preservatives. The composition can take the form of a suspension, solution or emulsion in an oily or aqueous vehicle, and can contain formulators such as suspending agents, stabilizers and/or dispersants. Alternatively, the active ingredient can be in powder form for resolubilization with a suitable vehicle (e.g., sterile pyrogen-free water) before use.

In some embodiments, the disclosure provides dosage forms (e.g., associated with a pump or other device for such delivery) that allow for continuous administration of an anti-CD3 antibody over a period of hours or days, for example, over a period of 1 hour, 2 hours, 3 hours, 4 hours, 6 hours, 8 hours, 10 hours, 12 hours, 16 hours, 20 hours, 24 hours, 30 hours, 36 hours, 4 days, 5 days, 7 days, 10 days, or 12 days. In some embodiments, the disclosure provides dosage forms that allow for administration of serially increasing doses, for example, from 106 µg/m ² /day to 850 µg/m ² /day or from 211 µg/m ² /day to 840 µg/m 2 /day within 24 hours, 30 hours, 36 hours, 4 days, 5 days, 7 days, 10 days, or ¹² days.

The composition can be formulated in neutral or salt form. Pharmaceutically acceptable salts include those formed with anions, such as those derived from hydrochloric acid, phosphoric acid, acetic acid, oxalic acid, tartaric acid, etc., and those formed with cations, such as those derived from sodium, potassium, ammonium, calcium, iron hydroxide, isopropylamine, triethylamine, 2-ethylaminoethanol, histidine, procaine, etc.

Typically, the components of the compositions disclosed herein are provided separately or mixed together in unit dosage form, for example, as lyophilized powders or anhydrous concentrates in sealed containers such as ampoules or sachets indicating the amount of active agent. In the case where the composition is administered by infusion, it can be dispensed with an infusion bottle containing sterile pharmaceutical grade water or saline. In the case where the composition is administered by injection, an ampoule of sterile water or saline for injection can be provided to allow mixing of the components prior to administration.

In particular, the present disclosure provides that the anti-CD3 antibody or its drug composition can be packaged in a sealed container such as an ampoule or a sachet indicating the amount of the dosage. In some embodiments, the anti-CD3 antibody or its drug composition is provided in a sealed container as a dry sterile lyophilized powder or anhydrous concentrate, and can be dissolved back to an appropriate concentration with water or saline for administration to a subject. Preferably, the anti-CD3 antibody or its drug composition is provided as a dry sterile lyophilized powder in a sealed container in a unit dose of at least 5 mg, more preferably at least 10 mg, at least 15 mg, at least 25 mg, at least 35 mg, at least 45 mg, at least 50 mg, at least 75 mg, or at least 100 mg. The lyophilized agent or pharmaceutical composition herein should be stored in its original container at 2°C to 8°C, and the therapeutic agent or pharmaceutical composition of the present disclosure should be administered within 1 week after reconstitution, preferably within 5 days, within 72 hours, within 48 hours, within 24 hours, within 12 hours, within 6 hours, within 5 hours, within 3 hours, or within 1 hour. In some embodiments, the pharmaceutical composition is supplied in a liquid form in a sealed container indicating the amount and concentration of the agent. Preferably, the liquid form of the composition for administration is supplied in a sealed container at least 0.25 mg/ml, more preferably at least 0.5 mg/ml, at least 1 mg/ml, at least 2.5 mg/ml, at least 5 mg/ml, at least 8 mg/ml, at least 10 mg/ml, at least 15 mg/ml, at least 25 mg/ml, at least 50 mg/ml, at least 75 mg/ml or at least 100 mg/ml. The liquid form should be stored at 2°C to 8°C in its original container.

In some embodiments, the present disclosure provides that the composition of the present disclosure is packaged in a sealed container such as an ampoule or a sachet indicating the amount of the anti-CD3 antibody.

If desired, the composition may be presented in a package or dispenser device which may contain one or more unit dosage forms containing the active ingredient. The package may comprise, for example, metal or plastic foil, such as a blister pack. The amount of an anti-CD3 antibody or a composition comprising an anti-CD3 antibody that is effective in treating one or more symptoms associated with T1D can be determined by standard clinical techniques. The precise dose used in the formulation may also depend on the route of administration and the severity of the condition, and should be decided according to the judgment of the physician and each patient's circumstances. The effective dose may be extrapolated from a dose-response curve derived from an in vitro or animal model test system. Verapamil

Verapamil is a calcium channel blocker used to treat angina, cardiac arrhythmias, and essential hypertension. The compound has the following structure:

Verapamil is a popular drug used daily by millions of elderly patients with heart disease. Its widespread use has led to its inclusion on the World Health Organization (WHO) list of essential medicines (see worldwideweb.who.int/medicines/publications/essentialmedicines/en/).

Pancreatic β-cell loss is a key factor in the pathogenesis of T1D, but there is a lack of treatments to stop this process. Verapamil is a safe and effective calcium channel blocker antihypertensive drug approved for use in adults. By relieving cellular stress, it is expected to become a β-cell protector. It has been previously reported that the approved antihypertensive calcium channel blocker verapamil promotes the survival of insulin-producing β-cells and reverses diabetes in a mouse model by reducing the expression of thioredoxin-interacting protein (Xu et al., Diabetes (2021) 61:848-56). These findings were recently translated to humans in a randomized, double-blind, placebo-controlled phase 2 trial evaluating the efficacy and safety of adding oral verapamil to standard insulin regimen for 12 months in adult subjects with recent-onset T1D (Ovalle et al., Nat Med. (2018) 24:1108-12).

In some embodiments, the combination of tilimumab with a daily oral beta cell targeted therapy can be used to enhance and prolong beta cell retention. The non-overlapping mechanisms of action of the two agents are not expected to result in additional side effects (Figure 32).

In some embodiments, for any dose of telizumab listed herein, the daily dose of verapamil (e.g., an oral dose) can be in the range of about 100 mg to about 480 mg per day (e.g., about 100 mg, 110 mg, 120 mg, 130 mg, 140 mg, 150 mg, 160 mg, 170 mg, 180 mg, 190 mg, 200 mg, 210 mg, 220 mg, 230 mg, 240 mg, 250 mg, 260 mg, 270 mg, 280 mg, 290 mg, 300 mg, 310 mg, 320 mg, 330 mg, 340 mg, 350 mg, 360 mg, 370 mg, 380 mg, 390 mg, 400 mg, 410 mg, 420 mg, 430 mg, 440 mg, 450 mg, 460 mg, mg, 470 mg or about 480 mg), whether administered in divided doses (e.g., 2 to 4 times per day) or as a single extended release dose.

In some embodiments, verapamil can be administered in a dosage of about 100 mg to about 480 mg per day. In some embodiments, verapamil can be administered in a dosage of about 300 mg to about 400 mg per day.

In some embodiments, Verapamil can be administered at a dosage of about 100 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 110 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 120 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 130 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 140 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 150 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 160 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 170 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 180 mg per day. In some embodiments, verapamil may be administered in a dosage of about 190 mg per day.

In some embodiments, Verapamil can be administered at a dosage of about 200 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 210 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 220 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 230 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 240 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 250 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 260 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 270 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 280 mg per day. In some embodiments, verapamil may be administered in a dosage of about 290 mg per day.

In some embodiments, Verapamil can be administered at a dosage of about 300 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 310 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 320 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 330 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 340 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 350 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 360 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 370 mg per day. In some embodiments, Verapamil can be administered at a dosage of about 380 mg per day. In some embodiments, verapamil can be administered in a dosage of about 390 mg per day. In some embodiments, verapamil can be administered in a dosage of about 400 mg per day.

In some embodiments, verapamil may be administered in an immediate release form.

In some embodiments, verapamil can be administered in a modified release form. In some embodiments, verapamil can be administered in a sustained release form. In some embodiments, verapamil can be administered in a controlled release form.

In some embodiments, verapamil can be administered in a slow release form. Methods and Uses

In some embodiments, the methods of the present disclosure include administering an anti-human CD3 antibody (such as telizumab) in combination with verapamil to a patient diagnosed with T1D with residual beta cell mass. In some embodiments, the patient diagnosed with T1D has a peak C-peptide level of ≥ 0.2 pmol/mL during a mixed meal tolerance test (MMTT). In some embodiments, the peak C-peptide level at screening is in the range of 0.2 pmol/mL (inclusive) to 0.7 pmol/mL (inclusive).

In some embodiments, the disclosure includes administering an anti-human CD3 antibody (e.g., telizumab) in combination with verapamil to patients aged 8 to 17 years who have a peak C-peptide level of ≥ 0.2 pmol/mL during a mixed meal tolerance test (MMTT) 6 weeks after diagnosis of T1D. In some embodiments, the peak C-peptide level at screening is in the range of 0.2 pmol/mL (inclusive) to 0.7 pmol/mL (inclusive).

In some embodiments, T1D diagnosis is made according to the American Diabetes Association (ADA) criteria. According to the American Diabetes Association (ADA) definition of clinical diagnosis of diabetes, an individual must meet one of the following 4 criteria: Fasting plasma glucose (FPG) ≥ 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours. 2-hour blood glucose (PG) ≥ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT). The test should be performed as described by the World Health Organization (WHO) using a glucose load containing the equivalent of 75 g of anhydrous glucose dissolved in water. Hemoglobin A1C (HbA1c) ≥ 6.5% (48 mmol/mol). The test should be performed in a laboratory using a method validated by the National Glycohemoglobin Standardization Program (NGSP) and standardized for the Diabetes Control and Complications Trial (DCCT) assay. In patients with typical hyperglycemic symptoms or hyperglycemic crisis, randomized PG ≥ 200 mg/dL (11.1 mmol/L).

For the diagnosis of clinical T1D, the ADA recommends that plasma glucose rather than HbA1C should be used to diagnose acute episodes of T1D in individuals with symptoms of hyperglycemia.

According to the ADA, blood glucose measurement is sufficient to diagnose clinical diabetes in patients with typical symptoms (symptomatic hyperglycemia or hyperglycemic crisis plus random blood glucose ≥ 200 mg/dL [11.1 mmol/L]). In these situations, knowing the blood glucose level is critical because it will inform management decisions in addition to confirming that the symptoms are due to diabetes. Some providers may also want to know the HbA1C to determine how long the patient has had hyperglycemia. In addition, T1D, formerly known as "insulin-dependent diabetes" or "juvenile-onset diabetes," accounts for 5%-10% of diabetes and is due to cell-mediated autoimmune destruction of pancreatic beta cells. Autoimmune markers include islet cell autoantibodies and autoantibodies to GAD (GAD65), insulin, tyrosine phosphatases IA-2 and IA-2 beta, and ZnT8. T1D is defined by the presence of one or more of these autoimmune markers.

In some embodiments, a patient diagnosed with clinical T1D tests positive for at least one of the following T1D-associated autoantibodies: glutamic acid decarboxylase 65 (GAD65) autoantibodies, islet antigen 2 (IA-2) autoantibodies, zinc transporter 8 (ZnT8) autoantibodies, islet cell cytoplasmic autoantibodies (ICA), or insulin autoantibodies (if tested within the first 14 days of insulin therapy). In some embodiments, the presence of autoantibodies is detected by ELISA, electrochemiluminescence (ECL), radioassay (see, e.g., Yu et al., J Clin Endocrinol Metab. (1996) 81:4264-7), agglutination PCR (Tsai et al., ACS Central Science (2016) 2(3):139-47), or any other method for detecting the immunological specificity of antibodies described herein or known to those skilled in the art.

It is recognized that β-cell loss continues after T1D diagnosis. To maximize the effect of β-cell sparing in patients whose endogenous insulin production can be restored, patients to be treated must have a peak C-peptide level ≥ 0.2 pmol/mL during a mixed meal tolerance test (MMTT) within 6 weeks of T1D diagnosis.

In some embodiments, the methods provided herein prevent or delay the need to administer insulin to a patient.

β cell function before, during and after treatment can be assessed by the methods described herein or any method known to those skilled in the art. For example, the Diabetes Control and Complications Trial (DCCT) research group has established the monitoring of glycosylated hemoglobin percentage (HA1 and HA1c) as a standard for assessing glycemic control (DCCT, N Engl J Med. (1993) 329:977-86). Alternatively, daily insulin requirements, C-peptide levels/responses, hypoglycemic episodes, and/or characterization of the FPIR can be used as markers of β-cell function or to establish a treatment index (see Keymeulen et al., N Engl J Med. (2005) 352:2598-608; Herold et al., Diabetes (2005) 54:1763-69; U.S. Patent Application Publication No. 2004/0038867 A1; and Greenbaum et al., Diabetes (2001) 50:470-76, respectively). For example, FPIR is calculated as the sum of insulin values at 1 minute and 3 minutes after IGTT according to the Islet Cell Antibody Registry User Research Protocol (see, e.g., Bingley et al., Diabetes (1996) 45:1720-8 and McCulloch et al., Diabetes Care (1993) 16:911-5).

In some embodiments, the method comprises administering the anti-CD3 antibody for a course of 8 to 16 days. In some embodiments, the anti-CD3 antibody can be administered orally, by intravenous injection, intramuscular injection, subcutaneous injection, intraperitoneal injection, topically, sublingually, intraarticularly, intradermally, orally, ophthalmologically (including intraocularly), intranasally, or by any other route. The anti-CD3 antibody can be administered orally, for example, as a tablet or sachet containing a predetermined amount of the anti-CD3 antibody, a gel, a pellet, a paste, a syrup, a bolus, a saccharide, a slurry, a capsule, a powder, a granule, as a solution or suspension in an aqueous liquid or a non-aqueous liquid, as an oil-in-water liquid emulsion or a water-in-oil liquid emulsion, by micellar formulation, by any formulation known in the art, or in some other form.

In some embodiments, the prophylactically effective amount of the antibody comprises a 10 to 14 day course of subcutaneous (SC) injection or intravenous (IV) infusion of an anti-CD3 antibody with a cumulative dose greater than 10,000 micrograms per square meter (μg/m ² ). In some embodiments, a prophylactically effective amount of an antibody comprises a 10 to 14 day course of subcutaneous (SC) injection or intravenous (IV) infusion or oral administration of an anti-CD3 antibody at a dose of about 9,500 to about 14,000 μg/m ² , about 9,500 to about 13,500 μg/m ² , about 9,500 to about 13,000 μg/m ² , about 9,500 to about 12,500 μg/m ² , about 9,500 to about 12,000 μg/m ² , about 9,500 to about 11,500 μg/m ² , about 9,500 to about 11,000 μg/m ² , about 9,500 to about 10,500 μg/m ² , about 9,500 to about 10,000 μg/m ² . In some embodiments, the prophylactically effective amount of the antibody comprises a 10 to 14 day course of subcutaneous (SC) injection or intravenous (IV) infusion or oral administration of an anti-CD3 antibody at a dose of about 10,000 μg/m ² , 10,500 μg/m ² , 11,000 μg/m ² , 11.500 μg/m ² , 12,000 μg/m ² , 12,500 μg/m ² , 13,000 μg/m ² , 13,500 μg/m ² or 14,000 μg/m ² . In some embodiments, the anti-CD3 antibody is or comprises teligrum.

In some embodiments, the method comprises administering a 14-day course of IV infusion of an anti-CD3 antibody such as teliguzumab at doses of about 60 μg/m ² , about 125 μg/m ² , about 250 μg/m ² , and about 500 μg/m ² on days 1 to 4, respectively, and about 1,000 μg/m ² on each day of days 5 to 14. In some embodiments, the cumulative dose is about 10,935 μg/m ² .

In some embodiments, the method comprises administering a 14-day course of IV infusion of an anti-CD3 antibody such as teliguzumab at doses of about 60 μg/m ² , about 125 μg/m ² , about 250 μg/m ² , and about 500 μg/m ² on days 1 to 4, respectively, and about 1,030 μg/m ² on each day of days 5 to 14. In some embodiments, the cumulative dose is about 11,235 μg/m ² .

In some embodiments, the method comprises administering a 14-day course of IV infusion of an anti-CD3 antibody such as teliguzumab at doses of about 100 μg/m ² , about 425 μg/m ² , about 850 μg/m ² , and about 850 μg/m ² on days 1 to 4, respectively, and about 1,000 μg/m ² on each day of days 5 to 14. In some embodiments, the cumulative dose is about 12,225 μg/m ² .

In some embodiments, the method comprises administering a 14-day course of IV infusion of an anti-CD3 antibody such as teliguzumab at doses of about 65 μg/m ² , about 125 μg/m ² , about 250 μg/m ² , and about 500 μg/m ² on days 1 to 4, respectively, and about 1,070 μg/m ² on each day of days 5 to 14. In some embodiments, the cumulative dose is about 11,640 μg/m ² .

In some embodiments, the method comprises administering a 14-day course of IV infusion of an anti-CD3 antibody such as teliguzumab at doses of about 65 μg/m ² , about 125 μg/m ² , about 250 μg/m ^{2 ,} and about 500 μg/m ² on days 1-4, respectively, and about 1,030 μg/m ² on each day of days 5 to 14. In some embodiments, the cumulative dose is about 11,240 μg/m ² .

In some embodiments, the effective amount comprises a 12-day course of subcutaneous intravenous (IV) infusion of an anti-CD3 antibody such as teligrumumab at 106 to 850 micrograms per square meter (μg/m ² ). In some embodiments, the effective amount comprises a 12-day course of IV infusion of teligrumumab, with a first dose of 106 μg/m ² teligrumumab on day 1, a second dose of 425 μg/m ² teligrumumab on day 2, and a daily dose of 850 μg/m ² on days 3 to 12. In some embodiments, the effective amount comprises a 12-day course of IV infusion of telizumab, a first dose of 211 μg/m ² of telizumab on day 1, a second dose of 423 μg/m ² of telizumab on day 2, and a dose of 840 μg/m ² per day on days 3 to 12. In some embodiments, the effective amount comprises a 12-day course of IV infusion of telizumab, a first dose of about 100 μg/m ² of telizumab on day 1, a second dose of about 400 μg/m ² of telizumab on day 2, a third dose of about 850 μg/m ² on day 3, and about 1,200 μg/m ² per day on days 4 to 12. In some embodiments, the effective amount comprises a 12-day course of IV infusion of teligrumumab, with a first dose of about 100 μg/m ² of teligrumumab on day 1, a second dose of about 400 μg/m ² of teligrumumab on day 2, a third dose of about 850 μg/m ² on day 3, and about 1,300 μg/m ² per day on days 4 to 12. In some embodiments, the effective amount comprises a 12-day course of IV infusion of teligrumumab, with a first dose of about 100 μg/m ² of teligrumumab on day 1, a second dose of about 400 μg/m ² of teligrumumab on day 2, a third dose of about 850 μg/m ² on day 3, and about 1,400 μg/m ² per day on days 4 to 12.

In some embodiments, the effective amount comprises a 12-day course of IV infusion of teligrumumab, with a first dose of about 200 μg/m ² of teligrumumab on day 1, a second dose of about 400 μg/m ² of teligrumumab on day 2, a third dose of about 850 μg/m ² on day 3, and about 1,200 μg/m ² per day on days 4 to 12. In some embodiments, the effective amount comprises a 12-day course of IV infusion of teligrumumab, with a first dose of about 200 μg/m ² of teligrumumab on day 1, a second dose of about 400 μg/m ² of teligrumumab on day 2, a third dose of about 850 μg/m ² on day 3, and about 1,300 μg/m ² per day on days 4 to 12. In some embodiments, the effective amount comprises a 12-day course of IV infusion of teligrum, with a first dose of about 200 μg/m ² of teligrum on day 1, a second dose of about 400 μg/m ² of teligrum on day 2, a third dose of about 850 μg/m ² on day 3, and about 1,400 μg/m ² per day on days 4 to 12.

The dosing regimen provided herein includes two or more courses of anti-CD3 antibodies such as tilizumab, including a first course administered in Week 1 and a second course administered in Week 26. In some embodiments, tilizumab is administered by IV infusion in two courses, the first course starting on Day 1 (Week 1) and the second course starting on about Day 182 (Week 26), each course including daily infusions for 12 days, and the cumulative dose of tilizumab in each course is 9000 µg/m ² . In some embodiments, telizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative telizumab dose for each course is 9500 µg/m ² . In some embodiments, telizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative telizumab dose for each course is 10000 µg/m ² . In some embodiments, telizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative telizumab dose for each course is 10,500 µg/m ² . In some embodiments, telizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative telizumab dose for each course is 11,000 µg/m ² . In some embodiments, telizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative telizumab dose for each course is 11500 µg/m ² . In some embodiments, telizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative telizumab dose for each course is 12000 µg/m ² . In some embodiments, tilizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative dose of tilizumab in each course is 12,500 µg/m ² . In some embodiments, tilizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative dose of tilizumab in each course is 13,000 µg/m ² . In some embodiments, telizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative telizumab dose for each course is 13500 µg/m ² . In some embodiments, telizumab is administered by IV infusion in two courses, the first course starting on day 1 (week 1), the second course starting on approximately day 182 (week 26), each course comprising daily infusions for 12 days, and the cumulative telizumab dose for each course is 14000 µg/m ² . In some embodiments, the 12-day course has a 2-day escalation phase and a 10-day fixed maximum dosing period. In some embodiments, 106 μg/m ² of telizumab is administered on day 1, 425 μg/m ² of telizumab is administered on day 2, and 850 μg/m ² of telizumab is administered daily on days 3 to 12.

In some embodiments, the total dose over the duration of the regimen is about 14000 µg/m ² , 13500 µg/m ² , 13000 µg/m ² , 12500 µg/m ² , 12000 µg/m ² , 11500 µg/m ² , 11000 µg/m ² , 10500 µg/m ² , 10000 µg/m ² , 9500 µg/m ² , 9000 µg/m ² , 8000 µg/m ² , 7000 µg/m ² , 6000 µg/m ² , and may be less than 5000 µg/m ² , 4000 µg/m ² , 3000 µg/m ² , 2000 µg/m ² or 1000 µg/m ² . In some embodiments, the total dose over the duration of the regimen is about 9030 μg/m ² to about 14000 μg/m ² , about 9030 μg/m ² to about 13500 μg/m ² , about 9000 μg/m 2 to about 13000 μg/m 2, about 9000 μg/m ² to about 12500 μg/m ² , about 9000 μg/m 2 to about 12000 μg/m 2, about 9000 μg/m ² to about 11500 μg/m ² , about 9000 μg/m 2 to about 11000 μg/m 2, about 9000 μg/m ² to about 10500 μg/m 2, about 9000 μg/m 2 to about 12500 μg/m ² , about 9000 μg/m 2 to about 12000 μg/m ² , about 9000 μg/m ² to about 11500 μg/m ² , about 9000 μg/m 2 to about 11000 μg/m ² , about 9000 μg/m 2 to about 10500 μg/m 2, about 9000 μg/m ² to about 12500 μg/m ² , about 9000 μg/m 2 to about 12000 μg/m 2 ² to about 10000 μg/m ² , about 9000 μg/m ² to about 9500 μg/m ² . In some embodiments, the total dose over the duration of the regimen is about 9030 μg/m ² to about 14000 μg/m ² , about 9030 μg/m ² to about 13500 μg/m ² , about 9030 μg/m 2 to about 13000 μg/m 2, about 9030 μg/m ² to about 12500 μg/m ² , about 9030 μg/m 2 to about 12000 μg/m 2, about 9030 μg/m ² to about 11500 μg/m ² , about 9030 μg/m 2 to about 11000 μg/m 2, about 9030 μg/m ² to about 10500 μg/m 2, about 9030 μg/m 2 to about 12500 μg/m ² , about 9030 μg/m 2 to about 12000 μg/m ² , about 9030 μg/m ² to about 11500 μg/m ² , about 9030 μg/m 2 to about 11000 μg/m ² , about 9030 μg/m 2 to about 10500 μg/m 2, about 9030 μg/m ² to about 12500 μg/m ² , about 9030 μg/m 2 to about 12000 μg/m 2 ² to about 10000 μg/m ² , about 9030 μg/m ² to about 9500 μg/m ² .

Without being constrained by this theory, cumulative doses of teligrumumab above approximately 9,000 µg/m ² would be expected to have comparable efficacy in C-peptide retention to that shown at approximately 9,000 mg. This is because the exposure/response curve unexpectedly reached a plateau beyond which increasing doses did not result in increased efficacy. C-peptide retention was assessed using data from the Protégé study. Model-predicted teligrumumab AUC was plotted against changes in C-peptide from baseline, and an Emax analysis was performed. These data demonstrate that the Emax model describes the relationship between teligrumumab exposure and changes in C-peptide over 2 years. As shown in Figure 31, no additional improvement in C-peptide with increasing exposure to tilezumab was observed at tilezumab AUC levels greater than about 1,500 ng*hr/mL (which is lower than the lowest AUC predicted for the about 9,000 µg/m ² dose, which is 1,789 ng*hr/mL). Therefore, these data suggest that doses of tilezumab greater than about 9,000 mg have comparable efficacy in C-peptide retention to that shown at about 9,000 mg.

In other embodiments, the dosing course can be repeated at intervals of 2 months, 4 months, 5 months, 6 months, 8 months, 9 months, 10 months, 12 months, 15 months, 18 months, 24 months, 30 months, or 36 months. In some embodiments, the efficacy of treatment with an anti-CD3 antibody such as teligrumab is measured as described herein, or as known in the art, 2 months, 4 months, 5 months, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months, 30 months, or 36 months after the previous treatment.

In some embodiments, an anti-CD3 antibody such as tilizumab is administered to a subject at one or more doses, preferably 12 daily doses, of about 5 to 1200 μg/m ² , preferably 106 to 850 μg/m ² to treat or slow the progression or improve one or more symptoms of T1D.

In some embodiments, the subject is administered a treatment regimen comprising two courses of daily doses of an effective amount of an anti-CD3 antibody such as teligrum, wherein the courses are administered over 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 days. In some embodiments, the treatment regimen comprises administering an effective amount of a dose every day, every 2 days, every 3 days, or every 4 days.

In some embodiments, a subject is administered a treatment regimen comprising one or more doses of a prophylactically effective amount of an anti-CD3 antibody such as tilimumab, wherein the prophylactically effective amount is 200 µg/kg/day, 175 µg/kg/day, 150 µg/kg/day, 125 µg/kg/day, 100 µg/kg/day, 95 µg/kg/day, 90 µg/kg/day, 85 µg/kg/day, 80 µg/kg/day, 75 µg/kg/day, 70 µg/kg/day, 65 µg/kg/day, 60 µg/kg/day, 55 µg/kg/day, 50 µg/kg/day, 45 µg/kg/day, 40 µg/kg/day, 35 µg/kg/day, 30 µg/kg/day, 26 µg/kg/day, 25 1 µg/kg/day, 20 µg/kg/day, 15 µg/kg/day, 13 µg/kg/day, 10 µg/kg/day, 6.5 µg/kg/day, 5 µg/kg/day, 3.2 µg/kg/day, 3 µg/kg/day, 2.5 µg/kg/day, 2 µg/kg/day, 1.6 µg/kg/day, 1.5 µg/kg/day, 1 µg/kg/day, 0.5 µg/kg/day, 0.25 µg/kg/day, 0.1 µg/kg/day or 0.05 µg/kg/day; and/or wherein the prophylactic effective amount is 1200 µg/m ² /day, 1150 µg/m ² /day, 1100 µg/m ² /day, 1050 µg/m ² /day, 1000 µg/m ² /day, 950 900 µg/m ^{2 /} day, 850 µg/m ² /day, 800 µg/m ² /day, 750 µg/m ² /day, 700 µg/m ² /day, 650 µg/m ² /day, 600 µg/m ² /day, 550 µg/m ² /day, 500 µg/m ² /day, 450 µg/m ² /day, 400 µg/m ² /day, 350 µg/m ^{2 /day, 300 µg/m 2 /} day, 250 µg/m ² day, 200 µg/m ² /day, 150 µg/m ² /day, 100 µg/m ² /day, 50 µg/m ² /day, 40 µg/m ^{2 /} day, 30 µg/m ² /day, 20 µg/m ² /day, 15 µg/m ² /day, 10 µg/m ² /day, or 5 µg/m ² /day.

In some embodiments, the intravenous dose is 1200 μg/m ² or less, 1150 μg/m ² or less, 1100 μg/m ² or less, 1050 μg/m ² or less, 1000 μg/m ² or less, 950 μg/m ² or less, 900 μg/m ² or less, 850 μg/m ² or less, 800 μg/m ² or less, 750 μg/m ² or less, 700 μg/m ² or less, 650 μg/m ² or less, 600 μg/m ² or less, 550 μg/m ² or less, 500 μg/m ² or less, 450 μg/m ² or less, 400 μg/m ² or less, 350 μg/m ^{2 or less, 300 μg/m 2} or less. ² or less, 250 µg/m ² or less, 200 µg/m ² or less, 150 µg/m ² or less, 100 µg/m ² or less, 50 µg/m ² or less, 40 µg/m ² or less, 30 µg/m ² or less, 20 µg/m ² or less, 15 µg/m ² or less, 10 µg/m ² or less, or 5 µg/m 2 or less. ² or less anti-CD3 antibodies such as tilimumab are administered within about 24 hours, about 22 hours, about 20 hours, about 18 hours, about 16 hours, about 14 hours, about 12 hours, about 10 hours, about 8 hours, about 6 hours, about 4 hours, about 2 hours, about 1.5 hours, about 1 hour, about 50 minutes, about 40 minutes, about 30 minutes, about 20 minutes, about 10 minutes, about 5 minutes, about 2 minutes, about 1 minute, about 30 seconds or about 10 seconds to prevent, treat or ameliorate one or more symptoms of type 1 diabetes. The total dose over the duration of the regimen is preferably less than about 14,000 µg/m ² , 13,500 µg/m ² , 13,000 µg/m ² , 12,500 µg/m ² , 12,000 µg/m ² , 11,500 µg/m ² , 11,000 µg/m ² , 10,500 µg/m ² , 10,000 µg/m ² , 9,500 µg/m ² , 9,000 µg/m ² , 8,000 µg/m ² , 7,000 µg/m ² , 6,000 µg/m ² , and may be less than 5,000 µg/m ² , 4,000 µg/m ² , 3,000 µg/m ² In some embodiments, the daily dose administered in the regimen is about 100 μg/m ² to about 200 μg/m ² , about 100 μg/m ² to about 500 μg/ ^{m 2 ,} about 100 μg/m ² to about 1000 μg/m ² , or about 500 μg/m ² to about 1000 μg/m ^{2 .}

In some embodiments, the dose is increased incrementally within the first three, first quarter doses of a treatment regimen (e.g., the first 3 days of a 12-day regimen of once-daily dosing) until an effective daily amount of the anti-CD3 antibody, such as teligrum, is reached. In some embodiments, a subject is administered a treatment regimen comprising one or more doses of an effective amount of an anti-CD3 antibody, such as tilimumab, wherein the effective amount increases daily by, for example, 0.01 µg/kg, 0.02 µg/kg, 0.04 µg/kg, 0.05 µg/kg, 0.06 µg/kg, 0.08 µg/kg, 0.1 µg/kg, 0.2 µg/kg, 0.25 µg/kg, 0.5 µg/kg, 0.75 µg/kg, 1 µg/kg, 1.5 µg/kg, 2 µg/kg, 4 µg/kg, 5 µg/kg, 10 µg/kg, 15 µg/kg, 20 µg/kg, 25 µg/kg, 30 µg/kg, 35 µg/kg, 40 µg/kg, 45 µg/kg, 50 µg/kg, 55 or increased daily as treatment progresses, for example, to 100 µg/m 2 , 150 µg/m ² , 200 µg/m 2 , 250 µg/m 2 , 300 µg/m ² , 350 µg/m ² , 400 µg/m ² , 450 µg/m ² , 500 µg/m ² , 550 ^{µg/m 2 , 600 µg/m 2 or 650 µg} / ^{m 2} . In some embodiments, a subject is administered a treatment regimen comprising one or more doses of an effective amount of an anti-CD3 antibody, such as tilizumab, wherein the effective amount is increased by 1.25-fold, 1.5-fold, 2-fold, 2.25-fold, 2.5-fold, or 5-fold until the daily effective amount of the anti-CD3 antibody, such as tilizumab, is reached.

In some embodiments, one or more doses of 200 μg/kg or less, preferably 175 μg/kg or less, 150 μg/kg or less, 125 μg/kg or less, 100 μg/kg or less, 95 μg/kg or less, 90 μg/kg or less, 85 μg/kg or less, 80 μg/kg or less, 75 μg/kg or less, 70 μg/kg or less, 65 μg/kg or less, 60 μg/kg or less, 55 μg/kg or less, 50 μg/kg or less, 45 μg/kg or less, 40 μg/kg or less, 35 μg/kg or less, 30 μg/kg or less, 25 μg/kg or less, 20 μg/kg or less, 15 μg/kg or less, 10 μg/kg or less, 5 µg/kg or less, 2.5 µg/kg or less, 2 µg/kg or less, 1.5 µg/kg or less, 1 µg/kg or less, 0.5 µg/kg or less, or 0.2 µg/kg or less of an anti-CD3 antibody such as teliguzumab to treat or ameliorate one or more symptoms of T1D.

In some embodiments, one or more doses of 200 μg/kg or less, preferably 175 μg/kg or less, 150 μg/kg or less, 125 μg/kg or less, 100 μg/kg or less, 95 μg/kg or less, 90 μg/kg or less, 85 μg/kg or less, 80 μg/kg or less, 75 μg/kg or less, 70 μg/kg or less, 65 μg/kg or less, 60 μg/kg or less, 55 μg/kg or less, 50 μg/kg or less, 45 μg/kg or less, 40 μg/kg or less, 35 μg/kg or less, 30 μg/kg or less, 25 μg/kg or less, 20 μg/kg or less, 15 μg/kg or less, 10 μg/kg or less, 5 µg/kg or less, 2.5 µg/kg or less, 2 µg/kg or less, 1.5 µg/kg or less, 1 µg/kg or less, 0.5 µg/kg or less, or 0.2 µg/kg or less of an anti-CD3 antibody such as teliguzumab to treat or ameliorate one or more symptoms of T1D.

In some embodiments, one or more doses of 100 μg/kg or less, preferably 95 μg/kg or less, 90 μg/kg or less, 85 μg/kg or less, 80 μg/kg or less, 75 μg/kg or less, 70 μg/kg or less, 65 μg/kg or less, 60 μg/kg or less, 55 μg/kg or less, 50 μg/kg or less, 45 μg/kg or less, 40 μg/kg or less, 35 μg/kg or less, 30 μg/kg or less, 25 μg/kg or less, 20 μg/kg or less, 15 μg/kg or less, 10 μg/kg or less, 5 μg/kg or less, 2.5 μg/kg or less, 2 μg/kg or less, 1.5 μg/kg or less, 1 µg/kg or less, 0.5 µg/kg or less, or 0.2 µg/kg or less of an anti-CD3 antibody such as teliguzumab to treat or ameliorate one or more symptoms of T1D. In some embodiments, the intravenous dose is 100 μg/kg or less, 95 μg/kg or less, 90 μg/kg or less, 85 μg/kg or less, 80 μg/kg or less, 75 μg/kg or less, 70 μg/kg or less, 65 μg/kg or less, 60 μg/kg or less, 55 μg/kg or less, 50 μg/kg or less, 45 μg/kg or less, 40 μg/kg or less, 35 μg/kg or less, 30 μg/kg or less, 25 μg/kg or less, 20 μg/kg or less, 15 μg/kg or less, 10 μg/kg or less, 5 μg/kg or less, 2.5 μg/kg or less, 2 μg/kg or less, 1.5 μg/kg or less, 1 μg/kg or less, 0.5 μg/kg or less, or 0.2 μg/kg or less of an anti-CD3 antibody such as tilimumab is administered within about 6 hours, about 4 hours, about 2 hours, about 1.5 hours, about 1 hour, about 50 minutes, about 40 minutes, about 30 minutes, about 20 minutes, about 10 minutes, about 5 minutes, about 2 minutes, about 1 minute, about 30 seconds or about 10 seconds to treat or ameliorate one or more symptoms of T1D.

In some embodiments, one or more doses of 100 μg/kg or less, preferably 95 μg/kg or less, 90 μg/kg or less, 85 μg/kg or less, 80 μg/kg or less, 75 μg/kg or less, 70 μg/kg or less, 65 μg/kg or less, 60 μg/kg or less, 55 μg/kg or less, 50 μg/kg or less, 45 μg/kg or less, 40 μg/kg or less, 35 μg/kg or less, 30 μg/kg or less, 25 μg/kg or less, 20 μg/kg or less, 15 μg/kg or less, 10 μg/kg or less, 5 μg/kg or less, 2.5 μg/kg or less, 2 μg/kg or less, 1.5 μg/kg or less, 1 μg/kg or less, 0.5 µg/kg or less, or 0.2 µg/kg or less of an anti-CD3 antibody such as teliguzumab, to treat or ameliorate one or more symptoms of T1D. In some embodiments, the oral dose is 100 µg/kg or less, 95 µg/kg or less, 90 µg/kg or less, 85 µg/kg or less, 80 µg/kg or less, 75 µg/kg or less, 70 µg/kg or less, 65 µg/kg or less, 60 µg/kg or less, 55 µg/kg or less, 50 µg/kg or less, 45 µg/kg or less, 40 µg/kg or less, 35 µg/kg or less, 30 µg/kg or less, 25 µg/kg or less, 20 µg/kg or less, 15 µg/kg or less, 10 µg/kg or less, 5 µg/kg or less, 2.5 µg/kg or less, 2 µg/kg or less, 1.5 µg/kg or less, 1 µg/kg or less, 0.5 µg/kg or less, or 0.2 μg/kg or less of an anti-CD3 antibody such as tilimumab is administered within about 6 hours, about 4 hours, about 2 hours, about 1.5 hours, about 1 hour, about 50 minutes, about 40 minutes, about 30 minutes, about 20 minutes, about 10 minutes, about 5 minutes, about 2 minutes, about 1 minute, about 30 seconds or about 10 seconds to treat or ameliorate one or more symptoms of T1D.

In some embodiments, wherein escalating doses are administered during the initial days of a dosing regimen, the dose on Day 1 of the regimen is 100 to 250 µg/m ² /day, preferably 106 µg/m ² /day, and is escalated to the daily doses described immediately above on Days 2 and 3. For example, on Day 1, a subject is administered a dose of about 106 µg/m ² /day, on Day 2 about 425 µg/m ² /day, and on subsequent days of the regimen (e.g., Days 3 to 12) 850 µg/m ² /day. In some embodiments, the subject is administered a dose of about 211 µg/m ² /day on day 1, about 423 µg/m ² /day on day 2, and about 840 µg/m ² /day on day 3 and subsequent days of the regimen (e.g., days 3 to 12).

In some embodiments, to reduce the possibility of cytokine release and other adverse reactions, the first 1, 2 or 3 doses or all doses in the regimen are administered more slowly by intravenous administration. For example, a dose of 106 μg/m ² /day can be administered in about 5 minutes, about 15 minutes, about 30 minutes, about 45 minutes, about 1 hour, about 2 hours, about 4 hours, about 6 hours, about 8 hours, about 10 hours, about 12 hours, about 14 hours, about 16 hours, about 18 hours, about 20 hours, and about 22 hours. In some embodiments, the dose is administered by slow infusion over a period of, for example, 20 to 24 hours. In some embodiments, the dose is infused in a pump, preferably with increasing concentrations of the administered antibody as the infusion progresses.

In some embodiments, the set dose portion of the above 106 μg/m ² /day to 850 μg/m ² /day regimen is administered in ascending doses.

In some embodiments, an anti-CD3 antibody such as tilizumab is not administered in daily doses over several days, but is administered by infusion in an uninterrupted manner over 4 hours, 6 hours, 8 hours, 10 hours, 12 hours, 15 hours, 18 hours, 20 hours, 24 hours, 30 hours, or 36 hours. The infusion can be constant, or can start with a lower dose, for example, in the first 1, 2, 3, 5, 6, or 8 hours of the infusion, and then increase to a higher dose. During the infusion, the patient receives a dose equal to the amount administered in the above 5 to 20 day regimen. For example, approximately 150 µg/m ² , 200 µg/m ² , 250 µg/m ² , 500 µg/m ² , 750 µg/m ² , 1000 µg/m ² , 1500 µg/m ² , 2000 µg/m ² , 3000 µg/m ² can be applied. , 4000 µg/m ² , 5000 µg/m ² , 6000 µg/m ² , 7000 µg/m ² , 8000 µg/m ² , 9000 µg/m ² , 9500 µg/m ² , 10000 µg/m ² , 10500 µg/m ² , 11000 µg/m ² , 11500 µg/m ² , 12000 µg/m ² , 12500 µg/m ² , 13000 µg/m ² , 13500 µg/m ² or 14000 µg/m ^2. In particular, the rate and duration of the infusion are designed to minimize the level of free anti-CD3 antibodies, such as tilizumab, in the subject after administration. In some embodiments, the level of free anti-CD3 antibodies, such as tilizumab, should not exceed 200 ng/ml free antibody. In addition, the infusion is designed to achieve at least 50%, 60%, 70%, 80%, 90%, 95% or 100% combined T cell receptor coating and modulation.

In some embodiments, anti-CD3 antibodies such as tilizumab are administered chronically to treat or slow the progression or improve one or more symptoms of type 1 diabetes. For example, in some embodiments, low doses of anti-CD3 antibodies such as tilizumab are administered once a month, twice a month, three times a month, once a week, or even more frequently, as an alternative to the above 6 to 14 day dosing regimen or after administration of such a regimen, to enhance or maintain its effect. Such low doses may be in the range of 1 μg/ ^m2 to 100 μg/ ^m2 , for example about ⁵ μg/m2, 10 μg/ ^m2 , 15 μg/ ^m2 , 20 μg/ ^m2 , 25 μg/ ^m2 , 30 μg/ ^m2 , 35 μg/ ^m2 , 40 μg/ ^m2 , 45 μg/ ^m2 or 50 μg/ ^m2 .

In some embodiments, subjects can be re-dosed at some time after two courses of an anti-CD3 antibody, such as tilizumab, on a dosing regimen, for example, based on one or more physiological or biomarker parameters, or can be re-dosed as a matter of course. Re-dosing and/or the need for such re-dosing can be administered and/or assessed at 2 months, 4 months, 6 months, 8 months, 9 months, 1 year, 15 months, 18 months, 2 years, 30 months, or 3 years after the dosing regimen is administered, and can include administering a course every 6 months, 9 months, 1 year, 15 months, 18 months, 2 years, 30 months, or 3 years indefinitely.

In some embodiments, the level (or relative amount) of phenotypically exhausted T cells, such as TIGIT+KLRG1+CD8+CD3+ cells relative to all CD3+ T cells, is determined, for example, by flow cytometry, before and/or after administration of a 12-day course of tilpizumab (e.g., at intervals of 1 to 6 months, or at intervals of 2 to 5 months, or at intervals of about 3 months). In some embodiments, the level of TIGIT+KLRG1+CD8+CD3+ T cells can be monitored, for example, by flow cytometry. In some embodiments, an additional 12-day course of an anti-CD3 antibody, such as tilpizumab, is administered when the level of TIGIT+KLRG1+CD8+CD3+ T cells corresponds to (e.g., returns to) baseline levels. In some embodiments, TIGIT+KLRG1+CD8+CD3+ T cells are measured about 3 months (or about 1 to 6 months) after the second 12-day course of treatment. In some embodiments, if the subject has more than about 10% TIGIT+KLRG1+CD8+ T cells among all CD3+ T cells, monitoring can be performed annually. In some embodiments, if the subject has less than about 10% TIGIT+KLRG1+CD8+ T cells among all CD3+ T cells, monitoring can be performed about every 3 to 6 months.

In some embodiments, re-dosing comprises administering an additional (e.g., a second, third, or more) 12-day course of tillizumab, each with a total dose of more than about 9000 μg/m ² , as described herein. In some embodiments, the additional 12-day course of tillizumab comprises a first dose of 106 μg/m ² tillizumab on day 1, a second dose of 425 μg/m ² tillizumab on day 2, and a dose of 850 μg/m ² each day from day 3 to day 12, wherein the total dose is about 9031 μg/m ² . In other embodiments, an additional 12-day course of teligrumumab includes a first dose of 211 μg/m ^{2 of} teligrumumab on day 1, a second dose of 423 μg/m ² of teligrumumab on day 2, and a dose of 840 μg/m ² each day on days 3 to 12, wherein the total dose is approximately 9034 μg/m ² .

In some embodiments, an additional (e.g., a second, third, or more) 12-day course of an anti-CD3 antibody such as telizumab can be administered about 12 months to about 24 months, e.g., 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, or 24 months after administration of the prior 12-day course.

In some embodiments, an anti-CD3 antibody such as telizumab is administered to achieve or maintain a level of glycated hemoglobin (HA1 or HA1c) of less than 8%, less than 7.5%, less than 7%, less than 6.5%, less than 6%, less than 5.5%, or 5% or less. At the start of treatment, the patient's HA1 or HA1c level is less than 8%, less than 7.5%, less than 7%, less than 6.5%, less than 6%, or more preferably 4% to 6% (preferably measured in the absence of other diabetes treatments, such as administration of exogenous insulin). Such patients preferably retain at least 95%, 90%, 80%, 70%, 60%, 50%, 40%, 30% or 20% of their beta cell function prior to starting treatment. In some embodiments, administration of an anti-CD3 antibody prevents damage, thereby slowing the progression of the disease and reducing the need for insulin administration. In some embodiments, the treatment methods provided herein result in levels of HA1 or HA1c of 7% or less, 6.5% or less, 6% or less, 5.5% or less, or 5% or less at 6 months, 9 months, 12 months, 15 months, 18 months, or 24 months after the previous treatment. In some embodiments, administration of an anti-CD3 antibody according to the methods provided herein reduces mean levels of HA1 or HA1c in a patient by about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, about 50%, about 55%, about 60%, about 65%, or about 70% compared to pre-treatment levels 6 months, 9 months, 12 months, 15 months, 18 months, or 24 months after the previous treatment. In some embodiments, administration of an anti-CD3 antibody according to the methods provided herein increases the mean level of HA1 or HA1c in a patient by only about 0.5%, about 1%, about 2.5%, about 5%, about 10%, about 15%, about 20%, about 25%, about 30%, about 35%, about 40%, about 45%, or about 50% compared to pre-treatment levels 6 months, 9 months, 12 months, 15 months, 18 months, or 24 months after the previous treatment.

In some embodiments, administration of an anti-CD3 antibody, particularly tilizumab, according to the methods provided herein slows beta cell loss and/or preserves beta cell function (as demonstrated by, for example, C-peptide levels, hypoglycemic or hyperglycemic episodes, time in range, insulin use, or other assessment methods known in the art) for 12 months, 13 months, 14 months, 15 months, 16 months, 17 months, 18 months, 19 months, 20 months, 21 months, 22 months, 2 months, 24 months, or longer in children and adolescents aged 8 to 17 years diagnosed with T1D within the first 6 weeks. In some embodiments, administration of an anti-CD3 antibody, particularly telizumab, according to the methods provided herein slows beta cell loss and/or preserves beta cell function over 18 months (78 weeks) in children and adolescents aged 8 to 17 years diagnosed with T1D within the first 6 weeks.

In some embodiments, the method comprises administering an effective amount of one or more anti-CD3 antibodies in combination with an effective amount of verapamil.

In some embodiments, an effective amount of verapamil is administered daily for at least 3 months, e.g., 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, or 24 months or longer. In some embodiments, an effective amount of verapamil is administered every few days (e.g., 2, 3, 4, 5, or 7 days) or once a week.

Alternatively, treatment of T1D may include multiple administrations of an effective dose of verapamil over a series of time periods, such as four times a day, three times a day, twice a day, once a day, once every few days, weekly, monthly, or once a year. As a non-limiting example, the combination disclosed herein may be administered to a patient once or twice a week. The administration schedule may depend on factors such as the severity of the patient's symptoms. For example, an effective dose of verapamil may be administered to a patient every few days for an indeterminate period of time, or until the patient no longer requires treatment.

In some embodiments, an effective amount of verapamil is administered until evidence of sustained beta cell regeneration is obtained. In some embodiments, beta cell regeneration can be assessed by HbA1c, blood glucose, spot C-peptide, or OGTT stimulated C-peptide, in all cases showing an improvement (e.g., closer to the normal range) compared to pre-treatment levels.

In some embodiments, an effective amount of Verapamil is administered orally, intraperitoneally, subcutaneously, or by infusion using a pump or any other delivery device known in the art. In further embodiments, an effective amount of Verapamil is administered orally.

In some embodiments, anti-CD3 antibody and verapamil are administered simultaneously. In some embodiments, anti-CD3 antibody and verapamil are administered sequentially.

In some embodiments, 3 months after initiation of combination therapy, patients are monitored for (1) immune effects of an anti-CD3 antibody (e.g., tirigetacycline), e.g., by assessing levels of circulating exhausted T cells; and (2) beta cell regeneration, e.g., by OGTT-stimulated C-peptide. Based on the results, a treatment algorithm can be implemented: •   If a patient has more than 10% exhausted T cells (TIGIT+KLRG1+CD8+CD3+ cells) relative to total CD3+ T cells, monitor exhausted T cells annually and metabolic assessments at least quarterly. Levels of exhausted T cells can be assessed, for example, by flow cytometry; •   If the patient has less than 10% exhausted T cells relative to CD3+ T cells, immune monitoring (e.g. by flow cytometry) can be performed every 6 months.

In some embodiments, when depleted T cells return to baseline levels, the patient can receive a new course of anti-CD3 antibody and the monitoring cycle will begin again with 3-month assessment of depleted T cells. In some embodiments, the new course of anti-CD3 antibody is a 12-day course of teligrum.

In some embodiments, anti-CD3 antibodies such as teligrum can be re-administered multiple times according to the algorithms disclosed herein or other algorithms or calendar schedules.

In some embodiments, administration of verapamil may be discontinued after 3 months following 2 consecutive quarterly metabolic assessments that indicate stable regeneration of beta cell mass, enabling it to be weaned off exogenous insulin. Even modest improvements in beta cell mass may reduce the need for exogenous insulin, improve glycemic control, and subsequently reduce diabetic complications. If the patient continues to produce normal amounts of insulin without further treatment, the administered dose may be reduced in intensity and/or frequency, or may be discontinued entirely.

In some embodiments, combination therapy may include co-administration of active agents (anti-CD3 antibody, verapamil) during treatment and/or separate administration of a single active agent at different time intervals during treatment.

In some embodiments, the treatment methods disclosed herein result in at least partial regeneration of pancreatic cells, which contributes to the increase of beta cell mass and the improvement of diabetic conditions. In some embodiments, the administration of the combination therapy partially or completely reverses the diabetic condition.

In some embodiments , anti-CD3 antibodies and verapamil can have an additive or surprisingly synergistic effect on the treatment of T1D, such that the effect is greater than that obtained using either compound alone.

Non-limiting exemplary embodiments of the present disclosure are further listed below. 1. A method for treating clinical type 1 diabetes (T1D) or delaying the progression of stage 2 T1D to stage 3 T1D, the method comprising administering to a subject in need: a 12- to 14-day course of teligrumumab, with a total dose of about 9000 μg/m ² to about 14000 μg/m ² ; and an effective amount of verapamil. 2. The method as described in Example 1, wherein the total dose is between about 9000 and about 9500 μg/m ² . 3. The method as described in Example 1, wherein the 12-day course of treatment comprises a first dose of 106 μg/m ² of telizumab on day 1, a second dose of 425 μg/m ² of telizumab on day 2, and a dose of 850 μg/m ² of telizumab each day from day 3 to day 12, wherein the total dose is approximately 9031 μg/m ^2. 4. The method as described in Example 1, wherein the 12-day course of treatment comprises a first dose of 211 μg/m ² of telizumab on day 1, a second dose of 423 μg/m ² of telizumab on day 2, and a dose of 840 μg/m ² of telizumab each day from day 3 to day 12, wherein the total dose is approximately 9034 μg/m ² . 5. The method of any one of embodiments 1 to 4, comprising administering a first and a second 12-day course of tilezumab. 6. The method of embodiment 5, wherein the first and second 12-day courses are administered at an interval of about 6 months. 7. The method of embodiment 5 or 6, further comprising administering a third or more 12-day or 14-day course of tilezumab to a subject in need thereof, the total dose of each course exceeding about 9000 μg/m ² , and optionally not exceeding 14000 μg/m ² . 8. The method of embodiment 7, wherein the third or more 12-day courses of tilgezumab include a first dose of 106 μg/m ² of tilgezumab on day 1, a second dose of 425 μg/m ² of tilgezumab on day 2, and a dose of 850 μg/m ² of tilgezumab each day from day 3 to day 12, wherein the total dose of each course is approximately 9031 μg/m ² . 9. The method as described in Example 7, wherein the third or more 12-day courses of tilgezumab include a first dose of 211 μg/m ² of tilgezumab on day 1, a second dose of 423 μg/m ² of tilgezumab on day 2, and a dose of 840 μg/m ² of tilgezumab each day from day 3 to day 12, wherein the total dose per course is approximately 9034 μg/m ^2. 10. The method as described in Example 7, wherein the third or more 12-day courses of tilgezumab are administered at an interval of about 12 months to about 24 months from the previous course. 11. The method of embodiment 1, comprising administering a 14-day course of teligrumab by intravenous (IV) infusion at a dose of about 60 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,000 μg/m ² per day on days 5 to 14. 12. The method of Example 1, comprising administering a 14-day course of tilizumab by IV infusion, at a dose of about 60 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,030 μg/m ² per day on days 5 to 14. 13. The method of Example 1, comprising administering a 14-day course of tilizumab by IV infusion, at a dose of about 65 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,030 μg/m ² per day on days 5 to 14. 14. The method of embodiment 1, comprising administering a 14-day course of tilizumab by IV infusion, at a dose of about 100 μg/m ² on day 1, about 425 μg/m ² on day 2, about 850 μg/m ² on day 3, about 850 μg/m ² on day 4, and about 1,000 μg/m ² per day on days 5 to 14. 15. The method of embodiment 1, comprising administering a 14-day course of tilizumab by IV infusion, at a dose of about 65 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,070 μg/m ² per day on days 5 to 14. 16. The method of embodiment 1, comprising administering a 14-day course of teligrum by IV infusion at a dose of about 65 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,370 μg/m ² per day on days 5 to 14. 17. The method of any one of embodiments 1 to 16, comprising determining a baseline of TIGIT+KLRG1+CD8+T cell levels relative to all CD3+ T cells approximately 3 months after administration, monitoring TIGIT+KLRG1+CD8+CD3+ T cell levels, and administering an additional 12 or 14 day course of tilizumab when TIGIT+KLRG1+CD8+CD3+ T cell levels return to baseline levels. 18. The method of embodiment 17, wherein TIGIT+KLRG1+CD8+CD3+ T cells are determined by flow cytometry. 19. The method of embodiment 17, wherein TIGIT+KLRG1+CD8+CD3+ T cells are monitored by flow cytometry. 20. The method of any one of embodiments 17 to 19, wherein if the subject has more than about 10% TIGIT+KLRG1+CD8+ T cells among all CD3+ T cells, subsequent monitoring is performed annually. 21. The method of any one of embodiments 17 to 19, wherein if the subject has less than about 10% TIGIT+KLRG1+CD8+ T cells among all CD3+ T cells, subsequent monitoring is performed approximately every 6 months. 22. The method of any one of embodiments 1 to 21, wherein the administering step results in at least a 10% reduction in insulin use, HbA1c levels, hypoglycemic episodes, or a combination thereof, compared to pre-treatment levels. 23. The method of any one of embodiments 1 to 22, wherein each dose of teligrumumab is administered parenterally, optionally by intravenous infusion. 24. The method of any one of embodiments 1 to 23, wherein the effective amount of verapamil is administered orally, intraperitoneally, subcutaneously, or by intravenous infusion. 25. The method of any one of embodiments 1 to 24, wherein the subject in need thereof is approximately 8 to 17 years old or is an adult. 26. The method of embodiment 25, wherein the subject has stage 3 T1D, and/or has new onset T1D within 12 weeks, 8 weeks, or 6 weeks, as appropriate. 27. The method of any one of embodiments 1 to 26, wherein the subject in need thereof has a peak C-peptide level of ≥ 0.2 pmol/mL during a mixed meal tolerance test (MMTT). 28. The method of any one of embodiments 1 to 27, wherein the subject receiving tilizumab has a higher mean C-peptide value after treatment compared to a control receiving a placebo. 29. The method of any one of embodiments 1 to 28, comprising assessing the area under the time-concentration curve (AUC) of C-peptide at 78 weeks after a mixed meal tolerance test (MMTT). 30. The method of any one of embodiments 1 to 29, wherein the subject in need thereof has at least 20% beta cell function prior to administration of tilizumab and verapamil. 31. The method of any one of embodiments 1 to 30, wherein the reduction in insulin use, HbA1c levels, hypoglycemic episodes, or a combination thereof is sustained for 12 months or longer. 32. The method of any one of embodiments 1 to 31, wherein verapamil is administered in an amount of about 100 mg to about 480 mg per day. 33. The method of any one of embodiments 1 to 32, wherein verapamil is administered in an amount of about 300 mg to about 400 mg per day. 34. The method of any one of embodiments 1 to 33, wherein verapamil is administered in an amount of about 360 mg per day. 35. The method of any one of embodiments 1 to 34, wherein verapamil is administered in a slow release form. 36. A tilizumab for use in the method of any one of Examples 1 to 35 to treat clinical type 1 diabetes (T1D) or delay the progression of stage 2 T1D to stage 3 T1D. 37. A verapamil for use in the method of any one of Examples 1 to 35 to treat clinical type 1 diabetes (T1D) or delay the progression of stage 2 T1D to stage 3 T1D. 38. Use of a tilizumab for the manufacture of a medicament for treating clinical type 1 diabetes (T1D) or delaying the progression of stage 2 T1D to stage 3 T1D in the method of any one of Examples 1 to 35. 39. Use of verapamil for the manufacture of a medicament for treating clinical type 1 diabetes (T1D) or delaying the progression of stage 2 T1D to stage 3 T1D in the method described in any one of Examples 1 to 35. Examples Example 1. Population pharmacokinetic simulation of teligrumumab Introduction

Tirelizumab (also known as PRV-031, hOKT3γ1[Ala-Ala], and MGA031) is a humanized, FcR-independent, 150 kD monoclonal antibody that binds to the CD3-ε epitope of the T-cell receptor (TCR) complex. The primary mechanism of action of the antibody involves binding to the CD3 antigen target on T cells. A population pharmacokinetic (PK) model was developed that describes the concentrations of tirelizumab after IV administration. Tirelizumab PK was described as a quasi-steady-state (QSS) approximation of the target-mediated drug disposition (TMDD) model. The objective of this study was to use this model to simulate and compare the concentration-time profiles of tirelizumab after several dosing regimens of interest. Objectives

The objectives of the analysis were to: • Apply a previously developed population PK model to simulate the following three dosing regimens: - “Herold dosing regimen”: Day 1: 51 µg/m ² ; Day 2: 103 µg/m ² ; Day 3: 207 µg/m ² ; Day 4: 413 µg/m ² ; Days 5-14: 826 µg/m ² ; - Regimen 1: Day 1: 211 µg/m ² ; Day 2: 423 µg/m ² ; Days 3-12: 840 µg/m ² ; - Regimen 2: Day 1: 106 µg/m ² ; Day 2: 425 µg/m ² ; Days 3-12: 850 µg/m ² . • Describe and compare the concentration-time course of teligrumumab for the 3 dosing regimens described above. Subjects and Methods Dosing Regimen

The Herold regimen was a 14-day course of telizumab consisting of daily intravenous (IV) infusions (at least 30 minutes) of 51 μg/m ² , 103 μg/m ² , 207 μg/m ² , and 413 μg/m ² on study days 1 to 4, and 826 μg/m ² on study days 5 to 14. The total dose for the 14-day course was approximately 9034 μg/m ² . For a subject with a body surface area (BSA) of 1.92 m ² , this dosing regimen delivered approximately 17 mg of telizumab. The maximum amount of drug delivered at steady state is designed to coat 50% to 80% of the available CD3 on T cells without a large excess of free, unbound drug (expected to be < 200 ng/mL at steady state).

New Regimen 1 is a 12-day course of telizumab, consisting of daily IV infusions (at least 30 minutes) of 211 μg/m ² and 423 μg/m ² on study days 1 and 2, respectively, and daily infusions of 840 μg/m ² on study days 3 to 12. The total dose for the 12-day course is approximately 9034 μg/m ² .

New Regimen 2 is a 12-day course of telizumab, consisting of daily IV infusions (at least 30 minutes) of 106 μg/m ² and 425 μg/m ² on study days 1 and 2, respectively, and daily infusions of 850 μg/m ² on study days 3 to 12. The total dose for the 12-day course is approximately 9031 μg/m ² .

Clearly, all three regimens will deliver the same total dose, but in regimens 1 and 2, delivery occurs over 12 days rather than the 14 days of the original Herold regimen.

The final model from the previous analysis was used for the simulations. The concentration-time course was simulated for 40 days (day 0 to day 40) with 10 time points per day. The model included study effects because patients from the Protégé Encore study were found to have higher clearance and central volumes than patients from the Protégé study. Therefore, the two studies were simulated separately. Simulations were performed using covariate values for four typical patients, specifically: • an adult patient with undetectable anti-drug antibodies [ADA]: 18 years old, 60 kg male, BSA of 1.67 m ² ; • an adult patient with high ADA levels: 18 years old, 60 kg male, BSA of 1.67 m ² ; • a pediatric patient with undetectable ADA: 13 years old, 45 kg male, BSA of 1.33 m ² ; • a pediatric patient with high ADA levels: 13 years old, 45 kg male, BSA of 1.33 m ² .

For each of these patients, a population prediction of the concentration over time for each of the 3 dosing regimens was calculated and then compared graphically. The parameters of 1000 similar patients were then simulated using the model-estimated inter-individual variability, and the individual concentration-time courses were calculated using the model. The median and 90% prediction intervals for the simulated concentrations at each time point for each regimen were calculated and compared graphically. In addition, the means and standard deviations of the simulated values 1 day after the last dose were calculated and compared. Software

Simulations were performed using NONMEM software version 7.4.1 (ICON Development Solutions). Computer resources included personal computers with Intel ^® processors, Windows 7 Professional or higher operating system, and Intel ^® Visual Fortran Professional compiler (version 11.0). Graphics and all other statistical analyses, including evaluation of NONMEM output, were performed using R version 3.4.4 for Windows (R Project, worldwideweb.r-project.org/).

Simulation results for a typical adult patient without detectable ADA are shown in Figure 1. Concentrations in the Protégé study were predicted to be higher than in the Encore study for all dosing regimens. Concentrations for dosing regimens 1 and 2 were nearly indistinguishable, except for slight differences during the first two days of dosing. Concentrations were lower in the Herold dosing regimen compared to dosing regimens 1 and 2 during the first 12 days of dosing, but were nearly identical after the last dose (Day 14 for the Herold regimen and Day 12 for regimens 1 and 2). Simulations that included inter-individual variability (Figures 2-4, Table 1) confirmed these observations. [ Table 1 ] . Prediction of Tilizumab concentrations: C _trough 1 day after the last dose The table shows the mean and standard deviation of the predicted concentrations (ng/mL) for 1000 simulated subjects in the Protégé study Patient groups Dosage plan Time point Mean (Standard Deviation) Eliminate residual errors Including residual error Age = 18 years, WT = 60 kg, BSA = 1.67 ^m2 Male subjects with no detectable ADA Herold Solution 14 days 425 (130) 426 (220) Solution 1 12 days 432 (133) 432 (224) Solution 2 12 days 435 (134) 435 (225) Age = 18 years, WT = 60 kg, BSA = 1.67 m ² Male subjects with very high ADA levels (HAHA2 = 10) Herold Solution 14 days 184 (82) 183 (113) Solution 1 12 days 189 (84) 197 (123) Solution 2 12 days 191 (85) 199 (124) Age = 13 years, WT = 45 kg, BSA = 1.33 ^m2 Male subjects without detectable ADA Herold Solution 14 days 394 (120) 393 (206) Solution 1 12 days 410 (123) 403 (210) Solution 2 12 days 413 (123) 406 (211) Age = 13 years, WT = 45 kg, BSA = 1.33 m ² Male subjects with very high ADA levels (HAHA2 = 10) Herold Solution 14 days 171 (79) 174 (112) Solution 1 12 days 173 (77) 173 (107) Solution 2 12 days 175 (78) 175 (108)

Simulation results for typical adult patients with high levels of detectable ADA are shown in Figures 5-8. As expected, overall teligrumumab levels were much lower for subjects with very high immunogenic responses, but the conclusions regarding differences between the three study dosing regimens still hold.

The simulation results for typical pediatric patients are shown in Figures 9-16. They are very similar to those for adult patients, indicating that BSA-proportional dosing provides similar exposures for pediatric and adult populations.

Figures 17-24 show the concentration curves comparing the Herold regimen and regimen 2 over a longer period of time, and Tables 2-3 summarize the Cmax and AUC from days 0 to 42 in the simulation. The figures show that by day 42, the concentrations are very low, so the values for AUC _0-42 are essentially the same as AUC infinite. [ Table 2 ] . Tilimab concentration prediction: _Cmax The table shows the mean and standard deviation of the predicted maximum concentrations (ng/mL) for 1000 simulated subjects using the Protégé model 205 Patient groups Dosage plan Mean (Standard Deviation) Eliminate residual errors Including residual error Age = 18 years, WT = 60 kg, BSA = 1.67 ^m2 Male subjects with no detectable ADA Herold Solution 849 (205) 850 (405) Solution 1 855 (200) 856 (399) Solution 2 863 (202) 864 (402) Age = 18 years, WT = 60 kg, BSA = 1.67 m ² Male subjects with very high ADA levels (HAHA2 = 10) Herold Solution 609 (178) 612 (304) Solution 1 607 (175) 610 (318) Solution 2 614 (177) 617 (321) Age = 13 years, WT = 45 kg, BSA = 1.33 ^m2 Male subjects without detectable ADA Herold Solution 788 (189) 785 (377) Solution 1 792 (199) 798 (386) Solution 2 799 (200) 806 (389) Age = 13 years, WT = 45 kg, BSA = 1.33 m ² Male subjects with very high ADA levels (HAHA2 = 10) Herold Solution 559 (159) 566 (292) Solution 1 561 (151) 552 (271) Solution 2 568 (153) 558 (274) [ Table 3 ] Tilimab concentration prediction: AUC _0-42 The table shows the mean and standard deviation of the predicted AUC (ng/mL*day) from day 0 to day 42 for 1000 simulated subjects using the Protégé model 205 Patient groups Dosage plan AUC _0-42 mean (standard deviation) Age = 18 years, WT = 60 kg, BSA = 1.67 ^m2 Male subjects with no detectable ADA Herold Solution 6548 (819) Solution 1 6662 (2085) Solution 2 6659 (2084) Age = 18 years, WT = 60 kg, BSA = 1.67 m ² Male subjects with very high ADA levels (HAHA2 = 10) Herold Solution 3082 (630) Solution 1 3099 (1044) Solution 2 3098 (1044) Age = 13 years, WT = 45 kg, BSA = 1.33 ^m2 Male subjects without detectable ADA Herold Solution 5939 (750) Solution 1 6032 (1936) Solution 2 6029 (1935) Age = 13 years, WT = 45 kg, BSA = 1.33 m ² Male subjects with very high ADA levels (HAHA2 = 10) Herold Solution 2830 (557) Solution 1 2837 (902) Solution 2 2836 (902) Conclusion

The simulation showed that: • The predicted concentrations of tilpizumab were almost identical for the 2 proposed dosing schedules (Schedule 1 and Schedule 2) except on the first day of dosing; • The predicted concentrations of tilpizumab increased faster during dosing in Schedules 1 and 2 compared with the Herold schedule, but were almost identical for all schedules on the last day of dosing; • The predicted concentrations of tilpizumab were almost identical for all 3 schedules 1 day after the last dose; • BSA-ratio dosing provided uniform exposure levels for adult and pediatric subjects with different body measurements. Example 2. A Phase 3 , randomized, double-blind, multinational, placebo-controlled study to evaluate the efficacy and safety of tilpizumab in children and adolescents newly diagnosed with T1D

T cells help initiate and coordinate the autoimmune processes responsible for type 1 diabetes (T1D). Tirelizumab was developed when preclinical studies showed that targeting T cells by binding to the CD3-epithelium epitope of the T-cell receptor altered diabetic immunopathogenesis and prevented and reversed disease in relevant animal models. The aim of this study was to evaluate Tirelizumab in children and adolescents recently diagnosed with T1D. Tirelizumab has the potential to become the first disease-modifying therapy to improve the medical management and overall outlook of patients who suffer the most devastating short- and long-term consequences of this disease. Hypothesis

The hypothesis of this study is that tilimumab is safe, well tolerated, and effective in slowing β-cell loss and maintaining clinically relevant levels of β-cell function in children and adolescents with newly diagnosed T1D, while improving key aspects of the clinical management of T1D over 18 months .

The primary objectives are:    To determine whether two courses of telizumab administered 6 months apart slow β-cell loss and maintain β-cell function over 18 months (78 weeks) in children and adolescents aged 8 to 17 years diagnosed with T1D within the past 6 weeks.

Secondary objectives are to: •   Evaluate participants’ improvements in key clinical parameters of diabetes management, including insulin use, glycemic control (including hemoglobin A1c [HbA1c] and time in target glucose range [TIR]), and clinically important hypoglycemic episodes •   Determine the safety and tolerability of two courses of teligrum administered intravenously (IV) 6 months apart •   Evaluate the pharmacokinetics (PK) and immunogenicity of two courses of IV teligrum

Exploratory objectives are: • Assess beta-cell function and clinical parameters focused on T1D • Assess immune, endocrine, molecular and genetic marker endpoints 1. The primary endpoints are: • The area under the time-concentration curve (AUC) of C-peptide after a 4-hour (4h) mixed meal tolerance test (MMTT) at Week 78, a measure of endogenous insulin production and beta-cell function. 2. The secondary endpoints are as follows: A. Key clinical endpoints: • Exogenous insulin use: defined as the daily average at Week 78, units/kg/day (U/kg/d) • HbA1c level: expressed as % and mmol/mol, Week 78 • TIR: expressed as the percentage of time in a day when the participant's 24-hour mean blood glucose (BG) was > 70 but ≤ 180 mg/dL (> 3.9 to ≤ 10.0 mmol/L), assessed using continuous glucose monitoring (CGM) at Week 78 • Clinically important hypoglycemic episodes: defined as BG readings < 54 mg/dL (3.0 B. Safety Endpoints: • The incidence of treatment-emergent adverse events (TEAEs), adverse events of special interest (AESIs), and serious adverse events (SAEs) • The incidence of treatment-emergent infections of special interest, including but not limited to tuberculosis, infections requiring IV antimicrobial therapy or hospitalization, Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections, or severe viremia (i.e., DNA polymerase chain reaction viral load > 10,000 copies/mL or ¹⁰⁶ cells) and herpes zoster Incidence and severity of immediate or delayed study drug infusion-related reactions, such as allergic reactions, pain requiring interruption or cessation of the infusion, cytokine release syndrome, and serum sickness C. PK and immunogenicity endpoints: • Tirezinib serum concentrations • Incidence and titer of anti-tirezinib antibodies after the course of treatment 3. Exploratory endpoints are as follows: A. Assessments of beta-cell function and health throughout the study: • 4h MMTT C-peptide AUC • Participants with a recognized clinically significant stimulated peak C-peptide ≥ 0.2 pmol/mL during the 4h and 2 hours (2h) MMTT • Proinsulin to C-peptide ratio, a measure of beta-cell endoplasmic reticulum stress and dysfunction B. T1D-focused clinical endpoints during the study period, unless otherwise stated: • Exogenous insulin use (U/kg/day) • HbA1c levels • Participants with poor glycemic control, defined as HbA1c ≥ 9% • Number of participants not requiring exogenous insulin because they were able to achieve local, regional, or national glycemic management goals based on age-based HbA1c and/or usual blood glucose levels • Glycemic control assessed based on BG values obtained from intermittent (i.e., spot checks, fingerstick) glucometer readings • Glycemic control assessed based on BG values obtained from CGM readings, including but not limited to TIR; time in high and low glucose range; daily, daytime, and nighttime average BG levels and estimated HbA1c; and glycemic variability • Clinically important hypoglycemic episodes from randomization to Week 39 and from Week 39 to Week 78 • The incidence of “classic” hypoglycemia, defined as BG level ≥ 54 mg/dL (3.0 mmol/L) but < 70 mg/dL (3.9 mmol/L) and/or non-serious clinical episodes • The incidence of diabetic ketoacidosis (DKA) requiring medical care, defined as serum or urine ketones elevated above the upper limit of normal (ULN) and serum bicarbonate < 15 mmol/L or blood pH < 7.3 or both, leading to an outpatient visit, emergency department visit, or hospitalization • Patient-reported outcomes measured by instruments such as the Quality of Life • Impact on family life, measured by the parent-reported PedsQL Family Impact QuestionnaireC. Composite clinical endpoints: • Participants whose HbA1c was within the American Diabetes Association (ADA) target range (i.e., < 7.5%) and whose exogenous insulin dose was within the specified range (< 0.25, 0.25 to < 0.50, 0.50 to < 0.75, 0.75 to < 1.0, 1.0 to < 1.25, and ≥ 1.25 U/k/d) Participants with ≤ 6.5% and ≤ 7.0% and exogenous insulin doses < 0.5 U/kg/day or 0.25 U/kg/day D. Other endpoints during the study: • Number, type, and titer of T1D autoantibodies • Association of human leukocyte antigen (HLA) type with clinical, metabolic, and immune assessments Study Design Overview

This is a phase 3, randomized, double-blind, placebo-controlled, multinational, multicenter study. Approximately 300 participants were recruited and randomly assigned in a 2:1 ratio to either the teligrum group (N = 200) or the placebo group (N = 100).

To minimize bias in treatment allocation, potential confounding factors, and to increase the validity of statistical analyses, participants were randomized in a 2:1 ratio using random permutation blocks and stratification based on the following criteria: •   Peak C-peptide level at screening: in the range of 0.2 (inclusion criterion) to 0.7 pmol/mL (inclusive), vs. > 0.7 pmol/mL •   Age at randomization: in the range of 8 to 12 years (inclusive), vs. > 12 to 17 years

Tilimumab or matching placebo was administered by IV infusion in two courses, with the first course starting on Day 1 (Week 1) and the second course starting approximately 6 months later on Day 182 (Week 26). Each course consisted of daily infusions for 12 days.

The total study duration for each participant was up to 84 weeks. This included a screening period of up to 6 weeks and a post-randomization period of 78 weeks. The treatment period consisted of two 12-day courses, 6 months apart, and a post-treatment observation period of approximately 52 weeks.

This study enrolled male and female participants aged 8 to 17 years with new-onset T1D who were able to be randomized and start study treatment within 6 weeks of diagnosis. To be eligible for randomization, participants had to be positive for at least one T1D-associated autoantibody and have a peak stimulated C-peptide ≥ 0.2 pmol/mL at screening. They also had to meet all specific inclusion criteria and not meet any exclusion criteria. Dosing and Administration

On the day of randomization (Day 1), each participant received the first dose of study drug in the first 12-day course as shown in the table below. On approximately Day 182, each participant received the first dose of the second 12-day course (Table 4). Study drug (teligrumumab or placebo) was administered by IV infusion at the study site or other qualified institution by study approvers. The dose of study drug was calculated based on the participant's body surface area (BSA) measured on the first day of each course. No dose adjustments were allowed. [ Table 4 ] . Treatment Regimens Treatment Name Tilimumab Placebo instruction Sterile solution for injection Sterile solution for injection Dosage per course of treatment Day 1: 106 µg/m ² Day 2: 425 µg/m ² Days 3 to 12: 850 µg/m ² Total dose per course: 9031 µg/m ² Volume matches active drug Frequency Two courses starting at week 1 and week 26 Two courses starting at week 1 and week 26 Delivery method IV infusion IV infusion Key Assessment

MMTT: To quantify endogenous beta cell function, participants undergo a standardized stimulated metabolic test of C-peptide (a 1:1 byproduct of insulin production). Participants consume a fixed amount of beverage containing known amounts of carbohydrate, fat, and protein. Following the beverage, BG, insulin, and C-peptide levels are measured over time. A 2h MMTT is performed at screening, and a 4h MMTT is performed at randomization and at weeks 26, 52, and 78 for critical endpoint assessments.

HbA1c: This is the percentage of red blood cells (measured as hemoglobin) that become non-enzymatically glycated in proportion to blood glucose levels. On average, this indicates the average blood glucose value over approximately 3 months. It is a key clinical target for T1D management.

Insulin Use: Data were averaged over 7 days collected prior to each designated visit to quantify exogenously injected insulin.

Hypoglycemia: Clinically important and potentially life-threatening hypoglycemia is a consequence of insulin therapy and is more likely to occur in patients trying to achieve glycemic control goals. Participants were asked to record information regarding BG levels < 70 mg/dL (3.9 mmol/L) and/or events consistent with hypoglycemia. Particular attention was paid to clinically significant hypoglycemic events, which were defined as a reliable blood glucose reading of < 54 mg/dL (3.0 mmol/L) and/or severe cognitive impairment and/or physical condition requiring external help to recover.

Glucose Monitoring: Intermittent glucose monitoring (e.g., spot checks or fingersticks) was performed multiple times daily by participants or caregivers as a necessary part of blood glucose management to gauge insulin dosing and to assist with diet and activity. All participants were to bring a blood glucose meter for testing at all visits. In addition to data on glycemic control, at specific times during the study, participants reported their daily pre-meal and bedtime BG readings and assessed glucose levels every 2 weeks using CGM.

Quality of Life Questionnaires: Surveys were used to assess participants’ overall health and well-being and the effects of telizumab, such as the PedsQL Diabetes Module, HFS, DTSQ, and the parent-reported PedsQL Family Impact Module.

Pharmacokinetic and Immunogenicity Assessments: Tirelizumab concentrations were analyzed in blood samples collected at specific time points throughout the study. Anti-tirelizumab antibodies, including neutralizing antibodies (NAbs), were measured.

A diagram of the study design is provided in Figure 25.

This study focused on individuals with substantial β-cell functional capacity. It is recognized that β-cell loss continues after T1D diagnosis. To maximize the effect of β-cell sparing in patients in whom endogenous insulin production levels can be restored, this study enrolled participants with peak C-peptide levels ≥ 0.2 pmol/mL during a mixed meal tolerance test (MMTT) within 6 weeks of T1D diagnosis. The 0.2 pmol/mL value was chosen because it is a critical and acceptable threshold for C-peptide that is associated with a lower incidence of clinically important T1D-related short- and long-term complications (Lachin 2014, Palmer 2001, Palmer 2009).

The total study duration for each participant was up to 84 weeks. This included a screening period of up to 6 weeks and a post-randomization period of 78 weeks. The post-randomization period included two 12-day treatment sessions, 6 months apart, and a post-treatment observation period of approximately 52 weeks. The last visit occurred at week 78.

The overall study length and timing of key assessments were chosen because of the natural course of residual β-cell loss after T1D diagnosis and the study objectives to demonstrate durability of effect and confirm the post-treatment safety of telizumab. At diagnosis, a significant number of β-cells may remain, typically estimated to be 10 to 20% of the normal β-cell mass but exceeding 40% in some cases (Matveyenko 2008, Campbell-Thompson 2016). At the time of T1D diagnosis, much of this reserve appears to be functionally impaired due to metabolic or immune (i.e., cytokine-induced) stress. With exogenous insulin therapy and correction of the pH, electrolyte, and fluid disturbances that are often present at diagnosis (i.e., DKA), some beta-cell function may be restored within days, weeks, or months. This observation is often referred to as the "honeymoon period," when insulin requirements can be significantly reduced, sometimes independent of exogenous insulin. These effects are transient, and over time, usually within a year after diagnosis, complete insulin replacement becomes inevitable due to autoimmune elimination of these remaining beta cells. Because of the known individual variability in the natural history of β-cell loss, the effects of disease-modifying therapies aimed at preserving β-cell function are difficult to distinguish from the effects of the initial 12-month honeymoon period following T1D diagnosis.

The 18-month time point for the primary and key secondary clinical endpoints provides critical data needed for acceptance of telizumab as a disease-modifying therapy for T1D into routine medical practice and is consistent with existing endpoint guidelines recommended by the EMA and FDA. Data from natural history studies and intervention trials in T1D suggest that β-cell loss in patients with T1D can be highly variable, especially in the weeks to months after diagnosis. Because this study enrolled younger participants close to T1D diagnosis (i.e., within 6 weeks), there is the potential for added complexity to consider the honeymoon phenomenon (or spontaneous, short-lived partial remission), which may persist for up to approximately 1 year in the study population (Abdul-Rasoul 2006). The 18-month duration of the primary and key secondary clinical endpoints allowed for minimization of the substantial inherent metabolic variability resulting from different trajectories of β-cell loss and/or transient enhancement of β-cell function due to the honeymoon phenomenon, thus allowing true effects of teligrum on β-cell function and clinical parameters to be distinguished from chance.

Additional key assessments will be conducted at randomization, Week 26 (6 months), and Week 52 (12 months) to better understand the natural history of beta-cell decline and the effect of telizumab in this specific study population.

In addition, the primary and key clinical endpoints were assessed approximately 1 year after the last dose of study drug. Duration of action is considered an important property of intermittent disease-modifying therapy in T1D. At this time, a 12-month treatment-free period can be considered a reasonable time frame to confirm claims of metabolically and clinically relevant durable benefits while maintaining positive metabolic and clinical effects.

Participants were assessed regularly throughout the study by face-to-face interviews and physical examinations, self-reports, and laboratory tests. Assessments were performed daily during the two 12-day treatment cycles and regularly at 6-month intervals between cycles and 12 months after the second cycle. The on-treatment and off-treatment observation periods in this study were well within, if not significantly exceeded, the times traditionally used to evaluate the safety and side effects of immunotherapies approved for other autoimmune diseases, including pediatric indications. At doses and schedules similar to those used in this study, teligrum was generally well tolerated with minimal side effects and no significant short-term or long-term adverse event signals. It is anticipated that, based on the additional confirmatory data from this study, the side effect profile of telizumab will continue to be considered acceptable and can be included in the care plans of children and adolescents newly diagnosed with T1D.

In some embodiments, T1D is diagnosed according to ADA criteria. In some embodiments, a patient diagnosed with T1D tests positive for at least one of the following T1D-associated autoantibodies: glutamic acid decarboxylase 65 (GAD65) autoantibodies, islet antigen 2 (IA-2) autoantibodies, zinc transporter 8 (ZnT8) autoantibodies, islet cell cytoplasmic autoantibodies (ICA), or insulin autoantibodies (if tested within the first 14 days of insulin therapy).

At the start of each 12-day course of study drug administration (Day 1 and Day 182), participants' current BSA was calculated using the Mosteller formula, BSA = square root [height (cm) x weight (kg)/3600], using height and weight obtained on that day.

Tilimumab and placebo were prepared according to the Pharmacy Manual provided to the site.

Polyvinyl chloride (PVC) infusion bags and tubing and normal saline should be used for study medication preparation and administration.

Two (2) mL of study drug should be withdrawn from the study drug vial and slowly reconstituted in 18 mL of 0.9% Sodium Chloride Injection by gentle mixing. The resulting 20 mL of a 1:10 dilution is used as the initial study drug solution, which contains placebo or teliguzumab at a concentration of 100 μg/mL. This initial drug solution should then be added to a PVC infusion bag containing 25 mL of 0.9% Sodium Chloride Solution. Finally, the resulting preparation should be gently mixed before administration to participants.

This study requires two courses of intravenous infusions and blood draws over 12 days. It should be recognized that venous access (for infusions and blood draws for laboratory sampling) may present challenges in the pediatric population that is the focus of this study. Children have smaller veins than adults, intravenous cannulation may be more challenging, and they may be significantly resistant to catheter placement and/or vesotomy.

Recognizing the above, this study permits the use of temporary, interim approaches to vascular access in addition to the use of “traditional” peripheral intravenous catheters. Specifically, “midline” or peripherally inserted central catheter (PICC) lines may be used for study medication infusion and blood draws (as appropriate, based on the characteristics of the access line and local, regional, or national guidance).

All enrolled participants, with the assistance of their healthcare provider, should receive intensive diabetes management of their T1D using approved therapies in accordance with American Diabetes Association (ADA) recommendations or local, regional, or national recommendations to achieve glucose levels that appear to reduce some of the short-term and long-term sequelae of T1D. Currently, ADA glycemic goals focus on management strategies to achieve HbA1c levels of <7.5% (58 mmol/mol) for individuals 17 years of age and younger and <7.0% (53 mmol/mol) for individuals 18 years of age and older, while minimizing severe or frequent hypoglycemic events.

Glycemic targets should be attempted through appropriate blood glucose monitoring, administration of exogenous insulin, and monitoring of activity levels and diet. Exogenous insulin may include rapid-acting, intermediate-acting, and/or long-acting insulin administered intermittently or through the use of a personal insulin pump. Blood glucose levels should be measured at least 4 times daily, including before meals and at bedtime.

Insulin use, including product type, dose, and dosing regimen, is expected to change during the study. As part of routine T1D clinical care, participants' insulin doses may be increased, decreased, or even discontinued if the nursing provider judges it is clinically appropriate.

If a participant does not achieve glycemic goals, the study team should contact the participant's primary clinical care team regarding possible adjustments to the insulin regimen, referral to a registered dietitian, or other methods that may improve glucose control.

Insulin therapy may be discontinued if the participant achieves an HbA1c level of ≤ 6.5% on insulin use ≤ 0.25 U/kg/day. Participants should continue to be monitored for blood glucose and HbA1c levels per protocol, and urine ketones should be monitored daily. During routine blood glucose monitoring, if a participant's blood glucose level exceeds 200 mg/dL (11.1 mmol/L) and/or urine ketones are moderate or higher, the participant should consult their primary care physician and/or clinical site staff for further evaluation. If fasting blood glucose exceeds 126 mg/dL (7 mmol/L) or HbA1c exceeds 6.5%, as evidenced by repeat testing, resumption of insulin therapy should be considered.

Dosing of study drug (telizumab or placebo) was based on BSA using height and weight obtained at this visit and the Mosteller formula (BSA = square root [height (cm) x weight (kg)/3600]). Study Visit Week 1

Patients receive premedication with an NSAID (e.g., ibuprofen) (or acetaminophen if NSAID use is contraindicated) and an antihistamine (e.g., diphenhydramine) for at least the first 5 days of the course of treatment unless contraindicated due to drug allergy or sensitivity. The infusion of study drug can begin at least 30 minutes after premedication. Because there is no preservative and drug losses may occur over time, administration of study drug should begin as soon as possible after preparation and no later than 2 hours after preparation. According to standard practice, study drug should be planned to be administered intravenously over 30 minutes, but the rate may be slowed if there are signs or symptoms of intolerance. When the contents of the infusion bag are completely administered, infuse an additional volume of saline equal to the volume contained in the infusion line at the same constant rate to ensure that all study drug has been cleared from the infusion line. The start and end times of the infusion should be recorded. Days 2 to 12: Continue with Course 1 infusion

If there are no clinical or laboratory concerns, patients may receive a single infusion as described above at least 30 minutes after administration of a prophylactic NSAID (or acetaminophen if NSAIDs are contraindicated) and an antihistamine. Close monitoring should be performed during and for 60 minutes after the infusion for any signs or symptoms of intolerance or infusion reactions. Days 2 to 11

On days 2 to 11, patients were then able to leave the facility and return the following day for their next study drug infusion. Day 12

On day 12 after the last infusion of the regimen and for at least 30 minutes of observation, a continuous glucose monitoring (CGM) sensor was applied and participants were provided with instructions on the care and use of CGM monitoring. Study Visits Weeks 4 , 8 , 12 , and 20

The visit window for these study visits was ± 4 days from the target visit date. During these visits, participants returned on-site for scheduled visits and clinical and/or laboratory assessments. Notably, at Week 12, a CGM sensor was applied and participants were provided instructions on the care and use of CGM monitoring.

At the Week 20 visit, participants were provided with instructions for the Week 26 4h MMTT, including overnight fasting and insulin administration prior to the MMTT. Study Visit Week 26 : 4h MMTT and Second Cycle

The visit window for these study visits is ± 3 days from the target visit date. Days 182 to 193

Day 182 Clinical and laboratory assessments (including 4-h MMTT) and administration of study medication for initiation of the second course of treatment.

Of particular note, height and weight should be obtained at this visit and used in BSA-based dosing calculations for Cycle 2. Patients should be premedicated with an oral NSAID (or acetaminophen if NSAIDs are contraindicated) and an antihistamine at least 30 minutes prior to the start of the first 5 study drug infusions (and subsequent infusions as needed) as directed for Study Drug Cycle 1. Administration of study drug should begin as soon as possible after preparation and no later than 2 hours after preparation, and an additional volume of saline equal to the volume contained in the infusion tube should be infused. Participants should be monitored for signs or symptoms of infusion reactions during the infusion and for an additional 60 minutes after the infusion.

On certain days, two blood draws were obtained to measure telizumab serum levels. One within 30 minutes before study drug infusion and the other within 30 minutes after study drug infusion and washout. Days 183 to 192 (Days 2 to 11 of Cycle 2 dosing)

On Days 183 to 192, patients can leave the facility and return the next day for their next study drug infusion. Day 193 (Day 12 of Cycle 2 dosing)

After the last infusion of the course and for at least 30 minutes, the CGM sensor was applied and the patient was provided with instructions on the care and use of CGM monitoring. Study Visits Weeks 30 , 34 , 39 , 52 , and 65

The visit window for these study visits was ± 4 days from the target visit date. At the Week 52 visit, a 4h MMTT was performed.

At the end of the 39th, 52nd, and 65th week visits, a CGM sensor was applied and additional training and instructional updates on CGM care and use were provided as needed. Study Visits Week 39 and Week 65

Patients were provided with instructions for the 4-h MMTT at Week 52 and Week 78, including overnight fasting and insulin administration prior to the MMTT. At the Week 65 visit, patients were assigned a CGM device to begin home use around Week 76. Study Visit Week 78

The study visit window was ± 7 days from the target visit date. During this visit, a 4h MMTT was performed. Mixed Meal Tolerance Test

A 2h MMTT was performed at screening to determine study eligibility (based on peak C-peptide levels). A 4h MMTT was performed at randomization and at weeks 26, 52, and 78 to obtain 4h C-peptide AUC and other data. The 4h MMTT was used at randomization and after randomization because it has been shown to be more accurate and reliable than the 2h MMTT in assessing MMTT-induced C-peptide AUC (Boyle 2015, Rigby 2013, Rigby 2016). Alternatively, a 2h-MMTT was used at screening because it was sufficient to capture the peak C-peptide levels required for study entry. Samples from these assessments were assessed for C-peptide, serum glucose, and insulin. Samples were stored for potential future assessments, including but not limited to proinsulin levels. C-peptide and glucose are measured in serum samples. The MMTT will be performed between approximately 7:00 am and 10:00 am in the morning after an overnight fast, with strict instructions for insulin use. The 2-hour MMTT takes approximately 130 minutes to perform, and the 4-hour MMTT takes approximately 250 minutes. Hemoglobin A1c

HbA1c was assessed as a blood test at selected study visits.

Participants recorded their daily insulin use in an electronic diary at selected times during the 7 days before randomization and at approximately Week 12, 26, 39, 52, 65, and 78 visits. Patients recorded all short-acting, intermediate-acting, and long-acting insulins administered as intermittent injections or used with an "insulin pump" during this period. Insulin use data were not recorded on the day before or on the day of a study visit. If a patient forgot to record insulin use on one or more days before a visit, they should continue to record insulin use for up to 72 hours after dosing to obtain data for up to 7 days. Every effort should be made to collect insulin use data for a total of 7 days at all of the above visits except Week 78 (the final visit), as patients returned the electronic diary at the final visit.

Throughout the study, participants recorded clinically significant and other non-serious and non-severe hypoglycemic episodes by assessing glucose meter readings. Glucose Monitoring (1) Intermittent Glucose Monitoring (Fingerstick)

Blood glucose levels outside of the MMTT and CGM were recorded and analyzed as endpoints at various times. BG levels were usually measured at least 4 times daily with a fingerstick glucose meter as part of routine care, including before each meal and at bedtime. At screening, participants were provided with a study-provided glucose meter and glucose meter strips, but participants were allowed to use their own glucose meter if they preferred, in which case glucose monitoring strips were not provided. Each participant was instructed to bring their glucose meter to each visit (if they used multiple glucose meters, such as at home and school) for checking. In addition, at approximately 7 times throughout the study, participants recorded their BG levels before breakfast, lunch, and dinner and at bedtime in their study electronic diaries for 7 consecutive days before the randomization visit and at the Weeks 12, 26, 39, 52, 65, and 78 visits. As with the recording of insulin use data, BG data from the day before and on the day of the study visit were not recorded. If participants forgot to record a fingerstick glucose measurement before a visit, it should be recorded immediately 72 hours after the visit. Every effort should be made to collect a total of 7 days of BG data for all of the above visits except Week 78 (the last visit), because participants returned the electronic diaries at the last visit. (2)  Continuous Glucose Monitoring

“Continuous” glucose monitors record interstitial glucose levels (which closely approximate blood glucose values) at fixed intervals, for example, every 5 to 15 minutes, depending on the device. A growing body of clinical research supports that this measurement and its assessment provide valuable and unique insights into diabetes glycemic control. In this study, CGM assessments were performed to provide key secondary clinical and exploratory endpoint data to address whether and how telizumab affects glycemic control, such as glucose excursions, time in a specific glucose range, and average daily glucose values (Steck 2014, Helminen 2016, Danne 2017). A recent international consensus statement on CGM monitoring supports the use of measures of percentage of time in range (target, hypoglycemia, and hyperglycemia) and glycemic variability as key diabetes control markers in clinical trials (Danne 2017).

Glycemic control was assessed using CGM approximately 7 times throughout the study: after randomization and completion of treatment at Week 26; after visits at Weeks 12, 39, 52, and 65; and before the Week 78 visit. CGM sensors were placed by qualified study personnel, who provided education and training on CGM use and care. Sensors were allowed to remain in place for up to 2 weeks. If a sensor became dislodged during these 2 weeks, it could be replaced by the participant, a knowledgeable family member/guardian, or a qualified healthcare professional.

To reduce any confounding of glucose measurements during study drug infusion, CGM sensors were placed on participants after completion of study drug administration in Cycles 1 and 2 and other clinical and laboratory assessments on the dates specified in the table in the event timeline. Sensors were placed on participants at Weeks 12, 39, 52, and 65 visits after completion of all clinical and laboratory assessments and the MMTT.

Study CGM readings are not used for the medical management of a participant's diabetes but may be performed under the supervision of the participant's healthcare team. Of note, routine use of a personal CGM is permitted under the guidance of the participant's regular healthcare provider.

Spot check and CGM blood glucose assessments are expected to include, but are not limited to, mean BG, blood glucose variability (BG standard deviation [SD]), maximum and minimum BG values over time, and the incidence and/or percentage of time with BG > 70 but ≤ 180 mg/dL (> 3.9 but ≤ 10.0 mmol/L), Grade 1 (> 180 but ≤ 250 mg/dL) (> 10 but ≤ 13.9 mmol/L)) and Grade 2 hyperglycemia (> 250 mg/dL (> 13.9 mmol/L)) and Grade 1 (≤ 70 but ≥ 54 mg/dL (≤ 3.9 but ≥ 3.0 mmol/L)) and Grade 2 (< 54 mg/dL (< 3.0 mmol/L)) hypoglycemia (Seaquist 2013, International Hypoglycaemia Study Group Group (IHSG) 2017, Agiostratidou 2017). Example 3. Summary of meta-analysis of C- peptide in five phase 3 T1D studies

Confirmatory evidence was provided in the form of a meta-analysis using pooled C-peptide data from five supporting studies, all of which were randomized clinical studies: Protégé, Encore, Study 1, AbATE, and Delay. These five studies compared teligrum with placebo or standard care in patients with newly diagnosed phase 3 T1D and had similar designs that allowed for between-study comparisons (Table 5).

Meta-analyses assessed changes from baseline in C-peptide AUC in the 4-hour mixed-meal tolerance test (MMTT). Analysis of variance (ANCOVA) was used to predict mean C-peptide values (least square means) as well as individual treatment differences. The meta-analysis had 2 components: one analysis was performed on all 5 studies with 1-year follow-up and the second analysis was performed on the 3 studies with 2-year follow-up.

In the pooled analysis of 1-year (Figure 26) and 2-year C-peptide data (Figure 27), patients treated with telizumab showed significantly higher C-peptide levels compared with controls (p < 0.001 for both). This effect was consistent for the observed and imputed data at 1 and 2 years, and in sensitivity analyses that assigned control data to missing data in the telizumab group.

To assess whether C-peptide differed between those without T1D and those who developed T1D, separate graphs of mean C-peptide over time were developed. As shown in Figure 28, patients treated with telizumab who remained free of T1D or who eventually developed T1D during the study period had higher mean C-peptide values compared to their respective controls. Study Design

Confirmatory evidence was performed in the form of a meta-analysis using pooled C-peptide data from 5 supportive randomized clinical studies: Protégé, Encore, Study 1, AbATE, and Delay. C-peptide AUC levels were obtained from a 4-hour MMTT.

Table 5 shows the study design characteristics of these 5 studies in patients with stage 3 T1D. These studies were selected because they represent all randomized studies conducted with telizumab in stage 3 T1D and used placebo or standard care as a control. A similar 14-day escalating dosing schedule was used throughout the studies. In Study 1, the 14-day weight-based dosing schedule was subsequently modified to a 12-day dosing schedule based on BSA. However, because there were significantly more AEs occurring during the early dosing period in the 12-day schedule with a 2-day escalation period, a 14-day schedule with a 4-day escalation period was adopted in subsequent clinical studies. Patients received two 14-day courses in Protégé, Encore, and AbATE and one course at baseline in Delay and Study 1.

The Protégé and Encore studies enrolled newly diagnosed patients with stage 3 T1D in four treatment arms: placebo and three teligrum dosing regimens (full-dose 14 days [9.0 mg/m ² cumulative dose], one-third-dose 14 days [approximately 3.0 mg/m ² cumulative dose], and shortened 6 days [approximately 2.5 mg/m ² cumulative dose]). In the meta-analysis, C-peptide data from the full-dose 14-day regimen were used. Study 1, AbATE, and Delay studies all used the full-dose 14-day regimen (9.0 mg/m ² cumulative dose). [ Table 5 ] . Study Design Characteristics of Supportive Studies Protégé Encore Study 1 AbATE Delay Follow Baseline, day 140, 12, 18, 24 months Baseline, day 140, 12, 18, 24 months Baseline, 6, 12, 18, 24 months Baseline, 6, 12, 18, 24 months Baseline, 6th and 12th months C-peptide endpoint status Secondary, unspecified time Secondary, unspecified time Major, 2 years Major, 2 years Major, 1 year Medication schedule 14 days 14 days 12 or 14 days 14 days 14 days plan 2 courses: Baseline, 6 months 2 courses: Baseline, 6 months 1 course: Baseline 2 courses: Baseline, 12 months 1 course: Baseline design Randomized, double-blind Randomized, double-blind Random, open label Random, open label Randomized, double-blind Control group Placebo Placebo Standard care Standard care Placebo Number of patients * Placebo: 98 Tilimumab: 453 Placebo: 62 Tilimumab: 192 Control: 21 Tilimumab: 21 Control: 25 Tilimumab: 52 Placebo: 27 Tilimumab: 31 *The meta-analysis included patients who received the full 14-day telugulimumab regimen and those who received placebo.

Patients enrolled in these studies (Table 6) represented the population of newly diagnosed T1D patients and excluded those with significant medical history, clinical abnormalities, or active infection. Key inclusion criteria were similar across studies. C-peptide levels at study entry were ≥ 0.2 nmol/L in AbATE, Delay, and Study 1, and detectable levels in Protégé and Encore. [ Table 6 ] Key inclusion criteria for supportive studies Protégé Encore Study 1 AbATE Delay Age at entry 8-35 years old 8-35 years old 7.5-30 years old 8-30 years old 8-30 years old Time from T1D diagnosis to treatment ≤ 12 weeks ≤ 12 weeks ≤ 6 weeks ≤ 8 weeks 4-12 months Autoantibodies Anti-ICA512, IA-2, Anti-GAD65, IAA Anti-ICA512, IA-2, Anti-GAD65, IAA Anti-GAD65, Anti-ICA512, IAA ICA, anti-GAD65, anti-ICA512 ICA, anti-GAD65, anti-ICA512 C-peptide level Detectable Detectable ≥ 0.2 nmol/L ≥ 0.2 nmol/L ≥ 0.2 nmol/L Weight ≥ 36 kg ≥ 36 kg N/A ≥ 25 kg ≥ 27.5 kg ^1At least 2 of these antibodies were present at study entry. Abbreviations: anti-GAD65 = anti-glutamic acid decarboxylase 65 antibody, IA-2 = islet antigen, IAA = insulin autoantibody, anti-ZnT8 = zinc transporter 8 antibody, CI = confidence interval, HLA = human leukocyte antigen, anti-ICA512 = anti-islet cell antibody, N/A = not available, T1D = type 1 diabetes

The primary endpoint of the meta-analysis was the change from baseline in C-peptide AUC during the 4-hour MMTT. Each study used the same sample collection time points during the MMTT to calculate C-peptide AUC. Meta-analysis of the change from baseline in C -peptide AUC during the 4- hour MMTT

Patients in the telinkizumab group had greater retention of C-peptide (i.e., smaller decreases from baseline) at 1 and 2 years of follow-up. This effect was consistent for observed and imputed data (p < 0.0001 for both analyses). In addition, a conservative sensitivity analysis using control-based imputation (assigning control data to the missing telinkizumab data) was also significant (p < 0.0001).

The results of the 1-year and 2-year pooled analyses are shown in forest plots in Figures 26 and 27, respectively. Both forest plots demonstrate that the observed (existing) and interpolated analyses produced consistent effects of teligrum in maintaining C-peptide AUC levels. In the 1-year forest plots, teligrum treatment was consistently more effective than placebo in all studies except Encore. The results of the Encore study were expected as the study was amended before completion because the companion Phase 3 study, Protégé, did not meet its 1-year primary endpoint, resulting in large amounts of missing data requiring extensive interpolation. Approximately 75% (93/125) of the MMTTs were missing. The primary endpoint of the Protégé study was a new, unvalidated composite endpoint focusing on metabolic parameters (HbA1c and insulin use).

In the forest plot of the 2-year data (Figure 27), teligrumumab treatment significantly preserved C-peptide AUC levels compared with placebo in all 3 studies with 2-year data. Example 4. Insulin Use in Five Phase 3 T1D Studies

In the same 5 studies included in the pooled analysis of C-peptide in Example 3, exogenous insulin use was assessed separately in each study. Mean insulin use at each time point in each study was numerically lower in patients treated with telizumab compared with placebo (Figure 29). In 2 studies (AbATE, Study 1), the differences were statistically significant.

Specifically, mean insulin use at each time point was lower in patients on teligrum compared with placebo in all five studies (Figure 29). Three studies (AbATE, Delay, and Study 1) demonstrated that teligrum treatment consistently resulted in statistically significantly lower levels of insulin requirements compared with placebo (Herold et al. 2013a; Herold et al. 2005; Herold et al. 2013b). Insulin use was also lower in the teligrum group compared with the placebo group in the Protégé and Encore studies, but this did not reach statistical significance. Thus, teligrum treatment preserved C-peptide levels, which is reflected in increased endogenous insulin production and reduced exogenous insulin requirements.

Overall, these data support that tilimumab preserves β-cell function, as measured by C-peptide levels, and correspondingly produces endogenous insulin, thereby reducing the need for exogenous insulin. Example 5. Clinical Pharmacokinetics and Pharmacodynamics

Mechanism of Action: Tilimumab is a humanized monoclonal antibody that targets the cluster of differentiation 3 (CD3) antigen, which is co-expressed with the T cell receptor (TCR) on the surface of T lymphocytes. Although the mechanism of action of Tilimumab for the proposed indication has not been confirmed, it appears to involve a weak agonist activity of signaling through the TCR-CD3 complex, which is thought to expand regulatory T cells and re-establish immune tolerance.

Pharmacokinetics: Figure 30 shows a plot of the predicted mean telucam concentrations over time using a 14-day intravenous (IV) dosing regimen with a 4-day ramp followed by repeat dosing of 826 μg/m2 on Days 5 to 14. The left graph represents a typical 60 kg male subject and the right graph represents typical 40 kg and 90 kg male subjects. Dosing based on body surface area (BSA) normalizes exposure across body size.

Repeated IV infusions resulted in elevated serum telizumab levels, although steady-state PK was not achieved at the end of dosing (day 14 of the dosing regimen). The mean cumulative ratio of area under the curve (AUC) between days 5 and 14 was 3.4. The predicted mean (±SD) total AUC for the 14-day dosing regimen was 6421 ± 1940 ng day/mL, with Cmax and Cmin on day 14 of 826 ± 391 and 418 ± 225 ng/mL, respectively.

Distribution: The central and peripheral distribution volumes for the population PK analysis were 3.4 L and 6.9 L, respectively.

Elimination: Tirelizumab clearance is not dose-proportional and may be driven by its saturable binding to CD3 receptors on the surface of T cells. Tirelizumab is expected to be degraded into smaller peptide fragments through catabolic pathways. Based on population PK analysis, the clearance of Tirelizumab after a 14-day dosing regimen was estimated to be 2.3 L/day, with a terminal half-life of approximately 4 days.

The planned commercial drug product was manufactured at a different facility than the clinical trial product and was not used in the clinical studies submitted to support efficacy and safety. A single-dose PK bridging study was conducted in healthy volunteers, which assessed the biocompatibility of the commercial drug product with the clinical trial product. The mean AUC0-inf for the commercial product was less than half the AUC0-inf of the product used in the primary efficacy study (48.5%, 90% CI: 43.6 to 54.1). This difference appeared to be due to more rapid clearance of drug from the circulation rather than differences in product strength, as similar concentrations were observed immediately following IV infusion (the Cmax for the commercial product was 94.5% (90% CI: 84.5 to 106) of that observed with the clinical trial product). Example 6. Adverse Events

Adverse events associated with the administration of tilimumab are also being investigated. Of note, although there are no overall safety signals for infections with tilimumab to date, based on data from completed studies, the number of infectious adverse events reported by patients who received a 12-day dosing regimen (1 or 2 cycles) rather than a 14-day regimen appears to be lower (Table 7). Example 7. Anti- CD3 + Verapamil Therapy in a Mouse Model of Type 1 Diabetes

The mouse model is a female newly diagnosed diabetic NOD (non-obese diabetic) mouse. The study design is shown in Figure 33. Hamster anti-mouse CD3 iv 2.5 μg/injection (D0-5) and verapamil 1 mg/ml in drinking water can be administered as recommended. Example 8. Study Design of Proposed Tilimumab + Verapamil POC Study in Adults with Newly Diagnosed T1D

A randomized, controlled, open-label arm of the Self-Tweaking Platform T1D-Plus study could be conducted to show the efficacy of telizumab plus verapamil treatment.

In adults with new-onset T1D within 6 weeks of diagnosis, telizumab (eg, a 12-day regimen for 0-6 months) plus verapamil (eg, 360 mg slow-release once daily) can be compared with verapamil alone.

Participants underwent a mixed-meal tolerance test (MMTT) every 3 months for up to 12 months, with the primary endpoint being the area under the curve C-peptide level adjusted for baseline levels at 12 months.

An interim assessment of futility can be performed approximately 9 months after recruitment.

Additional secondary endpoint data on CGM, hypoglycemia, insulin dosing, and HbA1c and PROs can be collected. Example 9. Effect of Verapamil Combined with Anti- CD3 Antibody on New-Onset Diabetic Female NOD Mice

Type 1 diabetes is a disease that occurs when the immune system attacks and destroys the cells that make insulin. People diagnosed with type 1 diabetes have elevated blood sugar levels and require insulin treatment to survive, and must check their blood sugar levels regularly throughout the day.

Tirelizumab has been engineered to alter the function of T lymphocytes that mediate the destruction of insulin-producing beta cells in the pancreatic islets. Tirelizumab binds to an epitope of the CD3 epsilon chain expressed on mature T cells and, by doing so, can modulate the immune response in a variety of autoimmune diseases, including T1D. Specifically, Tirelizumab can inhibit unwanted effector T cells and enhance beneficial regulatory T cell function, thereby promoting immune tolerance. By blocking the autoimmune response against pancreatic cells, Tirelizumab preserves beta cells by inhibiting a direct attack by the immune system. However, multiple studies have shown that β cells in T1D patients show signs of intrinsic metabolic dysfunction, which may still lead to β cell mass loss through stress-induced apoptotic cell death. Combination therapy including teligrumumab with agents that prevent stress-induced β cell apoptosis and promote β cell survival could greatly expand the therapeutic benefit of teligrumumab.

Thioredoxin-interacting protein (TXNIP) is a member of the alpha-arrestin family involved in redox sensing, which protects cells from oxidative stress. Accumulating evidence indicates that TXNIP is an important part of the thioredoxin system, mediating β-cell dysfunction. TXNIP has been found to control β-cell microRNA expression, β-cell function, and insulin production; moreover, TXNIP was the most highly glucose-induced gene in human islet microarray studies. Its expression was found to be significantly increased in β-cells of diabetic islets. Although elevated TXNIP levels induce β-cell apoptosis, TXNIP deficiency protects against both type 1 and type 2 diabetes by promoting β-cell survival.

Verapamil is a calcium channel blocker used as an antihypertensive agent. Studies in vitro and in a mouse model of type 1 diabetes have shown that verapamil blocks β-cell apoptosis and promotes their survival by inhibiting TXNIP transcription (Xu et al., Diabetes (2012) 61(4):848-856).

In a randomized, double-blind, placebo-controlled, Phase 2 trial, verapamil was found to be superior to placebo in preserving meal-stimulated C-peptide secretion in adults with newly diagnosed type 1 diabetes (Ovalle et al., Nat Med. (2018) 24:1108-12). The data showed that verapamil treatment was associated with a delay in disease progression of at least 2 years based on C-peptide preservation and insulin use.

Considering the complementary mechanisms by which verapamil and tilizumab protect pancreatic β cells, it was hypothesized that combination therapy might produce better outcomes than single therapy. A preclinical study in mice was designed to test this hypothesis. NOD mice are a preclinical model of T1D. Female NOD mice develop diabetic symptoms at approximately 16 weeks of age, and for the purposes of this study, diabetes onset was marked by glucose levels reaching 200 mg/dL. Newly diabetic animals were enrolled in the study and were untreated, treated with a rabbit IgG isotype control antibody plus verapamil, treated with anti-CD3, or treated with the anti-CD3+verapamil combination. Animals were treated with antibody daily from day 0 to day 4, with daily verapamil administration for 8 weeks. Figure 34 shows the treatment regimen for new-onset diabetes in NOD mice. Female new-onset diabetic NOD mice (blood glucose > 200 mg/dL measured on two consecutive occasions) were untreated (untr) or given short-term low-dose anti-CD3 therapy (aCD3, clone 145-2C11 2.5 µg/day i.v. for 5 consecutive days) alone or in combination with verapamil for 56 days. Verapamil was given continuously in drinking water at a dose of 1 mg/mL. No exogenous insulin replacement was provided to the animals to rigorously measure efficacy.

Disease progression was monitored by measuring glucose levels during the 8-week study in each animal. All but one of the 14 animals in the control group continued to progress, as evidenced by progressive increases in glucose levels. Verapamil and anti-CD3 were associated with disease regression in a large number of animals, but surprisingly, the combination treatment provided the greatest benefit by halting disease progression and even reversing the disease (measured as blood glucose levels less than 200 mg/dL) in about 50% of the animals at the end of the study and in about 50% to 60% of the animals during weeks 2 to 5. In the subgroup study, animals were separated by glucose levels at the start of the study. Moderate clinical symptoms (glucose levels < 350 mg/dL) generally indicate that a large number of beta cell clusters are still present, while high levels of glucose (> 350 mg/dL) indicate that most beta cells have been lost. Remarkably, the combination therapy was able to reverse diabetes in approximately 80% of animals with glucose levels > 350 mg/dL from Week 2 to Week 5, providing a benefit far greater than that achieved with either therapy alone (between 20% and 35% for each treatment over the same period). See Figures 35A-35E and 36A-36C.

Animals treated with anti-CD3, either as monotherapy or in combination with verapamil, showed a transient reduction in lymphocytes (but not granulocytes), which has also been shown in humans with teligrum. See Figures 37 and 38. Example 10. Treatment of Stage 3 T1D

Newly diagnosed, symptomatic, insulin-dependent stage 3 T1D patients with significant residual beta cell mass, as evidenced by blood C-peptide levels greater than 0.2 ng/ml, receive a 12-day course of daily subcutaneous administration of an anti-CD3 antibody and oral verapamil formulated such that all active agents are administered in therapeutically effective amounts to the subject in need thereof in each dose. Following the 12-day course, the patient continues to receive therapeutically effective oral doses of verapamil until the patient's need for insulin is significantly reduced or eliminated. Example 11. Treatment of stage 2 T1D

A patient with presymptomatic stage 2 T1D who had reduced functional beta cell mass, as evidenced by dysglycemia during blood glucose provocation, received a 12- to 14-day course of teligrum IV to reduce immune autoreactivity against beta cells and prevent further disease progression. Following teligrum treatment, the patient began oral verapamil therapy to maximize preservation of existing beta cell mass until dysglycemia was reduced by 50% from baseline or resolved.

In a variation of this example, an additional 12 to 14 day course of tilizumab is administered 6 months to about 1 year after the initial course of tilizumab to avoid rejection of the newly formed beta cells by the patient's immune system.

In variations of this example, verapamil is administered orally 1 to 4 times a day, once a week, once every two weeks, once every three weeks, or once a month.

Modifications and variations of the methods and compositions described in the present disclosure will be apparent to those skilled in the art without departing from the scope and spirit of the present disclosure. Although the present disclosure has been described in conjunction with specific embodiments, it should be understood that the present disclosure as claimed should not be unduly limited to such specific embodiments. Indeed, various modifications of the described modes for carrying out the present disclosure are intended and understood by those skilled in the relevant art to which the present disclosure belongs to be within the scope of the present disclosure as represented by the following claims.

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without

[Figure 1]: Simulated concentrations for the three dosing regimens: Population predictions for a typical male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and no detectable ADA.

[Figure 2]: Comparison of concentrations for dosing regimens 1 and 2: Model-based simulation of a typical male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and no detectable ADA.

[Figure 3]: Comparison of concentrations between the Herold regimen and regimen 1: Model-based simulation of a typical male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and no detectable ADA.

[Figure 4]: Comparison of concentrations on the last dosing day for the Herold regimen and regimen 1: Model-based simulation of a typical male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and no detectable ADA.

[Figure 5]: Simulated concentrations for the three dosing regimens: Population predictions for a typical male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and high levels of detectable ADA.

[Figure 6]: Comparison of concentrations for dosing regimens 1 and 2: Model-based simulation of a typical male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and high levels of detectable ADA.

[Figure 7]: Comparison of concentrations for the Herold regimen and regimen 1: Model-based simulation of a typical male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and high levels of detectable ADA.

[Figure 8]: Comparison of concentrations on the last dosing day for the Herold regimen and regimen 1: Model-based simulation of a typical male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and high levels of detectable ADA.

[Figure 9]: Simulated concentrations for the three dosing regimens: Population predictions for a typical male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and no detectable ADA.

[Figure 10]: Comparison of concentrations for dosing regimens 1 and 2: Model-based simulation of a typical male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and no detectable ADA.

[Figure 11]: Comparison of concentrations for the Herold regimen and regimen 1: Model-based simulation of a typical male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and no detectable ADA.

[Figure 12]: Comparison of concentrations on the last dosing day for the Herold regimen and regimen 1: Model-based simulation of a typical male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and no detectable ADA.

[Figure 13]: Simulated concentrations for the three dosing regimens: Population predictions for a typical male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and high levels of detectable ADA.

[Figure 14]: Comparison of concentrations for dosing regimens 1 and 2: Model-based simulation of a typical male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and high levels of detectable ADA.

[Figure 15]: Comparison of concentrations for the Herold regimen and regimen 1: Model-based simulation of a typical male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and high levels of detectable ADA.

[Figure 16]: Comparison of concentrations on the last dosing day for the Herold regimen and regimen 1: Model-based simulation of a typical male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and high levels of detectable ADA.

[Figure 17]: Comparison of concentrations between the Herold regimen and regimen 2: Model-based simulation (42 days) in a male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and no detectable ADA.

[Figure 18]: Comparison of median concentrations between the Herold regimen and dosing regimen 2: Model-based simulation (35 days) in a male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and no detectable ADA.

[Figure 19]: Comparison of concentrations between the Herold regimen and regimen 2: Model-based simulation (42 days) in a male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and high levels of detectable ADA.

[Figure 20]: Comparison of median concentrations between the Herold regimen and dosing regimen 2: Model-based simulation (35 days) in a male patient with WT = 60 kg, age = 18 years, BSA = 1.67 ^m2 and high levels of detectable ADA.

[Figure 21]: Comparison of concentrations between the Herold regimen and regimen 2: Model-based simulation (42 days) in a male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and no detectable ADA.

[Figure 22]: Comparison of median concentrations between the Herold regimen and dosing regimen 2: Model-based simulation (35 days) in a male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and no detectable ADA.

[Figure 23]: Comparison of concentrations between the Herold regimen and regimen 2: Model-based simulation (42 days) in a male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and high levels of detectable ADA.

[Figure 24]: Comparison of median concentrations between the Herold regimen and dosing regimen 2: Model-based simulation (35 days) in a male patient with WT = 45 kg, age = 13 years, BSA = 1.33 ^m2 and high levels of detectable ADA.

[Figure 25]: Schematic diagram of a research design according to an embodiment.

[Figure 26]: Predicted mean difference in change from baseline in C-peptide AUC (nmol/L) between telilucomab and control at 1-year follow-up in the meta-analysis of supportive studies.

[Figure 27]: Predicted mean difference in change from baseline in C-peptide AUC (nmol/L) between telilucomab and control at 2-year follow-up in the meta-analysis of supportive studies.

[Figure 28]: TN-10: C-peptide AUC (nmol/L) in T1D patients.

[Figure 29]: Average insulin usage per visit.

[Figure 30]: Predicted mean serum concentration of telicam monoclonal antibody and time curves after 14 days of regimen for different body weights.

[Figure 31]: Plotting the Emax model: exact change in C-peptide versus AUC at year 2. The Protégé study was conducted in newly diagnosed (stage 3) T1D patients and tested 3 teligrumab dosing schedules (full 14 days [approximately 9,030 μg/m ² cumulative dose], one-third [1/3] of the 14-day schedule, and reduced 6 days [the first 6 days of the full 14-day schedule]).

[Figure 32]: Proposed mechanism of action of teliguzumab-verapamil combination therapy.

[Figure 33]: Proposed mouse model study of anti-CD3-verapamil combination therapy.

[Figure 34]: Experimental design: Treatment of new-onset diabetes in NOD mice.

[Fig. 35A to 35E]: Blood glucose values during treatment with verapamil, anti-CD3, anti-CD3 + verapamil, or no treatment. Each line represents the blood glucose value of an individual animal over time. Hamster anti-mouse CD3 antibody (aCD3; clone 145-2C11, Bioxcell, West Lebanon, NH) or hamster anti-mouse isotype control (hIgG) was administered intravenously at a dose of 2.5 μg per day for 5 consecutive days (days 0-4). Verapamil (V; 1 mg/mL) was given daily with drinking water until day 56 after the start of treatment. The n per group is indicated in the figure title.

[Figures 36A to 36C]: Percentage of diabetes reversal. Newly diabetic female NOD mice were untreated (untr) or received anti-CD3 conjugates followed by verapamil administration. Bar graphs depict the percentage of diabetes reversal over time in all newly diabetic female mice (Figure 36A) or broken down into those with an initial blood glucose value of < 350 mg/dL (Figure 36B) or ≥ 350 mg/dL (Figure 36C). Mice with two consecutive blood glucose values of ≥ 200 mg/dL at the start of treatment were considered diabetic. aCD3 = anti-CD3; IgG = immunoglobulin G (isotype control); NOD = nonobese diabetic; Untr = untreated, V = verapamil.

[Figure 37]: Median lymphocyte counts in responders and non-responders.

[Figure 38]: Median number of pellets of responders and non-responders.

without

TW202448505A_113107615_SEQL.xml

Claims (39)

A method for treating clinical type 1 diabetes (T1D) or delaying progression of stage 2 T1D to stage 3 T1D, the method comprising administering to a subject in need thereof: a 12- to 14-day course of teplizumab at a total dose of about 9,000 μg/m ² to about 14,000 μg/m ² ; and an effective amount of verapamil. The method of claim 1, wherein the total dose is between about 9000 and about 9500 μg/m ² . The method as described in claim 1, wherein the 12-day treatment course includes a first dose of 106 μg/m ² of teligrum on day 1, a second dose of 425 μg/m ² of teligrum on day 2, and a dose of 850 μg/m ² of teligrum each day from day 3 to day 12, wherein the total dose is approximately 9031 μg/m ² . The method as described in claim 1, wherein the 12-day treatment course includes a first dose of 211 μg/m ² of teligrum on day 1, a second dose of 423 μg/m ² of teligrum on day 2, and a dose of 840 μg/m ² of teligrum each day from day 3 to day 12, wherein the total dose is approximately 9034 μg/m ² . The method of any one of claims 1 to 4, comprising administering a first and a second 12-day course of teligrumab. The method of claim 5, wherein the first and second 12-day courses are administered at intervals of about 6 months. The method of claim 5 or 6, further comprising administering to the subject in need thereof a third or more 12-day or 14-day course of tilizumab, with the total dose of each course exceeding about 9000 μg/m ² , and optionally not exceeding 14000 μg/m ² . The method as described in claim 7, wherein the third or more 12-day courses of tilpizumab include a first dose of 106 μg/m ² of tilpizumab on day 1, a second dose of 425 μg/m ² of tilpizumab on day 2, and a dose of 850 μg/m ² of tilpizumab each day from day 3 to day 12, wherein the total dose of each course is approximately 9031 μg/m ² . The method as described in claim 7, wherein the third or more 12-day courses of tilpizumab include a first dose of 211 μg/m ² of tilpizumab on day 1, a second dose of 423 μg/m ² of tilpizumab on day 2, and a dose of 840 μg/m ² of tilpizumab each day from day 3 to day 12, wherein the total dose of each course is approximately 9034 μg/m ² . The method of claim 7, wherein the third or more courses of teligrumab are administered at an interval of about 12 months to about 24 months from the previous course. The method of claim 1, comprising administering a 14-day course of teligrumab by intravenous (IV) infusion at a dose of about 60 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,000 μg/m ² per day on days 5 to 14. The method of claim 1, comprising administering a 14-day course of tilizumab by IV infusion at a dose of about 60 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,030 μg/m ² per day on days 5 to 14. The method of claim 1, comprising administering a 14-day course of tilizumab by IV infusion at a dose of about 65 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,030 μg/m ² per day on days 5 to 14. The method of claim 1, comprising administering a 14-day course of tilizumab by IV infusion at a dose of about 100 μg/m ² on day 1, about 425 μg/m ² on day 2, about 850 μg/m ² on day 3, about 850 μg/m ² on day 4, and about 1,000 μg/m ² per day on days 5 to 14. The method of claim 1, comprising administering a 14-day course of tilizumab by IV infusion at a dose of about 65 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,070 μg/m ² per day on days 5 to 14. The method of claim 1, comprising administering a 14-day course of tilizumab by IV infusion at a dose of about 65 μg/m ² on day 1, about 125 μg/m ² on day 2, about 250 μg/m ² on day 3, about 500 μg/m ² on day 4, and about 1,370 μg/m ² per day on days 5 to 14. A method as described in any of claims 1 to 16, comprising determining the baseline level of TIGIT+KLRG1+CD8+T cells relative to all CD3+ T cells 3 months after administration, monitoring the level of TIGIT+KLRG1+CD8+CD3+ T cells, and administering an additional 12 or 14 day course of teligrumab when the level of TIGIT+KLRG1+CD8+CD3+ T cells returns to baseline levels. The method of claim 17, wherein TIGIT+KLRG1+CD8+CD3+ T cells are determined by flow cytometry. The method of claim 17, wherein TIGIT+KLRG1+CD8+CD3+ T cells are monitored by flow cytometry. The method of any one of claims 17 to 19, wherein if the subject has greater than about 10% TIGIT+KLRG1+CD8+ T cells among all CD3+ T cells, subsequent monitoring is performed annually. The method of any one of claims 17 to 19, wherein if the subject has less than about 10% TIGIT+KLRG1+CD8+ T cells among all CD3+ T cells, subsequent monitoring is performed approximately every 6 months. The method of any one of claims 1 to 21, wherein the administering step results in at least a 10% decrease in insulin usage, HbA1c levels, hypoglycemic episodes, or a combination thereof compared to pre-treatment levels. The method of any one of claims 1 to 22, wherein each dose of teligrumumab is administered parenterally, optionally by intravenous infusion. The method of any one of claims 1 to 23, wherein the effective amount of verapamil is administered orally, intraperitoneally, subcutaneously or by intravenous infusion. The method of any one of claims 1 to 24, wherein the subject in need thereof is about 8 to 17 years old or an adult. The method of claim 25, wherein the subject has stage 3 T1D, and/or has new onset T1D, as diagnosed within 12 weeks, 8 weeks, or 6 weeks, as appropriate. The method of any one of claims 1 to 26, wherein the subject in need thereof has a peak C-peptide level of ≥ 0.2 pmol/mL during a mixed meal tolerance test (MMTT). The method of any one of claims 1 to 27, wherein the subject receiving teligrumumab has a higher mean C-peptide value after treatment compared to a control group receiving a placebo. The method of any one of claims 1 to 28, comprising assessing the area under the time-concentration curve (AUC) of C-peptide at 78 weeks after a mixed meal tolerance test (MMTT). The method of any one of claims 1 to 29, wherein the subject in need thereof has at least 20% beta cell function prior to administration of telizumab and verapamil. The method of any one of claims 1 to 30, wherein the reduction in insulin use, HbA1c levels, hypoglycemic episodes, or a combination thereof persists for 12 months or longer. The method of any one of claims 1 to 31, wherein verapamil is administered in an amount of about 100 mg to about 480 mg per day. The method of any one of claims 1 to 32, wherein verapamil is administered in an amount of about 300 mg to about 400 mg per day. The method of any one of claims 1 to 33, wherein verapamil is administered in an amount of about 360 mg per day. The method of any one of claims 1 to 34, wherein the verapamil is administered in a slow release form. A teligrumimab for use in the method of any one of claims 1 to 35 to treat clinical type 1 diabetes (T1D) or delay progression of stage 2 T1D to stage 3 T1D. Verapamil for use in the method of any one of claims 1 to 35 for treating clinical type 1 diabetes (T1D) or delaying progression of stage 2 T1D to stage 3 T1D. A use of tilizumab for the manufacture of a medicament for treating clinical type 1 diabetes (T1D) or delaying the progression of stage 2 T1D to stage 3 T1D in the method as described in any one of claims 1 to 35. Use of verapamil for the manufacture of a medicament for treating clinical type 1 diabetes (T1D) or delaying the progression of stage 2 T1D to stage 3 T1D in the method of any one of claims 1 to 35.